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)~ZZ?t4)rKec 
 
TESTIMONIALS.
  " We were a member of the Boylston Prize Committee, which offered the
question which Dr. Durkee has so ably answered.  We heartily commend this
volume to the profession.  We want such works. We want our own men to write
them.  We have relied too much and too long on foreign authors."
                                         Prof. CHANNING, of Boston.

From Professor R. D. Mussey, of Cincinnati, Ohio.
  It is gratifying to see, at length, a book on this subject strictly American —
and  still more to see it so well done.  The work ought to be in the hands of
all young practitioners, and  it may justly claim a conspicuous place in the
libraries of the ripened and skilful members of the medical profession.

From Dr. Thomas  C. Brinsmade, late  President of the Medical Society of
     the State of New York.
  It is an important and highly useful work.   The style is admirable ; and the
practical character of the volume is clearly shown on every page.  I doubt not
it will be well received by the American Medical Profession generally.  The
plates add greatly to the value of the text.

From Dixi Crosby, M.D., Professor of  Surgery and Obstetrics in Dartmouth
     College.
  I have examined Dr. Durkee's new work on Gonorrhoea and Syphilis, and a
sense of professional gratitude  impels me to record my unqualified approba-
tion  of it.

From Dr. Valentine Mott, Professor of Surgery, &c, New York City.
                                           New York, August 3, 1859.
  My Dear Sir:  Some little time before you did me the honor to send me a
copy of your work, I had procured it, and was therefore more or less acquainted
with its merits.  I thank you sincerely for the copy you have sent me, as I shall
take  more interest now in  making myself familiar with your views of the in-
teresting and complicated subject of the Venereal Disease.
  I am gratified to say, that in my opinion you have shown yourself familiar
with the literature of the  subject, and, what is vastly more important for the
profession of our country, to possess an intimate acquaintance with its  prac-
tical  details.  Your beautiful volume therefore will, and ought to, become a
standard work, alike an honor to the country and to yourself.
                                          Yours truly,      V. MOTT.
  Dr. Durkee. 
9
 From Dr. Wm. W. Mout.and, Physician to the Boston City Hospital.
   Dr. Durkee's work on Venereal Diseases has the great merit of combining
 a vast amount of the freshest information upon the topics of which it treats.
 It is  written in an  eminently agreeable style.  As a judicious and  reliable
 practical guide, it Is superior to any other work of  the kind.

                                              New York, Aug. 5, 1859.
   Dr. Durkee, — Dear Sir : Your recently published volume on Venereal Af-
 fections has  been in my possession  several weeks ;  in the meanwhile I have
 given it an attentive perusal, I may say quite  a study.  It is but limited praise
 to say the work is  honorable to the literature and science of the age, and will
 place its author high in  the rank of that  select corps who have augmented
 useful knowledge and advanced medical science.
   I am not wholly  unfamiliar with the writings of the  most renowned who
 have  contributed to the advancement of sound principles on that  special  and
 important subject to which your most interesting volume is devoted.   Profes-
 sionally and in practice I have had much to do with those diseases of pollution,
 and have studied the infirmities  of the sexual system with some devotion, in
 the several hospitals abroad appropriated to their special treatment.  Were it
 not for these circumstances, I should hardly feel justified  in giving an opinion
 touching the merits of a work so extensive, so elaborate in exposition, so mi-
 nute in nosological precision, and so practical in its suggestions.  Let me, after
 a copious reading of many works on the subject to which yours relates, give the
 assurances of my sincerest conviction that you have produced a  book possess-
 ing claims to consideration superior to any other that I have ever met with on
 the subject.  I think you  have proved yourself an unbiassed and clear observer
 of the varied phenomena of  a class of affections hitherto enumerated  among
 the vexed questions of scientific  medicine.   You have noticed and developed
 with philosophical  precision.  You have fortified original  observations by judi-
 cious  and sound authority.   You seem to me  to have had but one  great prin-
 ciple of action in  your laborious investigations — the desire to elucidate truth
 and present a faithful record of facts as they are offered to the clinical observer.
 Your  work has settled, in my opinion, several doubtful points long  in  contro-
 versy. You have attacked preposterous innovations, however high the authority.
 You have demonstrated to full conviction some of the popular delusions of the
 great  John Hunter, and the too partial deductions  of Ricord.  John Pearson,
 for more than twenty years a successor in renown next to John Hunter, has lost
 his prestige in your voluminous facts on corrosive sublimate. But I will weary
 you no longer in detail of this sort. I will briefly add that your work betrays on
 every  page your close observation and your philosophical powers.  The nation is
enhanced in the intellectual world by your analytical treatment of the most em-
barrassing subject in the entire field of practical  science; and you may rest assured
that the enlightened of both hemispheres will appreciate and honor your labors.
                 With sincere esteem,  clear  sir, your obligated friend,
                          JOHN W. FRANCIS, 1 Bond street, New York.
  This new work on Gonorrhoea and Syphilis, by Dr. Durkee, is an excellent
production. — Ohio Medical Gazette. 
3
  I have examined Dr. Durkee's work  on Venereal Affections, and am happy
to recommend it to the Medical Profession.
                          JONATHAN  KNIGHT, Professor of Surgery in
                             the Medical Institution of Yale College.

  I have carefully perused Dr. Durkee's Treatise on Gonorrhoea and Syphilis,
and consider it the best practical work of  the kind in the English language.
                          P. A. JEWETT, Professor, &c,
                                     Medical Institution of Yale College.

  " I am very much obliged for the copy you sent me, and, from  the examina-
tion I have made of it, I think it of great practical utility.   I am sure I shall
recommend it as the first American work on this subject, as well as for its own
excellence."
                                             Prof. E. R.  PEASLEE.

From Alden March, M. D., Professor of Surgery, Albany Medical College.
   Dr. Durkee, — My Dear Sir: Since I returned to Albany I  have  devoted
part of my leisure  hours to  the perusal of  your  recently published work on
Gonorrhoea and Syphilis, and to say that  I  have  been instructed and pleased
with your labors in the cause of medical and surgical  science, as unfolded in
this work, would fall far short of the meed of praise to which you are entitled.
   So far as I may be allowed to be a judge, I can  speak in the  highest terms
of the design, arrangement, and execution of your excellent treatise.   I admire
the direct, concise,  and lucid manner in which you have presented the respec-
tive subjects that  are discussed in,its pages.  The volume contains a vast
amount of information in a small compass, and I would especially recommend
it as a standard and reliable work.
   The  simple and  philosophical mode of treatment pointed out, and the ap-
propriate prescriptions, enhance its  value  to the young physician; and to
such, and to the students of our College,  I shall not hesitate to recommend it,
with the fullest confidence that it is worthy  of the many encomiums bestowed
upon it by some of the most distinguished in the ranks of the profession.

From John Homans, M. D., President of the Massachusetts Medical Society,
     and one  of the  Consulting  Physicians  at  the  Massachusetts  General
     Hospital.
   I have examined Dr. Durkee's treatise  on Venereal Diseases, and have
 derived much satisfaction from its perusal.  The style of the author is remark-
 ably clear, refined,  and'pertinent, and he treats the different subjects contained
 in  his book in a most judicious and acceptable manner.   His large experience,
 his accurate  powers of observation, and  his  extensive acquaintance  with all
 that has been written  upon Syphilitic Affections, have enabled him  to furnish
 a  volume of great excellence.   For reliability and usefulness I can truly say
 that I know not its equal in the English language.  In short, the work reflects
 the highest credit  upon the author, and is, in  the best sense, an honor to
 American medical literature.
                                                   JOHN HOMANS. 
4
   New Work on  Gonorriicea and Syphilis.— We are  gratified  to be
 able to announce that a work upon Gonorrhoea  and Syphilis, which has been
 long in the process of careful elaboration by its author, Dr. Silas Durkee, of
 this  city, is now  rapidly passing through the press.  We have had the op-
 portunity of perusing  the manuscript, and  have no hesitation in declaring that
 the volume will be  eminently a useful and practical one. — Boston Medical
 Journal.

   We especially like the critical and discriminating spirit which characterizes
 every part of this  work, and its freedom from  any servile or sycophantic sub-
 mission to what  are  called authorities. *  *  * We have read enough  of its
 pages to predict that  it will become a standard  authority in this department,
 regarding it, as we do, superior to any of the works we have seen on the sub-
 ject, whether foreign or domestic. — American Medical  Gazette.

   We have given this  work a careful perusal, and feel confident in the asser-
 tion that the medical profession in  this  country will agree  with us in the
 opinion that the author has  successfully carried out his design.
   An experience  of  thirty years in the  treatment of  skin   diseases,  as  a
 specialty, enables Dr. Durkee to speak  with peculiar authority on the diagnosis
 and management of secondary and tertiary Syphilis ; and on this subject, upon
 which  general  practitioners are most often at  fault, the work is particularly
 clear and elaborate.
   We confidently  recommend  it  to the profession  as  the best work,  for a
 manual on  these subjects,  which has yet been published. — American Medical
 Monthly.

   Dr. Durkee's work on Syphilis is the most complete and practical production
 of the kind in any  language.  The subject is evidently handled  by a master. —
 College Journal of Medical Science, Cincinnati.

   We are pleased to receive this first full treatise by an American physician as
 well acquainted with the whole  subject  as Dr. Durkee  seems to be.   We are
 glad to find in the  preface  that our author has had  such an extended experience
 in the treatment of Venereal Diseases.  The book is .eminently practical.   We
 think that  it is  bound to  have a  large sale, and  deservedly so. — Cincinnati
 Lancet and Observer.

  We welcome this volume as being the first comprehensive treatise, as far as
 we remember, on Gonorrhoea and Syphilis which has issued from the American
 press.
  The paramount design of the author has been to furnish a book that shall be
practacally useful, and we feel sure that its objects in this  respect will be ful-

  The chapters  on Syphilitic  Skin Diseases are made more  interesting by
several *ell-executed plates. - Charleston (S. C.)  Medical Journal. 
 

VC/'^' * -r  ■
B-ixpiaPrommens  Syphilitica,. 
A
TREATISE
GONOMH(EA AND SYPHILIS.
BY
        SILAS  DURKEE,  M. D.,
                 k v*~
CONSULTING SURGEON OF THE BOSTO.V CITY HOSPITAL; FELLOW OF THE MASSACHUSETTS MEDICAL
  SOCIETY; MEMBER OF THE BOSTON SOCIETY FOR MEDICAL IMPROVEMENT; HONORARY MEMBER
      OF THE MEDICAL SOCIETY OF THE STATE OF NEW YORK ; FELLOW OF THE
            AMERICAN ACADEMY OF ARTS AND SCIENCES, ETC.
Second Edition, Revised and Enlarged,
EIGHT COLORED ILLUSTRATIONS.
             PHILADELPHIA:
LINDSAY  AND BLA_KISTON.
                  18G4. 
I
V/CA
         Kntered, according to Act of Congress, in the year 1804, by




                  LINDSAY &  BLAKISTON,




In the Clerk's Office of the District Court for the Eastern District of Pennsylvania. 
TO
         THOMAS  C.  BRINSMADE, M.D.,
                           L A T K

  PRESIDENT OF THE MEDICAL SOCIETY OF THE STATE OF NEW YORK,
WHO, BY HIS UNWEARIED, INTELLIGENT, AND SUCCESSFUL LABORS TO ADVANCE
   THE GREAT INTERESTS  OK MEDICAL SCIENCE;  BY HIS DIGNIFIED AND
       COURTEOUS DEMEANOR, AND HIS TRUE MORAL EXCELLENCES
          OK CHARACTER, HAS RISEN TO A HIGHLY HONORABLE
             AND EMINENT POSITION IN THE PROFESSION,

                      2rf)t0 Uolume

   IS CORDIALLY  INSCRIBED AS AN EXPRESSION OF GRATITUDE

       FOP. VALUABLE INSTRUCTION LONG SINCE RECEIVED, AND AS
            A TOKEN OF WARM  REGARD AND FRIENDSHIP,
                        BY  HIS PUPIL,

                                THE  AUTHOR. 
 
PREFACE TO THE  SECOND  EDITION.
  The favorable reception accorded  to  the first edition of this
work, by the medical profession, is a source of gratification  to
the author, and affords occasion  for the issue of the present
revised and enlarged edition.  This would have appeared at an
earlier day, had  not circumstances, growing out of the existing
troubles of the country, prevented.
  In my endeavors more  perfectly to present a rational course
of treatment of  the various  phenomena of venereal affections,
and to acquaint my readers with the latest suggestions of those
whose enlightened experience and position entitle them to be
heard, I have diligently consulted  the most substantial medical
literature up to the present  day, and  have incorporated into
these  pages whatever has  been deemed  essential to a thorough
and practical comprehension  of the general subject, and con-
ducive to a knowledge of  the most  modern  and  successful
methods of conducting  individual  cases as they may, from time
to time, occur.
                                                   S. D.
  Boston, June, 1864.
1*
(H) 
 
PREFACE  TO  THE  FIRST  EDITION.
  A few years since, the author of the following pages prepared
an Essay on " The Constitutional Treatment of Syphilis," 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 en-
hanced.*
  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
posesses such  skill, will  confine himself to a few medicinal
   *  By a vote of 1826, the Board do not consider themselves as approving the
 doctrines contained in any of the dissertations  to which premiums may be ad-
 'udeed; and in case of the publication of a successful  dissertation, the author
 •  considered bound to print this vote in connection therewith.
                       A*                             W 
vi
PREFACE.
substances that may have  acquired  notoriety as specifics, while
they are endowed with no such qualities.
   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 promi-
nence 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 tho individ-
ual lesion ; and yet, in a broader signification, tho expression is 
                          PREFACE.                       vjj

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 occa-
sionally present themselves for his  decision and  management.
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 gen-
erally  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  Professor
Wilson has, with little variation, been adopted.  This arrange-
ment  will aid  in observing and  comprehending the laws that
usually regulate the development  of these external manifes-
tations, 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
                   1 
viii                      PREFACE.

ryphilitic 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 appar-
ent to the other party, who will not only be driven, like the fox,
from his subterfuges, but will yield  respect and  confidence  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-
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  arc  they brought forward for the  vain purpose
of establishing or demolishing any particular pathological the-
ory,  exclusive of other and  higher  considerations.  It  would 
PREFACE.
ix
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 unbiassed 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
comprehensive to embrace everything.   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, 
x
PREFACE.
 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 confiscations 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
 other services  of Ricord  are  entitled  to preeminent 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 syphilographer. 
CONTENTS.
                             CHAPTER  I.
                                                                  PAGE
Blennorrhagia. — Causes. — Leucorrhoea contagious. — Blennorrhagia not
  necessarily  connected with Guilt. — Letter from Dr. Buckingham.—
  Diagnosis of  Blennorrhagia. — Symptoms. — Terminates  in Gleet.—
  Gleet and Matrimony,.................13

                             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 Gonor-
  rhoea. — Cases. — Injections  in  Gonorrhoea. — Painful  Erections and
  Chordee. — Lupulin. — Camphor. — Urethral Hemorrhage. — Cases,   .   31

                            CHAPTER III.

Gleet. — Symptoms. — Case. — Microscopical  Appearance of  the  Dis-
  charge. — Treatment. — Blisters. — Injections. —The Bougie,....   60

                            CHAPTER IV.

Balanitis. — Opinions respecting the Prepuce. — Glandulse Odoriferse. —
  Case of Pseudo-Balanitis. — Causes of Balanitis. — Symptoms. — Treat-
  ment. — Phymosis. — Slitting up the Prepuce. — Circumcision. — Par-
  aphimosis. — Treatment,................72

                             CHAPTER  V.

Orchitis produced by Cubebs or Copaiba. — The Epididymis the usual Seat
  of the Disease. — Symptoms. — Treatment. — Puncturing the Testis
  and  Epididymis. — Compression of the Testis. — Dr. Fricke, Holmes,
  Coote, Ricord, and Henry J. Johnson on the Subject,......82

                             CHAPTER  VI.

Herpes Praeputialis. — Mistaken for Chancre. — Symptoms. — Cases.-—
  Treatment,.....................""
                                                     (xiii) 
xiv
CONTEXTS.
                           CHAPTER  VII.

Eczema Pneputialis. — Appears in Connection with Chronic Blennorrha-
  gia. — Fraternizes with Impetigo. — Mistaken  for a Venereal Disease.
— Treatment,
103
CHAPTER  VIII.
In Irritability of the  Bladder, the  System is rarely  disturbed. — In In-
  flammation of the Bladder, it is. — Difference of Symptoms in Irritable
  Bladder and Calculus.—Treatment of Irritable Bladder,  ..... 108
                           CHAPTER  IX.

Excoriations. — Most frequent  Locality — Generally but one excoriated
  Patch. — Complaint apt to return,......    ......113


                            CHAPTER X.

Urethral Pains. — The Testicles sometimes participate. — Also the Blad-
  der.— Depressing Influence on the Mind. — Treatment,.....118


                           CHAPTER  XI.

Spermatorrhoea. — Causes. —Pathology. — Treatment. — Mental  Disci-
  pline. — Lupulin. — Note from Dr  James Jackson. — Porte Caustique.
  — Anodyne Injections. — Bromide of Potassium. — Marriage. — Cas-
  tration,  ......................121


                           CHAPTER  XII.
Gonorrhoeal  Ophthalmia. — Disease not mentioned by John  Hunter. —
  Inoculation the most frequent Cause. — Opinions of Cooper and Others.
  — Letter  from  Dr. Henry W.  Williams, with  Cases. — Diagnosis.—
  Treatment......................140
                          CHAPTER  XIII.

Ophthalmia Neonatorum. — Most frequent Cause of the Disease.__Symp-
  toms.— Treatment...................152
                          CHAPTER XrV.

Gonorrhoeal  Rheumatism. — Specific Cause unknown. — Structures  in-
  volved.—Sir A. Cooper's first Case.—The Disease described by Mr.
  Brodie.—Dr. Johnson's Opinion. — Diagnosis.—Treatment,.  .  .   .156 
CONTENTS.
XV
                           CHAPTER XV.

Vegetations. — Are  not venereal. — Are known by sundry  Names. —
  Their Situation. — Their anatomical Structure. — Treatment. — Papil-
  lomata,......................162

                           CHAPTER XVI.

Blennorrhagia in the Female. — The Speculum. — Diagnosis of Blennor-
  rhagia in the Female. — Blennorrhagia in very young female Children. —
  Varieties. — Chronic Vaginitis. — Uterine Blennorrhagia. — Treatment.
  — Urethral Blennorrhagia in the Female,..........168

                           CHAPTER XVII.

Syphilis. — But  one Syphilitic Virus. — Its intrinsic Nature unknown. —
  Indurated Chancre of rare Occurrence. — Generally solitary. — Indura-
  tion deceptive. — Interval between Exposure and morbid Phenomena.
  — Abortive Treatment of Chancre,.............187

                           CHAPTER XVIII.

 Constitutional  Treatment of Chancre.—Principles of Health to be en-
   forced. — Analyses of the Blood by M. Grassi. — Influence of Iodide
   of Potassium on the Blood. — Artificial Syphilization. — Methods of
   treating the Venereal Disease,..............1"

                            CHAPTER XIX.

 Chancre. — Indurated Chancre. — According to Ricord, can alone  im-
   pregnate  the  System.—This Theory not sustained  by Facts. — Indu-
   rated Chancre rarely followed by suppurating Bubo. — Mercury the
   best Agent for  curing  indurated  Chancre. — Local  Applications.—
   Swelled Tongue.  — Ulcers on under Surface..........216

                            CHAPTER XX.

 Masked  Chancre. — Definition. — Usual Seat. — Chancre  and  Gonor-
   rhoea from the same impure Connection. — Chancre upon the Vagina and
   upon the Os Uteri,.............

                            CHAPTER XXI.

 Inflammatory Chancre. — Induced by improper Treatment. — Patients of
   irregular Habits  liable to it.—Treatment,..........23i

                            CHAPTER XXII.

 Phagedenic Chancre. - Difference between  Phagedena and Gangrene.
   _ Treatment. - Potassio-Tartrate  of  Iron. - Carbonate   of  Ammo-
   nia. — " Swan Alley Sore" of Prostitutes,........' 
xvi
CONTEXTS.
                          CHAPTER  XXIII.

Bubo. — " Bubon  D'Emblee." — Bubo occurs in the  same side with the
  Chancre. — That from  indurated Chancre rarely suppurates. — True
  Venereal Bubo indolent. — Treatment. — Sloughing Bubo,   .... 254

                          CHAPTER  XXIV.

Secondary Syphilis. — Period of Latency. — Longest time between pri-
  mary and secondary Lesions. — Shortest time. — Difficulty  and impor-
  tance of a correct Diagnosis,............... 266

                           CHAPTER XXV.

Syphilodermata.—The Action of the Venereal Poison slow. — Is in the
  Blood. — Diagnosis of Venereal  Eruptions. — Anaesthesia  or deficient
  Sensibility of the Skin. — Cicatrices,............273

                          CHAPTER  XXVI.

Secondary Symptoms  without  primary. — Cases. — Contagion  of the
  Blood. — Transmission of the Venereal Virus from the Nurse to the In-
  fant, and vice versa. — M. Trousseau. — Communicability of secondary
  Syphilis.......................281

                         CHAPTER XXVII.

Syphiloderma Erythematosum or  Roseola Syphilitica. — Is the simplest
  form of cutaneous Eruptions. — Eruptions produced by Balsam Copaiba
  and Cubebs. — Diagnosis. — Is occasionally confounded with Measles.
  — Treatment.....................306

                         CHAPTER  XXVIII.

Lichen. — Diagnosis. — Passes into Tubercles. — Associated with Tuber-
  cles, Squamae, and Pustules — also with Iritis. — Treatment, .... 310

                          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,..........325

                          CHAPTER XXX.

Tubercular Syphilitic Eruptions. — Present various Appearances. — Some-
  times  ulcerate. —Sometimes disappear by Absorption. — Phagedenic
  Ulcers, and Serpiginous  Ulcers. — Perforating or Syphilitic Tubercles.
  — Treatment of tubercular Eruptions — of ulcerated  Surfaces.__
  Mucous Tubercles,............                  040 
CONTEXTS.
xvii
                          CHAPTER XXXI.

Syphilitic Pustules. —Do not yield pure Pus. — Divided into two Groups
  by Willan. — Of Rupia, two Varieties. — Treatment of Pustular Syph-
  ilis,  .......................355

                          CHAPTER  XXXII.

Alopecia or Baldness,..................366

                          CHAPTER XXXIII.

Ulcers of the Tongue. — Fissures or Cracks. — Treatment. — Sloughing
  Ulcerations of the Throat. — Local Treatment. — Nitric Acid. — Com-
  pound Tincture of Benzoin.— Constitutional Remedies,.....370

                          CHAPTER  XXXIV.

Syphilitic Diseases of the Nostrils and Nasal Fossae. — May be secondary
  or tertiary, superficial or profound. — Insidious  in  their Approach.—
  Treatment,.....................386

                        .  CHAPTER XXXV.

Syphilitic Iritis. — Sometimes a secondary, sometimes a tertiary Affection.
  — Symptoms. — Diagnosis. — Treatment. — Mercury. — Mr.  Carmi-
  chael's Substitute. — Dr.  H. W. Williams's Plan of  Treatment,  .   .  .391

                          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 —
  Lunes — Liver — Brain  — Bones, etc. — Treatment. — Iodide of Po-
       •                                                             401
  tassium,.....................

                          CHAPTER  XXXVII.

 Syphilitic  Sarcocele, or Orchitis. — Belongs to no particular Period of
  " Syphilis. — Commences in the Tunica Albuginea. — Suppuration rarely
   takes  place in the Testicle. — Atrophy of the  Gland. —The Disease
   apt to recur. — Diagnosis.—Treatment,...........

                          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 
xviii
CONTENTS.
  Ireland. — Case related by Mr. Reeve. — Case in the Author's Practice.
  Case at Rainsford Island Hospital. — Diagnosis. — Treatment of Ter-
  tiary Pains — of Nodes.— Mercury. — Local Treatment,.....421

                         CHAPTER XXXIX.
                         INFANTILE SYPHILIS.
Not always secondary. — Procreating Element the Medium of contaminat-
  ing the Foetus. —Blight of Ovum and Abortion. —The Circulation the
  most common Mode of infecting the Foetus. — Infection rarely commu-
  nicated to the Child by the parturient Mother.— The milk of a Syphi-
  litic Nurse poisonous. — An Infant born with Syphilis cannot infect its
  Mother, but may a strange Wet-nurse, etc............432 
GONORRIKEA  AND  SYPHILIS.
                      CHAPTER  I.

                 BLENNORRHAGIA.

  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 patient 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 per-
sonages 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 satisfactory 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  witli  those that  give  rise to
syphilis,  a treatise  on the latter  disease, however judiciously
            2                               (13) 
14
GONORRHOEA AND SYPHILIS.
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-
nately to denote inflammation  of the  mucous membrane  of
the urethra and other portions  of the genito-urinary passages,
attended 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  charac-
ter 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 abnor-
mal  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 
BLENNORRHAGIA.
15
 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  labor-
 ing under leucorrhoea, or  some other morbid condition of the
 vulva, vagina, or uterus, which may furnish a  catarrhal  dis-
 charge possessing more or less  acrid  properties, but specifically
 different  in its  nature from the malignant gonorrhoea impura
just mentioned,  and which alone can  be propagated.  Men have
 also been known to receive a blennorrhagia from healthy women
 with  whom they have had sexual intercourse while the men-
 strual flux has  been upon them.  The vaginal secretions, just
 previous to menstruation, will  likewise occasion urethral  irrita-
 tion in men of peculiar susceptibilities.   In women, blennor-
 rhagia is a complaint rarely met  with, compared with  the  fre-
 quency 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  articles of  food,  such as
 salted meats, cayenne pepper, ginger, etc., have the reputation
 of causing mild  blennorrhagia.  Some persons cannot eat aspar-
 agus without having a gonorrhoeal 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, injections, bougies, and pessaries, will give rise to
 a  morbid  secretion  closely resembling  ordinary gonorrhoea.
 The same results occasionally supervene upon violent and long-
 continued dancing,  frequent venereal indulgence,  and the want
 of co-aptation in the genital organs  of the two  parties.  Mas-
 turbation, rheumatism, and gout will likewise occasion gonor-
 rhoea.   Druitt mentions a case of most obstinate local irrita-
tion, 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.  Blackmail relates the case of a patient sev-
enty 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  reck-
oned among the  causes that give rise to blennorrhagia.  Leu- 
16
GONORRHOEA AND  SYPHILIS.
corrhoeal 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
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  exam-
inations that have been made with a view to detect the charac-
teristic 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 difficulties
which spring up within the domestic  circle in  connection with
this embarrassing subject.  As the conscientious  interpreter  of
events, he can feel justified in  expressing a conviction that blen-
norrhagia 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 circum-
stances, and from a multiplicity of causes, as detailed above.
The bare fact  that a man or woman has the complaint, does not
necessarily carry with it demonstrative proof of guilt.  The dis-
ease may happen to  the most  virtuous  and  pure  individual,
male  or female.   If the surgeon  can obtain  access to all the
antecedents in the premises,  without  concealment from any
quarter, he will have no difficulty in  arriving  at a true diagno-
sis.  A great  and not infrequent obstacle which the me,:ical
attendant is compelled  to meet, in  endeavoring to form a cor-
rect  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  persons,  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 degree, will operate against
their interests, perhaps for life.
   Were it  possible to collect  all the reputed  sporadic cases  of 
BLENNORRHAGIA.
17
simple blennorrhagia  that occur in any one of our large  cities
during the average professional lifetime  of the physician,  the
number of such instances, reckoned in the abstract, might seem
considerable;  and the sensualist might essay to appropriate  the
fact to his personal advantage, in the  hope that it might shield
him from the multitude of his sins, however frequently 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 depar-
ture from rectitude, hundreds  would be  found to originate
under directly opposite  circumstances.  So that while the med-
ical man  admits  that various  innocent causes may induce gon-
orrhoeal  discharges,  I  think  he  may feel warranted in  the
opinion  that the combined agency of all these sources  is quite
insignificant, compared  with the agency attributable to the  one
chief cause, namely, cohabitation with an  individual 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 vari-
ous non-specific, non-contagious, inflammatory affections, which
occasionally attack the same organs, and are likewise character-
ized by  secretions more or less puriform.  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 somewhat 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,
              2* 
18
GONORRHOEA AND  SYPHILIS.
more or less, a majority of adult females.  I feel bound,  per
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 possi-
bility 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  leucorrhceal  secretion as a
source  of  blennorrhagia in the  male, is scarcely  equal to a
grain of mustard 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 sub-
ject, 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-

  * 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 enjoyed a more extensive range of observation than
the one here referred  to. 
BLENNORRHAGIA.
19
course,  and his wife was above  suspicion.  He had  had no
sexual communication with  her for about three months, as she
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 phagedenic 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 (Edematous.  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 
20
GONORRHOEA AND LYPHILIS.
 to the patient, in a coarse, rude manner, " that he had got the
 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  phagedenic  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 re-
 lating 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 nu-
 merous.  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 confesses 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 dis-
 charge from the  meatus, into which no  syringe or other instru-
 ment 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 swelling of 
BLENNORRHAGIA.
21
the testicle, which  yielded  easily.   I have  seen this  patient
to-day  (November 7, 1856), upon  other  business, and he  in-
forms me that since the date mentioned, he had no  returns
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  treat-
ment, which  gave me  great annoyance, and which you  may be
able to explain.  Several years since, a friend, himself  a physi-
cian, unmarried, called upon me for advice concerning what, upon
any other person, I  should have called an indurated chancre, sit-
uated upon one side of the prepuce and quite  near the fraenum.
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 be-
cause 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  rea-
 son, 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  inocula-
 tion, 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 cauter-
 ized with nitrate of silver, which did not put a stop to its spread-
 ing.   The prepuce  became very cedematous, and the inoculation
 had no effect.   As  the sore continued  to extend, at his own re-
 quest, 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 medicine, the sore began to heal, and
 so far as I know,  he  has never had any symptoms of  venereal
 affection.   I am frequently in the habit of seeing this gentleman, 
00
GONORRHOEA AXD SYPHILIS.
 and am quite certain that he is in perfectly good healtli.   I know
 also that while he  was under treatment  he became  a  married
 man, and am quite 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 acknowl-
 edged  to have taken place eight weeks anterior to  the blennor-
 rhagia, is to be  regarded as the occasion of the urethral difficul-
 ty.  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 ap-
 pearance 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 constitutions
 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
had  a  case not unlike this.   The  patient was a pale, thin,
feeble-bodied  man, forty years of age, and  suffered extremely 
BLENNORRHAGIA.
23
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
aci(L — 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. Baumes, 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
 In the treatment of gonorrhoea, an  erythematous efflorescence
 of the  skiu,  induced  by  the  free exhibition  of cubebs or 
24
GONORRHOEA AND SYPHILIS.
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.
  As an instance  of the devices resorted to by  patients for
purposes of  deception, let me present the following:__ 
BLENNORRHAGIA.                  25
  Case. — A married man  who was of good standing in his
neighborhood, called  upon  me  one  day for the cure of  ar
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.  A* 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
 subject 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  inter-
 course 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-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,
              3 
26
GONORRHOEA AXD SYPHILIS.
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
sedentary but dissolute life.   The disease degenerated into a
gleet, which lasted six months, and was  finally cured by the
application  of cantharidal collodion  to  the penis.   That  this
was  an instance of specific gonorrhoea, arising from  impure
connection, I cLo not doubt.  I have occasionally met with sim-
ilar instances.  Where the urethra has suffered  from repeated
attacks, 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 occurrence
of the blennorrhagic secretion is from four to five days. This
fact may help to form a tangible  basis,  on which  to construct
a differential diagnosis.  All deviations from the time here speci-
fied are  to be considered  as exceptional cases,  dependent 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 frsenum in thick,
transparent, ropy masses.   These symptoms constitute  the  ini-
tial stage of blennorrhagia.  By the second or  third day from
the first  appearance of the mucous secretion, the inflammation
acquires  more intensity.   The  discharge becomes more abun-
dant,  and instead of being merely a glutinous  substance,  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  effluvium  is 
BLENNORRHAGIA.
27
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 becomes puri-
form, the patient begins to complain of ardor urine, 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 patient
will complain of being hurt at this part, and  the physician will
here also detect distinct induration and abnormal  thickening of
the urethra.   If the disease should  advance,  and the  bulbous
portion of the canal be implicated in the inflammatory process,
pain will be felt along the perineum, 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 juncture,  still
other morbid phenomena will arise, unless those  already men-
tioned are subdued.  Pains  in the  head,  in  the lumbar  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 differ-
ent 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 organs,
or in their immediate neighborhood, accompanied with imflam-
matory  fever and  irritation  of the nervous  system,  and the
patient's life is endangered.  In those who are liable to eczema 
28
GONORRHOEA AND SYPHILIS.
 and other eruptions of the  skin, the  blennorrhagia  is prone to
 assume a chronic character  from the beginning, and is then dif-
 ficult 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 symptoms.  In
 such cases, if the previous  habits of the patient can be ascer-
 tained, it will generally be  found that he has led  an irregular
 life, or that he is susceptible to inflammatory affections of the
 mucous membranes; and the system refuses to respond 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 separate
 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 secretion.

  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
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 
BLENNORRHAGIA.
29
or female, the patient must be regarded as a source of conta-
gion, so far as relates to sexual intercourse.   This is the only
prudent ground for all  parties ; and it  is fit here to express a
word of caution relative to this subject, inasmuch as there are
Claudios in  every community, — men of ardent and impulsive
temperament, who have no control over their animal proclivi-
ties ; 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
replies 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 disadvantage of the
 young  physician.
   Another  subject, of greater moment than the  one just spoken
 of, is  frequently presented to the  medical adviser for his  deci-
 sion.   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 trans-
 parent 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, postpone-
 ment, 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 mis-
 chief;  and married men, who have  blennorrhcea, have  often
 stated that they have indulged  in sexual intimacy 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
                    3* 
30
GONORRHOEA AND SYPHILIS.
secretion during coition ; and it is fortunate 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 deter-
mining, in all cases, when this element 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 num-
ber, 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 commu-
nicated, and  giving rise  to the most disastrous domestic unhap-
piness.   M.  A'idal  relates two such.   The  disease was consid-
ered 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.

  In the male subject, the anterior or balanic portion  of the
urethra is in a majority of cases the primary seat of gonorrhoea;
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  dis-
charge, 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 commencing 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 attention 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 toward accomplishing all needful  pur-
poses   in this  direction.   If repeated evacuant  medicines be
given,  they will be  liable to interfere  with  the digestive func-
tions,— 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  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
                                                    (31) 
32
GONORRHOEA AND SYPHILIS.
by the alimentary canal.   It is important, as auxiliary to more
direct and specific  measures, to maintain a decidedly open con-
dition 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 dependences  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
sensation of dragging  weight in the testes, and about the peri-
neum 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  thera-
peutic 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.

  Injections op Nitrate  of Silver. — It was  formerly believed
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

       * It is recommended also by Mr. Acton and other surgeons. 
BLENNORRHAGLV.
33
accident.  Whether this theory be true or false, I pretend not to
say ; but in regard to what are called strong injections 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  employment.  If the  injection  be
resorted to before  the inflammatory stage has commenced, that
is, before  the patient complains of scalding in micturation, it
will sometime 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 imperiously 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 afterwards.   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 anni-
 hilate  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 encour-
 agement 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  comparatively
 weak injection may  be retained  three or four minutes by press-
 ing upon the orifice of the  urethra after  the  syringe is with-
 drawn.  The manner of manipulating with this instrument is a
  matter of  no small importance.   The  surgeon should use it
  upon the patient once  or twice before entrusting it to Ins 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 dis-
  ease, in whatever part of the canal it may be.   At  the moment
  the instrument is introduced, the penis should be turned upward 
34
GONORRHOEA AND SYPHILIS.
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 pre-
vented.  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  re-
lief,  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 urine  and other disagreeable symptoms.  This state of
things is a declaration that the disease has  reached a consider-
able 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  employment 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 exercise of a good share
of independence, as well as sound judgment, is requisite on the
part of the  young  surgeon, — otherwise he  may be  unduly
influenced by the solicitations and suggestions of the patient.
   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 
BLENNORRHAGIA.
35
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 ordi-
nary 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
 patient 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
 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 impu-
 nity-perhaps  with advantage; but  if in any given  instance
 a peculiar susceptibility should exist, the fact cannot be known 
36
GONORRHOEA AND  SYPHILIS.
until  the remedy has been  tried.  In such  a case, although
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 ordi-
nary private practice, too  many objections  lie in  the way of its
adoption.

   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
Philadelphia, was the first physician in this country to  recom-
mend the balsam  in the early stage  of gonorrhoea ; and  on his
authority 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 inflammatory
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,
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 
BLENNORRHAGIA.
37
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 modus  operandi  is
 not well understood.
   When copaiba acts as a purgative,  the urethral discharge will
 frequently be very much diminished, — sometimes will entirely
 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 affec-
 tion, it is frequently advisable to combine  it with some  astrin-
 gent 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 in very different
  proportions in  different samples. The quantity of volatile  oil
  has been found to be  twice as great  in  some samples 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 propor-
  tion of resin, which differs but little from  common resin of tur-

              * Vide Chapman's Therapeutics, vol. i., p. 416.
              t Journal de Pharmacie et de Chimie, vol. xi.
                  4 
38             GONORRHOEA AND  SYPHILIS.

pentine, 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 detected
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 with-
out offending the gustatory  apparatus.  But a still more agree-
able and convenient method of administering it is the follow-
ing : —

  R.  Copaiba?,..........
      Spiritus JEtheris Nitrici,.....
      Tincturae Kino.........
      Misturse Camphorse,......
      Morphia? Sulphatis,.......
  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-
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
  5«j-
  §ss.
  §ss.

gr. iv.  M.
* Dublin Quarterly Journal of Medicine, vol. v. 
BLEXXORRHAGIA.                   39
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 individual
is abroad, whether on business or pleasure, will effectually pre-
vent 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
 requisite 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, pledges him-
 self, 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 
40
GONORRHOEA AND SYPHILIS.
 collision, which might otherwise spring up and seriously disturb
 the amicable relations of the two parties.
   Among those who seek the aid of the surgeon for the cure
 of disease resulting from improper commerce with the opposite
 sex, it need scarcely be said that a troublesome fellow now and
 then  presents himself, who  does not hesitate to take advantage
 of his medical adviser, in some  way or other, especially 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 treatment do not progress
 favorably, they will allude to  some  casual  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 barriers 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 thing within the  range
 of medical science, while the captious patient does next to noth-
 ing in the right direction.  These remarks are not a mere irrel-
 evant digression.  They  have been suggested by the fact, that
 young surgeons  somewhat  frequently  express  regret that  in
 identifying themselves professionally 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 disappointment and loss.  But let us return to the consider-
 ation  of the direct physical treatment.

   Capsules of  Copaiba. — Individuals are occasionally  met
 with who cannot use  the 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
 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 tho
extract or  oil of cubebs, are kept by all  good druggists ; and
sometimes I have found them more efficient than those composed
of copaiba alone.
   Where it may be   deemed important to employ, with the 
BLENNORRHAGIA.
41
copaiba,  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,................3vj.
       Magnesias Calcinatae,............5 iss.
       Extracti Hyoscyami,............3 ss.
       Pulveris Camphorae,............3j«
       Theriacee.................3 iij-
       Micae Panis,...............§ iss.
   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  hyoscyamus
 allays irritation  of  the bladder or prostate,  and  that the cam-
 phor  checks  any  disposition to  involuntary  erections, which,
 without  it, often become a troublesome  complication.  A com-
 bination of the balsam with the powder of cubebs makes a good
 compound, and may  be employed according to the annexed
 prescription: —

   R. Copaibae,................
       Pulveris Cubebae, aa,............3 j-
       Liquoris Potassae,.............3 iij.
       Mistura? Camphorae,............3 1V*
       Aquae Cinnamomi,............    -J'.
       Morphiae Sulphatis,............Sr- U-  M-
   Dose. — Two drachms three times a day.

   In whatever form or combination the balsam is administered,
 the patient should be directed to continue its use in gradually
 diminished  quantities' for  ten  or twelve days  after the blen-
 norrhagia has entirely ceased.

   Copaiba as an  Injection.—The  repeated  experiments of
 Ricord, Egan, and others, tend  to  show, that  the  balsam of
 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 re-
 quires 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 trans-
                         4* 
42
GONORRHOEA AND  SYPHILIS.
 formation 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  com-
 plete 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 Copaibae,..............3j-
       Pulveris Acacia?,.............5 ij-
       Aquae Fontanae,.............3 vj. M.

   In subacute  gonorrhoea and in gleet, this  injection  may
 be used twice a  day for a  few days ;  afterwards more  fre-
 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.  Copaibae,.............         * j-
       Mucilaginis Acaciae,..........       z jgs
       Tincturae Opii,.............3 ss/  M

   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 medica.
 Ihe 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 occasion
constipation in some patients ;  in others, just the reverse
  The berries of cubebs are sometimes  adulterated with com- 
BLENNORRHAGIA.
43
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 stopper.
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 Cubebse,..............5 viiJ-
         "   Cinnamomi,............    3j.
         "   Aluminis,.............3J-
   M.  Div. in chart.  No. xxxij.  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
 perfectly quiet  state  of body; and even  to keep  in a  recum-
 bent 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 requi-
 site for a  complete and permanent restoration of  the parts to a
 normal 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 pru-

   Ts^with  the balsam copaiba, so with cubebs; they should
 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.  WeU-
    ithenticatod instances have been reported  of hernia humorahs
aul 
44
GONORRHOEA AND SYPHILIS.
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
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
* Med. Chir. Review, vol. xxiii. p. 550. 
BLENNORRHAGIA.
45
work for a single day, as  this would  bad  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,.............§ xij.
         "    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.  Tincturae Cubebae,.............S ij-
         "     Cantharidis.............§ iss.
       Misturae Camphorae,.........•  •  •   § nJ-
       Morphia? Sulphatis,.............gr. ij. M.
  Dose. — Two drachms three times a day, in half a gill of cold water.
  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 
46
GONORRHOEA AND SYPHILIS.
 dose.  I  refer  to the  fluid  extract,  which may  be prescribed
 thus: —

   R.  Extracti Cubeba?,.............§ iv.
       Mucilaginis Acacio?,.............
       Mistura? Camphorae,  aa,...........§ ij.
       Morphiae Sulphatis,.............gr. ij.  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  prescribed,
 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 may be 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-gonorrhoeal
 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  administration  of the  infusion of the leaves, with entire
 success; rarely having recourse to injections, excepting where the disease had
 been neglected. — London Lancet, December, 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 combi-
 nation : —

  R.   Copaiba?,.........                    »
       Olei Cubebae,...........             -
       Liquoris Potassa?.........             ,- ..."
       Spiritus Myristica?,........               -
       Mistura? Camphorae,   ...                         z . ' „
                 1               .........3J.  M.
   Dose. — Two table-spoonfuls, three times a day. — Druitt.

  In chronic gonorrhoea, or gleet, the balsam and the cubebs may be advanta-
geously given with preparations of  iron :__ 
BLENNORRHAGIA.
47
  R.  Pulveris Cubeba?,.............§ ss.
       Copaibae,    ...............3ij.
       Ferri Sulphatis,.............3j.
       Terebinthina? Chia?,............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 j ad 5 ij-
       Ferri Carbonatis,...........3 ss ad 3j-
  M. ft. pulv.   This mode of administering cubebs is much and  successfully
employed after the  acute symptoms of a blennorrhagia have subsided.  A
powder should be taken three times a day. — Langston Parker.
  R.   Copaiba?,...............§iss.
       Magnesiae Calcinata?,...........3j.
       Pulveris Aluminis,............gr. xv.
          "    Catechu,    ............3 iss.
          "    Opii,..............gr. xv.
        Spiritus Menthae Piperitae,.........
          "    Canella?, aa,...........gtt. xl.  M.
  For an electuary.   M. Beyran administers this electuary in subacute gonor-
rhea, at the commencement of the discharge, and before the inflammation has
extended throughout the urethra ;  also in the gleet.  The dose is a teaspoon-
ful 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.   Copaiba?................gtt. xv.
        Mistura? Acacia?,.............n3j-
        Cubebae,................3j.
        Spiritus ^Etheris Nitrici,..........Stt- xx-
        Misturae Camphorae,    ...........3 x.  M.
   The above quantity is to be taken  thrice  daily.   It is a standard prescrip-
tion  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
uncomplicated 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 cooperate in all well-directed therapeutic and hygienic meas-
ures   In such circumstances the skill of the surgeon will seldom be thwarted,
and there will rarely be occasion to resort to  an endless succession of remedies.

                    RELAPSES  IN  GONORRHOEA.

    Notwithstanding the  repeated  cautions  given to patients not
to discontinue  the  use of remedies  until several days  after the 
48
GONORRHOEA AND  SYPHILIS.
 cessation of the blennorrhagic discharge;  and, notwithstanding
 our advice to them not to respond  to the calls of business or
 pleasure, they will, either  from necessity or recklessness, disre-
 gard the warning; and, as a  consequence, the  enemy will sud-
 denly re-appear, and the battle, which  had apparently resulted
 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 patient
 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 membrane,
 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  gener-
 ally 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, rebellious to all restrictions.  Noth-
 ing 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 cedematous and pouting.
 No other symptoms.

  R.  Pulveris Cubebae,............§ vjij
         "     Cinnamomi,...........3;
         "     Aluminis,............?j   ]yj_
  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 
BLENNORRHAGIA.
49
now fully resume his employment, which is that of a clerk.
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.
       Aqua? Rosarum,............§ vj.  M.
  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 puri-
form; severe scalding;  prepuce inflamed and  excoriated; no
chordee  ; 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 magne-
sia, 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
symptoms 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.
                      5 
50
GONORRHOEA AND SYPHILIS.
 Feb. 13. Discharge has re-appeared.  No scalding, no chordee,
 no urethral  pains.   Inguinal  glands still enlarging, and are
 painful.

   R.   Capsules of copaiba and oil of cubebs, .   .  .  No. viij. per diem.

   And as an injection :

   R.  Plumbi Acetatis..............
      Zinci Sulphatis, aa,............gr. iv.
      Aqua? Fontana?,.............§ viij.  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 mod-
 erate  and muco-purulent;  slight ardor  urinae; glans inflamed
 and tumefied.  Patient was connected with an extensive 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 urethral  symptoms disappeared.
 Soon after this,  he  had connection  with  a  woman  for several
 successive nights.   The  discharge  returned, and the  capsules
were renewed;  the  lead and zinc  injections were  also recom-
mended.   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, 
BLENNORRHAGIA.
51
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
blennorrhagic trouble.  Accordingly, he abstained  from sexual
intercourse ;  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 — spermatorrhea supervening — cure.
   December  26, 1855.  L. S., aged eighteen years.  Tall,  slen-
der frame, constitution delicate.   By day, doing business in the
city; at night, is  ten  miles in the country by railroad.  Blen-
norrhagia eight days, profuse, yellow, puriform ; severe scalding
in micturition ;   painful erections  and  chordee.   Compound
cubebs  powder, six  drachms  a  day.  Had taken a saline ca-
thartic  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 returned.  To arrest
it, balsam of copaiba mixture was prescribed.  In ten  days the
running again ceased, excepting  a drop of thin, transparent
mucus in the  morning.  For this, injections were employed as
in Case II., together with  cantharidal collodion to the integu-
ment 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  spermatorrhoea.
He stated that, a  few  days  previous to the disappearance 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 numbered ten or twelve  in  a
week and were coincident  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, 
52
GONORRHOEA AND SYPHILIS.
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 observed.  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 vesic-
ulae 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 transpires
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  instrumentality of a great
diversity of  remedies, no one  of which is entitled to the charac-
ter 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  practi-
tioner to recognize it, yet he will  find it  a futile attempt if he
undertake to  employ a uniform mode for all cases.  But, al-
though 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  symptoms.   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 belief that  the virtues of  the two
remedies are best exerted when united ; some resort to antiphlo-
gistics, some to injections, 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, 
                      BLENNORRHAGIA.                   53

informs me that, during the  last three years,  he has treated
about eighteen hundred cases of gonorrhoea at that institution,
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 solution 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. Copaiba?,................
      Mucilaginis Acacia?, aa,...........|iv.
      Aqua? Camphorae,.............Sxvj-  ^L
   D0SE. — 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  convenient to
use it; but there are too  many obstacles, too many contingen-
cies, that will in maay cases arise in the way of its employment.
The objections lie chiefly with the patient himself.   He dreads
the pain ; nor will he submit to the inconvenience 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, " cito,  lute, et jucunde^ by strong  injections of nitrate
 of silver, is scarcely tenable so far as relates to private practice,
 yet,  in many cases,  injections  of some sort may  be  advanta-
 geously 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  indi-
 vidual no  longer  complains of  urethral  pains, nor  of  ardor
 urin*, then injections of a  mild, astringent, or  sedative  char-
 acter 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
 £Kfc any occasion to use injection.   To let well eiioug
 alone is  always  good policy.  Local  remedies sometimes disturb
                 5* 
54
GONORRHOEA AND  SYPHILIS.
 the  favorable action that is being  produced  by the agents al-
 ready at work.   But, if injections have been determined upon,
 the  surgeon sliould 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  usefully
 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  disease
 relapses into  a chronic  state, which  resists all means of cure :
 in addition to this, the  patient requires  a great deal of watch-
 ing,— 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,.........    _
      Tinctura? Catechu,.......
         "   Opii, aa,.........            •
      Aqua? Rosarum,..............gvj.  M.
  Injection.
  Acton states that his  experience fully sustains that of Ricord ;
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, 
BLENNORRHAGIA.
55
   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

   * R.  Plumbi Acetatis,..........gr. ij ad iij.
        Decoctionis Papaveris,.........S iij.     M.
   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,.............§ vj.
        Acidi Tannici,............gr. xviij.   M.
   For the male urethra.  For the vagina the quantity of  tannin may be
 doubled, or still further increased. — Langston Parker.
   R.   Solutionis Soda? Chloridi,........3 iij.
        Aqua?,..............5viiJ-   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,........3j.
         Aqu*...............§viiJ-   M'
    Injection. —For  chronic  blennorrhagia or gleet in  either  sex.  Maybe
 used  ad libitum.
    ft.  Ferri Iodidi,.............Sr' XVJ*
         Aqua? Rosarum,............3 VJ*
    In  gonorrhoea or gleet, to be used several times a day.— Prof. Dunglison.

    R.  Zinci Sulphatis,............
         Acidi Tannici, aa............^r"./''
         Aqua?,..............5 ^'
    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
  hundred of water,  as an injection in  chronic blennorrhagia with favorable
  results.
    M  Skey  surgeon to St.  Bartholomew's Hospital, considers that the most
  effectual 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 Quiniae Citratis,.........§ ss-
         Syrupi Aurantii,...........           M
         Aqua? Fontana?,  aa,.........     3 J-
    Dose.— 3j. three times a day in half a gill of cold water. 
58
GONORRHOEA AND SYPHILIS.
remedies, constitutional and topical, shows plainly enough, how
totally ineffectual all ordinary measures sometimes  prove.   Al-
though  the  affection  is  purely  local, and  would  seem, theo-
retically, to admit of easy cure, yet the testimony of experience
tells a different story; and Ave learn from it, that the disease 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 mar-
ried  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 mattress, with a light covering
over him. 
BLENNORRHAGIA.
57
  Lupulin. — The sedative and anti-blennorrhagic influence of
this  remedy depends upon  a resinous etlrero-oily  principle;
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 account,
it 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  sev-
eral hours; but the erethisms, for which it was given, were en-
tirely 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  erections in gonorrhoeal patients.   A late
number of the Gazette  des Hopitaux contains a formula for a
pill  consisting of belladonna, camphor, and lupulin, which  is
reputed to prevent at once the occurrence  of painful erections,
and invariably  to  allay the morbid erectile tendency  of the
genital organs.   The formula is : —

  R.  Extracti Belladonnae,.............9 j-
      Lupulinae Recentis,.............
      Pulveris Camphorae, aa,............3j>
  M.  ft. pil.  No. xlviij. Dose. — 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 pre-
scribed only for a short  time in any considerable quantities ; but
as regards its efficacy in relieving the complications under con-
sideration, 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  conditions.   If the  gum be
selected, it may  be  formed into pills with the extract of lettuce,
according to the annexed  formula : —

  R. Pulveris Camphorae,.............
      Extracti Lactucae, aa,.............^J'
  M.  ft. pil.  No. xx.  Dose. — One to six pills at night. 
58
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
chordee becomes chronic and  remains for a  long period after the
blennorrhagia has disappeared, and the penis acquires the hard-
ness of  cartilage or bone.   This peculiar condition, as  already
observed,  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 termination — 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 decoction of sarsaparilla,
and  the local employment of the unguentum hydrargyri cam-
phoratum  will constitute  the most suitable treatment for  the
removal of the singular accident in question.   The  iodide-of-
lead ointment will also be  worthy  of a trial; likewise, the appli-
cation of small blisters and of the compound 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  HAEMORRHAGE.

  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 hemorrhage 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
repressing it should be adopted ; and of these, the application of 
                       BLENNORRHAGIA.                 59

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 perinaeum.  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  urethra 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 ten-
sion,  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  indi-
vidual, 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 a leak  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 physician, at whose door
the bleeding lover was dropped, not being 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.

  This is the blennorrhcea chronica of Dr. Good ; blennorrhcea
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 dis-
charge is slight.  Sometimes only a drop or two is noticed about
the meatus urethra, in the morning.   The  orifice is  smeared
with a ropy, tenacious, serous or mucous fluid, partially 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 im-
prudence in  diet,  severe exercise, sexual intercourse, or  any-
thing which  tends  to excite the organs, the  gleet will  very
probably reappear.  The  most  common seat of blennorrhcea 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 urethra, 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
         (60) 
GLEET.
61
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 secretion,
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 dis-
charge has stopped.  Cases are on record in which the secretion
has  been  absent for a whole month, and then has  been  repro-
duced 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  cir-
cumstances involving no  small responsibility.
   Some men, with an old gleet, suffer great mental distress in
consequence of  its presence, although it does not  interfere with
their physical healtli.  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  urethral
canal was  found.   The  catheter slipped into the  bladder at
once ; virility was unimpaired.  The patient had been reading
 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  follow-
 ing :—

   R.   Tinctura? Cantharidis,  .  .     ........
        Olei Terebinthina?, aa,...........3j-
        Mucilaginis Acacia?.............§ y-   M.
   Dose. — One teaspoonful three times a day.
                       6 
62
GONORRHOEA AND  SYPHILIS.
   The following injection was also prescribed : —
   R.  Acidi Tannici,..............3 j.
       Plumbi Acetatis,.............gr. viij.
       Aqua? Fontanae,.............§ viij.  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 patient
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 detected
a relapse of his gleet, and forthwith  returned  to  me.  Nothing
would appease  him  but  a renewal of treatment,  although  I
assured him there was no call for it.  Meantime, as no gleet
appeared, his mind became tranquil, and he was convinced  that
he  had no occasion to return as he did from Philadelphia.  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 decom-
posed 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 difficulty
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 distinc-
tion that shall be mathematically correct; but  for all practical
purposes required in  therapeutic surgery, our  resources  are
sufficiently ample, and, for the most part, ultimately  successful •
although it must  be confessed that they are occasionally wholly
inefficient. 
GLEET.
63
  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 remedies
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 treatment 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 vesiculae  seminales, — or inflammation or irritation of the
neck of the bladder ;  or stricture in some portion of the urethra.
All these  contingences will suggest themselves to the considera-
tion 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 gonorrhoea 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 cannot make water;  and he
promises to cure the poor fellow for so much — usually an enor-
mous 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
recesses are in  a state of congestion or  hypertrophy, from pre-

  * " 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 fulness
of his pocket." — Henry J. Johnson. 
64
GONORRHOEA  AND SYPHILIS.
 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 opposi-
 tion 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's-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 bed-
 time.  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
 until the fifth or sixth  day  after vesication has  been produced ;
 sometimes eight or ten  days will intervene  before it  entirely

  * " If only pure gleet, sometimes mucous, sometimes purulent, be met with it
will, in almost every case, yield to a blister ; very rarelv does  it require a second
Bhstenng  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 condemned as a violent,  painful, unpleasant remedy.  I deny it."-
Milton in Med. Times and Gazette. 
GLEET.
65
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 evening.
During the following day they are obliged to remain at rest;
sometimes  for a longer period.
  There is still another region upon which large  blisters can be
applied in  cases of gonorrhoea and gleet, and that is high up on
the inner  surface  of the thighs.   They should be about three
inches by three, and be secured  by a margin of adhesive plaster,
and, as a  matter of convenience, sliould be  put on when the
patient goes to bed at night, and be allowed to remain on until
next morning.  A blister on each thigh may be applied  at the
same time.  The vesicated  surfaces may be  dressed with cold
cream, the benzoated zinc ointment, or lint soaked in castor oil.
Very likely the urethral  discharge may be increased for twenty-
four  or forty-eight  hours, and the patient will  experience an
inconvenient scalding on micturition, and it will be well for him
to  be provided with  an  antidote  as in the following prescrip-
tion : —

  R.  Mistura? Camphorae,............§ ij-
        Spiritus iEtheris Nitrici,..........5 j«
   M.  Mucilaginis Acaciae,............5 ss-
   Dose.__Two teaspoonfuls every hour until  four or five doses are taken, if
 necessary.   A warm bath also, if  the symptoms are urgent, of which there is
 very little probability.

   The final and speedy result of thus  blistering the thighs, has,
 in  some cases, proved entirely satisfactory.   I have tried them
 and have  succeeded; — I have tried them and have failed.

   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  patient
 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
                   6* 
66
GONORRHOEA AND  SYPHILIS.
 be employed less frequently, and even then may make the last
 state of the patient worse than the first.   Frequent injections of
 ice-water are usually productive of beneficial 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 having
 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 injec-
 tions, is nitric acid, diluted thus : —

   R.  Acidi Nitrici,..............gtt. xx.
       Aqua? Fontanae,.............§ viij.  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
 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
 oxymuriate 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, ...
         J     >       ............gr. iv.
       Acidi Nitrici, ....                             ...
  T.   Aqu*.......'•':*..'.::::  li;.vllJM.
  Inject one drachm thrice daily, after micturition.

  R.  Extracti Nucis Vomica?,  .
       Quiniae Sulphatis,.....                  %*• J-
       Extracti Hyoscyami, aa,
                  J   '  '    .........gr. xxiv.
meal *    ^ X°' "*" ^ TW° ^^ t0 be taken °ne hour  before ea^
Amer. Journal Medical Sciences, April, 1850, p. 542. 
GLEET.
67
  The chloride of zinc makes a valuable injection in some cases
of gleet  and also in gonorrhoea.   The  usual formula which  I
have employed is:

  R.   Zinci Chloridi,.............grs. vj.
       Aqua? Rosarum,.............§ vj.
  M.  To be used twice in the twenty-four hours for a few days, after which
more frequently, if no unpleasant effect is complained of by the patient.

  The acid  nitrate  of mercury (Hydrargyri Pernitratis Liquor),
is the only remaining therapeutic agent which 1 shall present in
this connection to the attention of the practitioner.  For several
years it has  been  employed by  Mr. Childs, Surgeon  to  the
Metropolitan Free Hospital, London, in cases  of urethritis, and,
as he states, with the most gratifying success.  The strength of
the injection employed is in the proportion of

  R.   Liquoris Hydrargyri Pernitratis,.......gtt. iij.
       Aqua? Destillata?,............§ viij. M.
  Injection. — To be used once, twice, or thrice daily,  as the patient can  con-
veniently bear.

   It is hardly worth while to continue an injection  if it do  not
exert  the  desired   action  in the  course  of one  week.  The
mucous membrane requires some other kind of stimulant.

   The  Bougie. — Few cases, comparatively, present themselves
in  private practice, under circumstances demanding the use of
this instrument.  Now that confidence  in  the  employment 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  vesication  of  the
penis and injections into the urethra, it  is highly probable  that
the bougie will  hereafter be in less frequent requisition than it
has been hitherto.   If  a patient have  stricture, the bougie  will
be needed.   It  may likewise be of service when  a  gleet is  pro-
tracted for a very long time 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 exhausted  ; for such cases, it
is to  be presumed,  will  still continue  to  occur, to the great 
68
GONORRHOEA  AND SYPHILIS.
 annoyance of the most skilful  surgeon ; and they will resist his
 best  endeavors, until  he avails himself of the bougie.   Such
 cases, however, will, without doubt, be extremely rare.   They
 include  those individuals who have never had stricture ; who
 have no  abnormal vesical irritability;  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, comparatively  rude  handling,  and  seem
 almost callous to the ordinary influence of injections.  And yet
 the judicious use of the simple  bougie may restore the urethra
 to a sound condition, 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  sufficiently
 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, according to the
 amount  of irritation it creates.  Its introduction,  in some  in-
 stances, 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 inflammation which
 they experience.  For  persons  in whom an incipient stricture is
 detected  the bougie should be used every third  or  fourth  dav  ;
 and during  the intervals an injection  of tannic acid and sul-
 phate 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  care-
 less manner.  Sir Astley Cooper mentions a case of the kind,
 to which  lie 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 hemorrhage
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, brought  on 
GLEET.
69
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  haemorrhage was per-
manently subdued.
  In some cases of  long-continued blennorrhagia, during which
a variety of remedies have been applied directly to the urethra,
it seems to  lose  its normal  susceptibility;  and if, after a  few
trials with the simple bougie, no effect is perceptible, the instru-
ment may be  coated with some  slightly  stimulating ointment,
thus: —

  R.  Unguenti Hydrargyri,...........1 part.
      Extracti Belladonna?,...........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
instrument 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 proportion
of one drachm to an ounce of  pure  olive-oil, is likewise a very
suitable  application under  the circumstances here  supposed.
Sometimes the oil of turpentine answers  a  better purpose 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 reme-
dies reputed to exert a specific  influence  upon the genital sys-
tem.  Little will ever be gained by any  process of starvation. 
70
GONORRHOEA AND SYPHILIS.
A plain but substantial diet should be  allowed, of which lean
meats  should constitute a  part.   The  subjoined  formulae are
among the best  that can be 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
exhibition.  A far  more  hopeful procedure will  be to  resort
to blistering,  as  already sufficiently recommended.

   R.  Copaibae,................§ ss.
       Tincturae Cantharidis,............§ ij.
          "    Ferri Sesquichloridi,.........§ j.   M.
   Dose. — Thirty drops three times a day in a gill of sweetened water.

   R.  Tinctura? Cantharidis.............§ j.
       Quiniae Sulphatis,.............5 ss.
       Tinctura? Ferri Sesquichloridi,.........3 ij.
       Acidi Sulphurici Diluti,...........3 ss.
       Aqua?>.................g viij. 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, i;;
Potassii Iodidi
3 iss.
       Spiritus Rectificati,.............? 3S
       Syrupi Aurantii,.............g ^ 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,.........               - ...
       Iodinii,......
                          ............gr. j.
       Aqua? Destillata?,.....                      Z .■ ,T
         ^                      ..........§vij. M.
   Dose. — One drachm three times a day.

   Ferruginous  preparations  are  likewise valuable  for patients
who have become pale, emaciated, nervous, and apathetic.   The 
GLEET.
71
potassio-tartrate of iron, or  the citrate of iron, should  be pre-
scribed in pretty liberal  quantities for several weeks.  Mr. 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,..............3 iss.
      Ferri Carbonatis,.............5 ij.
      Pulveris Vanilla?,.............
         "    Camphorae, aa............gr. vj.
  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 considera-
tion. 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
emulsion.   The annexed formula is as convenient as any : —

   R.  Morphia? Sulphatis,.............gr. j.
       Sacchari,................3 iij-
       Misturae Camphorae,............
       Mucilaginis Acacia?,  aa,...........5 VJ-
       Olei Terebinthina?,.............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.

   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 dis-
 ease thus  located, is also called balano-preputial blennorrhagia ;
 bastard chaude-pisse balanite by the French ; external blennor-
 rhagia ;  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 complaint.
 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 differ-
 ences are  found.   It is  somewhat amusing to compare the opin-
 ions 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 superero-
 gation.  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 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
           * Henry J. Johnson.
(72) 
BALANITIS.
73
prepuce is a superficial  piece of skin and mucous membrane,
which serves no other purpose  than acting as reservoir for the
collection of dirt, particularly when individuals are inattentive
to cleanliness."   In some men the prepuce is of remarkable
brevity — 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  glandulae 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 irri-
 tation and inflammation.  It  is scarcely necessary to remark
 that this accumulation is much more rapid and difficult of pre-
 vention 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 retraction.   I once
 knew a young medical student who had a redundancy of prepu-
 tial 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 pre-
 puce, a large  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
                 7 
74
GONORRHOEA  AND SYPHILIS.
 there was no urethral discharge.   The student, at once satisfied
 as  to the  cause  and source of his  complaint, was not a little
 mortified.   He listened to a few suggestions relative to personal
 cleanliness ; and with the use of weak lead-water, found himself
 well  at  the  end of a week.  Instances like this  occasionally
 present  themselves; and when  the patient  is  told  that his
 difficulty is attributable to  his  own carelessness, he is apt to
 manifest  surprise,  mingled with shame  and joy, at the  dis-
 covery.
  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 men-
 strual 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 generally
 begin to  show themselves in  a day or two after exposure.   The
 period of incubation is shorter than in cases of urethral blen-
 norrhagia.   The first warning of  the trouble is a slight tingling
 or smarting sensation in the prepuce or glans.  Anon, the pre-
 puce becomes very tender and cedematous;  and if it be drawn
 back upon the glans, the  latter will exhibit inflammatory 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 scald-
 ing in micturition.   If the trouble arise entirely from unclean-
 liness, it is more gradual in  its development; the symptoms
 declaring themselves more and  more manifestly as the acrid
 sebaceous product is allowed to  accumulate.  The muco-puru-
 lent matter, mingled with the  natural secretion from the parts,
 is sometimes very abundant, and  if the preputial orifice be  nar-
 row, 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 purpose  of evacuating it.   If  phymosis
 complicate  the  balanitis, and the case  be neglected, or injudi-
ciously conducted, sloughing 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. 
BALANITIS.
75
  Treatment op Balanitis. — Simple balanitis is quickly cured.
The patient should be  directed to draw back the prepuce so as
entirely to expose the  glans, as well as the mucous surface of
the prepuce, which should be. bathed in tepid water, and thor-
oughly cleansed of all  sebaceous and puriform deposit.   A fair
view can now be had of the parts implicated.  The surgeon will
find slight abrasions and  small patches of aphthae.   For the
cure  of these,  one of the best topical applications is the fol-
lowing : —

  R.   Liquoris Soda? Chlorinata?,.........§ ss.
       Aquae Fontana?..............§ vij.  M.

   Small  bits of  English lint  to be  saturated  with the solu-
 tion, 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 es-
 sential 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..............gr- JJ«
       Acidi Tannici,.............^r'..1V'
       Glycerina?,..............^)!'
       Aqua? Fontana?,.............§ iv.  M.
    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
  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 contrary, there 
76
GONORRHOEA  AND SYPHILIS.
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 cedematous 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-
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 
BALANITIS.
i <
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 reflec-
tion 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 bistoury
along the groove of the  director,  and transfix  the prepuce 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 lowest aspect by the side of the fraenum,  and  assign as  a
reason that less deformity and unseemliness 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 em-
 ployed is a pair of very delicate straight scissors, of  which one
 of the blades is terminated  by a  little button, like a probe-
 pointed bistoury.  The surgeon 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 sep-
 arates the  two blades, and by closing 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,  and cicatrization   follows.
 The operation leaves no deformity.   It is called Cullerier's oper-
 ation;  and has  been performed at the Pennsylvania Hospital
                  7* 
73
GONORRHOEA AND  SYPHILIS.
 for many years with success.*  Either of these operations may
 be resorted to with a view to give facilities for carrying  out
 other  measures of treatment.  If no congenital  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 perform  the  operation
 hastily, because the wounds might be inoculated with the chan-
 crous  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 chloride 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  prepuce.   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
 phagedaenic  ulceration is more  likely to  assume  a  healthy
 condition  after the prepuce is divided; and all the  parts  pro-
 ceed  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
 the removal of the prepuce.   Mr. Milton's plan is simple and
is  as  good as any.  It gives  a neat  appearance  to  the parts.
His mode of procedure is —to slit up the  skin  and mucous
membrane as far as the reflection of the  latter, and then cut

           * See Miller's Surgery, edited by Sargent, p. 587. 
BALANITIS.
79
away the fraenum  as  far as practicable.  The constricted  part,
which  is near the edge, is removed in a circle, and the bleed-
in"- being  stopped, the  skin  and  the mucous membrane are
brought together by stitches, 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 a  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
  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. 
80
GONORRHOEA AND SYPHILIS.
 Warm fomentations  during  night.  Next morning  preputial
 tumefaction and swelling of glans nearly gone, and paraphymo-
 sis much relieved, although the foreskin could  not  be brought
 over the glans; general condition of  the  patient  improved.
 Continued hot fomentations, and in the evening repeated 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 con-
 siderably diminished  by the procedure, it may be  pushed back-
 ward 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 successful.   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  handker-
 chief furnishes a good material for the bandage.   It sliould be
 torn into strips half  an  inch  wide, and  be applied so as to act
 equally on  the parts.  The  degree of pressure should  be  as
 great as can be borne conveniently, and no  more.  Each suc-
 cessive turn of bandage should overlie the previous one by about
 one-half its width.   If  the bandage exert  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 the 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 circumstances, will rarely be
 followed by successful results.  If  neither  the taxis  nor com-
 pression with bandages will overcome the difficulty, it  is not at
 all  probable that any instrumental  force will answer any good
 purpose ;  and the  surgeon 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 
BALANITIS.
81
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.

   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 condi-
tion, 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 separately and  con-
jointly, 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 manufac-
tured by the introduction and unskilful manceuvering of the
catheter, or  be induced  by violent exercise, excessive  stimula-
tion, or other imprudences, calculated to augment the existing
inflammation of  the urethra, and excite a morbid action in the
vesiculae seminales and vas deferens,  until it reaches  the epidid-
ymis ;  or it may be  generated  in virtue of what  physiologists
call the  common law  of sympathy,  the intervening parts  not 
ORCHITIS.
83
being involved in disease.   The action of a similar law is seen
in cases of hernia  humoralis, occasionally developed in connec-
tion with  mumps.   While the urethra is the  seat of a blennor-
rhagic discharge, the other portions of the genito-urinary appa-
ratus 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  termi-
nate, 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 protec-
tion  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 pro-
duced by the  presence of lymph and serum within the tunica
vaginalis.  The epididymis is, after  all, the chief seat of the
 disease 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
 questionable 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 tes-
 ticular 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
 swelling  is comparatively moderate ; there is no serious effusion
 into the cavity of the tunica vaginalis, and  the gland is drawn 
84
GONORRHOEA AND SYPHILIS.
 upward towards 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 painful;  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
 hundred  and fifty-six; all  the three parts, three hundred and
 seventeen.  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
 frequently involved.  From  the  above  evidence it is  manifest
 that no great  difference obtains as to the direction which nature
 takes, — the right or left.

   Symptoms   op Orchitis. —  The attack  commences  with  a
 sense of increased weight in the testis, with a 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  eo-g
 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

          •British and Foreign Med. Chir. Review, Oct. 1856. 
ORCHITIS.
85
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 reappears.  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 unfortu-
 nate 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 testicle  for more
 than  a  dozen years after his recovery  from an  old, neglected
 gonorrhoea.

    Treatment op  Orchitis. — The modern treatment of blen-
 norrhagia has doubtless caused a diminution in  the frequency of
                 8 
86
GONORRHOEA AND  SYPHILIS.
inflammation of the testicle, in this country at least, although,
judging from  the  accounts that come to us in the medical
journals from  the  other side of the Atlantic, such would not
seem to be the fact  in  relation to  the European population.*
Any apparent immunity from this  accident among our people,
compared with its frequency among  transatlantic subjects, 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  tlie  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 experi-
ence  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  imme-
diate dependences  can frequently be rescued from the impend-
ing 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  experienced; his
gonorrhoea ceases;  a  sharp pain, with swelling in the posterior
part of  the scrotum, and  other  abnormal phenomena already
specified, arouse his fears.  He  takes to  his room, and  the physi-
cian is summoned.   The individual  being in the condition here
supposed, should be directed to go to 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
  * " Whatever may be the success attendant upon the treatment of gonor-
rhoea in recent times, the number of cases of epididymitis does  not  seem to
diminish." — British and Foreign Med. Chir. Review. 
ORCHITIS.
87
exerted upon the cord.   The proper position of the parts being
well secured, they are to be  kept wet with  cloths  dipped  in
cold water.  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 com-
mence with ice-water.  It is  safer, as well  as more comfortable
to the person, to reduce the temperature gradually.  The appli-
cation may be continued without intermission, so  long as  it
gives relief.   A brisk cathartic should be prescribed ; low diet,
as orange-ade, 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 inflamma-
tory action.  They  constitute, at any rate, the most judicious
antiphlogistic treatment that can be instituted.   They are to be
persevered  in with greater or  less   energy,  according  to the
severity of  the case and the constitution 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 sliould 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 operation would not be free from danger.   It
 might  expose to phlebitis.  Instances of the kind are on  record.
 After a sufficient 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 con-
 spicuous.   As the inflammation subsides, the use of lukewarm
 water will be found to agree better than a refrigerant.

    Mercurial Ointment;  Iodide op Potassium  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
 it is liable to irritate the skin so severely that some men cannot
 bear it.  If it be  allowed  to remain for any  length of  time, it
 will occasionally bring out a vesicular  eruption  (eczema mer-
 curiale) which  will be a  source  of  no  little discomfort, if the 
8S              GONORRHOEA AND SYPHILIS.

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 enlargement,
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 considered, 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.  Iodinii,...............gr. ij.
       Potassii Iodidi,    ............" yj.
       Aqua? Ferventis,............§ xvj.  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 appli-
cation.  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 proportion
of one drachm to a quart of boiling water, and applied by means
of flannel cloths to the  scrotum,  and renewed repeatedly, will
sometimes  promptly relieve the  pain,  and render efficient  ser-
vice  in promoting a speedy cure.
  The employment of cathartics should be so timed, if possible,
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 
ORCHITIS.
89
find him irritable, disheartened, and in all respects worse than
he would have been after a night of rest.  Purgatives, there-
fore, 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 conva-
lescence of many persons, whose  genitals are the seat of inflam-
matory 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  laxatives,
 quiet repose, anodynes, opiates,  narcotics, and diaphoretics 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 seminal
 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 testicle 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 subsequent free use ot
  the tincture of hyoscyamus.   The latter  may  be  given in
  drachm doses, every  three hours, in  rice-water or  Darley-wat
  until a decided narcotic effect is produced  As soon  as  te
  patient experiences  the specific influence of the h^£
  Lai  symptoms will  almost  certainly abate; and it  may after
  wards be employed in diminished quantities.
    The following  combination  of antimony,  sulphate of magne
  sia, and  colchicum,  may likewise  be used in  many  cases ^
  good results.  It will be sure to maintain a *gl»tt^^n8
   and depressing effect on the stomach, while  at the same time 
90               GONORRHOEA  AND SYPHILIS.

will keep the bowels free, and help to  subdue the inflammatory
diathesis.

  R.   Antimonii Potassio-Tartratis,........gr. ij.
       Vini Colchici,.............5 "j-
       Magnesia? Sulphatis,...........3J-
       Aquae,    ...............S viij.  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.   Morphia? Sulphatis,...........gr. j.
       Aquae Camphorae,............§ iss. 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 refrigerant
lotions, and other antiphlogistic  treatment, will usually be pro-
ductive of amendment and complete cure in a short time. 
ORCHITIS.
91
  Compression of the Testis. — In 1836, Dr. Fricke, surgeon
to the General Hospital of Hamburg, recommended the appli-
cation of compression to the  testis, by means of strips of adhe-
sive plaster, as a substitute  for every other form  of remedial
appliances, in the treatment of orchitis.  Following the recom-
mendation and practice of Fricke, many other surgeons 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 atten-
tion required on the part of the medical  attendant.  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 epi-
didymitis, is regarded as the  best plan of treatment. 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 inflamma-
tion  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  prescribed 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 testicle, 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 adhe-
sive 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
as follows: The patient is placed  in a recumbent position, and
* Holmes Coote, on Gonorrhoea, 1857. 
92
GONORRHOEA AND SYPHILIS.
 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  prevent the testicle from slip-
 ping 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 testicle is completely enveloped and com-
 pressed.
   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, tlie  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 inflam-
 matory  action,  and will render  the  cure  more  effectual  and
 speedy.   The views of Ricord on this subject  are thus com-
 municated 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 necessary.  With-
out  watching, this  treatment  is  sometimes  accompanied with 
ORCHITIS.
93
disagreeable consequences, which  aggravate 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 inconveniences attending these cases.
M. Ricord places his  principal dependence  on leeches, mercurial
ointment and  plaster, and,  above  all, a purgative taken every
morning, consisting of aperient salts.  In this last recommenda-
tion, I can bear testimony most fully." *
  Mr.  Johnson is extremely severe in  his condemnation of tlie
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 inflam-
mation is acute, it is  a  piece of ridiculous cruelty; if mild, it
is disproportionately 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  inflammatory  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
 to have uncomfortable nights.  He is unfit for much physical
 activity by day, and the sleep of the  laboring man is not his.
* Lancet, December, 1854. 
04
GONORRHOEA AND SYPHILIS.
He, therefore, requires some artificial aid to ensure 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.  WThatever  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. vj.
      Pilulae Hydrargyri,.............
      Extracti  Hyoscyami, aa,............5 iss.
  M. ft. pil  No. xxx.
  The other mercurial preparation is the bichloride: —

  R.  Hydrargyri Chloridi Corrosivi,.........
      Ammonia? Muriatis,  aa,............gr. v.
  M. ft. pil.  No. lx.

  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,..............5 j:
      Tinctura? Cinchona? Composite?,........§ jss<
      Aquae Fontanae,.............     5 jj:  ]yj
  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 
ORCHITIS.
95
against the pubes three or four times  in the  day, will likewise
toad 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.EPt TIALIS.

  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 exist-
ence, and who have much practical experience  in its treatment,
may consider that it is lo insignificant, and so unlike any syphi-
litic sore, that it is hardly entitled to consideration 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  im-
proper treatment, to  say nothing of the moral bearings imme-
diately connected with the subject.
  Patients  who have contracted herpes upon the penis in con-
sequence 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 prod-
ucts.   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 internal  sur-
faces meet.   At first,  a  sensation  of heat  and smarting, accom-
panied  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 thick-
ened  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 sensa-
                                               (96) 
HERPES PR^PUTIALIS.
97
tion.  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  di-
mensions in the latter stages  which they had  at first.
  Instead of appearing on the confines  of the preputial orifice,
as mentioned above, the  eruption  may arise  at a little distance
from it, either on the mucous or cuticular surface of this mem-
brane.  In two or three days, the contents of these  globular
vesicles lose their transparency, and are slightly turbid ; 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, amounting 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 generally quite severe.  The
vesicles are usually a little larger  than when developed on the
external surface.   The  serous  exudation of herpes  passes rap-
idly into a lactescent state ; the membrane or sac containing it
is easily ruptured, and excoriations 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
days after its first appearance, — by which  time incrustations
may have formed on the skin, or the secretion have passed into
               9 
98              GONORRHOEA  AND SYPHILIS.
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 her-
petic.  Under  such circumstances  the practitioner  can very
properly claim a postponement for a day or two, before he  ex-
presses 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 pecul-
iar cutaneous susceptibility, are  troubled with frequent attacks.
The  eruption  will readily disappear under the  application 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
ulcerative 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, ceteris pari-
bus,  to contract a venereal  affection  than one who has no such
herpetic tendency.
  The following case occurred in my practice  a few years since.
I introduce it here, as illustrating a method of procedure which
may  be applicable to other patients in like circumstances: — 
HERPES PRAEPUTIALIS.
99
  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 credu-
lous, 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 cleri-
cal patient  had, however, imbibed the notion that  his wife was
the cause of his genital trouble, especially as it was aggravated
by sexual intercourse.  Another  circumstance, still more singu-
lar, was, he believed his complaint to be syphilis; and as  he
 proceeded in the narration of his case, he remarked, " I  sup-
 pose 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 examine 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 neglect of cleanliness.
 The treatment proposed was, to  keep the  bowels regular, exer-
 cise freely in  the open  air in all good weather, practise daily
 ablution of the whole  body and  limbs in  cold water,  and away
 with all thoughts of the "ladies' disease."  As a  topical appli-
 cation, the following lotion  was prescribed : —

    R.  Liquoris Soda? Chlorinata?,..........5 "J-
        »    -c  *                            . .  .  .   5x.  M.
        Aquae Fontana?,.............     °

    To be applied  constantly by means of a  soft  rag ;  also to be
 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; 
100
GONORRHOEA AND SYPHILIS.
received relief from smarting and soreness  in about  six weeks.
The disease seemed to be removed almost entirely in six weeks.
Occasionally I feel a little smarting  and experience a little in-
flammation 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 painful
erections and chordee the last two nights.   Prepuce very long,
contracted, and inflamed ; about the orifice, numerous herpetic
vesicles have formed.   Complete retraction of prepuce 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 undiminished
for four weeks  before the prepuce was  restored  to  its normal
condition, notwithstanding the free use  of  opiate lotions, 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 prevented
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 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 
HERPES PR^PUTIALIS.
101
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 vesicular eruption, and  as fol-
licular chancres and syphilitic preputial  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 pro-
portion of a drachm to four ounces of water, will do the  same ;
and  thus  prove the  non-venereal  character of the  eruption.
Sometimes  the  solid  nitrate of silver, lightly drawn over the
part  every three or four days, will  prove an effectual  remedy.
The hydrocyanic  acid is likewise a valuable article to be em-
ployed as a lotion in obstinate cases of herpes, not only when
situated on the  prepuce of the male, but also when it attacks the
genitals of females.   The  following  preparation will  be found
useful:—
   R.  Acidi Hydrocyanici,.............5ij-
       Spiritus Rectificati,.............5 VJ-
       Aquae Destillatae,.............§ 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  administered
 in sufficient quantities, without giving  rise to any of the un-
 pleasant consequences which sometimes follow the use of other
 arsenical  remedies.   It should be given in graduated  doses,
 commencing with one fifteenth of a grain once a day for the first
 eight days ;  then one fifteenth twice a day for 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,..............^r'..1V'
       Extracti Gentiana?,.............^'
       Pulveris Glycyrrhizse,............^
   M. ft. pil. No. lx.
                        9* 
 102            GONORRHOEA  AND SYPHILIS.

   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 prin-
ciple of  cardinal  importance to rectify any  constitutional  de-
rangement 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 remains
upon the patient as a source of sore vexation. 
CHAPTER  VII.
                 ECZEMA  PRAEPUTIALIS.

  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  pre-
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 frequent
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 distilled  in  sufficient
quantity  to stand in drops on the inflamed and denuded derma.
Tlie malady, at first, covers but a small patch of ground, but  is
rarely  content  to  keep within  its  original  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.
lailike 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 behavior, for  a few days highly
inflamed and yielding a copious  exudation, then  occasioning
                                                 (103) 
104
GONORRHOEA AND SYPHILIS.
scarcely  any moisture, itching, or redness ; but  a flimsy lam-
inated  incrustation  is  formed,  blended  with  newly  formed
cuticle.  This latter condition suggests to the inexperienced eye
a proximity of cure ; but in lieu of this, a few rough, involun-
tary scratches with the finger nails, which the affected parts arc
pretty sure to receive, reproduce the eruption in two-fold sever-
ity, 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
extention of the trouble  in every direction.  It is very apt to
assume a chronic form, and  when it does it  sometimes simulates
psoriasis.   It is, however, but a resemblance.  I do not believe
it ever loses its  identity, or  that it undergoes  a transformation
into another disease.  We  might as well say  that  one animal
or one plant  degenerates into  another.  The two  maladies in
question  are different in appearance, and require different treat-
ment.    Even where the vesicles have ceased to form in succes-
sive 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 integument,
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, remain for a  few days,
a new source  of trouble  to the patient, and then disappear.
These facts or circumstances do not happen in psoriasis.   Some-
times the eczematous  eruption, especially if it spread over the
dartos, or along the upper part of the thighs, or over  the pubic
region, fraternizes with impetigo ; that is, the exudation beneath
the cuticle consists, from almost the very beginning, of a  small 
ECZEMA PR^EPUTIALIS.
105
number of pus globules suspended in a large quantity of serum,
and giving it an  opalescent appearance;  and the inflammation,
the heat, the scalding, 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 impetig-
inous characters, is partial to the upper  part  of the thighs in
both sexes, and is  occasionally met with  as the joint production
of chronic blennorrhagia 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 integu-
ment is involved  at any one time, and  local applications  of  a
soothing, unstimulating kind may be relied upon.  During the
day the following lotion may be used : —

   R. Liquoris Plumbi,.............5 ij-
      Glycerinae,...............3 "j.
      Aqua? Fontana?..............§ viij.  M.

   At bedtime,  the  parts may be covered with the benzoated
 oxide of zinc ointment, prepared as follows: —

   R. Gummi Benzoini pulveris, v.........B "j-
      Adipis praeparata?,............5 uj-
      Liquefac, cum  leni calore, per horas viginti quatuor, in
         vaso clauso ; dein cola per linteum,  et 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,

   * " The benzoated oxyde of zinc ointment, properly prepared, is the most
 perfect local application  for  all  chronic inflammations of the skin that  is
 known." — Erasmus Wilson, on the Skin, fourth edition, p. 73. 
106             GONORRHOEA AND SYPHILIS.
it should be wiped off with a soft rag, but notivashed;  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 beneficial; so, also, equal  parts of
lemon-juice and water, dabbed  upon the spot with a bit of rag,
will, iu 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  re-
quires constitutional treatment.   The  first of such remedies in
importance, are moderate  saline cathartics, provided the patient
is of a full habit.  If of an opposite constitution, 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  single  day.  The uropoietic appa-
ratus may also be employed in the work of relieving the cuta-
neous vessels.  I have derived advantage from the use of bitter-
sweet and common yellow dock-root combined as follows: —

  R.  Solani  Dulcamara?,............§ j.
      Pulveris Radicis Rumicis Obtusifolia?,......§ 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 gradually
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 kid-
neys and  bowels;  and  amendment of the  cutaneous affection
follows very soon afterwards. 
ECZEMA PRAEPUTIALIS.
107
  The liquor potassae and  the  aqua acetatis ammoniae are like-
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  recom-
mended in herpes  praeputialis can  be prescribed with equal
advantage in eczema of the same or neighboring parts. 
CHAPTER  VIII.
             IRRITABILITY  OF  THE 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 insupportable.
  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 accu-
  mulation 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  disorder
  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-transparent,  tena-
  cious 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 the complaint
  extends to the ureters and kidneys, which contribute a share
  of the secretion  that is produced in such  extraordinary quan-
  tities.
             (108) 
IRRITABILITY OF THE BLADDER.          109
  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 enable
 the surgeon to form a correct  diagnosis of the case.  To such
 a course of  procedure with such results as  are here mentioned,
 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
  patient's  greatest suffering  is  after the last jet  of  urine has
  escaped  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
  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-
                  10 
110
GONORRHOEA AND SYPHILIS.
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
complaint.   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
recumbent 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 anything else of the kind.
It should be given in the early part of the day.  Its action 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.
   To keep the bladder in a state of repose, a  short  gum-elastic
catheter sliould be introduced as  far  as the distal end of the 
IRRITABILITY OF THE BLADDER.          m
urethra, but  must not be  allowed to enter  the bladder.  The
lengtli 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 tranquillizing 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.!   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  approved
•method  of  administering  injections is  the one employed by
 Mr. Fergusson, which is,  to  introduce  the water  in a contin-
 uous stream by  means of a double syringe like that of a stom-
 ach-pump. :j:
    If the complaint terminates in inflammation of the bladder,
 then, in addition to the liberal use of opiate enemata, hot baths,
♦ Astley Cooper.    t Lancet, 1854, p. 594.    % Miller's Surgery, p. 
 112             GONORRHOEA AND  SYPHILIS.

 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.  Morpha? Sulphatis, ....
       Mistura? Camphorae,  .  .  .
   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
 ingredients, 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.  Potassa? Carbonatis,.........
       Syrupi Aurantii,   ..........
       Aqua?,...........
       To this add the powder of citric acid, ....

   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.
.  .   .  .  gr. iij.
.  .   .  .  Silj.  M.
5ij.
§ iss.  M.
gr. xxiv. 
                     CHAPTER IX.

                     EXCORIATIONS.

  Simple  abrasion  of some portion 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 pre-
puce, 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 else-
where ; 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  pre-
putial 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 mod-
erate 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  extremely
reluctant to heal, —not on account of any peculiar, bad quality
inherent in them, but partly because of the structures in which
they  are situated, and partly from the fact that the secretions to
which the diseased surface is exposed  keep up a morbid irrita-
tion.  Generally, there is  but one irritated patch.   The patient
states that  it attracted  his  attention  immediately  after  the
                   10 *                             (H3) 
114
GONORRHOEA AND SYPHILIS.
 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 tlie cause.   If, when the medical 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 fur-
 nishes one of the surest " rational signs " which the case admits
 of; and  whatever the anatomical appearances may be, as sug-
 gestive of tlie nature of the affection,  they never, in my estima-
 tion, 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 surface
 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  chan-
 cres ;  nor have they any indurated base,  which many chancres
 have.   They are irregular in form and size.  After the excoria-
 tion has healed, the integument remains quite  tender for some
 time ; 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  generally worse   than  the
 original attack.  The surface of the excoriation is larger, and
 the morbid action now reestablished  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 unfortunate 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, impugns  the  treatment adopted, and ex-
presses a desire, perhaps a  determination, to be treated for  the
venereal  disease, —a complaint which he has  not got.   Thus 
EXCORIATIONS.
115
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 diagnosis.
   January 7,  1857. — A. B., aged 19.   Salesman.   Had inter-
course with a  girl of the town on the night of December 31,
1856.  WTas 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
 reappeared with increased severity.  The excoriation now occu-
 pied 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 perhaps forfeiting
  his clerkship.  He was told that simple as his local difficulty
  appeared to be and really was, it  would probably 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 treatment was assiduously pursued to no
  good purpose.   The inguinal  glands became enlarged and ten-
  der.  On  the  glans,  minute  vesiculo-pustules appeared from
  time to time in successive crops.   Trivial fluctuations of amend-
  ment and relapse took place.   Such is the history of the case up
  to the morning of

     February  10th. — At this  date, numerous well-defined, scar- 
116
GONORRHOEA AND SYPHILIS.
let-colored, erythematous blotches were seen upon the trunk,
hips and thighs, shoulders and arms.   They were totally differ-
ent, in appearance, from the eruption spoken of above, in con-
nection 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
disappeared.  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  phenom-
ena, together 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
symptoms 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, seemingly, 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
tlie 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,  9ss.  of the submuriate  to §iv. of lime-
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
advanced to  a state of ulceration, local  applications will be
sufficient to  cure  the patient at once, in all ordinary  cases.
The chloride of soda,  Goulard's extract, or dry lint, as  recom-
mended for preputial  herpes and  eczema, will  accomplish all 
EXCORIATIONS.
117
needful purposes,   Sliould other  local measures be  required,
the following lotion will be found useful: —

  R.   Liquoris Potassae,   .  .
       Glycerins?,   . .  .
       Acidi Hydrocyanici, aa,
       Aquae Fontanae, .  .

  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 envelop.

   R.  Liquoris Plumbi,
       Vini Opii,   .  .
       Spiritus Rectificati,
       Aqua?,   .  .  .

   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 application
 where the affection has become chronic  and  the inflammation
 feeble.  The  black wash, of maximum strength, is apt to pro-
 duce 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 ulcer-
 ations 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  internally,
 will only exasperate the morbid condition.
5j-

3ij.
§ iv.  M. Lotion.
3j-
3ij.
5j-
§ iv.  M. 
CHAPTER  X.
                   URETHRAL PAINS.

  Now and then, a man who has been cured of blennorrhagia
reports that he is troubled with pains in some  portton 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 sever-
ity, and amounting, in  the  estimation of the patient, to a bond
fide disease, engrafted upon  the  preexisting  malady,  or, at
least, in  some way connected  with it.   Occasionally, the testi-
cles participate in tlie' affection ; and  if the man  happen to
cross his legs or bring his thighs together carelessly, he experi-
ences in these glands a sharp pain, and at the same  moment a
sensation of faintness, with nausea and  other distressing symp-
toms of a nervous character.   In most instances, these  neural-
gic 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 particularly nervous con-
stitution.
  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
           (118) 
URETHRAL  PAINS.                 119
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 tem-
perament, the unexpected circumstances in which he finds him-
self exert a most depressing influence  upon his mind.  He is
sure to magnify the severity of his sufferings in the part, and to
regard  them as the  harbinger  of something worse to come.
For the time being, he is well nigh a monomaniac, and for an
explanation 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 instances, vesi-
 cation 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 integ-
 ument 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 moder-
  ate size, sometimes  proves sufficient to remove the complaint.
  Sea bathing is usually attended with excellent results, and the 
120            GONORRHOEA AND SYPHILIS.
dashing of iced water upon  the parts is  also beneficial.   At
night, camphor and opium will be serviceable.
  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  XL
                    SPERMATORRHOEA.

  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,  re-
curring at sufficiently frequent intervals to derange the general
health.  According to Lallemand, however, all excessive gener-
ative secretions are to  be regarded as spermatorrhoea, in what-
ever manner  they may  take  place, and whether  they  have
infringed upon the integrity of the system or not.   This sig-
nification and use  of the word is convenient, and  is applicable
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 im-
pending 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 coincidence of lascivious
dreams, — at least, the individual is not conscious of them when
he awakes ;  and he is surprised to find that the spermatic prod-
uct has escaped while his faculties  have been wrapped in pro-
found sleep.  These  remarks are  applicable  to those  that are
in a state of wedlock as well as to those who are not, although
to the  latter they are  particularly pertinent.  They are intro-
duced here, not because such infrequent seminal evacuations
               11                            (121)    , 
122
GONORRHOEA AND  SYPHILIS.
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  indi-
viduals 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  skil-
ful 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 affection
sliould remain  abandoned  by the  profession to  a few  solitary
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 arc 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  quarters, and to become the  victims  of
unprincipled men."

  I shall never forget the case of an estimable young gentleman
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 delu-
sion in regard to his procreative system, that his  ability for in-
tellectual employment was seriously impaired, and he  was every
way miserable.   He told a doleful  story, 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 
SPERMATORRHOEA.
123
practice, and was fearful  that he  had so far enfeebled his intel-
lectual 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 complexion,  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 en-
tirely 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 hallucina-
tion 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  generous 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 recreation 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  gratification,
without having the slightest  idea of the terrible consequences
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  example, the 
124            GONORRHOEA  AND SYPHILIS.

lad soon surrenders himself to  a frequent indulgence of the all-
absorbing and fatal propensity,  until morbid symptoms, of vari-
ous kinds and degrees  of  severity, are induced.  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 opportunity  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 evidence of declining health,
as a matter of course.   The  brain is usually the first organ to
give indications of disturbance originating in the debasing habit.
Among the  injurious effects exhibited from day to  day, may be
mentioned lassitude, dejection, failure of appetite, and of mus-
cular vigor.   Sometimes the boy becomes petulant and exceed-
ingly irascible ; and the impulse  of temper is occasionally so
intense that he is exhausted from its indulgence, and the admin-
istration of stimulants is required  to relieve the serious depres-
sion into which he has fallen.  In other instances, more frequent
than the above, the mind sinks into an absolutely stupid  condi-
tion, 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,
unless the toils which hold the infatuated victims  in their em-
brace 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 induced
by over-taxing and exhausting the energies of the entire ner-
vous  fabric;  and  not because  of  any waste of  spermatic fluid,
for this  is impossible.  "  The high  degree of nervous  excite-
ment," says Carpenter, " which the act of coition involves, pro-
duces a subsequent depression  of corresponding  amount, and the
too frequent repetition of  it is productive of  consequences very
injurious to the general health. This is still more  the case with 
SPERMATORRHOEA.
125
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 contracting them-
selves 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  stimulating
drinks,  etc., provoke  involuntary  emissions more readily than
they ought.  The intimate and reciprocal relations between the
vesiculae seminales and the  brain, induce lascivious dreams, les
plus desordonnes,  under the slightest  direct or indirect excite-
ment of the genital organs, and inevitable pollutions from the
reproduction of all the ideas which are connected 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 sem-
inal  apparatus, and  preternatural secretion of the  spermatic
fluid takes  place.  Pruritus ani  is another abnormal circum-
 stance, which, in  some individuals, exerts an influence in stim-
 ulating the function of the generative organs to an inordinate
 degree.  Other morbid conditions about  the  anal region may
 exist, and  operate as excitants  of frequent erections  and noc-
 turnal  emissions.   An inflammatory state of the urethra, whether
 arising from gonorrhoea or  otherwise, 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 perhaps  even to the epididymis and
 testes.   Inflammation or irritation of the bladder may also be
 mentioned as now  and then  giving  rise to  spermatorrhoea.
 Dalliance with women, and  inordinate  indulgence in  the ven-
 ereal 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
                  * Vide  Lallemand, vol. ii., page 337.
11
* 
126
GONORRHOEA AND SYPHILIS.
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 phil-
osopher 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 incarna-
tion 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 passion,
and experiencing all the phenomena that  attend the  complete
congress of  the  sexes.  These facts  were communicated by the
patient to several medical gentlemen,  whom he consulted occa-
sionally in reference to the  exuberance  of his animal feelings,
the gratifications of which he foresaw would ultimately sap the
vital organs, and bring him to an ignoble grave.  His forebod-
ings were verified in  the meridian of life.   His insatiable appe-
tite was destroyed only by the hand of death.

  A great difference obtains in different constitutions in regard
to the consequences  exerted  upon  the system  by  inordinate
indulgence  in  venereal  pleasures.   Lallemand  says :  " I have
met with men who have given themselves up early in life to the
greatest abuses of masturbation, and who have subsequently 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, following  the
slightest errors of their youth.  These differences do  not, by any 
SPERMATORRHOEA.
127
means coexist in a constant manner with those outward charac-
ters, 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 development 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  par-
ticulars 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 retained 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 imagina-
 tion, from an abnormal condition of  any portion of the  genera-
tive circle, not infrequently propound to the physician questions
 more or less related to the foregoing  facts, which, 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 severe
 and complicated cases of spermatorrhoea, in  which the patients 
12S             GONORRHOEA  AND SYPHILIS.

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 complaint, 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 appear-
ances were of the same character.   The mucous membrane of
the prostatic part of  the urethra was swollen and injected.  The
prostate was nearly destroyed 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 semi-
nales were infiltrated  with pus,  and  their walls thickened by
inflammation.   The  orifices of the ejaculatory canals were en-
larged  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  difficulty,  and it is sometimes tinged with blood.
This morbid condition  of the canal tends to excite seminal dis-
charges, to keep alive a train of lascivious  desires, and to cause
the patient's mind to be occupied with imaginary scenes of sen-
sual  gratification, to  the  exclusion  of  almost every other
subject.

  Treatment  of  Spermatorrhoea. — If we could rely  with
confidence on the representations made by the patient relative
to the facts in  his case, we  should, as  medical advisers, experi-
ence less  difficulty  than  we now do  in directing  the proper
course  of treatment.   But, unfortunately  for the parties con-
cerned, it  often  requires the ingenuity  of the most expert tacti-
cian  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
* Curling on the Testis, p. 329. 
SPERMATORRHOEA.
129
to regard his statements with many grains of caution and doubt.
Few men who are, or who  fancy they are, suffering from sper-
matorrhoea, 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 anticipations  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 en-
feebled : he was nervous and hypochondriacal, and disinclined
to go into company.  He complained 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 occur-
red  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 perceive the spermatic  fluid escaping and moistening
his  trowsers and making him feel very uncomfortable.  I ex-
amined 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  tlie
 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
 urethra 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 imaginary.
 I counselled 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 Ricord,
 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 animalcules
 and other characteristics of the semen.  I know that the con- 
130             GONORRHOEA AND SYPHILIS.
trary 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 intervals;
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 making
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 physi-
cian.   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, bladder, and vesiculae seminales,
give no evidence of anatomical lesion.   In some of  these organs
there exists a morbid irritability, and nothing more.   It is en-
couraging 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 circumstance  to deal with.   Although not the origin
of the spermatorrhoea, 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
associated with physical  means.  Both classes of remedies, psy-
chological and  pharmaceutical, are equally and properly within
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 accord-
ing to its  own peculiarities and merits; and in the  treatment 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 definite 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 phys-
ical system  through the combined  agency  of  salubrious air,
cold  ablutions, bodily  exercise,  and   other  restorative and 
                     SPERMATORRHOEA.                 131

hygienic measures.  If the patient still indulge in his indiscre-
tion, this must be  abandoned.  Self-control in this particular is
a sine qua non as  a means of cure, and will constitute the true
moral aegis of healtli  in  the future.   Having gained his con-
fidence, 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  ex-
press his rebuke, in a kind but decided manner, of the practice
of self-abuse.  Let  him  be told that this baneful habit, if  not
relinquished, will  surely plunge him  into the abyss of destruc-
tion, and that no efforts put forth by the medical man can save
him.   It  is sometimes  difficult  to  detect  the practice of this
solitary vice.  The physician maybe  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 extraor-
dinary cases a few  years since, has  given certain diagnostic
marks, which are not unworthy  of note.  The  eye  is " lack-
lustre," hollow, watery,  without  expression, 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, with-
 out  pain,  in  the limbs, and  especially about the loins  and
 sacrum; inaptitude for mental  or corporeal exertion;  great
 depression of spirits, and a variety of other symptoms of func-
 tional  disturbance  of the  central   organ  of circulation, the
 stomach, and  other  digestive  organs; nervous cerebral disturb-
 ance, etc.   " The disgusting  nature of the  subject," says the
 Medico Chirurgical Review,  " has  prevented English  writers
 from any description or investigation of the phenomena; but
 we are well convinced from many cases  which have presented
 themselves  to our  observation, and where  the  cause has been
 voluntarily confessed or unexpectedly drawn  forth, that a great
 number of cardiac affections, as well as anomalous symptoms of
 disorder in other parts of the  system, are owing to this destruc-
 tive vice.   We  have, therefore, though reluctantly, been in-
 duced 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."
* New Series, No. 17. 
132            GONORRHOEA AND SYPHILIS.

  If any symptoms of dyspepsia exist, care in the use of suita-
ble diet, and in  regulating  any abnormal condition of tlie ali-
mentary canal, sliould be a prominent feature in the treatment.
Very many persons who are severely troubled with spermator-
rhoea complain that their food does not set well on their stom-
ach ; 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 physical condition.
A judicious plan of diet and exercise is  scarcely subordinate in
importance to the  use of pharmaceutical remedies.  Tobacco,
in all its  forms, should be interdicted.  Wine and  porter may
be permitted 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 theatres, 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 occupa-
tion.  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 enter-
tain  and captivate  the individual, create no  unhealthy  excite-
ment, are  full 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 exhaust.   Mr. Curling mentions that  he once had a
patient, a man  of great  intelligence,  but without employ-
ment, 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 ennobling pursuit, in combination with vigorous corpo-
real  exercise.  The effect  of  such a course is  to  render less
active, or even to check altogether, the  processes by which the
spermatic secretion is elaborated.  This is a  physiological fact, 
SPERMATORRHOEA.
133
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 propor-
tion 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 voy-
age upon the sea.   While I have been  preparing  the contents
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 squirrels,
and  the like.  At night, he  occupied a large, well-ventilated
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 gained
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
 induced to resort to these regularly, and be encouraged to per-
 form 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 accomplished.
 But if, after a trial  of  a  few weeks, the plans above suggested
 fail to remove the difficulty, it will then be advisable to vesicate
 the  perineal  integument, or  that of the sacrum, by means of
 the cantharidal collodion, as  for the cure of gleet.  The vesica-
 tory 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
 stranguary, and  instead  of fearing a  frightful exaggeration of
 the spermatorrhoea, as Lallemand seems to  have done, the sur-
 geon may look forward with  the expectation of the most  grati-
                   12 
134             GONORRHOEA  AND SYPHILIS.

fying results from its use.  No local remedy acts so quicklv or
so surely in checking  the complaint.   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 irrita-
bility of the- sexual  organs ;  and for this purpose,  the exhibi-
tion of sedatives will be required.  The use of opium, at bed-
time, 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 invalidates
its claims in certain cases complicated with dyspepsia.  These
objections may be partially obviated by combining with it hyos-
cyamus 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.
Given in doses  ranging from  thirty  to sixty grains, in sweet-
ened water, when  the patient retires for the night, it frequently
induces 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 cere-
bral  plethora for a few hours  on the day following its use.   It
certainly acts as a harmless and quite efficient sedative or nar-
cotic.  Another thing in its favor: its  employment is  compati-
ble with that of tonics, or  almost any  other medicinal  agent
which it may be deemed advisable to prescribe.
  The following note from Dr.  James  Jackson, of this  city,
respecting the use  of lupulin, will be read with interest: —
* On Diseases of the Vesicula? Seminales, p. 89. 
SPERMATORRHOEA.
135
                               "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
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,
                                          "James Jackson.
'Dr. S. Durkee."
  The  secale cornutum exerts a powerful  influence over the
generative  system; and its  use  as an  anaphrodisiac, in old 
136             GONORRHOEA AND  SYPHILIS.
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.

  Hr.  Secalis Corr|uti.......,.......5 iss.
      Aqua? Ferventis,..............§ 1V-
  Infunde.
  D0SE# — One half, to  which may he  added two drachms of camphor mix-
ture, 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.

  Iii cases of long standing, in which irritation of  the prostatic
portion  of the  urethra has  become a well-marked feature, the
application of the  nitrate of silver  sometimes answers  a valua-
ble purpose in removing the irritable and sensitive condition, 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 irritability of the
parts, and thus break the  chain of morbid phenomena, is  an
important achievement; and it is claimed by the  advocates of
Lallcmand's  plan, that  the  nitrate  will  accomplish  this work,
and it is admitted that in some cases its action is perfectly ef-
fectual.  But the operation with the  porte caustique is extremely
painful, and  also  hazardous ; it  has not the merit of  uniform
success, and it does  not supersede the necessity of other meas-
ures.  It sometimes gives occasion  for their most energetic use,
for it is exceedingly  apt to provoke  a high  degree of inflamma-
tion, 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 contact 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, severe retention  of urine,
haemorrhage, and the most  excruciating agony, and even stric-
ture, 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 
SPERMATORRHOEA.
137
field of action.   It is  no more than truth to say that Lalle-
mand's instrument is now regarded with instinctive horror, and
as a barbarous weapon ;  and its introduction 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 attended
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 tlie day.  Water  employed as  an
injection  has a  soothing effect, and  is applicable  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 Belladonna?,............Sss-
       Veratria?,................9SS-  M-

    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
 tincture of hyoscyamus and camphor will form a good sedative,
 which may be administered at bedtime : —
  R.  Mucilaginis Acacia?,.............3 ss.
      Tinctura? Hyoscyami,............3 J;
      Misturae Camphorae,............° "•
  Dose. - Three drachms in toast-water or rice-water.  This may be 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.*

  * The observations of Thielmann and Pfaffer confirm the above statement
relative to the therapeutic action of the bromide.
                 12* 
138
GONORRHOEA AND SYPHILIS.
   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
 circumstances 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 mat-
 rimonial life.

   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 tes-
ticle was removed, but with no alleviation of symptoms.  Erec-
tions  and emissions,  both  nocturnal and diurnal,  returned  as
soon as the  patient recovered from the  inflammation that fol- 
SPERMATORRHOEA
139
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 exam-
ple at school, and to this  practice he attributed his infirmity. 
CHAPTER  XII.
              GONORRHOEAE  OPHTHALMIA.

   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, which 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, wliich 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.
He experienced very  severe  pain  in the  eyeball, the temples
and occipital  region,  and also that sensation  of animate, ex-
              (140) 
GONORRHOEAL OPHTHALMIA.             141
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 maimer,
 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
  take place, and  the lids are soon involved in acute inflammation.
  The chemosis becomes phlegmonous, forms a close band around 
142
GONORRHOEA AND  SYPHILIS.
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
time 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 the two latter diseases it is very  probable that  the  vital
fluid  is in an  abnormal state, so that any proof  or argument
  * " In these complaints there is every thing to show a morbid condition of the
blood, which is surcharged with compounds of carbon and of nitrogen, and the
local action is the expression and effect of constitutional deterioration." — John-
son on Gonorrhoea.  See also Simon's Chemistry of Man, page 225. 
GONORRHOEAL  OPHTHALMIA.
143
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  deFived 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 reappear  in
another, 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
 are one and the same disease, and that  without  any metastasis
 or inoculation,  one passes into  the other.  I have  no faith in
* Clinical Lectures, 2nd Edition, p. 401. 
144            GONORRHOEA  AND SYPHILIS.
  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 experi-
  ence induces him to extend  a considerable degree  of incredulity
  to the  ordinary agency of either.  His ideas of sympathy are,
  that it means  nothing, explains nothing, and implies  nothing,
  save that such  and  such conditions  often  coexist.   In  some
  individuals, he  believes there  exists  a constitutional  tendency
  to the ophthalmic affection.

   I take pleasure in transferring to  these pages  tlie 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
 a 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  surgery.
 Before citing cases, which have  occurred in my own experience,
 I will refer  for  a  moment  to  the  facts  which indirectly  cor-
 roborate the theory of contagion.  Among these  may  be men-
 tioned the far more  frequent  occurrence  of the disease in men
 than in women; tlie different situation of the urethra in the
 female and her  different style  of dress rendering 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 Vetch, which have often been cited, were by no means
 conclusive m their character,  and if they had been performed in
a mode  which would have  given them more  value, 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
* Medical Times, Nov. 4, 1848. 
GONORRHOEAL OPHTHALMIA.
145
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  metastasia; but the
morbid phenomena have their origin and seat in the conjunctiva,
which  is exposed  to  constant  danger of inoculation from un-
cleanly fingers, which have  become impregnated whilst examin-
ing 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 hospi-
tal attendants.  After the visit, she washed the speculum wliich
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, I saw,  in consultation,  a gentleman
 who had  a severe attack of ophthalmia, coexistent with gonor-
 rhoea, and  where circumstances  seemed  to fix the  moment of
 inoculation 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.

   " Case III. —About two years since I saw a case similar to
 the last in all its  important features.  Here the  moment of in-
                13 
146             GONORRHOEA AND  SYPHILIS.
troduction of the virus appeared to be definitely fixed.  In this
instance the termination was most favorable, although the symp-
toms were very severe.  Very slight traces remain of ulceration
of the cornea.

  " Case IV. — 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
progress 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,
                                   " Henry W. Williams."
  " Dr. Duhkee."

  Diagnosis. — One writer affirms that he  has found a symptom
in 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 generally
agreed that so far  as relates to mere symptoms, the  affection
has nothing characteristic which may not exist in other purulent
ophthalmiae.   If the patient can detect the potential cause, and
trace it to  a  coexisting  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  of  its specific
character is complete.  Experience sustains the opinion, that,

  * De  l'Ophthalmie  Gonorrhoique, — Louvain,  1846. — Vide  Egan  on-
Syphilis, p. 110. 
GONORRHOEAL OPHTHALMIA.
147
apart from a knowledge that the disease is received by inocu-
lation, the physician has no reliable means of diagnosis between
this complaint  and what  is called Egyptian ophthalmia, or ca-
tarrhal 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  requisite.
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 appalling 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 understood that inflam-
matory action of the mucous membranes, especially 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  diarrhosa, in dysentery, etc., bleeding
from the arm is now an obsolete idea.
   Saline aperients are preferable to any others.   The individual
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 blennorrhagia, 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 it.  Before
 the surgeon lets go his hold of the lid,  it is to be washed with 
148
GONORRHOEA AND  SYPHILIS.
 warm water, by means of a small syringe that will throw a fine
 stream.  The upper lid should be  subjected to the same treat-
 ment.   In  ten  or twelve hours it  may be necessary 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 discharge, 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.  Some-
 times 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-ointment.
   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
 water.*  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 destruc-
 tion, to  which the cornea and  other tissues are exposed.  The
 entire  cornea  sloughs away, protrusion  of  the iris and lens
 takes place, forming staphyloma, and resulting in total loss  of
 vision.  The late Mr. Tyrrell  employed  scarification so as  to

   * 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, pre-
fer vegetable astringents as topical remedies to the eye. 
GONORRHOEAL OPHTHALMIA.
149
radiate  from the  margin of  the  cornea.   This practice  was
based upon the theory that the cornea perished from strangula-
tion of its vessels.   Whether  this idea is  purely  theoretical,
having no foundation in fact, has been doubted; but the advan-
tage of adopting  prompt measures for the removal  of the infil-
trated matter, does not admit of any question.  If the chemosis
be  severe and  ©edematous,  forming a turgid ring  around tlie
cornea, it should  first be excised; if it be  phlegmonous, and
the  curved  scissors  cannot be advantageously employed,  it
should be scarified.   Either procedure will relieve the engorged
vessels of  the  overhanging conjunctiva, and will promote the
favorable action of other remedies.  After scarifying or excising
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 antiphlo-
gistic 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
 injury 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 physician
 may choose ; but it would scarcely  be good practice to employ
 any two at  the same time.  Their use  must be persevered 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  reproduce  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
                   13* 
150
GONORRHOEA AND SYPHILIS.
orbits or upon the temples  should  not be omitted.   Permanent
adhesions of some portion of the iris to the capsule of the crys-
talline 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 char-
acter.   The disease  becomes atonic;  and  the most effectual
mode of  treatment  will  consist in supporting the system by
generous diet, quinine, and the  like.  Blisters to the nape of
the neck will how 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. vj.
       Oxydi Zinci Impuri Praeparati,.......
       Boli Armenia?, aa.............gr. xviij.
       Unguenti Rosarum,...........g 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, wliich should
be made  merely  damp with the  acid, and  drawn lightly  and
quickly over the mucous membrane.  The lids  sliould 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 tlie  more advanced  and chronic period,  a  blue pill, every
second or third night, for a few times, and followed next morn-
ing 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 
GONORRHOEAL OPHTHALMIA.
151
this description.  An aperient  every other day, low diet, half a
dozen leeches to the temple occasionally, a small blister 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.

  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  tlie 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 in-
volved than the other.   It is frequently the seat  of ulcerations
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 membrane
of the conjunctiva.  In some instances, a transverse, red line
can be seen on the eyelid before the purulent exudation 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
       (152) 
OPHTHALMIA NEONATORUM.
153
pain, unless the child is exposed to a  glare of light.  This is
particularly the case as regards the first stage  of tlie  attack.
Infants witli 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 affec-
tion.   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 inflammatory action extends to the conjunctiva of the
eyeball and to tlie 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  sep-
arating 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 commencement of
the affection even in its mildest  form.   In  the attempt to open
the lids,  the eyes of the little patient are involuntarily  turned
upward  in the  socket,  so  as  completely to conceal  the  cornea
from  view,  and the physician has no  little difficulty in ascer-
taining 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 sim-
ultaneous 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  pre-
cisely 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.
Tlie  mother  states  that she has for several months had blen-
norrhagia.
Treatment. — The  character  and success of the  treatment 
154
GONORRHOEA AND  SYPHILIS.
will depend not a little on the time when the physician first sees
the  patient.   Should  he  be  called  early, a  mild course will
usually suffice to check at once the further progress of the affec-
tion, 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 firrnly 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 matter 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 pro-
ceed 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 cham-
omile, 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 pro-
portion of four grains to eight ounces of distilled water, may be
advantageously applied to the diseased  membrane two  or three
times  a day.   The eyes  should  be thoroughly  cleansed with
warm water before 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 prac-

  * Mr. Critchett, Surgeon of the Royal London Ophthalmic Hospital, says :
" Local stimuli should  be applied early, often, and thoroughly to the conjunc-
tival surface in purulent ophthalmia of infants." — Lancet for August, 1854. 
OPHTHALMIA  NEONATORUM.
155
tice for various forms of purulent ophthalmia and  chronic con-
junctivitis : —

   ft.  Cupri Sulphatis,.............gr. ij.
       Vini Opii.................3j.
       Aqua? Destillata?,.............3 vij. M.

   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. vj.
       Oxydi Zinci Impuri Praeparati,.........
       Boli Armeniae, aa,..........   .  .  .  gr. xij.
       Unguenti Rosarum.............§ 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 jaundiced
skin, as sometimes happens, of hydrargyrum  cum creta, 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  XIV.
              GONORRHOEAL  RHEUMATISM.

  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, sim-
ultaneously, 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
C. Brodie, the profession is indebted  for the first description of
this complaint, a few  cases of which are to be found in  his
                                            (156) 
                GONORRHOEAL RHEUMATISM.             157

" 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 embarrassment 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  ;
the constitutional disturbance being quite trifling, when con-
trasted with the  severity of the  local arthritic  affection.   Mr.
                     14 
158             GONORRHOEA  AND SYPHILIS.
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 syno-
vial membranes, erratic in  its  habit, rather giving rise to rapid
effusion than to violent  inflammatory action,  chiefly  affecting
the articulation of the knee, sudden in attack, tedious in course,
and treacherous in recurrence.  What are these but  the charac-
ters 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 condition of
the system  usually  attendant on the  complaint in its early
stages, are to be set down as the most reliable characteristic
marks which it exhibits, and may serve, when  taken in connec-
tion with  the  history of the patient, as sufficient grounds  for
separating it from  ordinary rheumatism, and from  those neu-
ralgic and nocturnal pains which a person not unfrequently
experiences  in the latter stages of constitutional syphilis.  In-
stances, however, arise, in which a differential diagnosis is diffi-
cult and even impossible ; but  fortunately, as regards the treat-
ment, 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  reestablish 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
to inoculate the  mucous membrane with the infectious mat-
ter borrowed  from  another   person.   The  same  course was 
GONORRHOEAL RHEUMATISM.
159
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
of the other  agents  mentioned  in  this connection.  The  poul-
tice should be  large enough to cover the  whole joint, and be 
160
GONORRHOEA AND  SYPHILIS.
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  sedative
abundantly  proved.   Professor  Carnochan,  of  ^Sew York city,
has prescribed it successfully in  many cases  at  the  Emigrants'
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  pro-
curing  sleep.    No  opium in  any  form was used.  The Drs.
Cutter,  father and son,  two highly intelligent and reliable phy-
sicians 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 oint-
ment, — care being taken to avoid  salivation.   Long-continued
rubbing with the bare hand, or with a hair mitten, should like-
wise be practised many times in the day.
  The wine  of  colchicum,  tincture of sanguinaria  canadensis,

  *  Since the above was written, an important communication prepared by a
committee of the Middlesex East District Medical  Society, Massachusetts, rela-
tive to the veratrum viride  as a safe and  valuable arterial sedative, has ap-
peared in the American Journal of Medical Sciences, for October,  1858. 
GONORRHOEAL RHEUMATISM.
161
the ammoniated tincture of gum guaiacum, tfie 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 employ-
ment may be persevered in for  a  long time.   But  in ordinary
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,  altera-
tives, 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.
                14* 
CHAPTER  XV.
                     VEGETATIONS.

  These morbid excrescences were  once, but are not now, re-
garded as the product of the syphilitic poison.  They are  some-
times the result of irritation from  the deposit of gonorrhoeal
matter;  and sometimes  they are generated  by the combined
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 aspect
they present to the eye or the fancy of the  physician or sur-
geon ;  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  other-
wise 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 blennorrhagia
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 when situated
in these parts, and constitute one of the greatest inconveniences
that attend gonorrhoea in  the female.   In  some  instances, large
                                          (162) 
VEGETATIONS.
103
warty  excrescences spring from the walls of the vagina at a
little distance from its orifice, and their  presence will keep up
a discharge  for a  long  time  after the blennorrhagia, in which
they originated, has ceased.   The  patient, perhaps,  makes no
complaint;  but if she  engages  in any active exercise, the dis-
charge will  probably return, and be as  abundant as ever, and
the ordinary treatment for arresting it  will  be employed with
little or no relief.  Under  these circumstances, if the speculum
be  used, the locality of fthese verrucae can be  ascertained, and
they can be removed with  the ecraseur,  or be destroyed by the
application of the acid nitrate of mercury.
   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 com-
paratively soft and  white  ; if they  remain  for a  considerable
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-
roach," and which had troubled her for about one  year.  The
abnormal mass was situated  on the pouch at the fourchctte.
Several small papilliform  warts were seen  pullulating in the 
164
GONORRHOEA AND SYPHILIS.
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 Vidal  considers these vegetations as syphi-
litic 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 wliich 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."
   Vegetations 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 tlie case can furnish a
perfectly reliable basis, on which to  establish a correct diagnosis.
Mere appearances may  deceive  the most practised eye.   This
they always have done and always will do. 
VEGETATIONS.                    165
  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 painful procedure  to
the patient, and will rarely succeed alone in annihilating these
disgusting formations.
   As  a  constant  application, the  liquor  plumbi,   somewhat
diluted, is one of  the  best.  It may be used  on dossils of soft
English lint.   When the warts are not situated on the prepuce,
they can generally be removed and be prevented from returning,
without recourse  to  tlie  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 solution is
preferred by Mr. Emerson, surgeon in  tlie 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 secretions.   Indeed,
such is my opinion of its utility in these cases, that I believe it
cannot be  dispensed with.  I  consider the solution the most
effectual, and, in some instances, the only, application (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 constant 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. These  new formations, when
they occur on the  external integument, are  limited to  distinct
portions of  the papillary stratum of  the true corium, or  of
the sebaceous follicles.   They are often known under  the name 
166             GONORRHOEA  AND SYPHILIS.
of  acuminated  condylomata,  and  have  very  properly been
termed  papillomata.    The  projections  which  constitute  the
papilloma  sometimes terminate in acute points ;  sometimes in
truncated, clavate extremities; and are in some instances sup-
ported 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 cauliflower 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 excrescences were com-
pletely destroyed  and did not reappear.   No other  treatment
was used.  This is a fair specimen of  the effects usually derived
from this powder.   In many instances the locality of the vegeta-
tions renders its application impracticable ;  but where it can be
used  conveniently, its  agency in  destroying  the  abnormal
growths is rapid,  without being  very painful.  Escharotics 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 con-
venient 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 perfectly destructive to

  * A minute description of these papillomata may be found in Wedl's Patho-
logical Histology. 
VEGETATIONS.
167
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 pro-
portion 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 mer-
cury.  Only so  much should   be employed as will saturate the
diseased growth.   Care  must be taken to avoid the adjacent
healthy  tissue ;  for  although the  solution  is  not  sufficiently
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 clean-
liness be observed. 
CHAPTER  XVI.
          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  sur-
gical 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 obtaining an exact knowl-
edge 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  wliich  we are called upon to  investigate and  treat, blen-
norrhagia,  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  practitioner 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, 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
particular  lesion that   cannot  otherwise  be detected.   They
relate directly and  chiefly to therapeutic measures.   Certain
modes of treatment, certain topical and constitutional remedies,
possessing specific qualities, adapted to particular functional or
structural derangements, and to no others, are thus suggested
                                              (168) 
            BLENNORRHAGIA IN THE FEMALE.          169

to the judgment  by what the eye has seen.  In the same man-
ner, an examination within  the buccal cavity,  by means of a
spatula, leads  to  definite conclusions in regard  to any morbid
condition of the mouth and throat.  Cases  not subjected to such
inspection  must  necessarily  be  conducted,  in some degree at
least,  according  to  the  doctrine of chances.   No sagacity or
experience 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 recognized
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 implied igno-
 rance, 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 speculum
 in severe  inflammatory gonorrhoea, accompanied with tumefac-
 tion 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 speculum should
 be employed  for the purpose of ascertaining whether  any ero-
 sions, vegetations, chancres, or ulcerations coexist with the  blen-
 norrhagic 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 exactness of manipulation are necessary.
 The speculum may, without impropriety, be regarded as suited
 to a numerous class of females who require medical and sur-
 gical treatment,  and who are always anxious to  be cured in the
 shortest time  possible.
   With the instrumentalities now at  his command, the intelli-
 gent practitioner asks only for  a few  days to accomplish a cure
 of maladies, which, while the speculum was ignored, were sub-
 jected to a tedious and oftentimes random treatment  of many
 weeks or  months.  Several kinds of speculum are  in vogue.
 The bivalve 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.
                       15 
170
GONORRHOEA AND SYPHILIS.
  Diagnosis of  Blennorrhagia in the Female. — The inves-
tigation of this subject is often beset with difficulty and embar-
rassment.   The  impossibility  of  determining in all  cases  be-
tween  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 occur
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 incon-
venience, at other times fretting and irritating the surfaces over
which it flows.   To these chronic cases the difficulty of discrim-
ination 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-contagious
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 contagion from another.
For  it must be  admitted that the vaginal  secretions of some
females who are  perfectly  chaste  and  entirely 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 secretions to provoke a
blennorrhagic urethral discharge.   Candor, indeed, compels me
to go farther, and to admit  that an acrid condition of the ordi-
nary  mucous moisture, — the epithelial  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 predis-
poses him to receive the infection. Thus, extraordinary  con-
ditions  appertaining  to  both parties at the same  time,  may
occasion non-specific symptoms in  a man, that  cannot be  dis-
tinguished in their  severity,  duration,  or  complications, from 
BLENNORRHAGIA  IN THE FEMALE.         171
those  phenomena attributable  to  contagion  derived from a
woman, who has, and who gives, a veritable  blennorrhagia at
the moment of sexual congress.  Such instances are, however,
exceedingly rare.  They will do to be mentioned as mere excep-
tions to the general rule, and this all they are worth.   All these
contingencies, these exceptions, and these extraordinary circum-
stances,  demonstrate the paramount importance  of  having a
full  and truthful history of the case presented  to the medical
attendant for his careful consideration.   If, short of such a his-
tory, he attempts to form an opinion, he will find himself some-
times, and when he least expects 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 wliich I have
already drawn  attention, is, that it seldom exists for  any great
lengtli of time as a primary disease, whether purely inflammatory
or blennorrhagic, without extending to the mucous 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 con-
gested and inflamed, and eventually, if the disease is not cured,
ulcerated.   Like  those who  have preceded 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 fully that an occa-
sional  exception may take  place.  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 
172
GONORRHOEA AND SYPHILIS.
up to the time they consult  me, the wife has nearly always a
tale of sorrow to record; her liusband is wild, dissipated, keeps
bad company, sleeps out at night, and generally speaking, lias
confessed  to her that he  has exposed  himself to contagion.
The  only anatomical  differences, however, which I have ob-
served in  blennorrhagic inflammation, are the very great quan-
tity of  pus  secreted,  the  extreme  redness,  congestion,  and
swelling of the mucous membrane, the occasional  extension of
the inflammation  to the urethra, 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 prrapuUum  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 in-
stances, but of very infrequent occurrence, a  leucorrhceal 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  practised 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
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 under
my observation several years ago, in a child two  years of age,
                  * Bennett on the Uterus, p. 179. 
            BLENNORRHAGIA IN  THE  FEMALE.         173

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  occur-
rence  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 reported by Dr.
Burke Ryan before the London Medical Society.  Two children,
sisters, aged respectively one and four years, were found labor-
ing 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  communication  of the
disease  to  these children was  this:  It was  ascertained  that
a young woman in  the  house had  profuse  gonorrhoeal  dis-
charge; 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 im-
portant in reference to matters of medical jurisprudence.   Sim-
ilar 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
 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
 nymph® ; 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 attrib-
 uted to some  other cause — as the accumulation of  filth, irri-
 tation from the  clothing, or some intestinal derangement.

             * London Medical Gazette, April, 1851, p. 744.
                     15* 
174             GONORRHOEA AND SYPHILIS.
   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 accidents result-
ing from blennorrhagia, may be  mentioned cystitis,  nephritis,
inflammation and obliteration  of  the Fallopian tubes, ovaritis,
sterility,  peritonitis,  inflammation  and suppuration of  the  in-
guinal lymphatic  glands and of the labia majora, chronic en-
largement 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 symptoms which  announce
the approach or  actual  existence  of the disorder, are,  a pe-
culiar 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
the nymphae, greatly  distending  these  bodies, which protrude
through the external labia, and become  cedematous, 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, 
BLENNORRHAGIA IN THE FEMALE.         175
over the inflamed  surface, causes no inconsiderable  smarting
and  scalding.  The inflammation soon reaches the vagina and
spreads in  circumscribed  patches, or perhaps extends through-
out the whole of its mucous membrane.   Its  numerous  papillae
and  follicles  become hypertrophied;  its  walls  contract  and
present a  granular  aspect;  and  if the  inflammation 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 dis-
eased  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 development.   They yield to treat-
ment  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 conse-
quent  upon uncleanliness.  The blennorrhagia,  either  from neg-
lect  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
she arrives at  the erroneous conclusion that simple leucorrhoea
is  her only trouble ;  but  if sexual intercourse  be indulged  in,
the other party is pretty certain to find that he has sought pleas-
ure at a poisonous fountain.

  Treatment. — Although, under  ordinary circumstances, gon-
orrhaea in the female does  not affect  so severe a type  as in the
male, it is, nevertheless, in all its  essential  features,  nearly as 
176
GONORRHOEA AND SYPHILIS.
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 exacer-
bation of the blennorrhagic affection.   To these  disadvantages
another remains to be added:  while the  menses are present, no
local  treatment  can be pursued; whereas, this constitutes an
important means of cure, especially while the difficulty is con-
fined to the vulva and vagina.
  In  the  acute  form  of  vaginal  blennorrhagia,  antiphlogistic
treatment is always appropriate.  The patient must be confined
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 ammo-
nia, 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 observed.
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 participation.   In most
instances, the condition of the  tongue, pulse, and skin, demon-
strates this.
  Balsam of copaiba, which is so valuable a remedy in urethri-
tis, is wholly impotent in vaginal gonorrhoea.
  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.   Tinctura? Lytta?,.............
       Tincturae Cubebae, aa,...........§ ij.
       Aquae Camphorae,............§ iv.
       Morphia? Sulphatis,............gr. iv.  M.
  Dose. — One drachm three times a day, in a gill of rice-water or toast-water. 
BLENNORRHAGIA IN  THE  FEMALE         17 J
  If no inconvenience arise from this quantity, the patient may
take four or five drachms in the twenty-four hours.  It is sel-
dom that strangury occurs to a degree that requires artificial
relief; but if this  should be the case, a warm  bath or an extra
fourth 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 con-
fident  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 regard
to the value of this class of medicines in urethritis in the male,
there  is no discrepancy as relates to their free employment 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 capable 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 secre-
tion, but exerts a decidedly curative influence upon  the dis-
eased  tissue itself.   A thin  mucilage, made of  the powdered
slippery elm bark, constitutes a soothing and quite useful injec-
tion ; flax-seed tea, and a weak decoction of poppy, are likewise
beneficial,  and may be used as directed  for  simple warm water
injection.  Either preparation, here spoken of, will serve a val-
uable purpose in appeasing the irritable and engorged condition
of  all  the parts implicated in the blennorrhagic complaint.  In
order that  the injection may irrigate  the  upper portion of the
vaginal cavity, and be prevented  from escaping  prematurely,
the patient sliould 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. 
178             GONORRHOEA  AND SYPHILIS.

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 expense, necessary for  procuring
the right kind of apparatus, will be lost.  If a  pump-syringe
cannot  be procured, a metallic instrument, 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 sliould 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 containing
the French chloride of soda will  be found useful.   Generally it
will be advisable to commence  with one ounce  of the  chlorine
solution to one pint of water, and let the patient  inject two or
three  ounces  repeatedly.   It should reach every part of the
vaginal canal.  If, after a trial  of six or eight days, the chlorin-
ated water does not yield satisfactory results, it should  be aban-
doned, 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  demand-
ing this local treatment, however, are few 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,
wliich may be repeated every third  or fourth day, it will gener-
ally arrest it in a short time.   If the surgeon decide  to try the
silver,  the entire surface  of  the  mucous membrane  should be
thoroughly cleansed with warm water 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 injected several times during the day.

  * Very good  syringes for vaginal  use are manufactured  by  Mr. Thomas
Lewis,  of this city;  also by Mr. Davidson, of Charlestown, Mass. 
             BLENNORRHAGIA IN  THE FEMALE.          179

A solution  of nitrate of silver  is  a favorite with many  sur-
geons.   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 application
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 § ss. tog viij. 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 appar-
ent when there is ulceration of the vaginal mucous membrane,
or about the cervix uteri.   M. Boinet, of France, uses the tinc-
ture  of iodine, with an equal  quantity of water, with great suc-
cess 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 Cinchona? Rubra? .  .   .
       Acidi Nitrici.........
   M.  To be used repeatedly during the day

    The chlorate of potash is likewise worthy of  a trial in gonor-
 rhoeal  and vaginal inflammation.   It has  been prescribed with
 the same well-known success that  attends  its use in  stomatitis.
 The  subjoined prescription is  appropriate: —

   R. Tannin,  . .  .
       Potassa? Chloratis,
       Aqua? Fontanse,
       Injection.

   The patient may use an ordinary female  syringeful at a tir
 and  repeat the operation ad  libitum.   Its  beneficial effects g.
 erally declare themselves in a few  days.
gtt. XX.
9ij.
5j-
gxvj.  M. 
180
GONORRHOEA AND  SYPHILIS.
  Chronic Vaginitis. — 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 usually be
successfully managed with  astringent  and tonic  injections.
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 tho  vagina  ought to be freely bathed with cold-water injec-
tions.  The latter may be regarded as both tonic and astringent
in their curative action, and may be resorted to with the great-
est freedom.
  The  speculum  is  to be  introduced  every few daiys 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  tincture
of iodine.  A  small  probang  is to be moistened  with the latter,
and applied wherever any aphthous patches, erosions, or ulcera-
tions 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.
  Vaginitis 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-
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 fomen-
tations, 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 sliould in  all respects be treated accord- 
BLENNORRHAGIA IN THE FEMALE.         181
ing 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 sur-
prising 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 occupy some portion
of the os uteri or its immediate neighborhood, the mucous
membrane being everywhere thickened.
   A copious, tenacious, semi-transparent or muco-purulent se-
cretion  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
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
               16 
182
GONORRHOEA AND SYPHILIS.
seen trickling down the sides of the os tincae  and lodging on
the vaginal surface, where  it rapidly accumulates in immense
quantities.  I have frequently  witnessed  these phenomena 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 temperament, are
liable to this variety of blennorrhagia.   The affection  gives rise
to  more or less constitutional  disturbance.   The  patient be-
comes 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 without 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 Blennorrhagia. — In the local  treat-
ment 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  requisite 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 potassa  cum calce  is pre-
ferred 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 supervening 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 
BLENNORRHAGIA IN  THE FEMALE.
183
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 potassa  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 practition-
ers 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 when-
ever 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 inten-
tion of destroying the follicles  from which the morbid secretion
comes.  The operation is said by M. Huguier to have  been suc-
cessful in  his hands, and not  to have been particularly painful.

   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 oc-
casional use, an intra-vaginal injection of a concentrated  decoc-
tion of black walnut leaves will be beneficial.*   The  speculum
is first to  be introduced, and the  neck  of  the womb exposed;
* This was a favorite remedy with Vidal. 
184            GONORRHOEA  AND SYPHILIS.
then with a large enema syringe, the decoction is to be thrown
up, in direct contact with the cervix, and a  tampon 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 infusion of walnut
leaves, with half a drachm of sulphate  of alumina 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 infusion.  It is slightly stimulating
as well as astringent, and  causes a sensation of warmth in the
parts, but no other inconvenience.   A composition consisting of
four ounces of glycerine and one ounce of tannin has been em-
ployed with advantage in  chronic vaginal and uterine blennor-
rhagia.  The  method is this:  after the puriform matter that
lines the walls of the vagina  has been thoroughly washed away
with cold water injections, 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  employed,  and fresh  plugs  introduced through the
speculum.
   Various  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 uterine
blennorrhagia, is that which has a large tonic element of some
sort.  The bowels should  be kept in a  healthy state; the diet
should be simple, nutritious, and liberal in allowance; and bath-
ing, cold or warm, as  the  patient may prefer, is to be practised
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 
             BLENNORRHAGIA  IN THE FEMALE.          185

with  a  man while a blennorrhagia  is upon  him, the vulva,
vagina and uterus sustain the injury,  while the urethra, from
the almost 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 variety of
blennorrhagia in the female.   It is sufficient to remark that the
symptoms  are essentially the  same as  those which  exist in
urethritis in the male.   If the  physician be in doubt whether
the secretion proceed from the urethra or the vagina, the ques-
tion  can be decided  by passing the  finger into the  latter, 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, that when
the urinary organs are  not involved.   The bladder is prone to
manifest a great  degree  of excitability, to allay wliich the free
use of opiates will be important.
   The internal administration of balsam of copaiba, cubebs, and
other anti-gonorrhoeal remedies, may be relied upon  with the
same prospect of advantage as in urethritis in men.   If, during the
acute stage of the complaint, much  febrile excitement prevail,
all specifics for the local affection  should be laid aside, until the
constitutional  symptoms have  been subdued  by antiphlogistic
measures.   To allay the  general disturbance, let the patient be
put upon the use of the following : —
                 16* 
186
GONORRHOEA AND SYPHILIS.
  R.   Soda? Sesquicarbonatis,...........^r.\XV"
       Potassa? Nitratis,.............^J"
       Spiritus .Etheris Nitrici,..........3 J'
       Vini Antimonii,.............3 VJ«
       Syrupi Simplicis,.............3 y-
       Aquae Fontanae,.............3v*  ^-
  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  constitutional  derangement, and it is
seldom that there is, the patient must at once be put upon the
use of remedies that act peculiarly 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.   Copaiba?,................
       Mucilaginis Acacia?,............
       Pulveris Cubebae, aa,   ...........§j.
       Spiritus ^Etheris Nitrici,..........§ ss.
       Mistura? Camphora?,............§ viij.  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 the 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  the acute  inflammation  of the
mucous tissues generally.   This we see verified  in conjunctiv-
itis,  in  dysenteric  and  pulmonary affections.   The same is
eminently  true  of the genital system.   On  the other hand, let
this fact be impressed on the patient's  mind, —that there is
no  malady  in  which indiscretions and irregularities of any
kind  are followed  by more  injurious consequences  than in
blennorrhagia. 
CHAPTER  XVII.
                         SYPHILIS.

  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 embodi-
ment, as well as its earliest incarnation, in the chancre ; and we
must regard  this lesion, with here  and  there  an  exception, as
the starting-point or focus from whence result all the malign
and diversified  influences and  developments known to the med-
ical 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,  wliich 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  phenomena  depending on  the
same morbific cause.
  It is well known that if several men have intercourse with a
woman diseased with syphilis, they may not all exhibit precisely
the same symptoms, although all receive  a  venereal infection.
Mr. Acton relates the following : Three students had connection
with the same griselte 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  men-
tions the case of a surgeon who  had connection with a  female.
Immediately  afterwards he 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
                                                (187) 
188
GONORRHOEA AND SYPHILIS.
purulent, proceeding  from an open ulcer, five  sores  formed by
inoculation.   Of  these,  only two  acquired  the  characteristic
induration at the  base.   Similar  instances, exhibiting the most
varied  abnormal conditions, occasioned  by the syphilitic virus,
now and then present themselves 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  surgical  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 incontestible  proof both  from natural  and
artificial inoculation of the contagiousness of the chancrous sub-
stance, and also, as I believe, in some  instances, of secondary
venereal matter ; but we are not furnished with a reliable foun-
dation, upon which to rest  any conclusions in  regard to  the
specific, primordial atom,  on the  presence of  which the com-

  * It is plain, that if we admit the doctrine of duality, on which I have just
dilated, 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 infecting the economy.  We, therefore, find that Ricord may side with
his pupil [M. Bassereau] without interfering with any of the tenets he has hith-
erto been maintaining.  He has, indeed, given in his adhesion, but in a some-
what 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, August, 1858. 
SYPHILIS.
189
municability 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 sur-
geon of the Hospital Receiving-ship  " Dreadnought," London,
and M. M. Lebert and Robin, of Paris, have devoted special atten-
tion 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 investiga-
tions respecting the minute structure of chancre, do not add any
thing to our knowledge 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
mentioned 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 character-
 istic induration of its base and edges and all the other peculiar
 attributes which constitute what is called the Hunterian 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 Hunterian chancre, is of rare  occurrence
 must be admitted.   The late Mr. Carmichael, whose experience
 both in hospital and private practice was very extensive, never 
190
GONORRHOEA AND SYPHILIS.
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 arc 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 ade-
quate or perfect, but considers it both partial and defective." *
Dr. John C. Egan, of Dublin, who has had an extensive  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  bo strictly classi-
fied under the  head of the genuine indurated and  excavated
ulcer of Hunter."}-
  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 believed that
the most simple chancres that have the least degree of indura-
tion, may be followed by constitutional symptoms.  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 pres-
ence 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 con-
dition, 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 impercep-
tibly, for a period  ranging from  five to fifteen days, before the
distinctive feature of induration begins to be developed, and  this
hardness requires 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 chan-
* Venereal Diseases, 1858, p. 90.       f Syphilitic Diseases, p. 49. 
SYPHILIS.
191
crous sore.  In  most instances,  the  chancre we are speaking
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 circumscribed  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  mortification  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 inflammation;  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 pri-
 mary 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., supervening 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
 known as the concealed chancre.  In the female, it 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.
          * British and Foreign Med. Chir. Review, October, 1856. 
 192            GONORRHOEA AND SYPHILIS.

   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 probably
 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  wliich,  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  mem-
 brane has been supposed to be the substance which furnishes
 the poisonous  matter.  The idea, however, is merely hypothet-
 ical ;  for  we  have  examples  of  chancres  showing  themselves
 in men after  they have had connection with  females who have
 at the time no lesion, except  the slightest abrasion or excoria-
 tion 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 contract 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
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
surface of the  mucous tissue than on the external surface. In- 
SYPHILIS.
193
deed, 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 wliich 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 axe 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 be-
fore  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  different
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 disposed
to advocate a rigid adherence to it.  If, as the result of con-
tagion 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  twofold:  to  destroy  the
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,
                17 
194
GONORRHOEA AND  SYPHILIS.
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  experimeut 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 possi-
ble constitutional manifestations, he would do an unpardonable
injustice to the case.
  Amid the absurdities, the fallacious  tests, and the uncertain
indications in which the judgment  of the surgeon is vacillating
and  perplexed, how shall he act ?   This question  can be dis-
posed of in a summary manner.  The  circumstances  relating
both to the history and existing condition  of the  patient, sug-
gest 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. Vidal  seems also  to have en-
tertained  a low appreciation  of the  efficacy of the  abortive
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 secondary
symptoms.   The local action, and that which ultimately con-
taminates the  entire organizations, in the cases here alluded to, 
SYPHILIS.
195
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.
Vidal commends itself to our judgment;  and yet  the  number
of cases  brought to our knowledge of constitutional symptoms
supervening upon the radical destruction of the primitive chan-
cre 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 justi-
fied 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
inoculation  of  the primary local disease  during which it is
expedient 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 fkid any sore which healed within
a fortnight of the application of the original poison followed by
secondary symptoms.    It seems rational to suppose that the
chances  of constitutional infection are, cceteris paribus, in pro-
portion to the duration of the local disease; and, therefore, the
earlier we destroy any erosion or pimple  induced  by exposure,
the more successful will  the  effort prove, and the  less occasion
will there be for any special constitutional treatment.   In offer-
ing  suggestions for caustic  applications, Ricord remarks: " In
the first  place, we are not to  reckon the age of the chancre 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 pa-
tient 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 proceed in
some cases.   Suppose  the individual does not discover any ab-
normal 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 
196
GONORRHOEA AND  SYPHILIS.
three or four days, or even eight days, from the time the lesion
was detected, would not the application of the  escharotic 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 confined
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 perfectly managea-
ble  in the hands of the surgeon.  The nitrate of silver I never
employ on  these occasions, nor yet the Vienna paste.  The sil-
ver 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  struc-
tures it forms an insoluble compound, which  acts as a prevent-
ive to its continuous power as a  caustic, by producing 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 confidence in our attempts to anni-
hilate 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 sub-
stance 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 escha-
rotic, and  then be brought in direct contact with the diseased
spot.  If the acid  nitrate of  mercury be preferred,  the same 
SYPHILIS.
197
method must  be observed.  In  three  or  four days, the slough,
supervening  upon  the  application,  will  be detached, and a
healthy, granulating surface will  appear.   If a solitary vesicle,
pimple, or pustule  is  to be destroyed, 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 re-
duced  to  a point, which is to be brought in contact  with  the
apex of the morbid growth, in the same  manner as in  the ordi-
nary 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 before 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  portion destroyed.  As the operation
throughout is void of  pain, no haste is required in its perform-
ance ;   but caution  and  exactness are both  necessary.   The
potassa is highly deliquescent, and it is difficult to preserve  the
solid stick in a dry state.   The surgeon had better place a par-
ticle 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 neutralize any superabundance of the caus-
tic.  The extent of  surface destroyed  by this corrosive sub-
stance 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 penetrates, 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 pus-
tule or sore, need not deter from the employment of any escha-
rotic.   The risk of increasing the inflammatory tendency is very
small.  Cold-water dressing, or a soft-cracker  poultice, may fol-
low 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 fol-
lowing dressing: —

   R.   Ferri Potassio Tartratis,..........9  y-
       Aqua? Fontana;,.............§ viij.  M.
                  17* 
198
GONORRHOEA AND  SYPHILIS.
  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 topi-
cal  measures are generally adequate to preserve the chancrous
sore in a healthy condition until a sound  cicatrix is formed.
Slight cases frequently occur, wliich, after the caustic is applied,
require little or no further care or treatment.  Instances  occa-
sionally present themselves, in  which healthy granulations fail
to appear, after the application of  the caustic and the subse-
quent dressings that have been  mentioned.  The  surface of the
wound assumes  a  spongy or fungoid aspect.  In such circum-
stances, the following astringent  and  tonic lotion will be well
suited  to the lesion: —

  R.   Acidi Tannici,.........         •  .  9 j.
       Tincturae Lavandulae,............5iv.
      Vini Rubri,...........• .  .  .  .   § iv.  M.

  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  char-
acter.
  As  a protection to the  sore by  night, the nitric oxide  of
mercury ointment should be ordered. 
CHAPTER  XVni.
     CONSTITUTIONAL  TREATMENT  OF  CHANCRE.

  Although the surgeon loses no opportune moment in attempt-
ing 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 wliich 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 com-
pletely  demolishing  a  chancrous   sore, we   are  warranted,
generally speaking, in  the conclusion that its poisonous element
is destroyed also ; and a  resort  to mercurial remedies  will be
uncalled for.  Egan advocates the employment of mercury, even
if the  specific ulcer yields kindly to the topical  applications ;
and  he considers that the surgeon who undertakes its cure with-
out 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 admit that if mercury
be given with  a view to cure  the  indurated 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 avocations, provided his general health
has not in any wise deteriorated during the local treatment that
has been needful.
  If any functional  derangement of the digestive organs exist,
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
                                                  (199) 
200
GONORRHOEA AND SYPHILIS.
a generous  description;  exercise  in  the open air,  ablution,
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 circumstances,
the first thing to be  done is to put him upon a regimen that may
serve, in some degree at least, as a sanitary cordon, 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 capable
of being excited into preternatural activity by various  remedial
agents.
  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 
       CONSTITUTIONAL TREATMENT OF  CHANCRE.      201

is to prescribe medicines, with  the expectation that they will be
taken and  employed  according to  directions.   This I say, be-
cause I  know from experience that  it is but too often that the
physician has to encounter strong opposition, if not downright
ob tinacy, when he gives salutary advice touching the daily and
nightly   indulgences  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 Span-
ish 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 chancrous sore on
the prepuce,  and a large bubo in the  groin, in an inflammatory
condition,  as was also his whole system, as indicated by the
pulse, skin, tongue, etc.   The apartment he occupied 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  exasperated, — 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
necessary  to  mention that stimulating drinks  must be inter-
dicted ;  the diet should be plain, but nutritious.   Among the
articles  of  food to be allowed, are milk and lean meats, and all
our  native 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-
lation, and thereby tend to preserve the normal richness of the
blood, sliould 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 
202             GONORRHOEA AND SYPHILIS.
 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 material
 deviation from its physiological  condition.  In  indurated chan-
 cre 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 following
 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
forty-eight parts in the thousand.   In  all  the  cases  examined,
the outbreak  of syphilis was  recent;  the  above results, there-
fore, do not represent the state of the  blood  in  the later stages
of the  disease.*   This  disturbance in the process of hsematosis
PartB.			Parts.
140.4	to	the	1000.
140.4	a	(<	«
140.5	u	a	u
138.1	it	u	K
133.6	u	i<	i<
* L'Union Medicale, May, 1857. 
CONSTITUTIONAL  TREATMENT  OF CHANCRE.
is followed more or less rapidly, in different individuals, by a
corresponding decrease of muscular strength, anaemia, and other
depressing symptoms.  By insisting on proper regulations as to
diet and regimen, the medical adviser will put the patient in
the most favorable attitude to forestall these adverse conditions,
and various others of a kindred nature, which might otherwise
be developed.

  Artificial  Syphilization. — The  second  indication being
strictly  therapeutic in its bearings,  introduces for consideration
the most appropriate constitutional treatment for subduing the
disease in all its different forms and phases.   In Paris and some
of the   other  continental  cities,  chivalrous experiments,  in
numerous instances, have been made within a few years, upon
men, women,  monkeys, and other  animals, with a  view to test
not only the prophylactic, but also the curative effects produced
by inoculating the pus of chancre upon  the healthy  skin  or
mucous membrane, and thus, it is  alleged, ultimately to carry
this process to the point of saturation in the system, as  is done
in vaccinia.    In this way, it is argued, patients may become not
only artificially syphilized, and ever after be proof against  the
action  of the  virus, but  it is further announced and believed,
that  the symptoms, which follow after exposure to  impure con-
nection,  promptly disappear  by having the patients artificially
inoculated on  the thighs, vulva, prepuce, abdomen,  etc.
  M. Turenne, a young French physician, commenced  a series
of experiments in 1844, or thereabouts, for the purpose  of test-
ing the  doctrine of Hunter, on the communicabilty  of the vene-
real virus to the lower animals.  After various trials, he at last
succeeded  in  causing  in monkeys, inoculated with chancrous
matter,  a complaint resembling, in all respects, a true chancre.
From monkeys it was transferred  to rabbits, cats, and horses,
and from these victimized  animals  it was returned by inocula-
tion to the human species.
  Dr. Robert Weltz, of Wiirzburg, having made  trial of it  on
himself, produced four veritable chancres on his own  person.
The  researches  of Turenne  led to the  curious discovery that
each succeeding  chancre,  from  inoculation,  became less and
less, until finally no chancrous  sores followed the application of
the poison.  This fact  gave rise to  experiments on the  human 
204             GONORRHOEA AND SYPHILIS.
subject, with a view to bring about the condition styled " syphi-
lization."  It is  asserted that the  process in question protects
the organization  from the venereal  disease subsequently, just as
an individual who has  had small-pox cannot have  it a second
time.  To arrive  at perfect immunity, the patient must undergo,
as rapidly as possible, reiterated inoculations, in order that it
may not jeopardize his health.
  The conclusions  drawn by Professor Boeck, of the University
of Norway,  from  eighty-four cases  which  he  treated  up  to
March, 1856, are that in all  cases  immunity from the venereal
virus is  obtained  sooner  or later by inoculation;  that  the
symptoms  of syphilis  present at  the commencement of syphili-
zation, disappear during the employment of  this mode of  treat-
ment ; that the  general  health  does not suffer from syphiliza-
tion— on the contrary, if the patient has  been in  poor health
before inoculation, he most materially improves  in strength
and appearance during the process.*
  That the immunity claimed as a result  of repeated inocula-
tions  is really acquired, is  rendered certain, if  we  can  place
reliance  on the  experiments and  the  testimony, not only of
Professor Boeck,  but likewise on the evidence furnished by M.
Sperino, of  Turin, Danielson,  of Bergen,  and  Carlsson, of
Stockholm.  It is further claimed  by some of the advocates of
syphilization,  that  it is the only remedy  we know; and that
the eruptions,  the rheumatic and neuralgic pains, and  other
symptoms  of  constitutional  syphilis, vanish  under  repeated
inoculations.
  I opine that the day is far distant when the  medical faculty
of this or any other enlightened  portion of the globe will credit
the idea that  the  waning health  of a human  being can be
restored or benefited by artificial syphilization, as intimated by
the Norwegian professor.   Certain it is, that no human provi-
dence can calculate or guard  against the physical  mischiefs that
might accrue to individuals subjected to this hypothetical and
insane line of treatment.   Instances of  the most  terrible  disas-
  * Boeck deprecates the use of mercury,  which he calls a devilish remedy.
He holds syphilization not to be merely a local  process, acting by derivation
or by reparative suppuration, but to be  analagous to vaccination ; that it fixes
a certain materies morbi of the body, and renders it latent,  but  does not
destroy it.  Neither syphilization nor mercury, according to this author, really
cures syphilis, but only renders it innocuous. 
        CONSTITUTIONAL TREATMENT  OF  CHANCRE.     205

ters  resulting from it have already been  reported.  Mr. Law-
rence, of London, states that one of the most troublesome cases
of phagedaenic ulceration of the thighs which ever came under
his notice, was in consequence of artificial inoculation performed
by a  physician.   Other  instances  are recorded, in  which the
chancrous sores, manufactured by reckless hands, have  refused
for a  long time  to heal or amend under any remedial measures.
It may be that  the  experience of Turenne and  others will in-
spire  hope and courage among libertines and their meretricious
companions, who hail from  the dens of Paris and  some of the
other continental cities, and who may be induced to submit to
such  a style of tattooing  and mutilation ; but it is scarcely to be
supposed that  the  medical  faculty of  this  country will  ever
countenance such a  beastly mode of treatment, — certainly not
until   investigations  and experiments shall ripen into  higher
completeness, and the sanative  power of the measure  has  had
time  to exert a  more persistent influence than has yet been dis-
played  in patients who  have resorted to prophylactic syphiliza-
tion.   Without  entering into any discussion of the real truth
or fallacy of the doctrines broached by the advocates of artificial
inoculation, it is enough to say that  the  demoralizing  associa-
tions  and consequences  connected with the practice, are suffi-
cient to  consign  it  to  unqualified condemnation.   The most
revolting feature appertaining to syphilization, and  the  one cal-
culated  to  provoke  unmitigated indignation,  consists in the
bold, barefaced  suggestion that it may be employed as a means
of safety for persons  who are as yet  untainted, and who can
subject themselves  to this factitious disease, and ever after be
shielded  from infection,  however deeply they may plunge  into
the foul  cess-pool of licentiousness  and corruption.  The  next
step  in  the march of improvement, peradventure, will  consist
in the internal  administration of pure venereal  pus, or perhaps
the mollified crusts of rupia, made  into a paste or bolus.   This
would be a fitting climax.*

   • Two physicians have lately been tried in a court of justice in France, for
practising artificial  syphilization on a  young boy at a charitable institution.
The boy had  favus, which got well after syphilization was  resorted to.   The
court, however, ignored  the pretensions of medical science in the case, and
imposed a fine on the physicians for giving the boy the venereal disease, and
which he might transmit hereafter to his offspring.
                 18 
206
GONORRHOEA AND SYPHILIS.
    The  organs composing the emunctory system — that is, the
  liver, the kidneys, the alimentary canal, the entire circle of the
  mucous membranes, and the skin, with its millions of sudorifer-
  ous and sebaceous glands and ducts — constitute  the machinery
  — the channels — through the medium of which  the syphilitic
  poison  can be removed from the animal economy.  Although
  the anatomical apparatus we have to work with  is situated in
  different portions of the  frame, and  in  structure possesses  no
  special homogeneousness or resemblance in its several parts as
  above named, yet as  a  group, and in  respect to  function, they
  sustain a close affinity or relation ; and fortunately, in a practi-
  cal point of view, they  can be brought to do  good service either
  by the  same  remedial agents, varying in quantity and in the
.  modes  of administration, or by different remedies  so   com-
  pounded as  to perform a harmonious action, and leading to
  the same practical results.   And  thus, if a case of constitutional
  syphilis  be cured, it is in  this way that these  emunctory forces,
  inherent in the system, carry away day by day, in homoeopathic
  quantities, the poisonous element, until the last particle is ex-
  hausted, and the morbid process  engendered  by its presence is
  brought to its final  rest.

    Methods op  Treating Syphilis. — Statistics of the various
  modes  of treatment that have  been  pursued,  from time  to
  time, in different countries,  are sufficiently numerous and  com-
  prehensive ; and, if the numerical  computation were  adopted
  as the basis upon which to form  an opinion  relative  to this or
  that method of cure, all parties might claim success, and  even
  triumph, for their cures are  reported in figures running up to
  thousands  and hundreds  of thousands.  And  if we  can rely
  upon human  testimony, we  are  compelled  to admit  that the
  venereal disease, in all its  forms, can  be cured  in more  ways
  than one, — that is, either with or without mercury.
    Of the great  variety of  remedies  that have  been  arrayed
  against the malady under consideration, probably no  one has
  encountered  more  formidable enemies, fought harder battles,
  or  achieved more  signal victories, than mercury.  During the
  last hundred years, the fortunes  of this article in the materia
  medica,  like the fortunes of some  men,'have been  somewhat
  checkered.  At one period it has  enjoyed the sunshine of  favor 
        CONSTITUTIONAL  TREATMENT OF CHANCRE.    207

throughout the medical world ;  at another, it has been doomed
to fall into disrepute, and  to give place to the vaunted claims
of various rivals,  which, in turn, have lived out their brief day
of popular notoriety, and then dropped into the grave with  the
pall  of oblivion  upon  them.   And now, again, it may be said
that  the medicine in  question has been resuscitated, Phoenix-
like, from its ashes :  for at the present day it is regarded by the
chief savans in the profession, not perhaps  in the  light of a spe-
cific  antidote to syphilis, as it once was, but as indispensable to
its best  management in a  great majority of cases ; and the sta-
bility of its popularity, as it  is now considered  and  modified,
can  scarcely be questioned.
  It seems but fair, in this connection, that the substance of the
experiments that have been tried, for the purpose of testing the
claims of the  mercurial and  non-mercurial treatment of syphi-
lis, should be stated.  This will be done with  all convenient
brevity.
   Some years ago, the results of two  thousand cases occurring
in two years, in the British army, were reported under the su-
pervision of the late Sir James  McGrigor.   These were all  rep-
resented as cases of  primary syphilitic ulcers on the penis, and
were reported as cured without mercury.  The  average length
of time required for the non-mercurial course to complete the
alleged cures, where no buboes existed, was twenty-one days ;
for those with buboes, forty-five  days.  From these  results, it
would appear that primary venereal sores  can be cured without
mercury, and in  a  shorter  period  than when that  mineral  is
used.   But, while this statement has been made by the advo-
cates of the anti-mercurial treatment, they at the same time
acknowledge  the utility  of mercury under certain circum-
stances, and admit that some cases prove obstinate  unless this
remedy is employed.   When  these  peculiar cases are likely  to
occur can never be known beforehand by the medical attendant.
It would therefore seem to be wiser policy to anticipate them  in
the onset, by  the timely and  careful use of mercury, rather than
trust to a code of practice which may not in all cases secure the
desired results without an  appeal to some mercurial preparation.
   In 1828, experiments instituted by Dr. Fricke, in the Ham-
burg General Hospital, were  first made public.   In  four years,
out  of one thousand six hundred and forty-nine patients of both 
208
GONORRHOEA AND SYPHILIS.
sexes, five  hundred  and eighty-two were treated with a  mild
course of mercurv, and one  thousand and  sixty-seven without
mercury.   The mean duration  of the  latter method was  forty-
one days, and that with mercury eighty-five days.  Dr. Fricke
states that relapses were more frequent, and  secondary accidents
more severe, where mercury was given.  He observes, also, that
he has treated more than five thousand patients without it, and
has still  to seek  cases  in which  that  remedy may be advanta-
geously  employed.
  In 18o3, the French Council of Health published the reports
sent in by the physicians and surgeons  attached  to regiments
and hospitals in various parts of France.   Some of these reports
were in favor of the  mercurial method, others adverse to it.
  From  various  published  documents,  embracing  more  than
80,000 cases,  Professor Bennett,  of  Edinburgh,  regards  it as
established that primary syphilis  is cured  by what is termed
the simple treatment  more readily than  by  any other, and with
less probability of the occurrence  of secondary symptoms.  He
considers that the diminution in late years of the  frightful sec-
ondary and tertiary  accidents, which were  so  common  many
years ago in Scotland, is to  be  attributed to important revolu-
tions in practice; and he is inclined to award the credit to the
non-mercurialists, and, so  far as  relates to the treatment of the
venereal  disease, he belongs to that class of  practitioners.  His
views,  however, of what  constitutes the mercurial treatment
appear to be different from what  the  present mode  of practice
would seem to sanction.  He remarks  that  this treatment con-
sists in keeping up a slight  salivation, at least, for the space of
a month.  Such a mercurial course would  doubtless, in  many
cases, be  well nigh as destructive  to the  patient as the malady
which it was intended  to cure, and no  wonder that Professor
Bennett and others object to it.   But this  is  not the method
that is advocated or practised at the present day by any intelli-
gent mercurialist.  Indeed,  the very term  mercurialist, in the
signification attached to it thirty years  ago, is perfectly obsolete
in this country, at least.  The word was applicable to a  class
of practitioners who  flourished some half a century since, and
are now dead.
  It has  not only been demonstrated  that all syphilitic manifes-
tations, whether primary or secondary, may  be removed without 
CONSTITUTIONAL TREATMENT OF CHANCRE.
the aid of mercury, but also that, in some  cases, the work is
accomplished  in  a shorter  period where this substance is  not
prescribed.  Ricord treated with mercury  two  hundred  and
ninety-two  men,  and, without  mercury, five  hundred  and
ninety-eight.  It required  forty-two  days, on an  average,  to
cure the former, and only twenty-eight days the latter.  Thus
it appears that the use of mercury delays the healing of  the
primary lesion  by one  third  the  period  required  when that
mineral is  not  employed.  It is  admitted,  however, that,  in
cases accompanied by much  induration, the administration of
mercury materially shortens the duration of the chancrous sore.
   With regard  to  the  greater or less frequency of  secondary
symptoms, after the removal of the primary accidents, treated
with  the  use  of mercury  or  without  it, I  am  persuaded, from
reliable evidence  thus far adduced,  that  such  symptoms  are
more frequent in cases where mercury has not constituted  an
essential part of the remedial course.  I am unable, however,
to credit the statement of Mr. Bacot,  who  says that  secondary
symptoms occur in the proportion of one case  in ten where no
mercury has been  used for the cure  of the  primary affection ;
whilst,  on the contrary, the proportion of such  cases is only one
in seventy-five where  that  remedy is employed.  Would that
this statement in  all its particulars were true, but the history
of syphilis,  as now seen, does not correspond with  the remark
of Bacot.  The proportion of cases in  wliich  consecutive lesions
appear  is much greater than he mentions.  " I cannot  agree,"
says Erichsen, " with  the  statement that secondary  symptoms
are less frequent after the simple than  after the mercurial treat-
ment of syphilis.  I have seen the non-mercurial  plan of treat-
ment very  extensively  employed  at  the University  College
Hospital: indeed, it was formerly almost  invariably practised
there, more particularly in the syphilitic cases occurring among
out-door patients under the late Mr. Morton, who  strongly advo-
cated it; and I have repeated occasion to observe the  frequency
with which it was followed by secondary symptoms.   In private
practice, also,  I have had considerable  opportunities of compar-
ing the  two  methods ;  and I can safely say that I have seen the
simple  treatment more frequently followed by  secondary symp-
toms  than the mercurial  plan has been  when  properly  and
judiciously employed."
                18* 
210
GONORRHOEA AND SYPHILIS.
  The advocates of the simple treatment are doubtless correct
in the idea that mercury has  no specific effect upon  the syphi-
litic poison, but that it acts,  like other remedies, as  an altera-
tive, by increasing the amount of secretions and  excretions ;
and thus, we argue, that it favors the elimination of the vene-
real virus.  Although  I am  far from believing  that the  mer^
curial preparations justify all  that has been  advanced  in  their
praise, I am  by no  means disposed  to discard them from the
catalogue of our  most useful remedies  in  the treatment of
various syphilitic affections.   I employ them as valuable and
important  additions to the simple plan  of treatment.  I  have
faith  in  them;  but it is  a  modification of the faith, which,
thirty years ago, ruled  and misguided  medical practice far and
wide.   For the cure of indurated chancre they are almost in-
dispensable.   But  great circumspection is demanded  in  their
administration.  Their influence upon  the  general  condition
of the  patient, as well  as upon the disease, cannot  be too  care-
fully watched.   In many cases it is  undeniable  that mercury
aggravates all the  symptoms.   One of the  earliest  and  most
frequent forms of syphilis, in  which it  is mischievous, is the
non-indurated chancre or ulcer, the  cure of which it tends to
prevent by altering the system in such  a manner as  to favor
the progress  of  ulceration, rather than  arrest it;  and it  can-
not in any way protect the  patient from secondary accidents
under  these circumstances.  It is well known, also,  that  mer-
cury will sometimes induce ulcerations sui generis.   The fault,
however,  is not always  in the medicine, but,  rather, in the
manner of prescribing  it.
  In  the treatment of patients of well-known  scrofulous dia-
thesis, or  in whom  any peculiar susceptibility to the action of
mercury exists, it is generally  an  easy matter to regulate the
dose so as to  meet this peculiarity, provided it  is certain  that
the remedy is demanded.   But the mere fact that any idiosyn-
crasy  does even exist in the patient, should deter from  the use
of any mercurial agent, except in the mildest form, in the  most
cautious manner, and  as wholly subsidiary to other therapeutic
measures.
   In  all  instances where  there is  a tendency  to  sloughing,
whether  in a  primary chancrous sore, in a bubo, or  in any of
the later  affections, the mineral of which we are now speaking 
CONSTITUTIONAL  TREATMENT  OF CHANCRE.
ought to be regarded as injurious, if not absolutely dangerous,
to the patient, and  therefore inadmissible.  It is  not  my pur-
pose, however, to set forth, in this place, a full  specification of
the circumstances and conditions of the  syphilitic  patient,
which  render the administration  of this potent remedy, in
any form or combination, judicious or otherwise.   Occasions for
speaking more explicitly will necessarily  occur  with sufficient
frequency, as we proceed to a consideration of the various acci-
dents that will present themselves for treatment.
   In  the  selection of mercurial  preparations for internal  use,
every practitioner is more or less partial to some particular
formula.   The blue pill and the hydrargyrum  cum creta are
preferred by some of  the most  substantial  English  surgeons
and  physicians.    The protochloride, the bichloride, the iodide,
and  the biniodide, have likewise their advocates.   Mr. Wilson
and Dr. Egan are in favor of the blue pill.  The latter writer
recommends that gentle  ptyalism be maintained  for several
weeks; but I feel warranted in stating that the leading prac-
titioners in this country  do not sanction or follow  such ad-
vice,  whatever  they  may have  done in  years gone by.   The
blue pill is easily managed.  One at night, for five or six nights,
either with or without  a  small quantity of opium, according
to the irritant action of the  pill  upon the bowels, will answer.
After some half a dozen  pills  have been  taken, one  may be
given  in  the morning  also, or every  other  morning.  This
cautious proceeding, which is  recommended by  Mr.  Wilson,
should  always be observed for the first few days, whatever be
the form  of mercury selected for use, because  its effects upon
the system have not yet been ascertained ; and if any peculiar-
ity exist, it will  readily  be discovered.   If the hydrargyrum
cum creta be preferred, the proper dose  will be three grains,
which are  about equal  to  five grains of blue pill, twice a  day.
   It  was once  considered important to  provoke  the  salivary
apparatus  to copious ptyalism in order  to obtain  the  greatest
benefit  from the mercurial  treatment.   The medical  men of
the old school probably never felt in a more jubilant mood than
on those occasions  when  they witnessed the flowing  streams
set in motion by the potent  magic of calomel, administered by
their  own  hands.  More  recently, the  opinion has  prevailed
that a  constant,  although moderate, soreness  of  the  gums  is 
212
GONORRHOEA AND SYPHILIS.
all that is necessary.   These two methods  seemed to be  based
on the theory that the morbid effect of the medicine upon  the
healthy tissues,  must precede its salutary action on  the  dis-
eased structures; whereas, it will appear  evident, if we care-
fully watch the  influence of the  mercury upon the  symptoms,
that  if the amendment  take  place at all, it commences I efore
the gums become red  and  tumefied.  The remedy produces
the good before  it does the harm.  We can now take a retro-
spective  view,  and see  that in  the treatment of the  disease
with mercurial preparations, the  various mischiefs which have
been inflicted upon  the gums, the  teeth, the buccal  mucous
membrane, the  salivary glands, and even upon the constitution
itself,  were unnecessary  and barbarous.   Had  the  prudent
method of Erasmus Wilson  been adopted half a  century ago,
the prejudice against mercurials would  never  have existed —a
prejudice which  had its  foundation in the evil practice of giv-
ing the mineral in question with a  recklessness  which seems
almost incredible, and  which, if pursued  at  the  present day,
would  be almost suicidal to the medical men who should coun-
tenance  it.   This treatment, to  which was  usually joined a
process of semi-starvation, was called heroic.  It was  so with
a vengeance.   Fortunately for the poor wight  who has syphilis,
a  more  enlightened  and  auspicious  epoch in the career of
medicine has arrived ;  and the action of mercury,  and  its abso-
lute  value in  subduing  certain  symptoms, arising  from  the
syphilitic virus, are now better  understood.  Implicit  faith in
the  power of this therapeutic agent  no  longer exists  in  the
ranks  of the medical  profession; and  since it has  been their
custom to  prescribe  it  in fewer  cases and in vastly less quan-
tities than formerly, the venereal disease  has  ceased to commit
such terrible ravages on the  human organization.  It need  not
be repeated that in the administration of mercury  it is  never
requisite or desirable to salivate.  The venereal poison cannot
be drawn into such an unnatural current,  and through this be
piloted out and disembogued from  the  system.  The patient
cannot spit out  the disease.  To  attempt  its elimination by es-
tablishing  an artificial  drain through  the salivary apparatus,
would  be like  beating  the air with  a feather with a  view to
expel  from it the miasm  of yellow fever. In both cases, the
poison is endowed with a sort of ubiquity; in the one, pervad- 
       CONSTITUTIONAL  TREATMENT  OF CHANCRE.     213

ing the human  constitution; in the other,  that of the  atmos-
phere.
  The  ultimate  point  to  which we should ever push  the  use
of mercury,  is,  merely to increase the redness of the  gums;
and  this increase in the  vascularity of the capillaries  of  the
mucous membrane,  should  be regarded as a warning  to with-
hold the article entirely for a few days, or else to employ it in
very much diminished quantities.
  In some instances,  persons, who have doubted  their ability
to take mercury in any  form or quantity,  on account of the
facility  with  which  they  imagined ptyalism  would occur, have
been prevailed upon to make trial, with the promise given to
them, that the moment any special physiological effect is  dis-
played  in the condition  of the gums  or breath,  the medicine
will  be  discontinued ;  and in  scarcely a single  instance has the
apprehended evil or disability been realized.   In  prescribing
mercury, nothing is gained by being in a hurry.   On the con-
trary, by a  little  patience, the physician will rarely  fail  to
manage the  patient in a  manner that will not  disturb  the  sys-
tem, which  can gradually be brought to tolerate  the medicine
to the  extent  required,  not  only without inconvenience,  but
with all desirable  comfort and advantage.   If received into
the stomach  in  connection with the meals, it  has appeared to
be borne  more  quietly than  when taken  under other  circum-
stances; and it is  not improbable  that by  accompanying  the
food, being  incorporated with it through the  different stages
of digestion, and mingling with  it in its progress to be trans-
formed  into  blood,  and finally  gaining  access  to the most
minute ramifications  of  the  tissues, it permeates  the  entire
organization  more  freely  than it otherwise would.   I therefore
always  direct the patient to  take it immediately after eating;
and  when this rule is observed, it produces no pain,  griping,
or other trouble in. the   alimentary canal,— considerations of
no small  importance.  The late Mr. Babington recommended
that mercury be used  as  here mentioned.  Of  course it cannot
be regarded  as part and parcel of the aliment of the economy;
and  yet it  fulfils a purpose  scarcely subordinate  to it in the
circumstances requiring its employment, for  it  serves as a sub-
stitute, and  sometimes more  than an  equivalent, for any other
medicinal substance.  When properly  administered, it  acts as 
214
GONORRHOEA AND SYPHILIS.
a benign and safe alterative upon  the  skin, kidneys, liver, and
gastro-pulmonary mucous tissue simultaneously.  Does not this
effect upon the emunctory system afford a solution of its modus
operandi in the cure we seek to accomplish ?   And  does it  not,
without any  forced  or  far-fetched  argument, justify and  com-
mend  its use ?  It  is not simply  because  two poisons cannot
exist in the system at the  same time, as  was first broached by
the  sagacious  Hunter ;  but because  it stimulates to greater
activity the different eliminative organs, between which nature
has established a consent or unity of functional labors.
   The mercurial practice has now become venerable with age,
and  a cloud  of witnesses, both  among the living and the dead,
and  of the highest  distinction  in  the  profession  of medicine,
might be adduced  to testify to its efficacy ;  but such a marshaling
of names is uncalled for; nor is it  necessary at this day for any
man to enter the lists as a special champion in its defence.
   In commenting upon  the use of different  mercurial  prepara-
tions, I have made no particular  allusion to the external em-
ployment of  the mercurial ointment.  Formerly, inunction  was
a prevalent method  of subduing venereal symptoms.   In later
years, this  plan has  been to a great extent laid aside, in  this
country at least.  It is still regarded by some  of the  most
eminent German physicians and surgeons as preferable to  any
other treatment.   Professor Carl Sigmund  in a recent publica-
tion, says:  "While  we  write  these lines,  the  result of the
records of cases [at the Vienna Hospital] from the year 1842 to
1855, lies before us.  9,379  cases  treated by the  external use
of mercurial  ointment as here laid down, justify the statements
which we have just made.  .  .   .   Our observations have been
verified by patients  from all professions  and all ages, and in
all the five parts  of the world  our  followers have  confirmed
these observations, in  cases without number.  We, therefore,
think ourselves authorized  in  asserting  that until  a  remedy
equally good  or better shall be pointed out, mercury, and  above
all, mercurial ointment externally, is to be preferred to all other
remedies."  Professor Hebra, of Vienna, agrees with Sigmund as
to the superiority of  mercury, and particularly of the ointment.
  It  has already been remarked that the  malady under consid-
eration has, ordinarily, its initial development in chancre.  But
it  does not stop here.   Its  tendency is to pursue an aggressive 
        CONSTITUTIONAL  TREATMENT OF CHANCRE.      215

course;  and when  not disturbed by the interference  of the
surgeon  or  physician,  it describes  a cycle of phenomena, —
primary, secondary, and tertiary, — with  great regularity, just
as we  witness  in  variola,  vaccinia,  or rubeola, except that its
different evolutions and periods require months or years,  instead
of days, for their completion.   But if the patient has undergone
medical treatment, the normal  series in the chain of successive
manifestations  is  frequently  broken,  and the  symptoms are
developed in an irregular manner.  For  instance, the use of
certain drugs may keep at bay  the  secondary  accidents,  but not
annihilate the syphilitic diathesis, and a train of tertiary  affec-
tions, over which  the treatment has exerted  no  control, may
appear.  Such instances every now and then present themselves.
   In more particularly presenting the plans of  treatment, it will
be advisable to speak of the disease separately  in the three prin-
cipal pathological stages, into which syphilographers have agreed
to divide it.  These several stages or forms, namely, the primary,
the secondary, and the tertiary, have each their individual and
well-marked characteristic features, which, for the most part,
appear in uniform, chronological order, and with almost mathe-
matical precision; and  as chancre claims priority, it will be the
theme for consideration in the next chapter. 
CHAPTER XIX.
                        CHANCRE.

  Of the  primary sores, there are several varieties.   The in-
durated form first claims our attention.  It is  generally admit-
ted by surgeons that as soon as a chancre has become indurated
— which usually takes place during the first week or two — and
is the true, classical, Hunterian chancre, the disease cannot be
regarded as any longer a purely local affection ; and the proba-
bility is that the abortive treatment can do the patient no good.
For  this,  the golden  opportunity  is  lost.  Cauterization and
caustics are, under ordinary circumstances, excluded from the
list of curatives;  and if thought of at all by the practitioner, it
is only that he must say of them  to the patient, — it is too late
for their  successful employment;  for  induration  is almost a
certain proof that the system is contaminated.   Ricord believes
that to this  rule  there is no exception, and that it is the
prerogative  of indurated  chancre,  alone, to impregnate  the
system.  Upon this latter point,  however, there is  not a uni-
formity of opinion.  Facts are  almost daily brought to light in
the history of syphilitic patients, which totally contravene the the-
ory that an individual, who has secondary symptoms, must have
had an indurated chancre at some former period.  The doctrine
so strenuously insisted upon by Ricord, is  not sustained by the
observations of other authorities, who  are entitled  to be heard
on this subject, and who do not  confine the origin of constitu-
tional syphilis exclusively to indurated  chancre.   I refer to the
teachings  of such men as Vidal, W7ilson, Lane, Sigmund, Trous-
seau, and Velpeau.   In my own practice, several instances  of
secondary accidents, in  adult  subjects,  have  occurred, in which
the parties were totally unconscious of   having  had  primary
disease.   Of this I am certain.  Is it  possible that in  each  of
these cases a  concealed  chancre existed ?   If  so,  it must have
healed spontaneously, and  without  causing enlargement of the
          (216) 
CHANCRE.
217
inguinal glands.   This supposition, to me, seems unreasonable.
Some of the cases to which I here refer, will be related in con-
nection with secondary affections.
  The indurated chancre is rarely followed by a  suppurating
bubo, although tumefaction of the inguinal glands usually takes
place on both sides, — not, however, in all  instances, as stated
by some writers.  Some years since, I saw  a case of indurated
chancre in a patient of Dr. John  Homans, of this city.  The
glands  on the right side, only, were  involved.   Consecutive
secondary and tertiary symptoms supervened and  lasted for  a
long period.    In the early part of March, 1857, a married man
came under my care for a large chancrous sore, situated on both
sides of  the  fraenum, and  implicating this membranous fold,
which was finally destroyed by ulceration.  Four  chancres, of
veritable  Hunterian type,  next appeared  upon the external
 surface of the prepuce near its border; and subsequently, a
 chancre  formed upon the abdomen, by accidental inoculation,
just  below  the umbilicus;  and  lastly, one on  the dorsum
 pCniSi —  also  by  inoculation from the patient himself, — near
 the pubes, — making a total  of seven chancres on this man.
 The healing of these  primary lesions consumed more than five
 months' time.  During the early period of  the first sore, a bubo
 of medium size came in the left groin, and remained six weeks.
 The  other inguinal region continued in a perfectly normal state.
 The  treatment for this patient consisted, internally, of bichloride
 of mercury  in pill, and for external  dressings, the black wash,
 aromatic wine, and weak chlorinated water, and the nitric oxide
 of mercury  ointment.  Blisters were applied over the tumified
 inguinal  glands.
   Although  there is  no  specific for the cure of any syphilitic
 affection, I feel justified in saying that  for indurated chancre
 mercury is the surest and safest remedial agent we can employ.
 Its salutary  operation in  obliterating the induration without
 detriment to the system, is now acknowledged, almost without a
 dissenting voice, in the highest circles of  the profession.  But
 let us  be sure that we have an indurated chancre to cure,  before
 we prescribe  this remedy.  The particular form which may be
 chosen, is not a  matter  of very great importance.  In  certain
 cases,  each  preparation  may  have  its advantages  or  disad-
 vantages ; but both are to  be regarded as mere casual circum-
                     19 
218
GONORRHOEA AND  SYPHILIS.
 stances, that are not inherent in the medicine.   The submuriate
 is quick and  rather harsh in its action; but in cases  of iritis,
 where there is  no time for delay,  and where  a mercurial  has
 been determined upon, it is particularly  appropriate.   It is  less
 valuable and less called for  in  indurated chancre.  It is more
 liable than the  other mercurial salts to disturb the bowels and
 debilitate the system to  a greater degree than is desirable.
   Plethora, and an anaemic  condition of the patient,  are both
 unfavorable for the advantageous  exhibition of  mercury.  In
 the  former case, before  commencing with this article, it will be
 best to reduce the system by a spare diet for three or four days,
 and by the use of a moderate  saline laxative, after  which  the
 mercurial treatment will be admissible.   If the  patient be pale,
 feeble, and wanting in constitutional vigor, mercurials should be
 dealt out in the most sparing manner, if at all; and given in
 connection with some ferruginous medicines.  Of these, the tar-
 trate of iron and potash  is by  far the best.  Whenever a tonic is
 required, as an adjuvant to mercury, the following is entitled to
 precedence above all others: —

  ft.  Ferri Potassio Tartratis,
       Aquae Fontanse, .  .  .

  Two teaspoonfuls of this solution may be taken  three times a
 day in a decoction of quassia prepared as follows: —

  ft.  Quassias Rasurae,.............►) xij.
  Div. in chart, No. vj.

  Steep  one parcel  in a pint of water for an hour.  Strain the
 decoction, and let a gill  of  it  be taken with  two drachms of the
 above ferruginous solution.
  An ounce of the potassio-tartrate of iron, of ordinary samples,
 is as much as can conveniently be dissolved  in  eight ounces  of
 cold water.  There  is quite a difference in the solubility of this
 salt as prepared  by different chemists.  Specimens which I have
 seen and used from Messrs. Morson & Son, of  London, I think
 are superior to  any other.  One ounce of their preparation will
readily dissolve in six ounces  of water.
  The citrate of iron and quinine makes a good tonic  also, and
may be taken  in conjunction with any of the mercurial salts, if
3J-
M. 
CHANCRE.
219
the individual find it inconvenient to make use of the first men-
tioned chalybeate.  The  citrate may be  given  in pills  of four
grains each, of which  three  may be taken per diem.   Should
constipation be  induced,  it may be  counteracted by the occa-
sional use of syrup  of senna, by eating freely of fruits, and by
other suitable diet.   If the blue  pill be  selected, as a  general
rule one  may be  taken at night with the fourth of a grain of
opium, and one  in the morning without the opium.  Should the
patient become  costive in consequence of the opium, then the
morning pills may be given in the  evening  as well as  in the
morning.   On the contrary, if the bowels are relaxed, the opium
is to be taken in the morning as well as at night.  With  this va-
riation in the pills, the mercury may  be continued until the sore
has disappeared and the hardness of its  base  subsided, unless
symptoms arise that indicate  an approaching ptyalism.  This, in
substance, is the plan  proposed by Professor Wilson.   The ben-
eficial action of  the remedy is usually manifested in a few days.
The average time which the  indurated  sore requires  for  passing
through  its different stages, before cicatrization is fully accom-
plished, is, under  favorable circumstances, four  weeks. ' During
the mercurial course,  the  patient should be carefully watched,
and be kept from  all exposure  to inclement weather.
  Ricord  is partial to  the proto-iodide  of mercury for the cure
of the Hunterian  chancre.  This preparation is perfectly man-
ageable with most persons, and may  be prescribed according  to
the subjoined formula : —

  ft.   Hydrargyri Proto-Iodidi,..........9 ij.
       Extracti Hyoscyami,...........3j-
  M.   Ft. pil.  No.  xl.

  Give one pill  at night.   At  the end  of a week, two pills per
diem  may  be  ordered, one in the morning and one at night.
The good  effects of the medicine  are observed  in the condition
of the induration, which  diminishes in extent  and  hardness ;
the discharge consists of well-elaborated pus ; the surface  of the
sore presents a  clean, healthy aspect, is covered  with granula-
tions,  and a cicatrix is soon formed.   These results follow when
any of the  preparations of mercury act kindly.  The  patient
should continue  one pill,  or half of  a pill, each day, for two  or
three  weeks after the induration has disappeared.  The absolute 
220             GONORRHOEA AND SYPHILIS.

quantity which  may  be requisite in any  given  case, is to be
determined, not only by the cicatrization of the lesion, but also
by the  perfect resolution of  the induration, which is the last
abnormal condition to yield.
  Some authorities recommend not to employ mercury during
the first few days after the appearance of the induration.   The
object of this delay is to ascertain if nature will not remove the
hardness, and thus prove that it is not of a specific  character.
If a man present  himself with a sore  having a hard  base, this
sore being the result  of a suspicious connection had a few days
previously, the temptation to prescribe mercury at once, is very
strong, provided the practitioner designs to trust  to this remedy
at all ; and yet,  the advice to defer the employment of mercury,
is good.  The induration may  be like that met with  in acne, and
not the persistent, cartilaginous mass, which constitutes the floor
of the true Hunterian chancre.   It has already been stated that
the form of indurated ulcer  described  by Hunter,  as  having a
hard base, with  a margin terminating abruptly, and not extend-
ing itself into the adjacent tissues, is seldom met with.
  In carrying out the  general rule that mercury should  be
given as long as the induration continues, and even longer, the
practitioner must not forget that in some protracted cases, the
mass may consist  of something more than specific induration.
It may be  composed  of organized  tissue, which  cannot be re-
moved or acted upon by the mercury, however long  persisted in.
This fact has been confirmed  by Wallace and others.   Persons
have been known to bear traces of induration for years after a
course of mercury has been discontinued, and yet no secondary
symptoms have followed.  It is evident, therefore,  that the direc-
tions given by some writers, for the administration of mercury
so long as any hardness remains at the bottom of the chancrous
sore, or where this sore was, are not to be  implicitly observed.
Out of thirty cases reported  by Dr. Egan, the induration passed
away in  twelve,  after moderate salivation.   In the remaining
eighteen, it persisted for an indefinite period  after the  effects of
mercury had ceased, notwithstanding  which, no symptoms of
constitutional infection were  observable, although many of this
class of  patients  were detained in hospital a long  time in the
anticipation of such an occurrence.
  Those  who  give preference of the  proto-iodide  over other 
CHANCRE.
221
forms of mercury,  claim  for it that  it will  not  only  cure the
local  disease, but that it  will  likewise, in a majority of  cases,
secure the patient  from secondary symptoms ; or, if secondary
affections supervene, they will  be of a mild type, and  the con-
stitution, not being injured by the previous use of the medicine,
will bear it a second time, if need be, not only with impunity,
but with every advantage.  The same may be said, however, in
regard to any mercurial preparation, with equal  truth.  If ad-
ministered properly, there is no danger;  their abuse is the evil
to be avoided.
   There is one  preparation  of  mercury — the bichloride —
which, for  more than  three  quarters of a century, enjoyed the
confidence of the most distinguished  members of the profession
in this country and in Europe for the cure of syphilis, but which,
of late  years,  and without  any good reason, has fallen into
desuetude in some quarters.  In the constitutional treatment of
indurated  chancre, and indeed of all specific symptoms, Drs.
David Hosack, and John  W. Francis, of New York, during the
most brilliant period of  their  professional career, were accus-
tomed to employ this  salt to the exclusion of  every other mer-
curial.
   Of the merits of the bichloride, Dr. Hosack says:  " In the
constitutional disease called  syphilis, as a general rule  I  have
found the  internal preferable  to the external  use  of  mercury,
and  the mercurial salt, wliich, from experience, I recommend as
combining most  advantages,  and as agreeing  best  with the
greatest  number of cases, is  the  corrosive  sublimate,  or the
oxymuriate of mercury.  This  salt, either in  the  form  of pill or
solution, I have uniformly employed in the cure of syphilis, not
only when the disease  may have been recently contracted, but
in the most malignant form which it assumes, when it  has  been
neglected or injudiciously managed.   A valuable auxiliary will
also  be found in the decoction  of the lignum  guaiaci and the
radix sarsaparillae as powerful  alteratives. Here I  cannot but
protest against the salivating system  by friction with mercurial
ointment and the use of calomel, so commonly had recourse to.
It is  true that these forms  of exhibiting the  article  very soon
affect  the  system ; but it is no less  true, that when mercury
exerts its influence upon  the  salivary glands,  in proportion as
                       19* 
000
GONORRHOEA AND  SYPHILIS.
this  influence  is manifested, it ceases  to  operate  upon  other
excretions  of the system, and consequently  is less active  in
eliminating from the body the poison of the disease.   Salivation,
it is now well  ascertained, is wholly unnecessary in  the  treat-
ment of syphilis, and the knowledge of this truth cannot be too
extensively circulated in a country, where,  notwithstanding the
respectable state of medical science, many of the most pernicious
errors of some of the older practitioners, are still sedulously cul-
tivated.  I am aware that in certain of the public  hospitals  of
Great Britain, as well as of the United States, the corrosive sub-
limate is rigidly prohibited for the cure both of the primary and
secondary stages  of lues venerea ;  but it deserves  to be  recol-
lected  that this form of mercury still retains, throughout the
European continent, the high celebrity it acquired long since  as
an anti-venereal.  In the venereal hospital  of  Paris, the largest
and  one of the best conducted establishments of Europe, the
corrosive sublimate is the  only form of mercury employed ; and
Professor Cullerier, after the most ample experience  at this
charity, knows  not an  instance  of failure with this remedy,  or
one in which it has produced injurious effects."
  I  will present the views  of Dr.  Francis, as expressed  in  an
Essay published in the Medical and Philosophical Register some
years since: —
  " Among the principal advantages which  the corrosive sub-
limate possesses over every  other preparation of mercury, are,
that judiciously administered, it is  particularly mild and safe  in
its  operation;  will  admit of more extensive use in  all the
various forms of lues venerea, and subject the patient to fewer
inconveniences;  that it enters  readily  into the  general  circu-
lation, becomes  miscible  with  the several fluids of the  body,
the  soonest arrests  the progress  of the complaint,  and elim-
inates  the morbid matter  through those  emunctories of the
body best  calculated for  that purpose; that it  supersedes the
necessity of salivation  by its  action on all the secretions, and  by
promoting, especially, the cuticular  discharges and  the  evacua-
tions from the kidneys;  that it is  the  only preparation  to  be
depended on in those  peculiar  habits of body so susceptible  to
become salivated by every other form of mercury  now in use;
that in its  ultimate effects upon the constitution, it is attended
with comparatively  no injury.   These  facts  are indeed truly 
CHANCRE.
223
important,  and  many  of  them  are  granted  by those  who
altogether reject the use of this preparation."
  One hundred years  ago, the bichloride of mercury was admin-
istered in the right  way; and  its power, as manifested through
the skilful use of it by the celebrated  Locker, chief surgeon to
the Venereal  Hospital  of Vienna, has not been surpassed by
any  article employed  since  his  day.   He  states that he cured
4,000  cases of syphilis, in different forms, with the  corrosive
sublimate alone, and without  inducing  salivation, or any un-
pleasant constitutional  effects.  These cases were all treated
between the years 1754  and 1762.
  A  late  number  of  the  London Lancet, referring to  the
oxymuriate of  mercury,  has  this expression:   " The bichlo-
ride  is borne  better than  any other form of  mercury, and
can be  continued with  safety longer than  any  other mercurial
preparation." *
  If  the bichloride was ever  entitled  to the confidence of the
profession, it is worthy  of that distinction  now.   Time has not
impaired its therapeutic qualities, — time  has not modified the
nature  of the  venereal  poison, nor has a change come over  the
organization of the human system.   The three are the same now
that they ever were, — a like immutability in  regard  to them
must always remain; and  the same  relations and the  same
influences must always subsist between them.  And it is certain
that all the anti-venereal qualities, which belong to any of the
modifications of mercury, or  to any of  its combinations  with
other ingredients, exist  in the greatest  simplicity, uniformity,
and purity, and in an  eminent degree, in the corrosive sublimate.
" One  would naturally  suppose,"  says Hunter,  " that  the sim-
plest preparation is  the best, — that which is easiest dissolved in
the animal juices, does  least mischief to the stomach or general
health, and is  least  disturbed or hindered  in  its operations;
for we can hardly suppose that any substance joined with mer-
cury, which alters either its chemical  or mechanical properties
out of the body, can add  to its  power in the body, excepting a
substance which had a similar power when acting alone."
  The  names  of the  two American physicians, who have just
been  mentioned,  are  among  the  most  eminent that  ever
flourished in the annals of medicine in this or any other coun-
* Lancet, 1857, p. 581. 
 224             GONORRHOEA AND SYPHILIS.

 try ;  and their opinion is most important evidence in favor of
 the  remedy now under consideration.   The practice of  Dr.
 Hosack, as set forth in the preceding extract from his writings,
 of administering the oxymuriate of mercury for  the cure of all
 forms of constitutional syphilis, was almost  precisely the same
 as that followed by Dupuytren at the Hotel Dieu  of Paris, where
 the  oxymuriate was  long in vogue as a favorite anti-syphilitic.
 Employed in the careful manner indicated by our distinguished
 countryman, it was  doubtless superior in efficacy to  any other
 method  known in his  day ; and  on the authority of his great
 name, the same course was pursued by the leading practitioners
 of this country in the management of the venereal disease in all
 its stages.   But now a different policy reigns.  The use of mer-
 cury is  very much  confined to the  treatment  of  indurated
 chancre; and  if  prescribed for secondary  affections,  it is,  in
 many cases, as an auxiliary to other  medicinal agents, rather
 than  as the sole or leading one.
   The most convenient way of administering the bichloride is
 in the form of a  pill, combined with an  equal quantity of the
 muriate  of ammonia: —

  ft.   Hydrargyri Chloridi Corrosivi,.........
       Ammonise Muriatis, aa,............gr. xvj.
       Aquae Destillatae,..............3 iss.
   Solutioni  addatur, panis medul. sic. q. s. — Ut fiat massa, in pil. cxxviij.
 dividenda.

   This formula  gives  one eighth of a grain  of the  corrosive
 sublimate to each pill.  The  quantity can therefore be regulated
 with  the greatest precision  for daily use.    One  pill  morning
 and night  in immediate connection with the meals.   In  five or
 six days one pill may be taken  three times a day.  Should  the
 patient be of a delicate  constitution, two pills per diem may be
 sufficient to produce the desired  result.   Some  individuals,
 especially females, complain  that they cannot take  pills.  In
 such cases, the annexed prescription can be directed instead of
the preceding: —
ft.  Hydrargyri Chloridi Corrosivi, .
    Ammonise Muriatis, aa, .   .  .
    Tincturse Cinchonae Compositae,
    Aquae Fontanae,......
giv.  M. 
CHANCRE.
225
  The dose is one drachm morning and evening for one week;
afterwards,  three drachms  each  day, directly  after eating.
When the bichloride  has been taken for twelve or fifteen days,
it is frequently judicious policy to omit it for four or five days,
and then resume it as before.
  Patients with indurated chancre, whether accompanied  with
bubo  or not, should  continue the bichloride for several weeks.
In ordinary  cases, there is no occasion  for  those  rigid pre-
cautionary measures  in regard to  diet and regimen, that are
recommended by some authorities ; nor  need the patient suspend
his usual avocations  from the mere fact  that he is using the
mercury.  But very  likely  there may  be other  circumstances
relating to his condition, which would render  it improper for
him to be abroad.  Indeed, a man or woman, with an indurated
chancre, will usually  find the sick chamber the most appropriate
place during treatment, be that treatment what it may.  Among
the objections of Professor Bennett to the mercurial remedies, is
this : that the  patient must be kept within doors, and submit to
a variety of other restrictions, not  required by the simple treat-
 ment.  But every  candid   mind  will  admit  that under  any
 treatment, the patient  will  recover  more rapidly, and will meet
 with fewer drawbacks and impediments, if he be kept as quiet
 as  possible ;  and his  course  of  living  sliould be  regulated
 according to his constitution.   For stout, athletic individuals,
 of sanguineous temperament, a spare  diet and  a slightly anti-
 phlogistic treatment for a  few days, are indicated, before com-
 mencing with  the oxymuriate ;  for with such patients there is
 occasion to guard against local inflammatory action;  but for the
 feeble, the lank, the lymphatic, who, perhaps, are already suffering
 from defective nutrition, such  a regimen and such a process of
 reduction would be prejudicial.  For the latter class of patients,
 a generous diet, and the employment of mild tonics, in conjunc-
 tion  with the mercurial, will be productive of the most desirable
 effects.   Whatever  measures  may be  calculated to rectify any
 abnormal condition of the  system, should be put in requisition.
 It frequently happens that an impaired state of the constitution,
 or some actually coexisting complaint, is the  direct cause  of
 the complications that accompany an indurated chancre.
   While  the  patient  is taking the  bichloride or any  other
 kindred preparation that may be selected, he will derive advan- 
 220             GONORRHOEA  AND SYPHILIS.

 tage from the use  of  saponaria  officinalis.   It is commonly
 known by the name of bouncing bet, or  soapwort.  It is used
 extensively by the German and English physicians  as an alter-
 ative, in  connection  with mercury.  It  is  regarded  by them as
 superior  to sarsaparilla.    The  two may be used together in the
 form of decoction, of which a pint may be taken daily.
   Among the various substances which have been employed in
 conjunction with  mercurial  remedies,  the lignum guaiaci and
 the  radix sarsaparillse  hold a  high rank  among many  of  our
 most distinguished practitioners;  and, from experience of their
 use  for many years, I can  add  my testimony in their favor.  I
 am aware that some physicians  and  surgeons consider that they
 should be discarded  from  the catalogue  of remedies.  Such an
 opinion, it seems to me,  must be the offspring of ignorance, not
 of  practical   knowledge.   It  is  justly  claimed  for  the  two
 ingredients before us, that when combined, their salutary oper-
 ation, associated with the  judicious  employment of mercurials,
 in the cure of indurated chancre, has been uniformly evinced in
 the  most satisfactory manner; and the  compound decoction of
 guaiacum and sarsaparilla has for years  been a  favorite drink
 with patients having any syphilitic complaint, whether recent or
 of long continuance.  It is prepared thus : —

  ft.  Guaiaci Ligni Rasuro?,...........
       Radicis Sarsaparillae Fissae, aa.........§j.
  Coq. in aqua fontan. lb. ij. ad lb. j.

  Of this decoction,  the  above quantity is to be taken, warm, in
 the course of  twenty-four  hours.   Although its effects are to be
 attributed chiefly to its action as a diaphoretic and diuretic, yet
 it is  a medicine of no mean value in sustaining the vigor of the
 constitution.*   Diaphoretics  and diuretics, taken liberally, are

  * Mr. Travers,  speaking of  sarsaparilla,  remarks : — " Its  power is most ex-
 traordinary ; more so than that of any  other drug with which I am acquainted.
 To regard it as inert, as a mere diluent or an offensive nutrient, is either a proof
 of a very limited experience, or  a very prejudiced observation.  It is, in the
 strictest sense, a tonic."
  The late  Dr. James Johnson, of the  London Medico-chirurgical Review, en-
dorsed the views of Mr. Travers, as  the following sentence will show: — "To
consider sarsaparilla as an inutile lignum — a thing no better than sawdust —
appears to  us to be the  acme of prejudice, the wild, fanatic skepticism of a
book-learned theoric." 
CHANCRE.                      227
calculated to dilute the virus,  while  they at the  same  time
arouse the different depurating organs  to increased action ; and
thus the morbid element is conducted out of the animal economy
faster than it is formed.  Were not this the fact, how else could
the disease ever be eliminated ?  The mere presence of mercury
and other drugs in  the tissues and  fluids  of the system would
not neutralize or annihilate the poison.   In  the language of
Dr. Graves, " syphilis  and mercury are not like two opposite
forces, not like  an acid and  an  alkali, so that  by putting them
together you are sure to neutralize them.  No ; it is  a melan-
choly fact that the  constitution  may be impregnated with  both
at the  same time."  Something  must be done through the
agency of the remedies we employ to  stimulate the emunctory
apparatus to  greater activity than  is required when the individ-
ual is in a state of health, or he  can  never be delivered  from
the enemy that exists within him.  Hence  the advantage of
using, in the  very beginning of constitutional treatment, various
decoctions and diluents as freely as possible, without injuriously
affecting the ordinary functions  of  the  system.   From the
moment an indurated chancre  has  established itself upon any
part,  no matter where, the constitution is probably impregnated
with  its virus as positively as it can  be  at any future  period,
although, in  regard  to the quantity of the morbid matter,  time
is doubtless requisite for its increase.   The virus is cumulative,
and  its  ultimate bounds we cannot  fully anticipate.   But it
would be unwise for the physician to wait until he witnessed the
vitiation of the  blood and the  other  fluids, or the death and
exfoliation of the bones, or the skin here and there dissolving  in
ulcerated patches, before resorting to other medicinal agents  as
auxiliary to the mercurial treatment.
  Of  all  the  various remedies which have hitherto been, or are
now,  employed for the cure of indurated chancre, I am disposed
to regard mercury, when judiciously administered, as entitled to
bear  the palm.  Induced by  the example of Dr. Hosack, sus-
tained as it was by  the profession  generally, I  was early led to
prescribe it in the form and manner recommended by him, and
have never had occasion to doubt  its efficacy or safety.   I  have
never induced salivation to the slightest degree with the oxymu-
riate pill.   As a general rule, I direct  the patient to prolong its
use for four or five weeks  after the specific sore and its charac- 
228
GONORRHOEA AND SYPHILIS.
teristic induration have disappeared ; and  to eke out the treat-
ment for a still longer period with  the potassio-tartrate of iron.
Ricord advises a  daily  mercurial dose that  shall produce a
sensible  physiological effect for six months.   But such a pro-
tracted course seems uncalled  for.   I  once had a patient, who
was a medical gentleman, who took the proto-iodide of mercury,
according to  Ricord's formula.  He resided at a distance, and
continued the medicine beyond the time allotted.   A long and
severe salivation ensued, greatly to his detriment.  This accident
is the only instance  of the kind that has ever happened to  an
individual who has taken any mercurial  by  my recommendation.
But, notwithstanding the value I attach to  mercury in the treat-
ment of  the  indurated chancre, I  am not disposed to make it a
hobby, — that is, to confide# in it to the  exclusion  of other
measures.  There is a more excellent way, and that way is  to
combine  it with some of the adjuvantia that have been mentioned.
They will always be  found important, even in  the management
of indurated chancre, although they are  less  demanded here,
perhaps,  than in the  secondary and still later periods of syphilis.
  In regard to the amount of drinks for daily use, the judgment
of every  sensible practitioner will offer, with sufficient clearness
and accuracy, all  proper suggestions.  So,  also, in  reference  to
mercury, the medical adviser  must be the judge as  to the
quantity  any individual case may require, in order to realize the
most favorable effects; and this quantity will  be most satisfac-
torily ascertained by commencing with a small dose, and increas-
ing it cautiously, until the  desired  change  is experienced in the
lesion, for which it is given.   Surely the surgeon need  not  be
told  of the  ever-varying differences and peculiarities that are
constantly met with in connection with this  disease, and with the
employment of mercury ;  and that no absolute rules can  be laid
down as  to the quantity or form  of the medicine, that may  be
best for the case in hand ; — nor will any medical man of obser-
vation and  reflection allow himself to be wedded to any exclu-
sive system, or to be  governed wholly by arbitrary prescriptions.
It should be borne in mind, however, that  the quantity of mer-
cury,  which  we  are  always compelled to give  for  the cure  of
indurated chancre, has a direct tendency to impair the vigor  of
the stoutest frame.  Like-opium, strychnine,  and many other
drugs, it  will kill as well as cure, if, in the  exhibition of it, it  be 
CHANCRE.
229
abused.   It  is, therefore,  the imperative duty of the medical
attendant to prescribe it with  due circumspection, and to fortify
the patient against all  mischief from it.  To this end, recourse
should be  had  to  tonics, — of which,  for  syphilitic patients,
the potassio-tartrate of iron is the best.

  Local Applications. — As a constant dressing during the day,
nitric acid, in the proportion of two drops to the ounce of water,
will be found convenient and well suited to the condition of the
sore.   Bits of lint should be saturated with it, and applied to the
diseased surface.  The lint must not be allowed to get dry; but,
without being  disturbed, should  be  moistened by means of a
camel's hair pencil dipped in the lotion.   If the lesion be on the
external  surface  of the  prepuce, a  piece of  thin gutta percha
should envelop the parts to prevent evaporation.   At night, the
nitric oxide  of mercury ointment must  be  substituted for the
wash.  A weak  solution of the French chloride  of soda, the
aromatic wine, with an equal portion of rain-water, a solution of
potassio-tartrate of iron, in  the  proportion of a drachm to eight
ounces of water, — are all entitled  to favorable remembrance
as suitable topical remedies.   The black wash, so long known to
all  practitioners, is likewise valuable  in  many cases.   Occasion-
ally it brings out a vesicular eruption upon the adjacent integu-
ments, and, when this happens, its employment will do harm.
  In  changing the dressings,  delicacy of manipulation should
be  observed.  The minute vessels  of the chancre  are easily
ruptured, and will bleed, and the normal healing process will
thereby be interrupted.   In the minor surgical attentions be-
stowed, let me  be permitted to say that  everything that borders
on  unnecessary rudeness, or carelessness, or  indifference  to the
comfort or feelings of the  patient, should on all  occasions be
studiously  avoided.

  Salivation. — If this unfortunate  accident happen from the
use of mercury, the  physician will probably have the mortifica-
tion of seeing  the disease, for  which the medicine was given,
assume a retrograde  course ;  for two poisons, instead  of one,
are now preying upon the system.  And we need not wonder at
the expression of Hunter, that there are now and then appear-
ances, which occur under  the treatment,   that will  at first
                20 
230            GONORRHOEA AND  SYPHILIS.
embarrass  the  practitioner.   " I  have,"  says he, " suspected
that mercury, flying into the mouth and  throat, has sometimes
produced sloughs in the tonsils, and these have been  taken for
venereal."'
  The patient requires the most gentle management.   In some
peculiar idiosyncrasies, the factitious  disease  presents  a very
serious and formidable aspect, — becomes  chronic, and produces
deep and unhealthy ulcerations in the tongue, cheeks, gums, and
elsewhere within  the  mouth  and throat;  gangrene may set in,
and the  death  of the patient be the  final  result.   It is well
for  the young practitioner to be apprized of all  these possible
events.

  Treatment. — At this crisis, the chlorate of potash will  ren-
der essential service.  In the most alarming cases  of stomatitis,
its restorative powers  have been abundantly tested.  A drachm
of the salt may be dissolved in a pint of water, and taken in the
course of the day.  It may likewise be prescribed as  a gargle,
in about the proportions here mentioned.
  It is better to order a gargle of moderate strength, which can
be resorted to  with freedom, rather than a  more potent one,
which can be employed only two or three times in the day.  If
ulcers exist in any part of the mouth, they will  generally in  a
very short time  exhibit evidence  of  improvement under the
action of  the chlorate.  The beneficial influence of  this salt,
in all  forms and stages of the affection, is unsurpassed by any
plan of treatment that has yet been adopted.
  The muriatic acid likewise makes a valuable topical applica-
tion.  It should be  used once daily, with a bit of soft sponge,
and the mouth be immediately cleansed with warm water.  The
acid is a  favorite with Mr. Acton.   He says  it never  fails.  I
have tried it, and can add  my testimony in its favor.   It is not
safe to trust the patient with it.
  The Rhus  Glabrum. — An infusion  of the inner bark of the
root of this shrub, commonly called  smooth Pennsylvania su-
mach, is  a remedy highly extolled by Dr. William M. Fahnes-
tock.*  It may be recommended  as  a  gargle  in every stage of
the disease.  Dr. F. states that when the  surface  of the mouth

     * Vide American Journal of the Medical Sciences, No. ix., p. 61. 
CHANCRE.
231
and  throat is irritated, it acts most beneficially as a mucilagi-
nous  refrigerant, astringent, and soothing application.   I  have
never  tested  this article;  but  the  respectable  authority,  on
which its  employment is  brought to notice, entitles it to favor-
able  consideration.  Dr.  F. regards the infusion as almost a
specific in the sore mouth attending inordinate mercurial sali-
vation.
  The tongue is liable to  become swollen in a manner seriously
to interfere with  respiration and deglutition.   In  such  cases, it
will be necessary to apply two or three leeches to the dorsum Or
lateral regions by means of a suitable glass tube.  This method
of abstracting blood is preferable  to  making incisions into the
organ.  Ulcers occasionally form on  the under surface of the
tongue, near its  edges, where  the  latter come  in contact with
the teeth.  These ulcers are attended  with a sensation of smart-
ing and burning  pain, and are thus a source of  great  trouble to
the individual.   To remedy this state  of things, a piece of soft
lint should be soaked  in  a very weak  solution  of tannin, or in
chlorinated  water, and placed between the tongue and  teeth.
This  is the best protection the  case will admit of, and should
never be  neglected.
  So long as salivation is excessive, it will be important to keep
the alimentary canal in a free state by saline laxatives.   Tonics
and  a generous  diet will be required, and  the patient  should
occupy a large  and well-ventilated apartment. 
CHAPTER  XX.
                   MASKED CHANCRE.

  When a chancre is situated in  the  urethra, in the vagina, or
upon the os tincae, it is called the  concealed or masked chancre.
It is this chancre  upon which  supervene, sooner or later, these
consecutive symptoms that were formerly supposed to have their
origin in blennorrhagia ;  and hence the latter affection was  be-
lieved to be a genuine syphilitic malady by some medical prac-
titioners and syphilographers.
  A chancre  may exist at  any  point  of  the  urethral  canal
between the external orifice and the  bladder.  The  most  fre-
quent site, however, is just within the meatus ; and, by everting
the lips, the lesion may be brought into view, and the  diagnosis
clearly made out.  But when the  sore occupies a deeper portion
of the canal, its presence is  not  so easily detected.  The exist-
ence of  a chancrous ulcer in some portion of the canal may be
suspected when, in a case of blennorrhagia, the discharge does
not appear until a late day after suspicious connection, — when
it is intermittent, and occurs at irregular intervals, and is vari-
able in character, being sometimes thin, scanty, and  sanious.
and at other times thick and profuse, or presenting a tenacious
slough,  similar to what is cast off from the indurated chancre in
its ulcerative stage.
   Sometimes a whole month elapses from the time of the  last
sexual  exposure  before  the appearance of any abnormal  dis-
charge, which arises from the urethral sore.  The other  signs,
which will aid  in  the diagnosis, are the presence of a distinct
induration at  the spot where the chancre  is concealed, which
can be  felt  on pressure with the finger.  The conditions  and
symptoms here stated do not obtain in  uncomplicated gonor-
rhoea.   But if the  chancre be  too  deeply  seated  within  the
canal to admit of inspection, inoculation may be resorted to
as  a test.  It  must, however, be tried at an early day, before
           (232) 
MASKED CHANCRE.                 233
the sore  has lost its  specific character; that is, while  it is ex-
tending,  and before it begins to heal.   If a real chancre exist,
the matter introduced beneath  the cuticle will be likely to give
rise  to  a true chancrous  pustule, and thus  all doubt will  be
removed.  But the patient may not apply until after  the pro-
gressive  stage has passed away, and then  the characteristic pus-
tule cannot  be raised by artificial means.  Another  obstacle
may be in the way of obtaining an accurate  knowledge of the
pathological  condition of the urethra.   The patient may object
to any experiments, and the surgeon will  be thrown back upon
his  own  ability  to decipher the true import  of  the  urethral
symptoms as  best he  may.  It  sometimes happens  that  the
sore, resulting from inoculation, is far more difficult to heal
than the original chancre; and hence, although the experiment
as  a test of  primary syphilis,  is  valuable, it is a  question
whether  it is  justifiable.    Does not the surgeon expose  the
individual to  evils which  he knows not  of?   Fortunately for
all parties, urethral  chancre, either in  the male  or female, is
rarely met with.  Instances have been  known where gonor-
rhoea and chancre have been contracted during the  same impure
connection.
   The  variety of chancre  now under review sometimes gives
rise to very serious mutilations.   If it be  at the orifice of the
urethra,  it  may  occasion  contraction of  that portion of  the
canal, so as to require  the long-continued use of small bougies
or  plugs to  prevent  closure of  the  meatus, or to expand it,
and restore the part,  in some good degree, to its normal  condi-
tion.  Sometimes, when the chancre  is  seated at a  distance
from the entrance of the canal, it causes, on healing, a trouble-
some traumatic  stricture,  wliich  is by no means  easily cured.
In  other instances, the ulcerative  process extends  through  the
entire parts, and perforations take place, usually  immediately
behind the glans penis; and large portions, even of  the ure-
thra  and of the bladder,  are destroyed,  the patient dying in
consequence.
   If a  primary chancre or ulcer  be situated in the vagina or
upon the os tincae, the  fact can be ascertained by means of the
speculum.   When there is such  a lesion, the exudation, wliich
it yields,  consists chiefly of a  slight  muco-purulent, muco-
sanious,  or  ichorous  discharge, which  irritates  the neighboring
                20* 
o^             GONORRHOEA AND SYPHILIS.

parts;  but otherwise the  patient experiences no  great  trouble
from it, unless  it attains a large  size.   She  then  complains of
severe  hypogastric  and lumbar pains, a  sensation of dragging
weight in the pelvis, etc.   But the mere fact that a discharge
exists,  under suspicious  circumstances,  justifies  the medical
attendant in proposing the introduction of the speculum.

  Treatment of Concealed  Chancre. — If the  chancre is at
the aperture of  the  urethra,  local applications  will form an
essential part of the  treatment.   The weak  nitric acid  lotion,
or the black wash, as  already mentioned,  may be kept upon the
part by means  of lint.  For ordinary  dressing, either of these
will  answer.   Should the  ulcer  show  a tendency  to  extend
around  the entire circle of the orifice, the application of  strong
nitric acid will  be required.  If the morbid process can be kept
in check, so as not to embrace the whole of the orifice, contrac-
tion, to any great degree,  will not  be  likely  to result.  A short
wax bougie, worn for an hour or two,  morning and night, while
the patient is in bed, will  be useful in maintaining the  normal
size of  the opening.
  If it be ascertained that a chancrous  sore has formed at a
distance  from the meatus, local remedies may,  even  here, do
much for the patient's advantage.   Injections of the chloride of
soda — one part  to twelve  of  water—must  be ordered  every
hour during the day, for a few days.   Afterwards, let aromatic
wine, in the ratio of one part to two of warm water, be  substi-
tuted, or a weak solution of the potassio-tartrate of iron — say,
one drachm to ten ounces of water — can  be employed with
safety any number of times during the twenty-four hours.  Mr.
Langston Parker recommends an  injection  of  warm olive oil,
three times a day, and in  the intervals the following solution of
tannin and opium : —

  ft.  Acidi Tannici,
      Extracti Opii,
      Aquae,   .  .
  M.  Fiat Lotio.

  A thin  shred of lint, soaked in this lotion,  may be introduced
into the passage, being removed when  the patient  has  occasion
to urinate.
gr. x.
Sr- ij-
5j- 
MASKED CHANCRE.
285
  If  serious local  inflammation should  be present,  measures
are to be adopted at an  early moment to subdue it  by appro-
priate antiphlogistics.   If possible, the  patient should have the
benefit  of  a warm bath morning and evening.  If only one
can be administered let it be in the evening.   The bath will be
important,   not  only in  reducing the  force  of inflammatory
action,  but  will  allay  the nervous  irritability of the  system,
wliich is exceedingly  liable to show itself at such times.  If
the chancre exist within  the  urethra of the  male, he is apt to
be  visited   with  nocturnal erections.   To prevent  these, the
physician cannot do better than prescribe large doses of lupu-
lin,  or  direct a  combination  of camphor  and hyoscyamus,
thus: —

  ft.  Camphorae,...............gr. xviij.
       Extracti Hyoscyami,............gr. xij.
  M.  ft. pil.  No. xij. Dose. — One or two pills at bedtime.

  The patient must be  restricted to a rigid diet, and be allowed ■
copious  draughts  of warm diluent drinks;  he  should  have a
moderate saline laxative every second day ; be kept in bed, and
free from excitement,  until the active, inflammatory symptoms
have been  subdued.   It will  then be  proper to put  him cau-
tiously  upon a  mercurial course of treatment, which is to be
prosecuted  as in  ordinary cases of indurated  chancre situated
externally.   The blennorrhagic symptoms,  if dependent  on a
concealed  chancre, will  cease,  of course,  when  the chancre
heals.  On  the contrary, if the urethral discharge proceed from
a different  cause, the foregoing treatment will prove inadequate
to its removal.   The complaint is a gonorrhoea, and the  patient
must be put upon the ordinary course for this malady.
  If  the os or cervix uteri, or the vagina, be  the seat of chan-
cres, their cure will be essentially forwarded  by  the application
of the concentrated nitric acid, or the acid  nitrate of mercury.
Either  of these substances may be  employed every second or
third day.   Another local remedy is the chloride of zinc : —

  ft.  Zinci Chloridi...............9ij.
       Aquae Fontanae,  .............§ xvj.  M.

  An ounce of this solution is to be injected three times during 
236
GONORRHOEA AND SYPHILIS.
the twenty-four hours.  In regard to constitutional treatment,
it is to be conducted on the same general principles applicable
to similar accidents in the male subject.
  The infrequency of indurated chancre of the os uteri may be
judged of from the fact that Dr. Egan did not meet with a single
case during his attendance at the Lock Hospital  of Westmore-
land for four years.  This hospital is exclusively for females. 
CHAPTER  XXI.
               INFLAMMATORY  CHANCRE.

  This  is the simple venereal  sore assuming an inflammatory
character, and the latter condition  may manifest itself at  any
period of the accident.  Sometimes the pain, swelling, and other
concomitant symptoms arise  very suddenly, and  increase  with
great rapidity ; and, if not arrested, gangrene and sloughing will
take place in  the  course  of four or five days,  or even in  less
time.  Where the  physician or surgeon is consulted at  an early
day, and adopts a  careful and judicious line  of treatment, this
form  of chancre is rarely seen.   The  state of things implied by
the term  inflammatory chancre, is  generally  induced  in conse-
quence of some irritating or caustic substance too freely applied
to the simple sore or chancre, in the haste to destroy it.
  Patients of irregular habits and of  sanguineous temperament
commonly furnish  the  raw material for the  variety of chancre
treated  of in  this chapter.   Comparatively few cases  are  met
with at the present day.  Some years since,  I saw a specimen on
a young man who  had been under the care  of an apothecary for
the cure of a simple chancre.  The abortive method was tried ;
that is, the apothecary  attempted  the  destruction of  the  sore
by  applying a saturated solution of  nitrate  of silver.  It  was
employed  daily, until a most  intense inflammation was excited,
and rapidly extended, notwithstanding every effort to arrest its
progress.  Phagedaena  and sloughing supervened, and the  pa-
tient was  compelled, as a last resort,  to submit to amputation
of  the penis.  He suffered for a long  period  from secondary
disease, but finally recovered,  and has since been remarkably
corpulent.   He had led a dissipated life.

  Treatment. — In  the treatment  of the  patient, the ordinary
principles of surgery for subduing inflammatory action must
be  our guide.  Rest in a horizontal  position is  indispensable.
                                                   (237) 
238
GONORRHOEA AND  SYPHILIS.
Without the strictest observance of this, all our efforts will be
unavailing.   It is better for the patient to be in bed, than to try
any other method of keeping the horizontal position.  If he un-
dertake to lounge about  upon a sofa or couch, with his clothes
on in the usual manner, he will  fail to  secure for himself the
advantages implied when we  speak of  the  recumbent posture.
The  warm bath sliould be taken  daily.  The patient  may be
allowed  orangeade  and  other  refrigerant  drinks;  moderate
saline  aperients and the usual antiphlogistics  are to be  relied
upon, until the inflammation is subdued, and the  lesion brought
into  a healthy condition, which  can be  accomplished  without
difficulty, provided the medical  attendant can maintain perfect
command over the habits of the individual.
  The late Mr. Key, of Guy's Hospital, had  a  high opinion of
the cold infusion  of  sarsaparilla in  lime-water,  as a constant
drink.  Its  power of allaying irritability of action, both  local
and constitutional, he regarded as incontestible in this  and all
other forms  of constitutional syphilis.  Irritability of the system
is sometimes one of the most intractable symptoms to manage,
and  shows itself in quite a variety of ways, sometimes in the
condition of the cerebral organs, sometimes in the state of the
bowels, sometimes in palpitations  of the heart;  and  at other
times the functions of all  these organs are  strangely deranged,
while the local  symptoms remain  at a high point of intensity.
In such circumstances, the patient should  be  kept under the
influence of opium.  There is no remedy that will  so speedily
and  so kindly  minister to his relief  as this.    It should  be
employed early; that is, the moment he begins to complain of
restlessness and inability to obtain sleep.   If he has had a bad
night, he  will in the morning report himself as exhausted ; and
an aggravation of all the  symptoms will be almost certain to
ensue on the following day.  Large  doses of opium will not only
allay the general irritability of the  system, but will assuage the
inflammation  and pain which complicate the local accident.
Whether the  solid gum be employed,  or the tincture, or the
sulphate of  morphia, is of minor consequence.  Two grains of
opium sliould be given every three hours, until  a decided im-
pression is manifested ; and this impression may be sustained,
if necessary, for  several days without interruption.  When the
influence of the opium is effectual in procuring refreshing sleep, 
INFLAMMATORY CHANCRE.
239
and inducing  and maintaining  a genial  state of  the  mental
powers, an improvement in the  condition of the chancre will
soon follow; and, whatever other appliances may be employed,
fue opium is  entitled to the credit of exerting an important
agency in bringing about the amendment.   Sometimes, where
large quantities of this narcotic are taken for several successive
days, the bladder loses its expulsive energy to such a degree as
quite to  alarm the patient.  In  such  cases  it will be advisable
to omit its use for the time being;  and the  patient will need a
warm bath or two, and perhaps the catheter may be required.
   Where the inflammation is excessive, it  will be requisite to
apply four or five leeches at a little  distance from the chancre,
and promote the bleeding by warm fomentations.  A saturated
solution of the watery extract of opium should be applied warm
 to the part, and  be renewed three or four times during the day.
 The solution should be strained through fine linen.  Cold dress-
 ings rarely suit.
   If phymosis or paraphymosis  take  place, the  surgeon  should
 lose no time in removing them.   The same mode of operating
 is  to be pursued as in ordinary cases, practical directions for
 which have already  been considered.  Mr. Acton mentions an
 accident which he once witnessed at  an operation performed by
 a hospital surgeon.   The latter designed to  slit up the prepuce
 for the  relief of phymosis.  The director was introduced into
 the urethra, instead  of passing  between the prepuce and glans.
 The bistoury followed the director ; and  the  urethra, as well as
 the prepuce,  was slit up to the extent of an inch.
   After the operation for the relief of phymosis or paraphymosis
 is  performed, the opium and water  dressing must be applied.
 Sometimes a  profuse hemorrhage takes place  in consequence
 of partial destruction of some blood-vessel by gangrene.  Dry
 lint  or  powdered alum will  generally control  it.
i 
CHAPTER  XXII.
                PHAGEDENIC  CHANCRE.

  Phagedenic  chancre  is the  result  of acute inflammation
unsuccessfully  treated.   Inflammatory  chancre is  liable to
progress  to  a  state of gangrene and sloughing, and the  pha-
gedaenic  sore is the ultimate stage or point to which inflam-
mation can  extend.
  Practically,  the distinguishing  line  between gangrene  and
phagedaena is  not very important; and yet there  is  a differ-
ence between the two, both  in  regard to the condition of the
patient's  system at the time, and as  respects the  state of the
parts involved  in  the  local  disease.  Abernethy employed the
term  phagedoena to express every form  of destructive sore,
whether owing  to ulceration  or  sloughing.  Acton's distinction
between phagedaena and gangrene is clear and brief.  It is this :
Some local irritating agent is the cause of inflammatory or  gan-
grenous chancre, whereas a  peculiar state of the  constitution
exists in  a  patient  suffering from phagedaena. In gangrene
the general  health is  not impaired;  in phagedaena it is.  In
gangrene  there is death of the parts ; in phagedaena a  sort of
liquefaction  takes  place, and a  melting down  of the  adjacent
structures, which have been  previously destroyed.   Dr. Egan,
speaking  of phagedaenic, primary ulcer, confines  his description
to that class of ulcer which  commences as a phagedaenic sore,
although he does  not  ignore the fact  that many  others  may
assume this character from  neglect, from  local irritation, or
from the internal use of even small quantities of mercury.  He
mentions one instance, under his care, which became phagedae-
nic from the administration of ten grains of blue pill.
  The phagedaenic chancre always denotes a depraved condition
of the animal economy.  The patient looks haggard, has what
we  call  a broken-down  constitution,  induced  perhaps by  a
                                                 (240) 
PHAGEDENIC CHANCRE.
241
variety of causes, such as intemperate habits, excessive debauch-
ery, and other irregularities connected with  a life of dissipation,
confinement in the wards of a badly-ventilated hospital, or living
in any unwholesome situation,  and by any other adverse condi-
tions, which the medical attendant will do well always to inquire
into.   Sailors who have been engaged  in long service, and who
consequently have been exposed to the hard vicissitudes of the
sea, and individuals of a scrofulous and lymphatic diathesis and
flabby muscular fibre, are also  to be included in the list of those
in whom the phagedaenic chancre is  apt to appear.   Now and
then we meet with patients who  are  not slow to  attribute this
form  of their disease  to  the  improper treatment which  they
fancy they have received from  the  attending surgeon  or physi-
cian ;  and thus  the  skill of the practitioner may be unjustly
impugned.   Not long since, I  was called in consultation  by a
young physician, and was witness to the  state of things  here
spoken of.   The patient, however, upon being  confronted and
closely questioned, admitted that he had  led  a  profligate life
for years ; and he was very plainly told that his  condition was
chargeable in every particular  to  his vile habits, and not to any
improper medical treatment.  The  young  physician retained
the daily charge of the case,  and heard no more insinuations
as to malpractice.
   The progress of this chancre, if neglected, is  very rapid  ; the
constitutional  symptoms, to which it  gives rise, are  of a more
serious type than those attending any other primary sore ; and
there is no accident, of a syphilitic origin, more worthy of the
study of the practitioner than this.   Let me be permitted  to
say, that he sliould make himself and keep himself familiar with
its nature, and with  the best  mode of managing it;  for he is
liable to be called upon in  circumstances requiring decision and
immediate action. True he may not be summoned to amputate
a limb ; but his cool and collected self-possession, his enlightened
judgment, and his practical  services  may be wanted in a crisis
of scarcely less magnitude ; and  a judicious, impromptu pro-
cedure may not only save an important part of the human frame
from destruction, but  even rescue the individual from impending
death.  Sometimes, when the  phagedaena seizes upon the pre-
puce, the whole of this membrane  will be swept away in thirty
hours;  and where the glans is attacked, the destructive action
                  21 
242
GONORRHOEA AND  SYPHILIS.
advances with nearly equal rapidity, involving all the structures
of the organ, which in two  or three days becomes a revolting
mass of putridity.
  The phagedaenic  chancre is seldom followed by secondary
symptoms.  In this lesion, the  condition of the parts, so far as
relates to contagion, is precisely what the surgeon secures when
he destroys the recent indurated chancre  by the application of
potassa fusa, or other escharotics.  In both  cases, the phagedaenic
action cuts off the  absorbent  vessels, and  the  poison, which is
still confined to its original locality, is also destroyed and cast off
with the detritus of the sore.   Thus  the patient escapes consti-
tutional  infection.   It is  not  absolutely certain, however, that
in all cases  no  secondary accidents will supervene  upon the
phagedaenic chancre.  The virus  may have  been taken up by
venous absorption, or have crept into the system through the
lymphatics, before  they  were  obliterated  by  the sloughing
process, but the danger is very trifling ; and those who advocate
the old method of mercurial treatment, consider it good practice
to spare the patient, at this juncture, the  debilitating effects of
such a course.

  Treatment.—In all cases, the  patient  sliould be required to
keep his bed, and, if possible, he  should have  the benefit of a
large, well-ventilated apartment.  He will need a generous diet
and a good  allowance of sherry wine.   A  decoction  of hops
with wine in it  makes a good tonic  beverage,  especially  for
those who, while in health, have been accustomed to  stimulating
libations.
  What has already been said in regard to the advantages to be
derived from the warm bath and  aperient medicines, is, in the
main, applicable here.  Although the evil we are now consider-
ing  is due to some specific cause, it is to  be  treated without
reference to this origin.   The existing condition of the patient,
both as relates to the local and  constitutional symptoms, sliould
engross the attention of the medical attendant exclusively, and
the  case should, in all particulars, be conducted as  a simple
phagedaena, uncomplicated with syphilis; for as soon as the un-
favorable symptoms are subjugated, and the chancre assumes the
character of a simple, healthy  sore, which  it can generally be
made to do, it will heal without difficulty, and the patient will
in all respects make a good recovery. 
PHAGEDENIC  CHANCRE.
243
   A  majority of patients  suffer extremely from  constitutional
irritation at  this crisis, and the  free employment of  opium  in
some form will be  imperiously demanded.  The solid  pill  is,
perhaps, to be preferred.  In  regard to the aggregate quantity
per diem,  the amount  must be proportioned to the condition  of
the patient, and his susceptibility  to the  specific action  of the
drug.   It  will be safe  to begin at early bedtime with a pill con-
taining two grains.   Let this  be repeated  every three hours,  or
thereabouts,  until the desired  effects are realized.   Two of these
pills will usually be sufficient  to procure quiet sleep, and on the
following day the patient will be likely to find himself in  a com-
fortable  state.   It is, however, sometimes necessary to  give six,
eight, or ten grains of  opium in the course of twenty-four hours.
If it should impair  the appetite, or otherwise disturb  the func-
tions of  the digestive organs, a little wine  in connection  with it
will, in a great measure, prevent any inconvenience.  The  wine
will not only tend to correct any unpleasant effects of the  opium,
but will act in  unison with it in bringing  about an amendment
of  the patient's general condition.   As soon as  the morbid irri-
tability is  quieted, the  amount  of  opium  should  be very much
diminished.
   The chlorate of potash is  a useful article to be employed in
arresting any phagedaenic tendency, and inducing  healthy action
in  the ulcerating surface.  Internally, it may be given, dissolved
in  barley-water, to the amount of a drachm during the day.   As
a topical application to the  ulcer, the annexed  formula  can  be
advantageously employed: —

    ft.  Potassae Chloratis,.............3iy-
       Aquae Destillatae,.............3 v"j-  M-
    To be  constantly applied, as a dressing, by means of lint.*

    Potassio-Tartrate   of  Iron. — I must again present  the
claims  of  this salt.   As a  therapeutic  agent  both  constitu-
tional and local, in the condition of things before us, it  is  often
to  be preferred to the  chlorate of potash, and, indeed, to every
other article in the materia medica.  It was first  recommended,
some fifteen years ago, by Ricord, who employed it " to  iron up
* Vide Guy's Hospital Reports, vol. vii., p. 331. 
244
GONORRHOEA AND  SYPHILIS.
the blood."   Where the patient is  in a feeble, anaemic state, re-
quiring a tonic course of treatment, this ferruginous preparation
is entitled to the highest confidence.   At the onset of phagede-
nic action it may be resorted to with  every prospect of advan-
tage.  The  opiates, which may  be appropriate  for a  time  to
allay the morbid sensibilities  of the patient, will constitute no
barrier to the free administration of the  iron.   While  these
medicines are in  constant  use, an  occasional  small  dose of cas-
tor-oil will  be required to  preserve the  bowels  in a  suitable
state.
  For phagedaenic ulcers, in  whatever tissue situated,  and  at
whatever period  of the  syphilitic disease, the  iron  will  display
an efficiency of power not inherent in any other remedial agent.
I have employed it almost  daily for about eight  years, with re-
sults every way satisfactory, for the improvement  of the  consti-
tution of individuals laboring under various forms  of venereal
affections.   It is especially adapted to   those cases in which the
exhibition of mercurials would  be prejudicial.   I can, scarcely
overrate its value.  In phagedaena  all   medical men  agree  that
mercurial agents should be excluded,  and  all who  have fairly
tested the potassio-tartrate of iron,  I know, will corroborate any
expressions of praise I might choose to  employ.   I am sure  that
this  article has not acquired  that notoriety and favor to which it
is entitled.   Administered internally as a tonic, it can be relied
upon as particularly suited to a numerous class of patients suf-
fering not only from phagedaena, or sloughing  ulcers, but  from
every other variety of venereal ulceration, especially if the  con-
stitutional integrity be much impaired.   In saying thus much, I
have to observe that I have  no experience with it in indurated
chancre, or  strictly inflammatory chancre.*   The iron  may be

  * Mr. Behrend, of Liverpool, extols the use of this remedy in every case
of primary  syphilis.  He was first induced to try it, in a case of  very large and
obstinate chancrous sore, in 1854.  It had  existed three months, and had been
treated with various local applications without benefit. The patient had other-
wise been under good medical  care, but had wasted  away from pain, loss of
appetite, and loss of sleep.  The sore was situated partly  on  the penis and
partly on the scrotum.   The patient commenced the use of the iron, and in
one month was cured   Mr. Behrend, holding the  opinion that  the virus of a
phagedaenic chancre is identical with that of every other  form (the phagedaena
being, in his opinion, attributable  to special circumstances, and, as it were, a
modification superadded to the original disease), determined to treat every case 
PHAGEDENIC  CHANCRE.
243
continued from  the moment any phagedaenic symptoms present
themselves until the chancre is healed.  The best mode for its
exhibition  has already been considered.  A saturated  solution
makes a valuable application for the  phagedaenic  sore.  After
the strong  solution has been applied for two or  three days, the
aspect of  the chancre  is  transformed  into that  of a simple
healthy  sore, exhibiting abundant  granulations, and  showing
no further  disposition to  spread.  The  solution should then be
much diluted.  A drachm  of the salt to eight or ten ounces of
water will  furnish  a lotion of suitable strength, and it can be
relied upon in maintaining a recuperative influence on  the local
disease.   Sometimes there is excessive irritability about the sore,
as well as about the patient, and it will not  at first bear stimula-
tion.   In such cases, the opiate  lotion must be employed  for  a
short period.   At a later day — that is, as  soon as the patient
has been brought under the constitutional effect of the opium and
ir011 — the local irritation will be essentially ameliorated, and  a
different management  of the  lesion  must be  adopted.   The
ferruginous   solution must be  taken  in the  manner already
advised.
   Although my experience  amply justifies the  encomium I have
bestowed on the potassio-tartrate of iron  as a  remedy in phage-
daena, there are cases  in which the concentrated nitric acid  is
to be preferred as a local remedy.  I refer to  those  in which
sloughing  phagedena  is  the  predominant complication of the
chancre.  If the  sloughing process advance with rapidity, there
is, in fact, acute gangrenous inflammation, and  the acid should
be applied.   Let  a bit of soft  sponge  be secured  to a piece of
whalebone, and be well charged with the acid, but not so  as  to
drip.  Pass it quickly over the  phagedaenic surface.  A bowl of
 warm water should be  at  hand, and the  superfluous acid be
instantly washed  off.   A  warm cracker poultice, to which  a
large  quantity  of the  solution  of the  watery  extract  of opium
 should be  added, must then be laid upon the part;  or, if a poul-
 tice cannot be employed conveniently on account of the locality

 of primary syphilis in precisely the same way ; and he states that the accumu-
 lative experience of each case has confirmed him in the correctness of his views,
' and has given him entire confidence in the  powers of the potassio-tartrate  of
 iron to cure  every kind of primary sore.— Vide London Lancet, 1856, pp.
 534, 673.
                 21* 
046             GONORRHOEA AND SYPHILIS.
of the chancre, the opiate  solution  can be  used alone.   The
patient will also require a large dose of opium  or morphia at
this time.  In a day or two the  slough will  be cast off, in  some
places at least, and a healthy surface here and there be brought
to view.  Although  the acid may not again  be  needed on  so
large  a surface as at first, still the surgeon may expect its par-
tial application will be required  every three or four days, until
the whole  surface  presents  a  granulating  appearance.   The
presence of the acid, as here recommended, gives intense agony
for the time being, and, in some instances, induces faintncss for
several  minutes.   To  prevent these  unpleasant  effects, it  may
be well  to put the patient  under the influence of ether.
   After the chancre has  acquired a healthy, florid aspect, and
inflammation and sloughing are no longer to be dreaded, it will
still be  necessary to employ the nitric acid, but in a different
manner from that advised above.  For  continued use, the fol-
lowing solution will be found to  answer a good purpose: —

  ft.  Acidi Nitrici,...............3 ss.
      Aquae Fontanae,..............§ xvj.  M.

   The chancre is to be kept covered with  linen  rag, wet with
the lotion.   Soft  linen rag is on some accounts better than  lint.
The latter is apt  to  get entangled with  the uneven surface of
the chancre, which is now very tender, and the granulations are
easily torn so as to bleed.   In  a few days  they  acquire more
firmness and consistency under the influence of the acid lotion,
and then the surface can  bear less delicate manipulation with-
out injury.  While this topical dressing is employed the patient
experiences a sensation of warmth and  a slight  itching in the
part, but no pain or  smarting.worth speaking of.   I have made
trial of  nearly all the local  remedies  in vogue for such lesions,
and know of none that keep the surface so  clean and nice as
this ;  and it generally exerts a  salutary influence in bringing
forward  healthy granulations.   Should the  chancre  yield an
offensive, purulent, or sanious  discharge,  a solution  of the
French  chloride of  soda  will correct this condition.  The fol-
lowing strength will be tolerated without complaint: —

  ft.  Solutionis Sodae Chloridi,...........§ ss.
      Aquae Fontana1,..............§ v.   M. 
PHAGEDENIC CHANCRE.
247
   The  chlorate  of  potash,  as  a lotion, may be  employed  as
 an excellent  detergent and antiseptic in chronic foetid,  sup-
 purating ulcers, wherever situated.   It  proves very serviceable,
 also, in ulcerated surfaces exhibiting a tendency to sloughing.
 The formula prescribed  at the Royal Free Hospital of Lon-
 don is  composed of half an ounce  of the chlorate  of  potash
 to a pint of water, with forty drops of strong hydrochloric acid.
 It is stimulating  in its action also, and converts a foul  ulcer into
 a healthy, granulating sore.  The sore should be kept constantly
 wet with the solution by means  of surgeon's lint saturated with
 it, and  covered with thin  sheet  gutta-percha.   As soon  as the
 recuperative  process is well established, the strength  of the
 solution sliould be  reduced.


   Carbonate op 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  practi-
 tioner.   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 immediate
 impression upon the stomach,  and  the  genial thrill which  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  account of any inflam-
 matory diathesis  or  action that may exist.   Its use is compati-
 ble with  that  of opium, or of the favorite ferruginous prepara-
 tion 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  suffering from the additional
 weight  of  the particular affection   under  consideration.  In
 these  circumstances, I have  been accustomed to  prescribe  the
ammonia for several  years, as in the annexed formula: — 
248
GONORRHOEA AND  SYPHILIS.
   ft.  Ammonise Carbonatis,............5j-
       Pulveris Acaciae,.............
         "    Sacchari, aa,............3 ij.
       Aquae Fontanae,..............§ iv.
       Cinnamomi Olei,.............gtt. 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 mar-
shal 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 subjects especially,
it will be found an excellent substitute for alcoholic stimulants.
  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, ir-
regular hours, and various  other predisposing causes connected
with a dissolute life, and who is now the victim of a foul, angry-
looking,  eroding ulcer — the  mere dregs  of  syphilis — 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 mercurial preparation in such
a shattered frame.  If he should administer it, it  will  be found
not only  barren of all good results, 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 increas-
ing 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 remarks.  I will cite one instance. 
PHAGEDENIC CHANCRE.
249
  Case.   May 18//t. — 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 surrounded
by all the  paraphernalia of filth and moral degradation.   He
had a prostitute for his nurse.
  It appeared that, a  few days  after exposure, a  chancre  came
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 mean-
time in  the streets, regardless of any advice to the contrary.
Erysipelatous  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 integu-
ment farther back  were much tumefied and ©edematous.  The
serous effusion  had infiltrated the meshes of the interstitial cel-
lular membrane in a somewhat  interrupted  manner, so as to be
confined in small  elongated sacs, wliich  took a spiral direction
part of  the way around the swollen organ ; and thus there were
three or four bands producing a twisting and partial strangula-
tion.   The virile  member, as  a whole,  bore  no small resem-
blance 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 witnessed  in the  early
stage of delirium tremens.   For the two  previous nights he got
but little sleep.   He had  taken submuriate of mercury  pills
for eight or nine days, but no specific  effect  had been produced
in the mouth. 
250
GONORRHOEA AND SYPHILIS.
  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 under the influence of this drug so long as any constitu-
tional  irritability  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 disgorgement 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 carbonate of ammonia julep,
according to the formula just given, together  with wine and
quinine.    The  chancre was  touched  with  the  concentrated
nitric acid  several times ;  and, for  an  ordinary  dressing, the
opiate solution was prescribed for a short time; then  the chlo-
ride 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 por-
tion 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  unpromising aspect. From the walls of the chasm occa-
sioned by  the sloughing, granulations sprung  up in  healthy
style; the mutilated glans was soon brought in  apposition with
the cavernous 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 phy-
mosis over the glans.   There is a thin, bloody, and  highly offen-
sive discharge from the preputial orifice, which is much con-
tracted.   As no  other  lesion  of these parts  is  at  all likely to
yield such a peculiar secretion, it may be considered, in connec-
tion  with  the concomitant  phenomena, as furnishing almost
unequivocal evidence  that there is.  a  concealed,  phagedaenic, 
PHAGEDENIC  CHANCRE.              251
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 fer-
ruginous 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, the
pultaceous diphtheritic  chancre,  the  serpiginous, or  creeping,
chancre, etc.  In all these  varieties the abnormal process  is of
similar character, and requires to be  dealt with in a manner
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 generous
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 nym-
phae, 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  presence.
The first symptom that  attracts  her attention is a sensation of
smarting and prickling, occasioned  by the  act  of micturition.
If, however, the chancres are allowed to have their own way,
 unchecked,  they sometimes penetrate into  the  cellular  tissue,
 and degenerate into sloughing ulcers, and total destruction 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 gen-
 erally commences  as an abrasion, or perhaps as  an angry-look-
 ing 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 
252            GONORRHOEA AND  SYPHILIS.
direction, and  yields a  thin, sanious, foetid discharge, 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 opening of the pelvis is  deprived of
the soft parts in consequence of the sloughing process.    Exces-
sive local pain at length becomes a prominent and abiding symp-
tom ;  there is high  irritation  or inflammatory fever, which ulti-
mately assumes a  typhoid character, with more or less delirium ;
the pulse is rapid, and indicative  of great constitutional debil-
ity ;  the appetite  fails; all the vital functions  are deranged;
exhausting hemorrhages 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.   For-
tunately 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 charitable institution.  But, in  consequence of delay, her
chances of  cure  are exceedingly small.   If the case receive
proper  medical  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
constitutional 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."  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  immense
underground vault for weeks and months together, without see-
ing the light  of  day, or inhaling a  breath of  salubrious 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 fifteen to twenty-five years of
age.  They were decoyed from  the country by Jews, who kept 
                 PHAGEDENIC CHANCRE.              253

these subterranean abodes, and were systematically 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  contagious matter, nor do the
females  who recover from them  ever  have  secondary constitu-
tional symptoms.   So said the late Mr. Travers, who furnished
a graphic description of them, a few years since, in the London
Medico-chirurgical Review.
                22 
CHAPTER  XXHT.
                           BUBO.

  Hunter  regarded the syphilitic bubo as a primary accident.
There is no instance recorded in wliich this lesion has ever had
its origin in a secondary  venereal  sore; nor is it, on the con-
trary, with a few rare  exceptions, ever developed as a specific
affection, unless a chancre has preexisted.   A few well-authen-
ticated  cases of bubon  d'emblee,  or primitive bubo, have  been
met with.*  Ricord mentions eight; Mr. Erichseu 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 disposed  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  an intermediate position between  primary and sec-
ondary  syphilis.   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; others
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  situated  on
the fraenum, a bubo  may  be developed in  either groin, or  in
both right  and left.  Buboes that arise in consequence of indu-

   * M. Ricord, it is  said, now denies the existence  of the primitive virulent
bubo, — "bubon d'emblee," produced by the absorption  of a special virus, and
where there has been no suspicious antecedent, — chancre, excoriation, or sore.
                                              (254) 
BUBO.
255
rated chancre, rarely suppurate, being subject to the same law
of morbid action that governs  the  chancre.  Such buboes are
regarded by some writers as nothing more  nor less than chan-
cres seated  in these  glandular bodies.  They are also denomi-
nated indurated, indolent, constitutional  buboes, and, as they
never suppurate specifically, some  surgeons consider  that  no
local treatment is ever serviceable in their removal.
  The period at which a bubo appears, after the occurrence of
chancre, is not limited to  any  definite time, although it gener-
ally begins to  show itself about the second  week after the for-
mation  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  urethrce, or near the
anterior verge of the anus.  If the patient has a good  consti-
tution, and is  seen sufficiently  early for the successful applica-
tion of the abortive  treatment, a  bubo will  not supervene.
Surgeons formerly had  an idea that if  the  chancre  was de-
stroyed at an  early period, the  virus  might  be driven  into the
system, and that a bubo would  consequently be  more likely to
form.
  Tlie 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 sys-
tem 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 varieties of chancre  is
more  acute, more painful, and generally involves the glands of
only one side;   Buboes are sometimes produced, not by absorp-
tion, but by irritation, in scrofulous and  other  unhealthy sub-
jects.   These  cases are not difficult to be distinguished.  Sim-
ple 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.  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 
256
GONORRHOEA AND SYPHILIS.
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 swell-
ing 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 correct
in our diagnosis  of the kind of bubo we meet with, because
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  for-
merly attended for constitutional syphilis, called upon  me  one
morning, in great distress  on account of a bubo  in the right
groin.  He first noticed a slight  tenderness and swelling four
weeks before he made this morning call.   He  had  already  con-
sulted a young medical friend of his in reference to his case,
wliich 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 swelling.   The
patient, being connected with an extensive mercantile house,
and having, on a  former occasion, been detained from business
for several months, had great reluctance to incur a second sus-
pension from  duty, especially  for such  a reason, and conse-
quently continued, as usual,  at his employment, but suffering
constant pain, which increased from day to day with 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 
BUBO.
257
in the swelling.  The mass was perfectly 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 pre-
tended 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.  I examined the penis, and it did not take long to dis-
cover 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 con-
tents several days  previously, and a thin, flat scale  had formed
upon their  summit;  other vesicles had been  broken  more
recently, and were without 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 habits
of the patient.  Instances of this vesicular affection, produced
by non-venereal vaginal discharges,  are  occasionally met with.
The herpetic eruption, when developed in highly sensitive sub-
jects, will  sometimes  give rise to tenderness  and pain in  the
inguinal glands.  In the present instance, the patient had been
told that he  had a chancre on the  prepuce, although this was
                  22* 
258
GONORRHOEA AND SYPHILIS.
not the fact;  and he was  at once, and  very  naturally, appre-
hensive 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 preputial  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  sponle, at the
just conclusion that there was no  syphilitic element in it.  In
further explanation of the case, wliich 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 severev and the  patient continued
to suffer more and more, until his condition  became  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 emaciation and 
BUBO.
259
debility ensued; but, fortunately for the  poor  fellow, he ulti-
mately 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, how-
ever, I know not a  more appropriate epithet to employ than the
one I have chosen ; for the inguinal swellings, wliich the patient
had, and  their entire history, correspond in character with the
scrofulous bubo so graphically depicted by Hunter.   The pa-
tient had no  sore  throat, no disease of the skin, bones, or peri-
osteum, during the period  embraced in the foregoing account.
Nevertheless,  if we go  back a step farther, and inquire whence
this scrofulous  diathesis was derived, we  need not hesitate  to
admit that  the previous constitutional syphilis  contributed a
large share  to its  production, using the  term  scrofula  in the
sense  adopted by Hunter.  Perhaps, in more modern phraseol-
ogy, 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.   Yidal  says  that a bubo which should  suppurate
 will suppurate, no matter what we do ; and the bubo that should
 disappear by  resolution will thus disappear, in spite of the ordi-
 nary suppuratives, except  they  be too violently  used; and yet
 Yidal 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
 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 sliould  be followed up faithfully. 
230
GONORRHOEA AND SYPHILIS.
  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, con-
sisted in the application of a blister over the bubo, with a subse-
quent dressing to  the vesicated surface, of a solution, 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 substi-
tuted.   When  the  bubo   was very  large  the  solution was
repeated.   The  success attending this harsh procedure in re-
moving 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 practised it.  It is most
beneficial  when  pursued in the  formative  stage of bubo, and
when the inflammatory action  is moderate.
  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.
Even where suppuration seems inevitable,  the application  of
a vesicatory will sometimes  cause the swelling to subside under
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 covering
the tumefaction  have become attenuated and of a deep purplish
* Vide London Lancet, 1855, p. 340. 
BUBO.
261
hue, thus showing that they are more or less disorganized, and
are passing into a gangrenous state, then the blister 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 employment 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 vesication
takes place,  the  cuticle is removed and  the denuded surface
dressed with the following ointment: —
   ft.  Unguenti Hydrargyri,  . .
       Pulveris Ammoniae Muriatis,

   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 observed
 until  the total obliteration of  the swelling  has been  accom-
 plished,  or until something  transpires in  the progress  of the
 case to contraindicate such a  course.   This plan of local treat-
 ment I consider as good as any, and I have tried  all the recog-
 nized 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 regard  to
 nearly all topical appliances.
    Collodion  has  been  applied to  buboes when there  is not
  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
3'ss.
M 
262
GONORRHOEA AND  SYPHILIS.
of compression, we are told, had  its origin  in the accredited
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  woman.
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 progress-
ing and terminating in the usual manner in the inguinal glands,
was intercepted, and pursued divers other routes, establishing
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  advise that blood be taken
from the arm with the lancet, or from the immediate vicinity pf
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 
BUBO.
263
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 system, but because, so far
as  the  blood has  any  agency,  its equilibrium  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  general 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 resolu-
tion 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 suppurative
process has  continued  to progress slowly, and  I   have been
defeated  in  the effort to  bring about  absorption, and have
regretted 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 controlla-
 ble than the Vienna paste or the  potassa fusa, and the surgeon
 can instantly release the contents of the abscess by an incision,
 wliich will not give a tithe  of the pain caused  by these escha-
 rotics, 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 saturated  solution  of
 opium should be ordered for the first day or two  after the open-
 ing of the bubo.   So long as the suppurating surface presents a
 healthy character, and  shows a disposition to  heal, although at
 a slow rate, the surgeon may look forward to a happy termina-
 tion 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 
264
GONORRHOEA AND SYPHILIS.
towards a cure, the chlorinated water will be advisable during
the day, and  at  night  the  nitric oxide of mercury ointment
somewhat diluted.  For a simple bubo, ordinary dressings only
will be required.  But when the bubo assumes an unusual char-
acter,— 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 top-
ical 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  mer-
curial  ointment to this portion, 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
intractable 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 a drachm  of
the iron to twelve ounces of the water.
   If the iron should not act favorably as a local application, the
acid solution of chlorate of potash, of the strength already men-
tioned,  may be advantageously substituted.

   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 suf-
ficient quantity to procure sleep, and thus remove the irritabil-
ity of the system, wliich is apt to be  a most annoying symptom.
Mr. Key (Guy's Hospital Reports)  recommends the  iodide  of
potassium;  so, also, does  Mr. Acton, particularly in serpigi-
nous  chancres and ulcerations.  But the  latter surgeon  holds
the potassio-tartrate of iron in higher estimation than any other 
BUBO.                        265
remedy, as may be inferred from the following 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  phagedaenic or sloughing  chancre is  in  all
respects, both locally and constitutionally, appropriate  for the
cure of the phagedaenic or sloughing bubo.
   To the  injudicious administration of mercury, and  the mea-
gre, dietetic fare to which patients  were subjected, is to be
attributed the frequency of phagedaenic or sloughing bubo in
former times.  Happily it is a variety of ulceration extremely
rare at the present day.

   Sinuses. — Occasionally it happens, while we  are attempting
 to heal a bubo,  that a sinus forms, having its opening, or mouth,
 near the  most dependent border of  the bubo.  A portion of the
 purulent deposit works its way downward very gradually, and
 will continue to do this  for an indefinite time,  unless checked
 by surgical means; the  best  of which, in ordinary cases, con-
 sists in  the use of an injection of tincture  of iodine  into the
 orifice of the sinus.  The injection may be squeezed out imme-
 diately, and repeated  in four or five days, if necessary.  One
 injection will frequently close  up the whole  track  of the sinus
 completely.
    If, after a few trials with the iodine, the sinus does not heal,
 the acid nitrate of mercury,  in the proportion of one drachm
 to four ounces  of distilled water, may be used in its stead, and
 a few drops be  injected every  day, or every other day.   Should
 the  latter injection fail to accomplish  the  desired object, the
 sinus may be laid open,  provided it lies immediately under the
 skin, which can be incised without  endangering any bloodvessel
  or other tissue. 
CHAPTER  XXIV.
                 SECONDARY SYPHILIS.

  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 vene-
real  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
indefinite 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 in-
flammation and hypertrophy of the tonsils and the adjacent mu-
cous 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 agent shall intervene, and bring it from its hiding-
place to the light of day.
  At whatever period the secondary constitutional  development
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 atmosphere.  If
the  patient should work in the open air, or take a ride in a cold,
stormy day, or remain in a damp cellar, or encounter any try-
ing  vicissitudes of weather for  a short time  only, the hidden
                                           (266) 
SECONDARY  SYPHILIS.
267
enemy, which he may have carried about him in embryo for
years, will be provoked to make known its presence when and
where it was little expected.
  The average period between the existence of primary chancre
and the accession of any secondary cutaneous affection, is vari-
ously 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 interval than this
passed between  the chancre  and the  outbreak of any consecu-
tive, cutaneous accident.   M.  Legendre, formerly a pupil at the
St. Louis  Hospital, and  author of a thesis on syphilitic  erup-
tions, says:  " I have  obtained, as a general medium,  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 arc 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 extremes 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 poison, that which gen-
erates 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 producing 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-four
days after the occurrence of chancre, and the other one month.
Psoriasis appeared  in two subjects at the distance of four and 
268
GONORRHOEA AND SYPHILIS.
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 treat-
ment  whatever has been  resorted to.*  The longest interval of
time between the primary disease and the secondary cutaneous
affection has been, in my  own practice, twenty years.  The
case was an interesting one, and I will here  transcribe 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 juxtaposition, 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 awakened
was like the prick of a pin or the sting of a mosquito ; 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  posterior part, and down-
ward  as far as the eye could reach along the walls of the phar-
ynx,  was  found hypertrophied  from chronic   inflammation.
The mucous membrane of the whole buccal cavity was cedema-
tous,  and presented a mixture of white and red points, the
papillae being swollen,  and  the  epithelium displaced  from a
portion  of them, and  rolled up into white granules.  A few
days before I saw the case, the right tonsil had been removed by
the late Dr. Samuel Parkman.  Previous to the operation, there
* Lancet, November, 1858. 
SECONDARY  SYPHILIS.
269
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 condition
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  consecutive
lesions on the  skin, was only eleven years.
   June, 1856. — Patient A. B., age  thirty-six years; married.
Remarkably stout-built,  florid  complexion, full face, speaks of
uncommon muscular  strength, weight 190  pounds, is of me-
dium height.   In 1844, he was inoculated in  the natural way
with chancre on  the under side  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 en-
joyed uninterrupted  health until  1852, seven years, when a
moderately sore throat troubled him for a few weeks in the
autumn;  and  on several occasions since he has had an uncom-
fortable bronchitis in cold, stormy weather.  About a year ago
a  crop  of tubercles, occupying  a  portion of integument as
large as a penny, came on the right temple.  Their habits were
                    2a* 
270
GONORRHOEA AND SYPHILIS.
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 disap-
peared, whether ulcerated or not, a new crop,  usually number-
ing 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 intervals,  for more than  eighteen  months
before  the morbid condition 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 junction of the  eyebrows.  Strange to say, this  lone
specimen, which never attained the size of a  split pea, main-
tained  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 copying
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 con-
secutive  symptom; and,  so far  as we  have  any record, the
shortest time that has been known to  intervene between expo-
sure 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  bronchitis ; and
the peculiar sound of his voice  announces at once that the
organs of speech  are in an  unsound  state.    The  vascular
plexus, both of the mucous and cutaneous membranes, shows
an increased afflux of blood, and a moderate febrile action pre-
vails ;  but these conditions are rarely suspected by the  individ-
ual 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  appetite, loss of
flesh ;  has pains  in the cerebellum, back  of the neck, and in
the larger joints, especially by night; is  nervous,  languid, 
SECONDARY  SYPHILIS.
271
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 aggregrate, and as they
frequently present themselves  in a young man, they are signifi-
cant of this malady, and there is a meaning and 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 the patient's demeanor, which serves as a sort of
tableau, or mirror, declaring, in unmistakable language, the na-
ture 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 mat-
ter.   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 biassed 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, whatever may
be the variety of either,  unless their real character has been
greatly modified or wholly  lost  in consequence of some  indis-
creet medical interference.  But far different is the case when
the keenest eye and the shrewdest  intellect are brought in con-
tact with the dubious pathology of the various consecutive mal-
adies that affect the cutaneous and mucous tissues, and other por-
tions of the corporeal system, and which may or may not be the
offspring  of the syphilitic  virus.   Occasions  and circumstances   #
will  present themselves  calculated  to  bewilder,  to  astonish,
and to unsettle the judgment of  the physician, however rich he 
272
GONORRHOEA AND SYPHILIS.
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 mistake 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 sus-
tained 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 con-
summated, 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 domestic  scene.  Instead of lamentation and bitter
wailing, the voice of reconciliation and  peace  was heard, and
the contemplated 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 matter of diagnosis, will be sufficiently obvious, and  for this
purpose 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.

   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 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 poison-
ous  element which interferes with  its well-being.   The disease
is in the blood.  Here it commences its  life, as a minute, inap-
preciable  atom received into the  vital current by imbibition;
and from that moment to the time when the cutaneous derange-
ment is about to declare itself, it continues to circulate 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 activity, but by exactly
their opposite.   Its  operation is exceedingly slow and gentle.
It is feeble to an infinitesimal degree, when contemplated in con-
trast with the activity of the poison  of hydrophobia, the virus
                                                 (273) 
 274            GONORRHOEA AND  SYPHILIS.

 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 mor-
 bific principle,— and as is  the  case  with all other poisons, 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  struggle of elimina-
 tion,  other organs and  structures  are required to  share in the
 labor and participate in the disasters wliich the enemy is  sure
 to inflict.  The accumulated poison  makes known its  presence
 by a development, first in one tissue, then  in another, by suc-
 cessive  steps and at long  intervals;  each tissue and  each de-
 velopment  presenting  a group of symptoms peculiar to itself.
 Hence we can see the propriety and advantage of classifying the
 morbid phenomena of the disease  into primary, secondary, and
 tertiary  stages or  accidents, — an arrangement originally de-
 vised by Thierry de Hery, and  recently revived and  rendered
 popular  by Ricord.  In the adult subject, nearly all the syphil-
 itic  eruptions  belong  to the  second stage;  a few  only are
 reckoned as tertiary manifestations.   They all proceed from the
 same original, primitive poison.  The syphilodermata of the in-
 fant, who derives the disease by inheritance,  are the product of a
 secondary virus, which has been modified, diluted, and weakened,
 in consequence 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 erup-
 tions  that are  named  and known  according to the elementary
 forms which they present; but all  these forms exist also, inde-
 pendently of any  syphilitic parentage.  Ricord does not include
 the bullce 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 syphilo-
 dermata ; but  the  syphilitic  origin  of  such  discolorations is
 extremely problematical.
  To all who are familiar with the venereal  eruptions, it is well
known that time brings about important modifications in the 
SYPHILODERMATA.
275
physiognomy and general characters of  these eruptions; and
with a view to render them more  easy of comprehension,  Pro-
fessor Wilson, in the last edition of his work on diseases of the
skin, has classified  them in  a  tabular  form, according to their
chronological development.   Thus, the eruptions belonging to
secondary syphilis are : —

            1.  Syphiloderma Erythematosum.
                           Roseola syphilitica,
                           Maculae syphiliticse.
            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 syphilitic
  parents: —
             1. Syphiloderma Erythematosum.
                             Erythema syphiliticum infantile.
             2. Syphiloderma Tuberculosum.
                             Lupus syphiliticus.
             3. Lepra. 
276
GONORRHOEA AND  SYPHILIS.
   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 present
 themselves  with great uniformity in the history of venereal sub-
 jects.   And I am confident that the more frequently and atten-
 tively the arrangement is referred  to in the study of the syphil-
 odermata, 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 prin-
 ciple, 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 syphilodermata
 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 genuine
 syphilis  this mark or sign  is totally wanting.   The reddish,
 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 some-
 times for the influence  due to the topical remedies that have
 been employed.   The period or duration of the eruption is also
 to be considered.   We are to take into the account the particular
 region which is  the  seat of the  complaint.   The age of the
individual and his exposure to atmospheric or 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 
                     SYPHILODERMATA.                  277

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 disease, and should not be lost sight of
when we examine a patient laboring under a suspicious cutane-
ous affection.  Sometimes 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 arrive at a differential diagnosis.  The color of syph-
ilitic eruptions  is not uniform.  Sometimes it  has a violet tint,
or it may present a coppery appearance, varying in the degree
of intensity, 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  influenced  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 satisfactory degree.  But if
the disorder be in an active state,  or in the incipient stage, with
much roseolar blush upon the general 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 circumstances to  be of syphilitic  origin, I
have searched  for the existence  of this special  tint upon  the
integument, and have not been able to detect the slightest trace
of it.  Once it  was  regarded  as  absolutely essential to meet
with the copper  stain, or to  suspend  any  declaration  of  our
diagnosis, if that diagnosis involved the idea that the affection
was venereal.   But that day, with me at least, has gone by,  and
I can say, " nimium ne-crede colori."
   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 char-
acterizes the syphilodermata.  It is not, however, an easy matter
to present a true description or analysis of the various predomi-
                 24 
278
GONORRHOEA AND SYPHILIS.
nating shades and varieties of color that are met with in venereal
maladies of the skin.  To the practised eye, these affections, hav-
ing any  of the peculiar colorations alluded to, are recognized
with sufficient  ease, because these shades  or tints  rarely ever
accompany any corresponding 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 ordi-
nary 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 have been seated.  This  condition  of the sur-
face is generally considered  indicative of syphilis.   It is a con-
comitant of ulcerative venereal affections  very  frequently met
with;  but this brown appearance is  also present in  non-syph-
ilitic 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  ex-
plains  the  occurrence of the  coloration.   The copper color,
when present, generally affords strong circumstantial evidence
of a venereal  taint  in the  system; but  sometimes it  does  not
warrant any such conclusion or inference.   For instance, when
there is an eruption of impetigo or ecthyma, or ulcers of a non-
syphilitic character, on  the lower extremities, we not  unfre-
quently find, in debilitated  subjects, a tendency in the  part to
exhibit a coppery tint, in consequence of the dependent position
of the limb, and the congested state of the minute cutaneous
veins, and their remoteness  from  the centre  of circulation.
   I have heard eminent practitioners, both surgical and medi-
cal, decide that such and such a cutaneous affection could not
be venereal, because the  copper  color was  not  to  be found in
connection 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 regard
what I here offer upon the subject as  a labor of supererogation.
   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 
SYPHILODERMATA.
279
ANESTHESIA,  OR  DEFICIENT  SENSIBILITY  OF TLIE
                           SKIN.
  It is well known to most practitioners that the ordinary, non-
specific, cutaneous maladies, of every type, and throughout all
their various  stages,  are  accompanied by itching, smarting,
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
announcement  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  inconvenience which
the syphilitic patient realizes  under these  circumstances.  He
never so much as complains of itching at any period.   If ulcer-
ations  are seated over or involve the muscles of locomotion, he
will complain, of course, of inability to  move about without suf-
fering  pain ; but otherwise he would scarcely  be conscious of
their existence, at least so far as any discomfort 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 func-
tion 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  manner,  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 vene-
real eruptions are present.   To my mind  the fact is of more 
280
GONORRHOEA AND  SYPHILIS.
importance than has usually been attached to it in guiding to a
correct diagnosis; it is certainly  of more value than the copper
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
reports 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,  com-
mencing  with the papular.   When the  morbid affection pro-
ceeds 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. 
CHAPTER  XXVI.
     SECONDARY SYMPTOMS  WITHOUT PRIMARY.

  Before  proceeding to the consideration  of  the  syphiloder-
mata 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 occurrence,
inasmuch  as  their origin, or mode of reception, was not  con-
formable  to  the  theory inculcated  by Ricord.   Such instances
arise occasionally in the practice of other medical men.   In-
deed, they are numerous ; and  the  fact is calculated to shake
one's faith in certain views promulgated by that prince of syph-
ilographers 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 forehead,
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 discrete, and  in a
few weeks acquired the well-defined anatomical 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  cir-
cumvallate  papillae.  A preternatural redness, amounting  to
decided erythema, with  moderate  hypertrophy  of the  mucous
membrane of the  fauces  and pharynx,  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
             24*                          (281) 
 282            GONORRHOEA AND SYPHILIS.

 she made no complaint.  The husband was of a roving charac-
 ter, 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 disease, nor had she  any trouble in the
 genital organs, either  antecedent to  the symptoms  here de-
 scribed, or synchronous with them.   The family physician, Dr.
 W. E. Coale, bad 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 con-
 curred with him in  his views.  That this woman ever had  pri-
 mary  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 twelvemonth 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.  Tlie 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,  wliich  need not here be rehearsed.
 The forearms were the seat of numerous superficial ulcerations,
 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 gen-
 erally 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 entertained any doubt in
regard  to the  specific  character of the cutaneous  and  other
symptoms in  this instance, nor in relation to the statements of
the patient as to the non-existence  of any primary lesion. 
        SECONDARY  SYMPTOMS WITHOUT PRIMARY.    283

  Case  III. — About a year after the occurrence of the preced-
ing case, a  frail young girl consulted  me with reference to an
extensive crop of  pustules and ulcers, wliich had troubled her
for more than two years, and which had gone on increasing 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 travelled  by railroad fifty miles, with the  expectation of
being received into the Massachusetts General  Hospital, but, in
accordance with the  standing  regulations of that institution  in
such cases, was refused admittance.  On entering my office, she
was so exhausted  that she  immediately lay  down upon  a sofa.
She had taken no nourishment for fifteen hours.  She was ac-
companied 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 sallow-
ness,  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 external sur-
face was^concerned, the disease appeared to  have  a partiality for
the face, the  scalp, the fore-arms, and the knees.  Upon  the lat-
ter, three or  four broad, superficial ulcers were in a pretty active
state, requiring the protection of several folds  of rag, and ren-
dering it difficult for the girl to walk.  The face was covered
with nuu<erous 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  representations  we meet
with in  some  of the modern treatises on syphilitic dermatology.
The mouth and throat had undergone equal ravages.  In addi-
tion to the inflamed  and hypertrophied condition of the amyg-
dalae, and the congested state  of the fauces and  mucous mem-
branes 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 succes-
sion,  partly  from general exhaustion,  and partly, no doubt, 
284            GONORRHOEA AND  SYPHILIS.
because the  morbid process had  reached the chordae vocales
and the arytenoid cartilages.  The patient knew that  her com-
plaint  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. — February, 1858.   I saw, in consultation, Mrs. R.,
a married woman aged  thirty-four 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 became  pustular ; at a little later  period,  some of the  pus-
tules  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 tuber-
cles 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 variola
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
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 con-
sidered it a simple, non-specific ecthyma.  The case has recently 
        SECONDARY  SYMPTOMS  WITHOUT PRIMARY.     285

been examined by several physicians in Boston and vicinity, 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.  Generally
speaking, I know that the denial, on the  part of the patient, 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  presenting 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 hypothe-
sis 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 di-
rectly into the system through the circulation, without entering
the lymphatic channels ;  and in this way the secondary manifest-
ations may  appear, without  antecedents  of a  primary character.
He relates the case of a  medical  gentleman, that is directly in
point, as confirmatory of what I have stated.   I will here  tran-
 scribe the last paragraph :  " On mentioning  to him," says Wil-
 son, " my conviction of his case being constitutional syphilis, he
 told me that, although he  had been  repeatedly exposed to tin;
 dangers of  contagion from impure connection, he had never had
 a symptom of primary disease, — that is, nothing that ever at-
 tracted his  attention, or  called for treatment.  With regard to
 the disease, there is no doubt as to  its nature in my mind; and 
286
GONORRHOEA AND  SYPHILIS.
lean only come to the conclusion that this case is an illustration
of absorption of the syphilitic 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 manifestations of second-
ary syphilis are contagious.   He founds his belief of this upon
the long-standing opinion on  this subject, the general assent of
physicians to its truth, and the daily experience of the  profes-
sion, as well as upon clinical observations, the fact  of its heredi-
tary transmissibility, and the results of inoculation itself.  Prob-
ably 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  communicability from  secondary affections,
such as plaques muqucttses, etc.  Dr. Henry K. Oliver, of Bos-
ton,  who has  recently enjoyed  the  instructions  of this  distin-
guished German professor, states : " I have seen  him produce a
true chancre by inoculation from a plaque  muqueuse.   He does
not lay so much stress upon  the Hunterian chancre as Ricord
does, insisting that constitutional syphilis is by no means always
preceded by an indurated chancre, especially in females.   He
says  it is an every-day occurrence  for females to enter his wards
with constitutional symptoms and a chancre quite free from this
induration  ; 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 secondary
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 with  ref-
erence to this  fact, and not the slightest  degree  of irritation,
sore, excoriation, or  discharge, could be detected in either.  In
both instances  the wives had  almost precisely the  same symp-
toms 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
  *  Vide Boston Med. and Surg. Journal,  Aug. 20, 1857.  Letter to Dr. J.
M. Warren. 
        SECONDARY  SYMPTOMS WITHOUT PRIMARY.     287

venerea can be communicated by the seminal fluid.   " However
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, 1 think a careful exam-
ination 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 puru-
lent matter."   The facts which this eminent surgeon has ob-
served 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  inter-
vention of pregnancy, contaminate the woman with  the second-
ary  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 pro-
duce 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 second-
ary syphilis.   Waller made an  experiment on  a  lad of  fifteen
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  thirty^
four days after the  operation  a few distinctive  venereal tubercles
were developed near the point of  insertion.  These were fol-
lowed by  an extensive exanthematous eruption, — that is, a
characteristic roseola ; and the latter was succeeded  by pimples
and tubercles  on various parts  of the surface, and  which were
easily diagnosticated as syphilitic.
   That syphilis has been communicated by vaccination admits
of no dispute.  Dr. Alexandre  Viennois, pupil of M. Rollet, of 
288
GONORRHOEA AND SYPHILIS.
Lyons, has devoted  much study to this  subject,  and he  cites
numerous cases in which the venereal poison has been conveyed
along with the vaccine lymph taken  from persons who have had
latent constitutional  syphilis.  The venereal infection thus pro-
duced  is derived  from a particle  of blood  accompanying the
lymph,  and shows itself in the development of the papular,
vesicular, or pustular eruptions, but never  in the form  of a
primary  chancre.*
  The following report of three cases of venereal disease, origi-
nating 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 en-
joyed 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, several 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 wliich  she was ignorant 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 swallow-
ing anything 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 par-
tially opened ;  its roof  was slightly ulcerated, and  there  was
great hoarseness.  Ten months before, a node appeared on each

     * Yide British and Foreign Medico-Chir. Review, July, 1861, p.  54. 
SECONDARY  SYMPTOMS WITHOUT PRIMARY.
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 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  severity.
From these primary symptoms she soon recovered under  med-
ical 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 potassium and by the local application of tincture
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  inflammation of the whole
fauces; and upon the back part  of the  throat  were large, whit-
ish 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 potassium and compound infusion
of gentian, subsequently with tartrate 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 ulcer-
ation.  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 wliich 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.
               25 
290
GONORRHOEA AND SYPHILIS.
  Transmission op  the virus from  the nurse to the tnfant,
and vice  versa.—Upon this  subject,  M. Trousseau recently
communicated  the  following facts and  opinions in a lecture at
the Hotel  Dieu of Paris : —
  " 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 con-
sultation in  the family of one of his patients.   He informed me
that the lady of the house was delivered, seven months before, 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 became af-
fected in the breast.   I was called in  a short  time after, and sat-
isfied 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 
SECONDARY  SYMPTOMS WITHOUT PRIMARY.
they  are, nevertheless, transmitted ;  and when communicated
from the child to the  nurse the contagion depends upon special
conditions, on which I wish to fix for a moment your attention."
  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 carefully inves-
tigated, 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 med-
ical attendant of the family, after consultation with me, caused
her to be discharged.  She, in consequence, brought an action
against the medical man  who had  caused the syphilitic infant
to be sent to her, and mistaken the  disease.  The lawyer she
employed then took me to visit nurse 2, whose whole body was
covered with  a  syphilitic  tubercular eruption.  Both  nurses
ultimately succeeded in obtaining compensation from the med-
ical 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
a nursling to the nurse.  The infant, at the age of five months,
      * London and Edinb. Journal of Med. Sciences, 1852, p. 570. 
292
GONORRHOEA AND  SYPHILIS.
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 apprised 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 indispen-
sable 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. 8th. — 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 second-
ary 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 tin
character  of this  ulcer, thinking the probabilities were against
its being of a syphilitic nature.
* Vide Boston Med. and Surg. Journal, January 6, 1859. 
SECONDARY  SYMPTOMS WITHOUT PRIMARY.      293
  " 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
l,est 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 Lancet
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 always
 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 re-
  appearance in the offspring.   Several cases are on record where
  the disease is thus entailed.  That there is no certainty as to
                    25* 
294
GONORRHOEA AND SYPHILIS.
reappearance is evident from another case mentioned by Trous-
seau, in which the patient, a cavalry officer, who  bad had syph-
ilis 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-men-
tioned patient,  came to  Boston to  consult Dr. Hayward con-
cerning her daughter and  grandchild, and, finding he had gone
to Europe, she called upon Dr.  Hayward, Jr., for advice.  From
the statement of the case given above, wliich 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. H. 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. H. therefore
prescribed  for her  hydriodate of  potassa and  decoction  of
sarsaparilla internally, and  black wash, composed of a  drachm
of calomel to eight ounces of limewater, externally;  the infant
to drink the sarsaparilla, and have the black wash applied. 
SECONDARY  SYMPTOMS WITHOUT PRIMARY.
  uAng. 14. — Mrs. B. called again, and reported her daughter
and grandchild as much better, the eruption very much dimin-
ished.   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 exam-
ination,  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  liydriodate of potassa and sarsaparilla 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 improved, 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, wliich  she said  was
sore.  Dr. H. examined it, and found, to  his surprise, that  it
presented every appearance of  syphilitic sore throat.  On ques-
tioning  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 abscess 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 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, more-
over, that the matter discharged from it was of a greenish color, 
296
GONORRHOEA AND  SYPHILIS.
and resembled that wliich came from the infant's abscess.  This
sore on the back of the  left wrist was followed by red and cop-
per-colored spots, similar to those which Mrs. A. had  had, and
finally by sore throat.  The  sore throat yielded to fumigations
of cinnabar and applications of nitrate of silver ; and when that
was well, she was ordered liydriodate 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 net quite free from it now.  Dr. H. thinks that there wa^
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 charac-
ters, and that of their wives, firmly believed  that all this disease,
misery, and mortification arose from suckling  a diseased  child
upon  a fissured nipple.   W7ith this conviction, he remarked that
it seemed to  him  of the utmost  consequence, first, that, before
allowing any strange child to nurse a woman, the family physi-
cian should be consulted, which was not done in this case ; and,
secondly, 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 evidence of the pro-
tracted  existence  of the lesion  in  the mother's  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  conviction which 
SECONDARY  SYMPTOMS  WITHOUT PRIMARY.
297
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  unsyphilized  subject.   Sec-
ondary  and constitutional lesion  is  well  known to be  almost
never so.  The present discussion  is to the point whether sec-
ondary  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 wliich 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 demands a rigorous scru-
tiny of any case adduced  in contradiction of his results.  Grant
a venereal eruption to be identified as such (which is often  dif-
ficult, sometimes  impossible), the question of its origin 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, persistently denied  or honestly ignored  by
the individual last affected.  No other medical subject presents,
like this, the sacrifice 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  strong a
guaranty of immunity as  posterity had a right to expect, 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. 
298             GONORRHOEA AND SYPHILIS.
   " 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 Surgeons,
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 respectable 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 entitled  to our remem-
brance, whatever theory  we may entertain on the subject.*
   " In view of such  facts, Dr. D. asked if any member of this
society would feel justified  in giving  his professional opinion
that a syphilitic infant might safely be committed to the custody
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 sit-
uation, but, upon examination, should be found to  have second-
ary syphilis, would any  gentleman  present be inclined to en-
courage the friends of the  child to  commit it to the  fostering
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 evidence
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  chancre.
Once he was a believer in Ricord's theory.   But facts observed
in his own  practice, as well as those adduced by the most trust-
worthy men from  all quarters of the medical world, had  fully
convinced him that Ricord  was not sound on  this point.  He is
preeminently entitled to praise for the great  scientific advance-
* These cases are inserted on p. 291. 
SECONDARY  SYMPTOMS WITHOUT PRIMARY.
299
ment 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  which 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 periods.
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 Con-
tinent, 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 contagiousness of small-pox differs
in different years.  Is  it not within the bounds of possibility that
syphilis may, under different circumstances of epidemic predispo-
sition,  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  following interesting case was kindly furnished  me by
Dr. S.  L. Abbot, Physician to out-patients of the Massachusetts
General Hospital. 
300
GONORRHOEA  AND SYPHILIS.
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 sur-
face 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, respect-
able, reliable person, as follows : —
  " Early in the previous October  the child was taken with scar-
latina, 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 ex-
pose themselves to the contagion of the disease, and she accord-
ingly 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 attend-
ance 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  she  had a very sore mouth, the corners of it
being greatly disfigured and covered with  crusts.   Apprehen-
sive that some disorder might be communicated to  her child,
although not dreaming of the  possibility of  any syphilitic  con* 
       SECONDARY SYMPTOMS WITHOUT  PRIMARY.    201

tadon, she questioned her about her mouth, and was told, in
reply, that  the trouble was only ' canker,' to which the doctor
was applying caustic every day.  She did admit, however, that
some months previously she had had a complaint of a venereal
character, of short duration, which she had taken from her hus-
band.  She had been well of this, however, for months.  The
natural caution of the mother, notwithstanding, led her to check
her frequent impulse to kiss the infant; but in spite of this she
frequently observed her disobeying her injunction, and imprint-
ing 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 contin-
ued three or four weeks without benefit from the domestic rem-
edies employed, when the mucous papules made their appear-
ance.  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 unknown to me; but the frank-
ness of his manner, and the  extreme solicitude of both parents
in behalf of the 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 connec-
tion with  the infliction  of  this grievous disorder upon  it.   In
order to supply all  the evidence possible, the mother submitted
most willingly to examination, 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 desir-
able, 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
                      26 
302
GONORRHOEA AND SYPHILIS.
examination, 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  complaint, she  said,  was a
slight ' runnine:' from the vagina, which lasted but a few davs.
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 dis-
order 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 dis-
order ' 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 tho angles of the mouth, on the inner sur-
face 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  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  informed  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 miscar-
ried three times within a year, each time before the completion
of the third month of pregnancy.   After one of these abortions,
the occurrence of which she attributed t.) weakness, she lost her
hair, owing, as she thought, to the subsequent fever.  I did not
make any further  examination, as information which  I  had
received  of her  history subsequent to the time when  she  had
charge of  the child  made any facts which might have been thus
obtained  of no special value.  This, then, is the whole history, 
SECONDARY  SYMPTOMS WITHOUT PRIMARY.     303
 and I am unable to resist the conviction that the child derived
 its disease from her attendant, who was affected witli it at the
 time, probably, in a secondary form.  The difficulty of obtaining
 final, irrefragable evidence in such a case is, of  course, ex-
 tremely 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 disease was communicated to the child ?  It is ex-
 tremely  improbable  that she  bad for  two reasons: first, the
 assurance of the mother and the woman 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 without any knowl-
 edge  of its professional significance, and according with the
 well-known  facts in similar cases ; and, second, there is no 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  acknowledges  repeated abortions  and
  alopecia, —common  enough  results of constitutional syphilis. 
304
GONORRHOEA AND  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
remonstrances, 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  inflammation  and  excoriation of  the mother's
nipple.
  " Such are the facts, and their value will be different with dif-
ferent 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 affected 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  con-
sequences to herself;  and, until that was accomplished, to wash
the nipple with liquor sodae chlorinatas, after each application of
the child to the breast, and  to wash over the excoriated  surface
daily  with a solution  of  nitrate  of silver, 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  con-
dylomata, 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 prejudicial 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 recov-
ery should be complete."

  The general bearing of what is embraced in the present chap-
ter, 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, except in
hereditary syphilis.  In a legal and moral, as well as in a med-
ical, point of view, the subject is one that demands close and
impartial study.  Its investigation  is acknowledged to be fraught 
        SECONDARY  SYMPTOMS WITHOUT PRIMARY.     305

with difficulties.   It is not wholly free from the influences flow-
ing 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 thus 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 secondary syphilis  is a fact as  firmly
established  as is  the  contagiousness 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 par-
ties is  at stake, to ponder upon  the facts and opinions embraced
in this  chapter.   To  ignore  them would be unreasonable,  un-
safe and unjust.
  The theory has been broached by Simon, an eminent patholo-
gist, 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, and
acts, as is seen in its  influence  on the foetus in utero, through
the unbroken walls of the bloodvessels  by  endosmosis, convert-
ing 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 ?
                 26* 
CHAPTER  XXVII.
   SYPHILODERMA ERYTHEMATOSUM,  OR ROSEOLA
                       SYPHILITICA.

  The exanthematous affections, including the maculae, roseola,
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 disturbance.
In some instances, especially in  plethoric subjects, the eruption
of roseola, of lichen, etc., is  ushered  in  by a slight febrile  ex-
citement.  Sometimes, as I  have  elsewhere stated, a  species of
urticaria, or lichen, is  seen upon the whole  surface in conse-
quence  of the peculiar  action of balsam of  copaiba, or of the
powder of cubebs, taken  in large quantities for the cure of gon-
orrhoea, 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 consternation
was felt by the patient, because  he  apprehended that his habits
and his condition would  come to the knowledge of his imme-
diate friends.   But upon the discontinuance of the medicine,
                                                  (306) 
SYPHILODERMA  ERYTHEMATOSUM.
307
the peculiar  erythematous  excitement of the integument en-
tirely 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, tho 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 exten-
sive regions, it has very much the mottled  aspect of measles;
and it then comes out in  circular or crescentic blotches, is un-
accompanied by constitutional symptoms, and is free from itch-
ing.  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 mi-
grating from spot to spot, and exhibiting its  dusky shade  espe-
cially on the lower extremities, where the cutaneous capillaries
are more readily  congested than elsewhere.
   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  exfo-
liation.  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 termi-
nates 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  discoloration may be, it always lacks  that
bright scarlet which  belongs to  simple roseola.    Sometimes it
assumes the annulate form. This variety, however, is  uncom-
mon.  I have met with two instances, both in females, one of
whom, a noted actress, was of  a full, plethoric  habit, and suf-
fered 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 suffering from primary sores at the same time.
The eruption appeared upon the face, neck, and extremities ; 
308
GONORRHOEA AND SYPHILIS.
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  usu-
ally  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 sor-
des,  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 her liusband, denied ever hav-
ing had any venereal symptoms.  After the eruption had existed
for several weeks, Dr. Salter and myself were called in  consul-
tation.  The posterior cervical glands were  enlarged ;  the  mu-
cous  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 suf-
ficiently  distinct in  character not  to be confounded with any
other exanthem, especially when considered  in  connection  with
the  other concomitant  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
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 
             SYPHILODERMA ERYTHEMATOSUM.         309

cough, the  sneezing, the quick pulse, and  the  alternation  of
chills and  fever, which exist in measles, are wanting.

  Treatment. — If any febrile symptoms arc present, wliich 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 constant  tendency to accumu-
late; 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 employment  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  regularity
in the habits of the patient, is all that  will be required at this
crisis by way of constitutional treatment. 
CHAPTER   XXVIII.
                  PAPULAR ERUPTIONS.

  Syphilitic papules exhibit themselves under the guise of two
principal forms.  In the one, they are closely associated together
in groups, and assume  a semilunar 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,! think it is correct to
state that  the  individual papules  are  larger  than when de-
veloped in  crowded clusters.  The  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 wliich  is  so generally, I cannot
say always, characteristic of venereal eruptions.    At no period
are they pruriginous, even when they terminate, as they some-
times 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 resem-
blance  to acne indurata, and  have been honored with the digni-
fied sobriquet of corona veneris.  They  create no constitutional
disturbance, unless they burst forth suddenly as an acute affec-
tion, 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, wliich is very rough, and
in an  unperspirable  state; the  pulse is accelerated,  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.
                                                 (310) 
 
PI II
itic Lichen. 
PAPULAR ERUPTIONS.
311
  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
obstinaey  of the attacks,  something depends upon  the period
that has intervened between the primary affection and  the con-
stitutional 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, arc likewise so many con-
tingent circumstances  which will more or less  influence  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  denominated  lichen
corymbosus; where  they appear  separately, they  are  termed
lichen disseminatus.   Professor Wilson makes still other vari-
eties, according to the  particular mode of  development; but
these subdivisions  I do  not regard  as very important 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 consider-
ation.   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 are  avail-
able as so many well-known  signs or aids wliich 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 abnor-
mal  condition   of the several parts of the  mouth and  mucous 
312
GONORRHOEA AND SYPHILIS.
membrane of the eyelids, joined  to  the  phenomena 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 tubercular
form, wliich 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 accompani-
ment 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 external 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 covered with dry, delicate
scabs or incrustations.  When  developed 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 syphilitic 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
upon the face,  the innumerable pimples impart  to the coun-
tenance  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 
PAPULAR ERUPTIONS.
313
the most practised 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 practition-
ers have fallen into error in their diagnosis.   So difficult 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 consequence of which
he has inserted the following sentence in his work: " This case
led me to trust alone to concomitant symptoms, and I deter-
mined never to characterize a papular  eruption 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 distin-
guished 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 falla-
cious  theory,  pronounced that the disease was not  syphilitic.
Acton treated it successfully with mercury, and regarded it as
venereal.
   After the healing of a chancre, the  syphilitic taint will remain
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 assuming  the
usual  pustular character.   Otherwise, the  entire surface  looks
perfectly healthy.   This insignificant  disc, perhaps not an inch
in diameter, may constitute  the only external manifestation  of
the expulsive effort of nature to relieve herself of the " peccant
humor,"  which she has,  until now, retained within  her pre-
cincts 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
                  27 
314
GONORRHOEA AND  SYPHILIS.
this  trifling cutaneous affection, a morbid state of the buccal
mucous membrane very commonly coexists.   On  examination,
the fauces will  be found  swollen  and  of  a  purplish  hue, but
perhaps giving the individual no trouble.   The medical attend-
ant,  however, will need a reliable history to aid him in the
diagnosis.   These cases  occur with  considerable  frequency.
The  therapeutic principles, upon  which  the  most successful
treatment is  based, are abundantly simple.   Every day's  expe-
rience, 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  adminis-
tered ; or what is  termed the emollient bath may be used  in  its
stead.   This  is  prepared   by  pouring  four  quarts  of boiling
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 ten-
dency 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.
      Aquae,   ...............Cong. xxx.

  Add to this solution : —

      Ichthyocollae,.............lb. ij.
      Aquae Bullientis Solutae,   .........  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.
  In the acute  variety of  lichen, there  is usually considerable 
PAPULAR ERUPTIONS.
315
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
action.   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 tlie
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 top-
ical  means are  prescribed  for this  purpose.    The following
ointment may  be employed at bedtime: —
  K.   Hydrargyri Deuto-Iodidi,.........gr. j.
       Pulveris Camphorae,   ..........gr. viij.
       Unguenti Rosarum,...........§ iss.   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: —
  ft.   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 " 
316
GONORRHOEA AND  SYPHILIS.
  If it  produce much  smarting, the  proportion  of the dento-
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 absorption
of the  papules.  The iodide of sulphur ointment is sometimes
an effective  local remedy in these cases.

  ft. Sulphuris Iodidi,............9j-
      Pulveris Camphorae,...........gr. vj.
      Olei Bergamotae,............
        u Lavandulae, aa,   ..........gtt. v.
      Unguenti Rosarum,...........5 j.   M.

  This  preparation  can  be rubbed  upon the  papules  every
night.   A drachm of the iodide of sulphur to two  ounces 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
patients  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.

  ft. Olei Bergamotae,.....
      Plumbi Acetatis,   ....
      Unguenti Hydrargyri Nitratis,
          "    Cetacei,   ....

  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
gtt. v.
Bj-
|ss.
Sj.  M. 
PAPULAR ERUPTIONS.                317
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
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 hurtful
as any remedial  course can possibly  be.   Even in primary
phagedenic sores Mr. Parker does not hesitate to  employ these
fumigations.   In regard to the merits of his practice with mer-
curial  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,  manner, or quan-
tity    To me it seems to be a matter of doubt how the salutary
influence of moist mercurial  vapor is produced.  Does the good
effect  ensue  in  virtue  of  the  absorption  of the exceedingly
niinute 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 sup-
posed  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 mer-
 curial substance  from gaining free access to the interior of the
 system.    And  therefore the query suggests itself, is   it the
 mineral agent  that goes  into  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.   The simple, unmedicated vapor-bath, administered
 to persons suffering not only  from papular but from various other
 forms of cutaneous  eruptions, exerts a  highly  beneficial in-
 fluence.   The  stimulating  and tonic action of  the  vapor  of
 sulphur, combined with heat and moisture, agrees, I am certain,
                 27* 
318
GONORRHOEA AND  SYPHILIS.
with indolent sores and ulcerated surfaces  generally, whether
venereal or not; and the use  of such  baths  can hardly ever be
ill-timed,  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 remarkable.   But to secure its  best effects, a  high, moist
temperature  is requisite, in  order  to  induce a copious  perspi-
ration for  an  hour or two every  day, or  every  other day,  as the
physical 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 efficacy,
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  con-
trary, generally  promote  the improvement  of the  syphilitic
invalid.
   I am  inclined to the belief that nearly or.quite all  the benefits
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 touching  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 framework.
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 
PAPULAR ERUPTIONS.
319
or the binoxide.   Under each of these, a  spirit  lamp.  The
patient is thus exposed to the influence 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, beyond  which I do  not  prolong the bath, it  is
generally excessive.  The lamps are now removed,  and the tem-
perature gradually allowed to sink.  When the patient has be-
come moderately 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 : —

  ft.  Acidi Nitrici Dilirti,   ............gtt. xxx.
      Syrupi Aurantii,.............§ ij.
      Decoctionis Saponariae,...........§ xij.
  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 secondary
eruptions by the administration of stomachic and tonic remedies
and good diet, conjoined with the following : —

  ft.   Antimonii Sulphured,
      Potassae Nitratis, aa,............9 v.
      Sulphuris Sublimati,............  § iiss.  M.

  Of this powder, the dose is thirty-five grains, night and morn-
ing, 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 ob-.
tained.  The medicine is to be  persevered in for some weeks
after the cutaneous affection has died away.  I have made only
*Of June 27, 1857. 
320
GONORRHOEA AND SYPHILIS.
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  before she ap-
plied 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 after-
wards.   The patient resided in the country at the time, lived
well, and had the benefit of wholesome 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 con-
junction 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 enlargement
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 appear-
ance of being slightly freckled ; that is, very small, yellow spots,
with  their outlines not well marked, are scattered over the  fore-
head 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  epidermic 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 subsequently to  those on the face. 
PAPULAR ERUPTIONS.
321
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 small, micaceous exfoliations.
The  integument  here is also free from  any  coppery tinge.
The hands present an appearance 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 peculiarity is due to a specific cause.   Along the belly
of the gastrocnemii muscles, and farther downwards, were some
eight  or  ten  round,  deep ulcerations, wliich 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, liche-
noid character; but the greater portion of  them had grown
into  good-sized tubercles, or had  advanced  still farther and
had become  tubercula 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 with-
out 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-pas-
sages were obstructed by tenacious 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  re-
marked that he had for several months  been troubled with what
he supposed  was bronchitis.  The  right  testicle was enlarged 
322
GONORRHOEA AND  SYPHILIS.
and  at times painful.  I had no particular acquaintance with
this  individual, and knew nothing of bis  previous habits ; but
from the evidence presented, 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. II. 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.  lie 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 his  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 sliould commence.  To  this I saw no objection, and the
following  course was adopted : —

   ft.  Hydrargyri Chloridi Corrosivi,..........
       Ammonias Muriatis, aa,   .  ,..........gr. viij.
   M.  ft. pil. No. lxiv.
   Dose. — One.pill morning and evening, directly after eating.

   Of the solution of tartrate of iron and  potassium, 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 : —

  ft-  Sulphuris Iodidi, .
      Pulveris Camphorae,
      Olei Bergamotae, .
      Unguenti Rosarum,

   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,
9ij.
gr. v.
gtt. vj.
Si-  M. 
PAPULAR ERUPTIONS.
323
like other people ; to have a generous  diet, and to abstain  from
tobacco :  all which he promised to do.
  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  occa-
sions the gums  became slightly tender.   The pills were accord-
ingly intermitted for  five or six  days, and then resumed.  He
continued his avocations most of  the  time as usual.   Fortu-
nately, no appearance of  the skin upon  the. face or  hands be-
trayed 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 charac-
teristic 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 tuber-
cles 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 syphi-
litic  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  arc 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 agree-
able to the patient than the iodide of sulphur.

  ft.  Hydrargyri Sulphatis Flavi,
      Unguenti Rosarum, .  .

  While applying any of  the ointments, the utmost care should
9j-
l\.  M. 
324
GONORRHOEA  AND SYPHILIS.
 be observed to keep  the diseased  surface  in  a cleanly state by
 the use of warm bran-water every day before  the inunction.
   Stimulating lotions will  frequently exert a favorable influence
 upon the papules, if applied in the early stage and before their
 transition into the larger prominences, which  are, strictly speak-
 ing, tubercular.  The annexed prescription is one of the best: —

   ft.  Hydrargyri Chloridi Corrosivi,.........gr. xij.
      Aquae Colognae,..............
      Spiritus Rectificati, aa,...........3j.
      Aquae Fontanse,..............§ viij.  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 excel-
 lent application.   It will  be borne, without  complaint, of  the
 following strength, and will in many instances promote the  dis-
 persion of the  papules : —

  ft.  Acidi Nitrici,.........
         "   Muriatici, aa,......
       Aqua1 Fontana1,........
  Lotiox. — 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 em-
ployed.
3j.
Sxvj. M. 
CHAPTER  XXIX.
          SQUAMOUS  SYPHILITIC  ERUPTIONS.

  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 sub-
jects 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 maturer
growth ; and the  great difficulty is to distinguish between those
that arc venereal  and 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
following quotation: "The squamous forms  of syphilide  are
generally so perfectly  characterized by the coppery and some-
times  nearly  black  color of the eruption, by the  soft,  smooth
                  28                             C325) 
326
GONORRHOEA AND SYPHILIS.
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 lamina'
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 influences."
  There  are  other ways and circumstances by which  syphilitic
psoriasis or lepra may be distinguished  from that which is non-
venereal.  In the former variety the patches or  discs usually
occupy less  surface  than  in the latter;  they do not generally
show themselves around the elbow and knee joints, as is the case
with simple  psoriasis ; and if the  eruption has  been of long
duration  it acquires a very dark color (psoriasis nigricans) ; the
scales are thinner and the complaint yields almost invariably to
the moderate use of mercury.
  Mr. Burgess, who is usually good  authority, informs us that
the characteristic color is  always to be  found; for, no  matter
how sm ill 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 tho 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 liabil-
ity 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 pecu-
liar discoloration did not exist.  The patient  came to Boston.
It was in September, 18—.   He was twenty-nine 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 
 
ID
Anru.e.r Crustaceous Eruption. 
SQUAMOUS  SYPHILITIC  ERUPTIONS.
327
man was married to  a  healthy woman, who had  suffered two
miscarriages.  He  was  of diminutive stature,  emaciated and
feeble ;  could  scarcely walk a  hundred rods ;  his appetite was
miserable ; he had much trouble from constipation ;  his tongue
was  coated ; the  pulse  one hundred; and  there  was extreme
pallor of countenance.  There  were several squamous blotches
on 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 erup-
tion in  different stages of development.   The  most singular
and  interesting specimens  consisted of annular, tuberculo-crus-
taccous  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 par-
tially softened on their summits, and yielded a very scanty puru-
lent exudation, — the latter having  desiccated 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 tendency ; that is. as it
got well in  the central  part, new tubercles would appear, just
outside  the  borders of the cicatrix, which widened in every di-
rection  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 instances,
took the annulate  form, and varied in size  from half an inch
to thrice  that diameter,  squamous  in  some  spots, in  others
tuberculo-cru^taceous.  On the entire surface  there were  some
seventy  or eighty of  these sores.   They  produced  no itching,
but gave rise to a most  offensive  exhalation.  The patient had
neglected to bathe  for a long  time.  The sebaceous apparatus 
r,28             GONORRHOEA AND  SYPHILIS.

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 weather, there had
been  sore  throat  to a moderate degree.   The patient was ex-
tremely  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 fol-
 lowing day with  the son.   On  this  occasion he acknowledged,
 after a few evasions, that he  contracted a gonorrhoea in New
 York two years previous to the appearance 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 unembarrassed.   The
 father, who was waiting in another apartment, 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  mani-
 fested by father and son,  and the written  opinion of the emi-
 nent 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 consultation; and  that, if their  diagnosis
  harmonized with mine, the decision should be considered  cor-
  rect and  final, and that I should have  the professional care
  of the patient.  The  first  part  of  this arrangement was  con-
  summated in a few hours;  and after a thorough examination ot
  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 ot
   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 lor- 
            SQUAMOUS  SYPHILITIC  ERUPTIONS.         329

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
not tell me that;  the Boston doctors  are right."   The  last
remains 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 one
drachm  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 careful attention to diet,
particularly the  free  use of fruits, such  as  apples, pears, or-
anges, and grapes, the normal function of the bowels was grad-
ually  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 sometimes 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 circula-
tion being well established, as shown by  warmth of the extremi-
ties, the use of the bichloride of mercury, in pills, was added
as auxiliary to the ferruginous  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 apparatus.  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 inconvenience was experienced
from it.   From the  moment the treatment was instituted to its
close  no retrocession  of  symptoms  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 dis-
appeared, so far  as relates to  actual symptoms.   The patient,
               28* 
330            GONORRHOEA  AND SYPHILIS.
who, from the beginning, carried  out  the  prescribed course in
its minutest details, has enjoyed comfortable  health  for several
years.
  Besides the remedies  above mentioned, other suitable medi-
cines were  employed, such  as dilute nitric acid, large libations
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  quantities of the iodide
of potassium, together  with the  use  of various  topical appli-
ances,  already sufficiently alluded to  in previous  pages.   Nor
was  the benefit  resulting from  a salubrious atmosphere  and
agreeable exercise forgotten.  The  patient took board a short
distance from the city, and, as soon and as fast as  his  strength
would  permit, he was daily on the  wing,  making  short excur-
sions 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 gath-
ered from  his past  history.   All the  sources of information
sliould be explored.   The entire facts  in the  case  are  as essen-
tial 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 cannot
exchange words upon the topic with safety or propriety.  Such
circumstances do now and then happen.   Upon the  subject of
syphilis the physician is  bound to keep silence.   In suspicious 
SQUAMOUS  SYPHILITIC ERUPTIONS
331
 instances,  the  usual  avenues to the  truth  being unavailable,
 mercury may be properly summoned as a witness, provided the
 general health  and the condition of  the person 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 wliich the mineral in question,
 even if administered till the system be absolutely saturated with
 it, would afford no clew to the real  character of the complaint.
 It is not every  syphilitic subject who can tolerate the action  of
 mercury in any form  or quantity.
   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  occa-
 sionally show a disposition to yield a very little purulent dis-
 charge;  but I am inclined to believe that in a  majority of in-
 stances,  regarded  as  squamous, the  lichenoid  papule or the
 tubercle precedes the squama, the latter  condition being simply
 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 particular
 portions most commonly occupied are the  scalp, the anterior
 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, 
332
GONORRHOEA AND SYPHILIS.
although  the  inflammation is  of a low, subacute  type.  The
usual characters of  inflammatory action, such as  heat, pain,
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  peculiarities 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 ner-
vous defection gives rise to other singular features  that apper-
tain 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 central
point, thus presenting an annulate figure.  It  is  called psoriasis
palmaris  centrifuga, or erythema palmare annulatum syphiliti-
cum.   Distinct and well-marked tubercles are often found asso-
ciated 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 consequence of enfeebled capil-
lary 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 constitu-
tional 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 syphilitica, characterized by dark,
fuliginous  squamae.  The blotches assume  various  tortuous
appearances or forms, which are  modifications  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 eyelids, 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 superior
portion  of the trunk, associated with tubercles on  the  arms,
while ulcerations of various extent occupy the inferior extremi-
ties.  These several  coexisting phenomena  indicate a serious
impairment of the  system, and are rarely  present  unless  the 
             SQUAMOUS SYPHILITIC ERUPTIONS.          833

patient has struggled for a very long period against the venereal
poison.   When  the  squamae appear  upon the scalp,  the hair
usually  falls  out, and  it can seldom be restored to any great
extent.  In  non-specific  squamous eruptions the pilous appa-
ratus remains intact, or nearly so.

        TREATMENT OF  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 sel-
dom 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  syphilo-
derma.  The  gums  should  bo  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 properly sus-
tained 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 some-
what protracted use  of mercury.  Its depressing 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  opinion, no way to cure him of con-
stitutional 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 tlie 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 with-
out 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 
334             GONORRHOEA AND  SYPHILIS.
guard against.   To check this downward inclination most ef-
fectually, we must sustain the energies of the system by  food at
once nutritious and easy of digestion, and  thus confer upon the
various organs, tissues, and fluids ability to  antagonize  the  in-
imical principle that is hidden within the physical organization.
Milk will usually agree  with  the patient.  It  comes already
cooked, and contains such a combination of animal  and  vegeta«
ble 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 hesitate to allow the addi-
tion 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 accomplish 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 haema-
tosis in the  economy is facilitated, and  that, in  the  normal
growth and development of the blood, its characteristic  corpus-
cles  are  augmented numerically;  and  hence the  therapeutic
value of chalybeates, whether  given  in  conjunction with mer-
curials or with the iodide of potassium.
  With a view, also, of restoring the lost  tone of the constitu-
tion, the cod-liver  oil may,  in many  cases,  be advantageously
prescribed in doses of two drachms three times a day, gradually
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 confi-
dence, in the condition  of things we  are now  considering, can-
not be doubted.   It is usually retained quite well  if adminis-
tered 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 
SQUAMOUS  SYPHILITIC ERUPTIONS.
335
favor 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 re-
pugnance to the oil.  As a medicine  its value is equal to that
of the latter substance, while it possesses the important advan-
tage of being  in a great degree deprived of its nauseous proper-
tics, and is tolerated  by persons who cannot endure  the  oil.   It
contains eighty-five per cent, of the latter.   It can be swallowed,
without masticating, in  a little  sweetened water.  Used in this
manner tho 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 ema-
ciation.
   Cod-liver oil has also been converted into a dietetic form by
Mr.  Lebague,  a chocolate manufacturer of London.*   It is com-
bined  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  medi-
cine.  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 com-
bination  with opium, thus : —

   ft.  Hydrargyri Chloridi Corrosivi,.........  gr. xij.
       Pulveris Opii,..............gr. xx. M.
   Ft. pil. No. xxxvj.

   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
gave the preference to the oxymuriate over the  other forms  of

   * Of No.  10 Little Tichfield Street, St. Marylebone.  The  chocolate can
be obtained at Metcalf s, Tremont Street, Boston. 
336
GONORRHOEA AND  SYPHILIS.
mercury.  Wilson is partial to the bin-iodide, as at first recom-
mended  by Biett, although Biett soon relinquished the bin-iodide
for the proto-iodide, which is more manageable, and is an clhni-
native agent of  great  power.  The formula, as  preferred 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 combination with the
proto-iodide,  the therapeutic qualities of the  latter are  com-
pletely neutralized, and  therefore it should be prescribed in an
uncombined form.   Biett made this  discovery.
   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 evi-
dence 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 substitute.   In
such  cases the iodide  of potassium  will frequently prove  a
valuable  article.
   In  some instances that have long been under mercurial treat-
ment  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 advisable  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.
  It may be directed as follows : —
  ft.  Potassii Iodidi,.............5 }j_
      Extracti Gentianae,   ...........q. s.  M.
  Ft. pil. No xxx. 
SQUAMOUS SYPHILITIC ERUPTIONS.          337
   Give one pill three times daily.  Or the following: —

  ft.  Potassii Iodidi,..............3 iij.
       Syrupi Sarsaparillae,............
       Aquae Fontanae. aa,............§ iiss.  M.
   Dose. — One  drachm, morning, noon, and  night, in  a wineglass full of
 cold water, in immediate connection with the meals.

   I have known persons who could not tolerate the iodide, even
 to  the amount of only one grain in the day, on account of the
 severe and  sudden inflammation  which  it excited in the skin.
 The subjoined instance is an illustration: —
   A few years since, Dr. J. Mason Warren recommended to my
 care a lady who  had suffered for several months from consti-
 tutional syphilis.  I  took  charge of the case, Dr. W. being  re-
 tained as consulting  surgeon.   In the process of treatment a
 crisis arrived when it was  judged expedient to try the iodide of
 potassium in small quantities.   Within twenty-four hours  from
 the time the first dose was taken an erythematous  condition of
 the integument  of  the face, neck, and chest  displayed itself;
 and at the expiration of a  few  days more an abundant lichenoid
 eruption appeared, to the great annoyance and  alarm of the
 patient.   The  medicine was discontinued, and in a short period
 the lichen disappeared.   Several weeks subsequent to this acci-
 dent a second  attempt  was made with the iodide  in  pills  of
 two grains.  The patient took  a  pill at night.   The  next  morn-
 ing the  face was thickly dotted over  with a  minute  papular
 eruption.   The iodide was abandoned for  one month, when a
 third trial  was made, and a pill,  containing one  grain of the
 salt, was used at bedtime.    The lichen was produced  as  on
 former  occasions, but  with  less  severity.   This  is the  only
 instance of such  peculiar idiosyncrasy that I have witnessed.
 and I was at first incredulous as to its reality.*

  * Dr. Morland  has recently had under his care a man who manifested a pe-
 culiar susceptibility as regards the iodide.  The patient was  thirty-nine years
 of age.  The  iodide  was  given in the compound decoction  of sarsaparilla.
 Only two grains and a half were taken at a time, twice a day.  On the second
 day the  patient had so severe a coryza and headache, and was so uncomfort-
 able every way, that Dr.  M.  was about to suspend the medicine, it seeming
 evidently to be the cause of these symptoms.   It was,  however, given once on
the third day, when, almost immediately after its administration, there was so
                  29 
338            GONORRHOEA AND  SYPHILIS.

  Patients sometimes  complain of a painful sensation in the
throat  and at the epigastrium for an hour  or two after  swal-
lowing the potassium  even in moderate  doses.   The  aversion
to it has  been  somewhat  frequent  in  my experience;  and
occasionally of such  a decisive tone that  I have been  com-
pelled  to  abandon  its  use before  a fair trial  of its  curative
effects  could be  made.  It has appeared, in some instances, to
be better borne  if made into pills with the  extract of gentian,
than when given  in solution; but I have  known  individuals to
complain of a distressed, sinking feeling  in  the  stomach, occa-
sioned  by the pills.   In whatever form administered it  is apt
to produce a thick, white coating upon  the  tongue;  the mouth
is sometimes  exceedingly troubled by the secretion  of a ropy
mucus ; the patient suffers somewhat as from slight ptyalism,
and  a loss of appetite ensues.
  The abnormal condition of the mucous  membrane, buccal
glands, and stomach soon disappears if the potassium be dis-
continued.  Still more serious and  noxious pathogenic effects,
attendant on  the employment of this  article,  are on  record.
It now and then  provokes epistaxis.  In some persons  an  acute
coryza is  induced; and I have known it to occasion  swelling
of the  face, — the conjunctiva at  the same  time being  highly
injected and painful,  as a  consequence of  the  peculiar  action
of the medicine.  It  has  been thought  to  bring out patches
of purpura upon various portions of  the skin.  Its influence
on the general circulation is of a sedative nature, and  it  dimin-
ishes the  force and number of the arterial  pulsations.  Some-
times it excites irritation in the  intestinal  mucous membrane,
and  a diarrhoea  sets  in ;  at other  times what  is termed the
iodic intoxication is  observed.  This latter condition may be
known  by a  disturbance of  the involuntary muscular  move-
ments, as spasmodic  twitchings; and even the mental faculties
are disturbed  for a few hours.  All these unpleasant  accidents,
however,  subside very soon after the discontinuance of the Vem-
edy  ; and  it is but just to say that they really constitute no
valid objection to its general use.  Some patients, even females,

great an aggravation of the symptoms mentioned,  that he abandoned the use
of the remedy.  In  less than twenty-four hours  all the disagreeable sensations
had vanished. 
SQUAMOUS  SYPHILITIC  ERUPTIONS.         339
can take two or three drachms of the potassium in the twenty-
four hours  without inconvenience; and it has been  adminis-
tered to the amount of twelve and  sixteen drachms in the day,
and  yet  its properties, in  these instances, were  perfectly in-
nocuous.
  For  the purpose of  rendering  the  medicinal  substance  in
question  more agreeable and efficient, I  have for a year  or
two  past  been  accustomed to combine it  with the carbonate
of ammonia, which is a decided improvement.  The impression
upon the stomach and  upon  the general  sensations of the pa-
tient is very pleasant.  This  is the report uniformly rendered
by those who  have made trial of the combination,—wliich is
the following: —

  ft.  Ammoniae Carbonatis,............5 iss.
      Potassii Iodidi,..............3 iij.
      Syrupi Sarsaparillae Compositi,    ........
      Aquae Fontanae, aa,.............§ iiss. M.

  The  usual portion  is one drachm, three or four  times daily,
in a  gill of cold water.*
  The  extremes as to the dose of the  potassium are at a great
remove  from  each other.   No  other  remedy of  established
reputation  enjoys  so  wide a range in this respect.   What is
considered a medium quantity,  in ordinary  cases, is a  matter
quite unsettled among the  leading  practitioners  of the day;
and  there is no uniformity of opinion  as  to the class of cases
in which it  should be given,  excepting  those belonging to the
tertiary syphilitic  period.  For the removal of these  tertiary
conditions  its curative  power is preeminent   over  all  other
medicines.  In some  tardy  secondary  affections  I have occa-
sionally prescribed it with the most satisfactory results.  The
amount which I prefer for long-continued use rarely  exceeds
six or  seven grains three times  daily.  The London  surgeons
are mostly in  favor of small  quantities, in the  belief that from
these all  the benefit will accrue that can be derived from large
doses.   Acton  and Ricord  employ large  doses if small  ones

  * An opinion prevails at Guy's Hospital that the efficacy of the potassium is
very much increased by its union with the ammonia.  Vide Medical Times and
Gazette, 1854, p. 488. 
340
GONORRHOEA AND SYPHILIS.
do  not  succeed,  and  they  order it  in conjunction with  the
tartrate of iron and potassium.
  In June, ISoT, I saw a girl, twenty years of age, then under
the care of Dr. Salter, for  constitutional syphilis, from which
she had suffered for more than two years.   For some months
she had received no regular medical attention from any quarter,
and her symptoms, wliich were both secondary and tertiary, had
been gradually augmenting  in severity.   She was anaemic and
much emaciated.   For several weeks Dr. S. directed a moderate
use of the iodide, together with tonics and a good diet; but as
no abiding amendment was  perceptible, he  increased it to one.
drachm three times a day.  This  quantity was taken every day
for  four months.  The patient  experienced no  inconvenience
from the  medicine; on the  contrary, she began to convalesce
very soon  and very satisfactorily  after  commencing with the
large  portions of the potassium, and  entirely recovered under
this treatment, without any  return of her symptoms.   This is
the only instance in which I  have known the salt to be adminis-
tered so liberally for so long  a period.
  The comparative merits of mercury and the iodide of potas-
sium seem to have had a fair  trial in the hands of Mr. Ormerod,
at St. Bartholomew's Hospital.  In reference to the latter medi-
cine, the subjoined  extract is the concluding paragraph of Mr.
Ormerod's report: —
  " The  employment of iodine,  however, has  been attended
with greater and more uniform success than any other remedy,
except mercury, which has ever  been introduced for the treat-
ment  of venereal diseases.   Those affections which  yield least
to mercury,  and  that condition  of  health  which succeeds to
long-standing disease, and  to the employment  of  very  large
quantities of mercury, yield   to iodine in the most marked and
decided manner."   The opinion of Willis, as expressed in  his
" Illustrations of Cutaneous  Diseases,"  in regard to the potas-
sium, is this:  " In broken  constitutions, where mercury has
been freely used at  some former period,  I  believe that the
iodide of potassium deserves all the credit  it has obtained; it
is an invaluable addition to our materia  anti-syphilitica."

  Iodide op  Sodium. — This salt can be employed as an anti-
syphilitic, instead  of the  iodide of potassium, in cases where 
SQUAMOUS SYPHILITIC ERUPTIONS.         341
the patient cannot take the latter.  It is not disagreeable to the
taste,  and is not followed  by unpleasant effects.   It may  be
ordered in all instances where the potassium is indicated.   The
daily quantity is from a scruple to two drachms.    Dr. Gamber-
lini, of the Hospital  of St. Orsola,  Bologna, and  Mr. Langston
Parker, speak in terms of commendation of this  remedy  as a
valuable  addition to  the  substances  usually employed in  the
cure  of the venereal disease.
   The subjoined formula will be found convenient: —

   ft.  Sodae Iodidi,   ..............5;
       Syrupi Sarsaparillae Compositi,........
       Aquae Fontanae, aa,............§ iij.  M.
  Dose. — One drachm thrice, daily, in a gill of cold water. *

   The liquor potassae has gained a reputation for the cure  of
syphilitic  squamous  eruptions.   It  may be  administered  in
milk  or in an infusion of hops.   The  dose is one drachm three
or four times in the day.   The dilute nitric acid  is also a valu-
able remedy  for many venereal  patients.  It is well calculated
to revive the tone of the  digestive  organs, and is particularly
indicated after a mercurial course has been pursued for a long
period.  Thirty or forty minims, per diem, in sweetened barley-
water, may be given for two or three weeks.
   Donovan's solution sometimes proves an efficacious remedy in
this  form  of cutaneous affection.   It  is the liquor hydriodatis
hydrargyri et arsenici.  The dose of this  compound solution is
ten minims three times a day.   It should always  be taken on a
full  stomach.   The  following will  be  found a  suitable for-
mula : —

  ft.  Liquoris hydriodatis hydrargyri et arsenici,   •  • •   •  §j-
       Syrupi Aurantii..............§ vj.  M.
  Give one tea  spoonful in half a gill of cold water.

  The mercurial  vapor-bath,  or  the simple vapor-bath, can  be
beneficially employed  if its application be practicable.

  * For making the iodide of sodium economically and easily,  a formula  can be
found in the American Journal of Pharmacy for 1854, p. 305.
                  29* 
CHAPTER  XXX.
        TUBERCULAR SYPHILITIC  ERUPTIONS.

  These may almost be  regarded as a larger  growth of the
mere papules of lichen.   In their  original  size and type, how-
ever, they are bigger than the minute, shot-like papules of true
lichen.  As elementary  cutaneous lesions,  they  are commonly
described  as indurated  lumps developed  in the substance  of
the skin.
  The late Mr. Babington believed that they had their origin in
the sebaceous glands ; and this is partly true.  They vary some-
what in diameter when  they  first appear, as well as  in  their
subsequent  progress, according to the number of papillae and
follicles involved in  the inflammatory congestion.  They differ,
also, in prominence.   By bearing in mind the manner in which
the lichenoid  eruption  is developed,, it will  not be difficult to
comprehend the process  of growth  which results in  the for-
mation we are now  to  consider.   The pimples  of lichen  often
advance and  swell  into  veritable tubercles; and  both, that
is, the lichen and the tubercle, are preceded by a roseolous or
erythematous condition of the derma.
   The tubercles may be crowned  with a scab upon their sum-
mits when the  patient first  presents himself for  medical aid, or
they may  be without this covering.   Many specimens are dry,
and almost hard to the touch; others impart  a  sensation of
moisture to the finger ;  they are  often slightly elastic, and  yield
under gentle pressure.   At one time they are perfectly indolent,
and remain for weeks  or months without  perceptible change.
At another time they will be transformed with great rapidity into
sloughing  ulcers, and spread  over large portions of  skin in  a
short period.   In feeble and anaemic patients the skin seems, as
it were, to dissolve and  melt away under this morbid process, in
a manner  truly frightful, especially  when  the disease is seated
on the forehead, which  is one of  its  favorite localities.   Occa-
                                               (342) 

 
Ti'.V
	
«	
9 * 0	Cf
& *
*^^Jft^
Tubercular  Syphilis. 
Pl.V.

Tubercular Syphilis. 
 
TUBERCULAR SYPHILILIC ERUPTIONS.        343
 sionally the tubercles, appearing in small clusters, continue for a
 while distinct and isolated, and afterwards  blend at their bases
 by a  process of  peripheral  augmentation  which  fills up the
 interspaces.   Each  tubercle has now lost its individuality, and
 the integument appears as  if  covered  with  the  eruption of
 psoriasis.  When a  long term of years has intervened between
 a primary chancre and the development  of tubercles, the latter
 are apt to prove peculiarly obstinate  in their resistance to treat-
 ment.  If they  appear upon any part of the face, they  exhibit a
 brighter; red color than when seated upon other districts that are
 protected by the clothing.
   As  with the  papules of lichen  so with syphilitic  tubercles,
 there  is  some  variety  in their style of  distribution ; hence
 Wilson  has given the names, tubercula corymbosa, tubercula
 circumscripta, tubercula disseminata,  tubercula annulata;  and
 when  there is a  strong pyogenic tendency in the system, and any
 of these varieties are converted into ulcerations, they are termed
 tubercula ulcerantia.  These divisions  are not entirely nominal.
 They are fully warranted and exemplified by the different modes
 of distribution of tubercular  eruptions that are frequently met
 with  in the venereal patients; and, considered in a  scientific
 light,  we cannot but approve of Wilson's classical nomencla-
 ture.   [Plates IV.,  V.]
   A  large proportion of tubercles  pass into  foul, excavated
 ulcers with elevated edges, which,  when they heal, leave behind
 them  a  deeply  pitted cicatrix.  Sometimes  they  disappear  by
 resolution or  absorption, without  yielding any discharge ;  but
 even then they occasionally imprint a significant, depressed, and
 indelible mark upon  the spot they have occupied, although not
 so profound nor so conspicuous as when ulceration has  attended
 their destruction.
   Phagedaenic syphilitic ulcers, which are formed upon the soft
 parts   near the  commissure  of the lips, upon the  cheeks,  and
 elsewhere, have  their origin in  tubercles, which first soften and
 ulcerate at their summits, and  subsequently extend in every
 direction.  It is not uncommon for several tubercles in the same
 neighborhood to  ulcerate simultaneously.  These ulcers coalesce,
 spread outwardly, present hard, jagged edges,  and  pour out a
 thin,  dirty, sanious  discharge at some points,  while at others
they are covered with dark, firmly adherent incrustations. 
344
GONORRHOEA AND  SYPHILIS.
  Another form of ulcer, originating in tubercle, is the serpig-
inous.   In some instances  this ulcer is quite superficial, and
may occupy a large portion  of integument without serious detri-
ment to the general system.  It causes quite limited destruction
of the  dermoid tissue;  but  creeps  along in circles or segments
of a circle, in spirals and other circumvolutions, the lesion vary-
ing in width from the  eighth  to  the  fourth of an inch,  and
sometimes  wandering  over  an  immense  tract of  skin.   It
appears most  frequently on  the  neck, chest, and back, pursuing
a centrifugal course, and  healing along  the inner border while
it progresses  in the line of the external  margin.  Again, the
serpiginous ulcer is seen with an evident tendency to penetrate
into the substance of the skin, and to exhibit sharp, well-defined,
hardened edges.-   It is often developed upon the integument of
the larger articulations, as about the knee and  elbow; and when
it heals, it leaves a dark-red, ridgy cicatrix, as if the skin had
recovered from the burn of a hot iron.   In some instances, this
variety of serpiginous ulcer undermines the cutaneous  integu-
ment here and  there, without actually  destroying it to the full
extent of  its course ; and the overhanging skin conceals a portion
of the ulcerated surface.
  When tubercles are  situated on the  face, the copper color is
generally  sufficiently distinct to mark  the disease as the off-
spring of the venereal  poison.   It has  already been observed
that, in some  specimens, it is not a little difficult to distinguish
syphilitic  tubercles, when situated upon  the face, from the erup-
tion of acne  indurata;  especially is the difficulty increased in
persons of a  sallow or brunette complexion.   The most skilful
eye will be at a loss to decide.  Indeed, it would be unjust as
well as unscientific to  form a  diagnosis from visual evidence
alone.
  There is another variety of tubercles, which, fortunately, is
very rare.  It comes  on the forehead, alae nasi, near  the angle
of the  mouth, on the tongue, and  sometimes  at the aural pa-
vilion.   These tubercles  always ulcerate; but the discharge is
scanty  and of viscid consistence.  They are sometimes described
under the  name  of perforating syphilitic  tubercles.   They are
likewise known by the title  of syphilitic  lupus.  They occasion-
ally unite into one common  mass, and  cause considerable tume-
faction.  The disease commences like a reddish nodule, without 
TUBERCULAR SYPHILITIC ERUPTIONS.        345
well-defined limits.   It  soon  increases  in activity;  and  on
account of the peculiar diffused redness of the surface, which
for a time is a prominent feature in the case, it has been desig-
nated the  lupous  efflorescence.   Sometimes the tubercles  will
disappear for a while, but they  usually  return and perform a
horrible work of destruction.  Softening and ulceration proceed
from their apices, and  penetrate  slowly until the parts are com-
pletely demolished.   At first a small, deep, perpendicular sore
is formed.   It  yields a very little  exudation of  semi-purulent
matter.  A thick  crust is produced,  beneath which the ulcer-
ative  process invades  the adjacent  soft tissues, which in turn
give way; and if the disease be located  on  the nasal  organ
the most revolting mutilation is  sure  to take place.  This kind
of tubercular syphilide bears a close affinity to lupus both in its
general features and  in the chronic  course  which  it pursues.
It often exists in association with  a carious condition  of the
vomer or other nasal bones.   Such cases generally terminate in
nearly a total destruction of the nose, in spite of all treatment.
The malady has been confounded  with  cancer.   Although its
local ravages may equal those of the most  malignant variety of
 the latter, they are attended with much less pain, and give rise
 to much less constitutional disturbance, than usually accompany
 cancerous affections.

   Treatment of Tubercular Eruptions. — In  whatever man-
 ner tubercles  may  be  developed, whether in  the  aggregated
 form, or whether they arc sparsely  disseminated  upon the face,
 trunk, and extremities, the  treatment which they require is
 substantially the same.
   The first point to  be definitely settled  is, as in all  constitu-
 tional symptoms, to adjust a suitable hygienic course, which the
 patient should feel bound strictly to pursue.   It is but too often
 that we have occasion to break  in upon divers irregularities and
 improprieties of habit in which  the victim of syphilis indulges,
 and which, if not abandoned, will  tend directly to oppose and
 render abortive the best remedial measures which the physician
 can employ ;  nay, more, such excesses  will give strength to the
 syphilitic virus, while  at the same time they enfeeble the organi-
 zation which it pervades.
   A good, nourishing  diet should be  allowed, and spirituous 
346
GONORRHOEA AND SYPHILIS.
and fermented liquors be prohibited.   If their abandonment be
a privation, the  more urgent the reason for this prohibition.
Both parties should understand, if they do not already know,
that a due regard  to the general health is  a matter of impor-
tance no less than the skilful use of medicines.   The patient, if
he be so disposed, can do a vast deal towards the subjugation of
his intractable disorder.  The physician can boast of no specifics.
He can exert his talents in the application of various substances
in the  materia  medica, with a  view to extinguish the morbid
phenomena as they arise from time to time in long succession ;
and he may, ordinarily, feel justified in encouraging the  poor
sufferer  that he will finally recover a  fair amount of health.
There  are  many syphilitic individuals who, to  all appearance,
wholly regain their original vigor of body  and mind.  Others
there are, and the number is not  small, who never enjoy this
boon.
  What has already been  offered, respecting the constitutional
management of syphilis in its  earlier  stages, leaves  but  little
room for any additional suggestions in this place.  Whether the
tubercles are all in a state  of induration, or whether a portion
of them have passed into a state of softening and ulceration, the
bichloride of mercury may  be employed to the amount of one-
tenth  of a  grain, morning  and evening, provided there is no
indication to the contrary.  If this salt  have already been suf-
ficiently tried without  benefit, the iodide of potassium, or  some
other remedy of acknowledged reputation,  must  be selected.
The carbonate  of  ammonia has been known to  accomplish  a
speedy cure where mercurial preparations have failed.   It may
be  administered in the form of julep, commencing  with one
drachm of the  salt in the course of the day, and gradually in-
creasing the  quantity  until  the  patient  takes two or  three
drachms in the  twenty-four hours.
   I  have often  made  trial of the  iodide of iron in  the  latter
stages of secondary ulcerations, but have never had the good
fortune  to realize  any marked beneficial   effect from its ad-
ministration.  I have  ordered it in small and in liberal doses,
with the hope that it might operate as a tonic to  the blood, the
humoral character of which we cannot  doubt at  this crisis of
 the  syphilitic disease, if we ever did before.  The ferruginous
 preparation here mentioned has been considered, and even now 
TUBERCULAR SYPHILITIC ERUPTIONS.
is regarded  by some practitioners, as a  powerful agent when
prescribed in large quantities, and  as  particularly adapted to
cases where  a decided syphilitic  cachexia exists, or  a state of
anaemia combined with scrofula.  This salt  is readily decom-
posed ; and  I have always been  in  doubt whether,  even when
given in the form of syrup, it can be preserved  in  its normal
state for any great lengtli of time.   At  any rate, my want of
success with it has induced me to  relinquish its use,  and to em-
ploy in its stead the potassio-tartrate of  iron, or the iodide of
potassium, together with  other  tonics, such  as nitric acid  and
quinine.   I  have confidence also in  the efficacy of sarsaparilla,
given largely for several successive weeks.   Warm baths, or,
what  is  still  better, vapor baths, should likewise  be admin-
istered.  They not only purify the surface, but essentially pro-
mote capillary circulation, and render more active the sebaceous
and sudoriparous apparatus, and thus greatly aid in eliminating
the morbific element from the system.
  The course above suggested  will  usually  accomplish  the
resolution of most, if not all, of the indurated tubercles;  and
if any  have  passed  into a suppurative  condition or stage of
ulceration, they  will also undergo an  amendment from the same
constitutional measures.  Arsenical  preparations, the decoction
of rumex obtusifolius, the decoction of Feltz, the decoction of
Zittman, directions for wliich can be found in the books, will all
be useful, and should be  tried in cases that prove particularly
obstinate.

  Local Treatment. — The nitric oxide  of mercury ointment
will constitute a  valuable application  to indurated tubercles.
If they are situated on the face, their speedy removal will afford
great relief  to the feelings of the patient; and  a small quantity
of the unguent rubbed upon them at  night will assist in hasten-
ing this result.   The iodide of sulphur ointment and  the citrine
ointment  are likewise very efficient  remedies.   If the circum-
stances of the patient will allow of these appliances  during the
day, he will  be rid of the  morbid growths all the sooner.
  As  local  applications  to ulcerated  surfaces,  following the
softening  of tubercles, the compound tincture  of Benzoin, the
nitric acid,   the  aromatic wine  with opium, the solution of
potassio-tartrate  of iron of different degrees of strength, the 
348
GONORRHOEA AND  SYPHILIS.
tincture  of iodine, a dilute solution of chloride of soda,  etc.,
will naturally suggest themselves  to  the surgeon as important
auxiliaries to the constitutional treatment.
  If the  practitioner be dealing  with a serpiginous ulcer, which
is very apt to eat its way under  the skin  in a tortuous manner,
the compound tincture  of iodine may be  applied directly to the
ulcerated surface where the matter has burrowed, and it may be
allowed  to impinge upon  the  entire walls of the  ulcer.   A
drachm or two of the tincture  may be used every second day.
Its employment should  be followed immediately by the use of
warm water, and  thus  the  iodine will be at once  diluted and
washed out.    This method of local treatment will frequently
succeed satisfactorily.   The employment  of the iodine does not
give much pain.  The morbid secretion from the ulcer is spread
over its surface as a sort of varnish, and in a good degree pro-
tects it from any violent or very  painful effect.   Patients do not
complain of the severity of the  operation.   When  the  ulcer is
brought  into  a healthy state,  which will  be  evinced by its
carneous, granulating aspect, it can generally be kept so by the
constant  use of the weak nitric acid lotion, half a drachm to
the pint of water.
  When  the process of undermining the skin reaches to any
great extent, so that local remedies cannot be used and retained
on lint to advantage, it will be best to slit  open the loose integu-
ment  throughout the  whole  distance  with   a spear-pointed
bistoury  and thus obtain a better chance for the action of topical
applications.
  If the  ulcers become  painful they will  require  to be dressed
with a warm solution of the extract of opium  several times in
the day,  and  at  night with an  ointment  containing  prussic
acid.

  ft. Acidi Hydrocyanici,...........3 ss.
      Cerati Simplicis,............§ iss.  M.

  Bits  of lint, smeared with this  cerate,  should be placed in
contact with every accessible portion of the sores.
  If the   ulcers  remain indolent,  the following solution  will
often prove a convenient and useful stimulating dressing,  when
others fail to answer the purpose :  — 
TUBERCULAR SYPHILITIC ERUPTIONS.          349
  ft.  Plumbi Acetatis,.............9ss.
      Ammoniae Carbonatis,...........3 ss.
      Aquae Fontanae,.............§ viij.  M.
  Apply on lint.
  If at  any time the ulcers  assume an  inflammatory aspect, a
local  antiphlogistic  treatment will be appropriate.   Should  a
sloughing condition take place, the  nitric acid undiluted, or the
compound  tincture of Benzoin, will be indicated for topical use.
The chloride of zinc is  a  favorite dressing with some surgeons.
The following is a medium strength : —
  ft.  Zinci Chloridi,..............5j.
      Aquae Fontanae,.............§ viij.  M.
  Dossils of lint, saturated  with" this solution, are  to be laid
upon  the diseased surface, and renewed thrice daily.
  Bromine.—This is an  elementary  substance obtained from
bittern  and possessing many analogies to chlorine  and iodine.
It is sparingly soluble in water.   As  a therapeutic agent it has
recently acquired  a reputation among some of our army sur-
geons, who have employed it as  a caustic in cases of sloughing
ulcerations and gangrene, instead of nitric acid.   But it remains
to be seen whether its superiority over the acid will be fully demon-
strated after having been more generally used in surgical practice.
  It is not, however,  particularly as a caustic that I propose to
speak of it, but rather to commend  its use  in a very diluted
state as  a constant lotion to  atonic  ulcers and those of a phage-
daenic character requiring a stimulating dressing.   The bromide
of potassium can also be administered  internally in cases where
the iodide of potassium is indicated, but where the  patient, from
peculiar idiosyncrasy, is unable  to tolerate  it.   The bromide,
however, is quite inferior to the  iodide for  internal use.   It is
also of less value than the iodide of soda.
  The subjoined formulae for  the use of the bromine and the
bromide of potassium, are the  principal ones in  vogue : —

                     For Internal Use.
  No.  1.   R. Potassii Bromidi,..........5 ss.
            Glycerinae,.............S ss.
            Aquae...............§ iiiss.
         M.  Ft. mistura.
            Dose. — 5 ij. thrice daily in half a gill of cold water.
             30 
350
GONORRHOEA AND  SYPHILIS.
  No. 2.  ft.  Potassii Bromidi,.........9j-
             Brominii,............gtt- viij.
             Aquae..............§ iv-
         M.  Ft. mistura.
          Dose. — 3 ij. thrice daily in half a gill of cold water.
                      For Fxternal  Use.
  No. 1.  ft.  Brominii,............gtt. xvj.
             Aquae,.............§ viij.
         M.  Ft. lotio.  To be applied with lint as a constant dressing to
               indolent ulcers.

  No. 2.  ft.  Brominii,............gtt. x.
             Potassii Bromidi,.........Bij-
             Aquae,.............§ viij.
         M.  Ft. lotio.   In the same cases as the preceding.

  No. 3.  ft.  Brominii.............gtt. xx.
             Cerat. Cetacei,..........§ i.
         M.  ft. unguent.  To be applied to the sores  night and morning,
               on lint.

  No. 4.  R.  Potassii Bromidi,.........gr. x.
             Brominii,............gtt. viij.
             Cerat. Cetacei,..........§j.
         M.  ft. unguent.  In the same cases as the last.*

                   MUCOUS TUBERCLES.

  Syphilitic  patients  do not  all  experience  the same  constitu-
tional accidents; nor do these accidents uniformly  exhibit them-
selves 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 symptoms.   In some rare
instances the  primary  disease  and the  tertiary manifestations
coexist, although Ricord  is entirely absolute that  primary, con-
secutive, secondary, transitionary, and tertiary  accidents follow
each other with the most  perfect  regularity.   This order in the
series of morbid syphilitic  phenomena 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
* Caillault on the skin, p. 287. 
TUBERCULAR  SYPHILITIC  ERUPTIONS.        351
again it is not always  easy  to  assign to every morbid develop-
ment 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   syphilis.   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 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  eruption 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  tubercles  as belonging to
secondary syphilis rather than to tertiary.   They are designated
by  several  correlative terms, or synonyms, 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 occasionally seen sprouting from the umbili-
cal depression, within the buccal cavity,  within the nostrils, and
just at  the orifice of the external auditory canal.   Occasionally
they are observed at the commissure of the lips,  and about the
roots of the nails.   They are found  in  women much more fre-
quently  than in men.  With the former, they mostly infest the
inner surface of  tlie 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  grow-
ing unmolested for  several months.  They occupied the whole 
352
GONORRHOEA AND SYPHILIS.
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  been sub-
jected 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 vene-
real 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 excori-
ated.   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  tlie surrounding integument.  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 exudation  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  connective
tissue cells which abound  in  the morbid  growth.  The  condylo-
mata 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 increase  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 indi- 
TUBERCULAR SYPHILITIC ERUPTIONS.
353
vidual;  in others, if neglected, they occasionally  give  rise to
superficial  ulcerations,  and  harass  the  patient  not a little.
When they infest the anal region they occasionally  give rise to
fistulous sores ;  and  inflammation and  stricture  of the  rectum
have  been known to  occur  in  consequence  of them.   The
stricture is usually situated about two inches from  the verge of
the anus ;  its form is that of a double  funnel, and it gives rise
to a  sero-purulent discharge  occasioned  by ulcerations of the
mucous membrane;  the faeces are liquid, and  are expelled
without much difficulty.
   In  a case which I recently saw, at one of our public institutions,
the tubercles covered the clitoris and the entire mucous  surface
of the labia.   In some places they  had the cauliflower or rasp-
berry appearance.  There was engorgement of the mucous sur-
face as far as the examination could extend without  the use of
the speculum.   The epithelium  of the  labia was  disorganized
and at several points detached, thus  showing excoriations,  from
which a trivial discharge was constantly oozing.   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 exhibited consecutive lesions.  The
woman had been married about  eight  months, and  dated her
sickness from that event.  For several weeks  she suffered con-
siderably from constitutional disturbance arising from her vene-
real symptoms.  She was pregnant.
   These mucous tubercles or patches may appear  upon any part
of the body of an infant; whilst, on the contrary, in the adult,
they are confined to the mucous tissues and to those portions of
skin that are peculiarly delicate and exposed to  friction.  It is
important that they should not be confounded with other tuber-
cular syphilides, which are non-contagious, whereas the mucous
tubercle or broad condyloma takes the first  rank among the
secondary or constitutional symptoms of syphilis, which are com-
municable by contagion.
  The mucous tubercle usually appears at an earlier period than
the other variety, and is  strictly a  secondary  lesion.   In  some
instances, however, the mucous patches are developed upon the
tongue or  other parts within the mouth and elsewhere, while the
ordinary syphilitic tubercular eruption is disseminated upon the
face, trunk and limbs.
               30* 
354             GONORRHOEA AND  SYPHILIS.
   It is sometimes no easy matter  to  make  out the differential
diagnosis of these mucous tubercles, and they afford  a good
theme for clinical study.

   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 rapidity and efficacy
in causing them to wither away in  a short time.   If the tuber-
cles have become greatly hypertrophied and  present an exten-
sive vegetating surface, the concentrated nitric acid, or the acid
nitrate of mercury, will be found more beneficial and appropriate
than  any other  topical remedy.  Either  of the two fluids last
mentioned may be applied about every four days, until the con-
dylomata are nearly  annihilated, after  wliich  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  aperture, 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 appendages  once in the twenty-four hours, will accom-
plish 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 sliould  be
thoroughly cleansed with chlorinated water, and wiped dry.

   Constitutional Treatment. — The  bichloride of  mercury,
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 substi-
tute the iodide of potassium.   In conjunction  with the mercu-
rial 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. 
s
\ 
P1VI
Pustular Syphilis, 
CHAPTER  XXXI.
                 SYPHILITIC PUSTULES.

  The pustulae may be considered  as forming the third  link in
the metainorphic  development of  the syphilides.  The  papule
is usually but the  prelude  of the tubercle.   The pustule is
engrafted 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 naturae would pur-
sue, in all cases, an  undeviating method in this strange work of
development, wliich is neither more nor less than the result of
the various surgical experiments which nature institutes in  her
own self-defence.
  The syphilitic pustule is  formed upon  the  summit  of  the
tubercle, wliich softens at this  point, while the part that reposes
upon or within the derma may remain 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 decidedly
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 impetiginous
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
behavior, 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
the  economy.   Sometimes  the pustules  degenerate into  con-
                                                 (355) 
356            GONORRHOEA AND SYPHILIS.
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
acquire 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 pus-
tules.  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  foregoing
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 meas-
ures.   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
accumulations  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,  elevated,  and rough crust  of  rupia prominens is  pro- 
SYPHILITIC PUSTULES.
357
duced.  When this curious hollow cone is complete, the origi-
nal stratum 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 extraordi-
nary  features  than  the  physiognomy  of   rupia  prominens.
Judging  from outward  appearances  alone,  it  would  be im-
possible to trace  any affinity or relationship between this mal-
ady and its progenitor, the insignificant, harmless-looking pim-
ple, 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 tlie  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 denomination
of pustular syphilis is rupia, an  affection depending especially
on a pyogenic condition of the  constitution.   But it would be a
digression  from  the  design of this  work to  proceed more at
length into discussion here, with a view to settle any unimpor-
tant differences which the pustular as well as other syphiloder-
mata present  at different epochs of their history.
  Wherever  the  pustules are situated, they are very  apt to 
358
GONORRHOEA AND SYPHILIS.
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.

  Rupia 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
condition  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
instance  of  purpura  coexisting  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
altitude and circumference.   In shape and general aspect these 
SYPHILITIC PUSTULES.
359
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 liusband  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 lengtli 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 diam-
eter 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 circumference
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,
and a generous  diet were prescribed.   In four  months  the 
360
GONORRHOEA AND SYPHILIS.
 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, I 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  part 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 de-
 velopment  and  decline  of this  rupial sore.  The woman, ac- 
                  SYPHILITIC PUSTULES.                361

cording  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
believed 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 liusband
believed the infection  took place anterior to 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 patient 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
                 31 
3(5-2            GONORRHOEA AND  SYPHILIS.

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 organization
may 'not quietly bear their entire prohibition, unless a substitute
be "provided.  The carbonate of ammonia  julep, to the amount
of S iv. during the day, will  appease the cravings of this appe-
tite 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 inter-
rupt 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
degrees  of severity in the symptoms, with  so many  complica-
tions, with  such  a diversity of constitutions, and other circum-
stances  appertaining to the general health,  that  he  cannot
follow any absolute rules of practice that shall be applicable to
all persons.
   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 syph-
 ilitic pustules.  I have already signified my disposition to adopt,
 with slight variation, the views and the nomenclature  of  Pro-
 fessor 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
  skill, so, it may be presumed, the medical practitioner, who can 
SYPHILITIC PUSTULES.
363
conduct cases of rupia to a successful termination, may regard
himself as able  to manage the  lesser pustular forms that arise
in syphilitic patients.
  Tlie  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 employed
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 manifestations, 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 notwithstanding  the symptoms yield  so
readily to its influence, and the patient continues to  improve,
and  even, perhaps, may remain  to all  appearances cured for a
while,  the disease is liable to return.   The  same  remedy cau
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 venereal 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
without producing the  desired  improvement.  Failing of suc-
cess  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 seems sud-
denly to lose all power to tolerate medicines of any description.
The iodic, or what is still worse, perhaps, the  mercurial intoxi- 
364
GONORRHOEA AND  SYPHILIS.
cation, may be upon him.   In  such circumstances  favorable
results will probably be realized by allowing him to rest  for a
short period  from the  use  of all potent remedies.  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  resumed  with better
success.
  Mr. Wilson relates an extraordinary instance of  rupia exist-
ing  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
generally suffers extremely, especially during  the  night,  and
he will require the tranquillizing 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 stimu-
lating substance.  Dossils of lint, soaked in a weak solution of
 nitric acid,  or  in the  potassio-tartrate of iron solution, consti-
 tute an appropriate dressing to  the  sores during 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. 
SYPHILITIC PUSTULES.
365
 .The  small  pustular and ulcerative affections  that  appear
between the toes and  at the  roots of the nails  do well when
lressed with  aromatic wine and  opium, balsam  of Peru, com-
 ound tincture of Benzoin, or the weak nitric  acid lotion.   A
Dolution 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,
      Aquae Ferventis,  .  .  .
      Cola, et adde,   ....
      Solutionis Sodse Chloridi,

  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.
                 31*
gr. xxv.
§ viij.

5vj.  M. 
CHAPTER XXXII.
                 ALOPECIA. — BALDNESS.

   The principal changes produced in the hair, in consequence
of  the  syphilitic  diathesis, consist  in  alteration of  its  color,
glossiness, elasticity, and partial or total alopecia.
   The affection last named  is not a very frequent accompani-
ment 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
mortification ;  and, unless the surgeon  prescribe for it, the indi-
vidual 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 malady 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 accom-
panied by a  light furfuraceous desquamation  of the epidermis.
The accident has been  attributed  to the peculiar effect of mer-
cury on the  matrix that  supplies the hair.   The charge  is doubt-
less unjust.
  The process of decadence can usually be arrested if suitable
measures are adopted  early.   The long-continued 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 applica-
tions that  have proved serviceable.  The following  lotion is
worthy of trial: —
  R.  Tincturee Cantharidis,...........5 iij.
      Olei Amygdalae Dulcis,...........
      Liquoris Ammonia?, aa,..........§ j.
      Aquae Mellis,..............5 j;
      Spiritus Rosmarini,..........       Z iv.
  M.  Lotion.
                (366) 
ALOPECIA. —BALDNESS.
367
  Two or  three drachms are  to be rubbed upon the scalp at
nioiit.  This lotion bears the reputation of bringing out a new
crop of hair, unless the hair  follicles, with  their productive
base or matrix,  are  destroyed, wliich is not often the case with
young syphilitic  subjects,  although  it  is  the  fact  in  senile
baldness.
  The following lotion is an agreeable, and oftentimes an  effica-
cious remedy: —

  R.   Aquae Colognae,.............
       Spiritus Rectificati, aa,..........3j-
       Tincturae Cantharidis............3 iij.
       Aquae  Fontanae,............§ viij.  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.
       Essentiae Jasmini.............3j.
       Tincturee Cantharidis,...........3 ij-
       Unguenti  Rosarum............§j.    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 occasionally
been followed by  a  reproduction of  the hair: —

   R.  Creosoti,...............gtl-x-
       Olei Limonis,.............    1V*
       Unguenti  Rosarum,...........3J-   -*1-

   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 rubbed
 into the bald patches with the finger.   Meantime the iodide 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 subjoined
 preparation can be prescribed : —

   R-  Pulveris Camphorae,...........
       Hydrargyri Proto-Iodidi, aa,........^ f8,
       Unguenti Rosarum,............°J' 
368
GONORRHOEA AND SYPHILIS.
  A small quantity of this  is  to be thoroughly rubbed into the
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   pomade,
although  it is  by no  means certain that  the  preparation can
rightly claim such paternity: —

  R. Olei Caryophylli,
       " Canellae, aa,  .  .
      Plumbi Acetatis,
      Balsami Peruviani, .  ,
       Spiritus Rectificati,
      Medulhe Ossium Bovis,

  Another: —

  R. Unguenti Hydrargyri Nitratis,........3 ij.
       Olei Olivae,..............gj.   M

  The last prescription will often do  the patient essential service
in obstinate cases of alopecia.  If the scalp has been the seat of
syphilitic lepra, or of any tubercular or pustular affection, leav-
ing a scaly condition of the integument, this compound may be
usefully employed.  I have also frequently ordered it with satis-
factory  results in cases of non-specific alopecia,  accompanied
with a slight pityriasis.  I  know of no better topical remedy,
whatever may have been the original cause  of  the  complaint.
It may be perfumed with a few  drops of bergamot 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
.   gtt. xvj.
.   3ij.
.   3ij-
•   Sj-
.   S viij. M. 
                 ALOPECIA. — BALDNESS.               369

of the mouth, partial loss of  the nails (syphilitic ungual  alo-
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 calvaria, the
general  treatment indicated  by  these concomitant  symptoms
should be employed 
CHAPTER  XXXIII.
               ULCERS  ON  THE  TONGUE.

  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  arc developed upon the  latter  tissue.    This
tendency is not  manifest in the  syphilodermata alone ;   it is
seen in scarlatina, in measles, in severe eczematous inflamma-
tion, 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 con-
stitution, 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 occasion-
ally meet with eruptions and ulcers so nearly resembling 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  com-
mit a mistake in  this matter; for he may thus  charge the pa-
tient  with crime he never committed, and, by this false accusa-
tion,  provoke a  displeasure wliich  may never  have  an  end.
Sailors who  make long  voyages, and who are  reduced  to short
           (370) 
ULCERS  ON THE  TONGUE.
371
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 secondary symptoms.   In
examining seamen at the Marine Hospital, 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  mucous surface  can be pro-
nounced, per se,  to be syphilitic, unless  accompanied by other
corroborative testimony.   I answer in the negative.   The opin-
ion here expressed, however, is not applicable to infantile syph-
ilis.   In  new-born children it is extremely  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 concluding 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, however, they
prove the  most  obstinate  morbid conditions we attempt  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 was pro-
nounced  by several eminent surgeons  to be  cancer.  It was
touched with caustic,  and the iodide of potassium administered
* Vol. VTL, p. 345. 
372            GONORRHOEA AND SYPHILIS.
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
iodide of  potassium,  for a few days  only, has  been  known to
create swelling,  soreness, and  lumps upon the tongue, closely
resembling 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 appear-
ances presented  by the member, apart from all other considera-
tions, 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 w'fere 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  arc sometimes  affected with small
ulcers, having well-marked  indurated edges, as a  consequence
of  long-continued attrition against the sharp  fragment  of  a
decayed tooth.  These sores bear a close resemblance  to syph-
ilitic  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 medi-
cine.   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 consist
in  superficial  abrasions, of various  extent and shape, and
situated  on  the  dorsum, among  the   circumvallate  papillae. 
ULCERS  ON  THE  TONGUE.
373
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 margin
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 in-
stances 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 complained of.
It is, in most cases,~a source of no little  annoyance to  the indi-
vidual, who can neither eat nor converse with comfort or free-
dom.  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
 attributed them to  its influence.   The  affection  is  occasion-
 ally attended with a  slight oozing of  blood from the diseased
 surfaces.

   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 cause the
 ulcerated  walls to  close up and heal kindly  in a very  short
                   32 
374
GONORRHOEA AND  SYPHILIS.
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 tincture  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's hair
pencil: —

  R.  Extracti Opii Aquosi,............gr. vj.
      Aquae Ferventis..............§ iij.
  M.  Cola, — et adde,
      Mellis Communis,.............5 ij.
      Tincturae Myrrhae,.............3 vj.

  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
the pharynx.   These  ulcerations may form  either  in  the  sec-
ondary  or  tertiary period  of  syphilis.   Their  disposition  is, 
ULCERS ON THE  TONGUE.
375
 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-
 heres firmly to the throat; expectoration becomes difficult; so
 much so that  he  thrusts  his fingers into his mouth to  pull 
376
GONORRHOEA AND  SYPHILIS.
 away  the  ropy mass, and  thus save himself from suffocation.
 By day there is a ceaseless inclination, but without the ability,
 to vomit;  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.   The
 power of speech becomes more  and more feeble, until,  at length,
 complete aphonia  supervenes.   Day after day the  symptoms
 assume a  more desperate  character, until the sufferings of the
 miserable  victim finally become terrific.  He can  neither cat,
 drink, nor sleep, and he falls   into a condition from  which no
 human skill can  rescue him.   I have seen  a few  instances of
 this description,  the last of which occurred  about two years
 since in this city.   The agony, bodily and mental, in the case,
 was so unremitting and dreadful, that the patient often  begged
 for chloroform to put an end to his existence.  Reduced nearly
 to a skeleton, he  sank at last under  the weight of his accumu-
 lated miseries.
   Those of  my readers who have had an opportunity to ob-
 serve  from day to day  the symptoms  of an individual  strug-
 gling with  the variety 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 forty years  ago  such  cases  were  far more
 common among venereal patients than they have been since a
 more simple  and rational treatment  has  characterized medical
 practice.

  Treatment. —This resolves itself into local  and general, as is
 the fact in  nearly all venereal affections.
  In the diversified syphilitic ulcerations and other morbid con-
 ditions 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 re-
course 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 professional
attendant will often find  his highest skill put to a severe test.

   Nitric  Acid.  — For  sloughing  ulcers   the  concentrated
nitric acid  is justly regarded as an  excellent topical remedy. 
ULCERS  ON  THE TONGUE.
377
It  is suited to a majority of such  sores.  If the  surgeon de-
sire to touch it upon the tonsils, fauces or any part nearer to
the oral  aperture, a small  bit of sponge, secured to whalebone
and slightly wet with  the  acid, should  be  used.   The  utmost
care must be observed not to  have any dripping of the fluid.
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  tumbler-full
bf warm water should  be at hand, that the patient may 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 well.  If the
posterior  surface  of the  pharynx  be the  seat  of  disease,
and if the  application of the escharotic be made there, the
operation is not so  simple as when performed on the parts just
spoken of.   This is true  at least so far as relates to the patient.
  In  spite of all precaution it will sometimes  happen that the
dense vapor generated  while  the acid is being 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.  The 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
the 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 not so large
as  a common  chestnut.  This was done every second or third
                    32* 
378
GONORRHOEA AND SYPHILIS.
day, for two or three weeks, care being always 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 moment 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 tinc-
ture of Benzoin was substituted, and the fruits of its good service
in maintaining 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, however, which I have now made with the Benzoin tincture,
and the prompt and beneficial results that have uniformly been
obtained, 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 wliich, it is scarcely necessary to
say, it is  injurious, as it  would excite too much inflammation,
and thus prevent union by the first intention.  As a local appli-
cation to the pharynx it can be intrusted  to the patient's man-
agement  with safety.   If a  few  drops happen to be swallowed
no harm  can result. 
ULCERS  ON THE  TONGUE.
379
  Case. — Sloughing ulcer of the pharynx— compound tincture
of Benzoin employed—cure.

  April 7,1856.   The patient was a married lady, of education
and high  social  position,  aged 28  years.   She was  extremely
pallid, thin in flesh, and dejected in spirits.  Four years ago she
received the primary inoculation from her husband, 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 inflammation and hypertrophy
of the  fauces, and a few vegetations  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 re-
ported, that the latter had  a larger base than those  on  the
fauces.   They were, doubtless, broad, flattened,  mucous tuber-
cles.   A   few slender  excrescences  were also  hanging  from
the velum.  At the date above specified an extensive ulcer occu-
pied the pharynx, giving  much discomfort and pain, and occa-
sioning serious impediment in deglutition, especially when she
attempted to swallow solid food.  The skin was free from disease,
although  numerous  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 Ben-
 zoin 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 complained of very little
 inconvenience from the  immediate impression 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 con-
 centrated 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 irritability
 of the system, and to secure refreshing sleep by  night; quinine,
 decoction of sarsaparilla, decoction of yellow dock root, gener- 
380
GONORRHOEA AND SYPHILIS.
ous 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, whilst the
patient was under my care.  She improved gradually, and with-
out  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, although
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 mottled
appearance; integument, generally, felt  harsh and dry; and a
furfuraceous exfoliation of the epiderma of  the upper extrem-
ities, 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 diffi-
culty of deglutition.   She was unable to swallow a particle of
solid food,  and had lost eighteen  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 suffered from saliva-
tion.  Upon examination  of the  mouth, a large portion of  the
fauces, the tonsils, and soft palate  was found to have been de-
stroyed, and the buccal cavity presented  a hideous look.  How
much  of  this  extensive  destruction  was  due  to  mercurial
action, and how much to the syphilitic poison, could not be deter-
mined ; but the fact that the skin had never been disturbed by 
ULCERS  ON  THE  TONGUE.
381
any papular, tubercular, or other morbid condition of a serious
character, led me to doubt whether all the mischief  wliich had
happened within the 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 com-
pound 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 dis-
eased surfaces were  healed.  An ingenious artisan constructed
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  verj* 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
ulcers, and  to secondary phagedaenic  or sloughing ulcers.   In
the  treatment  of  primary  phagedaenic,  chancrous  sores,  1
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 arc
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  degrees  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 of the mouth, whether syphilitic
or mercurial.  The  bark of the root is the part to be steeped, in
the proportion of  one ounce to the pint of water.    The oxymel
of subacetate of copper, diluted  with  water, is another prepara- 
382
GONORRHOEA AND  SYPHILIS.
tion that will be found excellent.  The following is the strength
generally to be employed: —

  R.  Oxymellis Cupri Subacetatis,..........§ ij
      Aquae Fontanae,..............§ vj.
  M. ft. gargarisma.  To be used repeatedly during the day.

  Another: —

  R.  Decocti Cinchonae Corticis,..........5 x.
      Acidi Hydrochlorici Diluti,..........5 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 Cinchona; Rubrae,..........3ij-
      Aqua-,.................§ xij.  M.

  Boil down to  eight ounces, and add one scruple of the watery
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, sliould
be kept in contact with it.

  Constitutional Remedies. — The brief epitome of the gen-
eral treatment pursued in the two last cases reported, together
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 disas-
trous.   He is sufficiently miserable without the hazard of be-
coming  still more so by  its action;  and in such a juncture the
practitioner should study to spare the poor victim any exposure
to causes that might provoke a serious aggravation of symptoms.
Mercury, therefore, should  be withholden.   But when the pa- 
ULCERS  ON  THE  TONGUE.
tient 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 consti-
tution 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 prescribed in combination with tonics, sudo-
rifics, and  a generous diet.  The effect of 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 potassium 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 transi-
tion-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 alter-
nated, 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  sarsaparilla 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  fur-
nish the mind of the judicious medical  attendant with  ample
resources from which to make appropriate selections, according
to the different varieties and phases which  the ulcerations may
present.   If the  consecutive phenomena now under considera-
tion are seen at an early period, they  can usually be  subdued
without difficulty, and the probability of their reappearance  in
their original severity is  not very great, even if they return  at
all.   For  the twofold  purpose, however, of guarding  the sys-
tem as far as  possible  against a recurrence  of these symptoms,
and of protecting it against any tertiary phenomena, the potas-
sium 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. 
384
GONORRHOEA AND  SYPHILIS.
   If a  long period has intervened since the advent  of  these
secondary  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 shrivelled features, by the soft,
adynamic state of the muscles, and by the serious deterioration
of the general  health, — all which are indications that tertiary
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 mal-
ady ;  and  the  chances  are  that,  before  many months  have
elapsed, the patient will again present  himself with the neces-
sity upon  hiin of once more testing  our skill ; or, what is quite
as possible,  some professional neighbor may be  called upon to
occupy our post.

  Larynx. — When a  patient has  for a  long period suffered
from constitutional  syphilis, he is liable to become affected with
various  morbid  conditions of tho larynx.   The local  affection
may be  simply  a  catarrhal congestion, or it  may advance  to an
intense  inflammatory action,  resulting in extensive ulceration
and consequent loss of  substance.   There is copious expectora-
tion  of  foetid purulent  matter, mixed with  blood ;  and if  the
morbid action is not arrested at an early period, the  glottis, the
cricoid,  and other cartilages, are  either totally destroyed,  or, as
has been  noticed in some fatal cases, are found in a  state of
caries and necrosis.
   In some instances soft, whitish, irregular tubercles, or condy-
lomata, are formed upon  the  surface, together with oedema and
gradual thickening of the mucous  and sub-mucous tissues, in-
volving more or less the inter-cartilaginous portions  of the  vocal
cords, and producing hoarseness, cough, stridulous breathing,
dysphonia, or even  total  loss of voice.   Under these abnormal
circumstances,  as may be seen with the laryngoscope, the diame-
ter of the laryngeal canal is very much diminished by the tume-
faction of its walls. This narrowing, or  contraction, is termed
syphilitic stenosis, and is seldom influenced  by the use of any
local remedies.  Occasionally the application of nitrate of sil- 
                 ULCERS ON THE TONGUE.              385

ver or a weak solution of the bichloride of mercury (one grain
to the ounce) has proved efficacious ; and in one instance which
recently occurred in the  London  Hospital, under the care of
Mr. McKenzie, great  improvement appeared to result  from a
" pulverized solution " of perchloride of iron, which the patient
inhaled.   The strength of the solution was in the proportion of
five grains to the ounce.*
   The iodide of potassium is the most promising constitutional
agent  for subduing these laryngeal phenomena, which belong
partly to  the secondary  and partly  to  the tertiary  group of
symptoms.

       * London Medical Times and Gazette, March 5, 1864, p. 253.
                  33 
CHAPTER  XXXIV.
SYPHILITIC  DISEASES OF  THE NOSTRILS AND NASAL
                         FOSSJE.

  These accidents require but a  brief special  notice.   They
usually  appear subsequently to the affections wliich 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
neglect  or necessity, have failed to  receive  proper  medical
attention.

   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 mem-
brane, 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 secreted in con-
sequence of a cold.  Sometimes no abnormal exudation occurs
           (386) 
NOSTRILS AND  NASAL FOSSiE.
387
until several weeks have passed, when ulceration takes place in
some portions 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 de-
stroyed.  It exhales a most offensive odor.  Sometimes it con-
cretes 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  simplest  and most superficial
form  of  ulceration  which occurs within  the nasal apparatus.
It belongs to  the secondary accidents, 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 dis-
tant  intervals from one of  the  turbinated  bones, from the
ethmoid or vomer.  These facts will  show, with sufficient plain-
ness, that ostitis exists, with ulceration of the soft coverings of
the bones.  The  two lesions often accompany each other ; and
the medical practitioner who has  had  much  experience  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, and terminate only  with
a total loss of the whole interior of the  nose.  The complaint 
388
GONORRHOEA AND  SYPHILIS.
seems to die out, in such cases, because 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 meas-
ure.   At whatever point of  the  nasal mucous lining the ulcer-
ation 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,..........3 iv.
       Aqua> Fontana',.............§ vj.  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 framework 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, injections 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 pie-
scribed, provided  that the individual is  otherwise in fair health,
and  has never been  affected by the specific  influence  of any
mercurial preparation.   Chalybeatcs in some  form, the iodide
of potassium,  and  other  tonics, will  be  appropriate for  most 
NOSTRILS  AND NASAL FOSS.E.
389
patients who complain of  this  local  trouble, which, in very
many instances, is but the  sure  harbinger of  a more profound
mischief that awaits the ill-fated  orjran.
  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 thera-
peutics ;  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  arc  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 instances, it is but little
benefited by any medicinal remedies.    All  the  tissues that con-
stitute 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  implicated.  The external integ-
ument of the nose, the mucous membrane, and the  periosteum,
yield up their substance little by little to the morbid encroach-
ments; and  the  fragile bones  become  denuded, perforated, and
eroded by the  same destructive  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 inconceivable  sluggishness, showing itself at
distant intervals in  decrements  of a solitary granule of bone,
or in a microscopic relic of soft  tissue, dislodged from the  dis-
eased locality, together with other effete matters.
  The  exhibition of the iodide  of potassium  alternately with
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.
                33* 
390             GONORRHOEA  AND SYPHILIS.

  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.

   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 secondary
 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, occurring  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 structures
 besides the iris are implicated  in  the morbid  processes.  They
 regard the attack as a profound ophthalmia.
  Iridal inflammation may attack one  eye or  both at  the same
time.   One of the earliest appreciable  effects  consequent upon
                                          (391) 
392
GONORRHOEA AND SYPHILIS.
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 occurring 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 hypopium.  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, I  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 irrep-
arable  disease.   When the attack occasions such  phenomena,
one may well  question the propriety of regarding it simply as
an iritis. 
SYPHILITIC IRITIS.
393
  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 the 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 popy-water
were  directed, and proved  entirely adequate.   The  malady
became  chronic and intermittent.   Vision was nearly lost and
restored 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-
ficiently marked  to constitute a rational basis  for diagnosis.
The medical  attendant can  rely with safety only on a true his- 
394
GONORRHOEA AND  SYPHILIS.
 tory  of the  antecedents  and  the  concomitants  of this  local
 trouble.
   Generally speaking, it may be stated  that the deviation  from
 the normal  color of  the  iris,  loss of  its brilliancy,  and stri-
 ated  appearance, are more observable than in the  non-specific
 varieties of  the  complaint.   The capillaries exhibit a greater
 disposition to deposit lymph,  and the  pupil is more  irregular
 and turbid,  than  in the rheumatic  or strumous form  of the
 disease.
   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 structure,
 almost  exclude  the possibility  of  mistake; but where the in-
 flammation 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  beint*
 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 previ-
ously.   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- 
SYPHILITIC IRITIS.
395
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.

  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 employment.
 But no fixed rule can be laid down : —

   R.  Pulveris Opii,..............Jr•.xv*
       Hydrargyri Chloridi Mitis,.........3 iss. 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  ordi-
  narily such  preparatory measures will not be demanded.   I he
  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 contraction of the

  PUThe  utmost  vigilance  will  be requisite to keep the pupil
  dilated,  otherwise  permanent  adhesion  of  the ins to be  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 
396
GONORRHOEA AND  SYPHILIS.
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 orbi-
tar or frontal pains.  It acts  more rapidly, and is more con-
venient and  cleanly for external use, than the extract, and is
now employed  by many surgeons as a substitute  for it.  A sin-
gle drop of  a  solution, made  by dissolving two grains of the
atropia in three ounces  of distilled water by means of three or
four drops of acetic acid,  is  to be applied  to the inner surface
of  the lower lid.
   Ricord's formula for iritis  is the following : —

   R.  Extracti Opii,..............&■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, physiolog-
 ical  properties  upon the  salivary apparatus.  The circulating
 current is the  medium through which  the salutary agency is
 exerted.  Mr. Addison, in his able work on scrofula and con-
 sumption, offers the following explanation relative to the bene-
 ficial 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 tender-
 est  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  removal."  These  are
 ingenious thoughts; but  the  fact that iritis can be cured with- 
                     SYPHILITIC IRITIS.                  397

out the administration of mercury would seem to cast  a doubt
upon the solution offered by the learned author as to the methodus
curandi of the potent mineral.  And I cannot  but regard the
therapeutic problem as still remaining unsolved.
  After iritis is subdued, the iodide of potassium  should be
administered 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
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 in-
flamed.
   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 ques-
tion, been administered too exclusively and too indiscriminately.
   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
possess  but  few traces of organization,  mercury  will tend to
increase 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
wliich  it was intended  to  remove, and which, in a less  debili-
tated 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 mercu-
rial preparations.   In all the exceptional cases and  conditions

     * Vide London Lancet, March, 1855. — Mr. Critchett's Lecture.
                  34 
398
GONORRHOEA AND  SYPHILIS.
here supposed, far  better effects may be  anticipated from the
iodide  of potassium, ferruginous tonics, nitric  acid, and gener-
ous living.
  If, from the  constitutional circumstances of the patient, the
physician cannot with  prudence appeal to the well-known influ-
ence 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
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 terebinthinae rectificati,     ........§j-
       Vitellum unius ovi tere simul, et adde gradatim,  .  .
       Emulsionis amygdalarum,.........    § iv.
       Syrupi corticis aurantii, .      ........|ij.'
       Spiritus lavandulae compositae,   ........3 iv.
       Olei cinnamomi, guttas,...........ij. vel. iv.
  Dose. — § j. three or four times daily.

  Some  of the most eminent and  practical ophthalmic surgeons
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.  Williams has
reported a large number of cases successfully  treated with the
use  of tonics,  mydriatics,  and  the iodide  of potassium, 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.

  Heredito-Syphilitic Iritis. — Syphilitic children, from a few
weeks to a few years old, are occasionally the subjects  of iritis.
They are generally feeble,  cachectic, and troubled with  other
symptoms besides  those which  invade the  eyes.   Sometimes,
however, the iridal complaint is the only abnormal  condition
which they  actually exhibit.  If the malady  is recognized  by
the  medical attendant at an early day it seldom  acquires the
severity which marks its course  in the adult subject.   Mr. Jon- 
SYPHILITIC IRITIS.
399
athan Hutchinson, states that the female sex is far more subject
to it than the male, and it makes its invasion  at about the fifth
month, oftener than  at  any other age of the child.

  Treatment. — Mercury, either in the form  of the bichloride
in solution, in doses of one-sixtieth  of a grain of the salt twice
a day, or one or two  grains per day of the hydrargyrum cum
creta, with generous diet  and  mild tonics, will be sufficient, so
far  as internal  remedies are  required.   The application  of
atropia  should be resorted to  from the commencement,  and
repeated every day, or every other  day, according  to its appar-
ent effect on the pupil.   The strength  of  the  solution may vary
from  a  quarter  of a  grain to a grain  in  an  ounce of  distilled
water.

  Besides iritis, the syphilitic virus  produces other specific path-
ological changes within  the interior of the eye, to which we will
briefly allude. It is well known that individuals laboring under
constitutional syphilis frequently lose the  power of vision, while
no imperfection of the organ can be discovered by the ordinary
methods of examination; and  it was not until the ophthalmo-
scope was brought into practical use  as  a  means  of diagnosis,
that the deeper tissues and humors of  the  eye  could be ex-
posed, and their true  condition  determined  with  accuracy.   By
means of  this instrument it has been  demonstrated  that the
choroid  and hyaloid membranes, the retina, and vitreous humor,
may, one or all,  be in a diseased state for  a  long  period, with
only a trifling degree of pain, and unattended by congestion or
other disturbance of the outer  tunics of the  eye; and what is
termed  amaurosis  syphilitica is  dependent,  according to Pro-
fessor A. Von Graefe, upon choroiditis or retinitis.
  Like iritis, the different forms of ocular disease here  men-
tioned usually occur at  a period which places them among the
secondary phenomena;   and their  treatment should  be con-
ducted on  the same general  principles as  are suited to ordinary
cases  of iritis,—tonics and mercurials.   The latter  class of
remedies should be  prescribed with a sparing hand,  and the
mode of their administration varied according to circumstances.
Whether given internally or through the cutaneous surface, the
results  will be  substantially  the  same.    The  latter  method 
400
GONORRHOEA AND  SYPHILIS.
seems of late  to  be quite  popular, and  mercurial fumigations
and mercurial inunctions are without any reasonable objections,
if the parties  interested choose to employ  them ;  although in
private practice in this country, and among the better class of
patients, the  internal use  of the medicine in question  will
probably be preferred. 
CHAPTER  XXXVI.
               TERTIARY  SY^PHILIS.

   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
human  organization.   The  arrangement of  these  consecutive
phenomena into  distinct periods  renders  their  study  highly
interesting and satisfactory to the student, while the  practitioner
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, inflamma-
tion of the periosteum, exostosis, and caries of the bones, belong
to the division upon  which we have now entered.
   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.
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
                    34 *                           (401) 
402
GONORRHOEA AND  SYPHILIS.
the laws 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  it syphilis 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, in 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
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- 
TERTIARY SYPHILIS.
403
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
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, tumores 
404
GONORRHOEA AND SYPHILIS.
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, wliich  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.

   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. 
TERTIARY  SYPHILIS.
405
  The patient has at times had sore throat, with pretty extensive
ulcerations;  the tonsils are  destroyed, and cutaneous affections
have existed in almost every  variety of type and severity.   Dur-
ino1 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  somewhat  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 suppurate, 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 secondary affec-
tions,  presented herself, having two  gummy  tubercles, one on
each side, just below the angle of the  jaw.   They were not en-
larged 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 inconvenience, 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
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 potassium
was again resorted to with like beneficial results.   Coetaneously
with these gummata,  the patient had  caries and exfoliation of 
406
GONORRHOEA AND SYPHILIS.
the nasal bones ; and in  consequence of this ostitis, the lachry-
mal 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 several 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 insertion of the stilctte.   This destruc-
tion of bone was sufficient to cause a depression  and consequent
deformity of the organ ;  there were  also obstructed respiration
and impaired phonation.   The patient  was under my care and
that of other medical men for about five years.  She took mer-
cury 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 employment of any mercurial preparations, which were
always administered  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-
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. 
TERTIARY SYPHILIS.
407
This tumor was carefully removed by a surgeon, and no ill con-
sequences 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  accomplishing their
absorption.
   Syphilitic gummata are occasionally met with in  the muscles.
Ricord states that as soon as this venereal condition commences,
the muscular tissue, which seems to undergo a sort of degener-
ation,  contracts, but  this  contraction is hardly noticeable  as
long as the muscle gets passively  shorter.  There is at first a
plastic transformation, which may by proper treatment entirely
disappear without  any deformity  being  left behind ; but, if the
disease be allowed  to reach a more advanced stage, the conse-
quence may be either a complete atrophy, through resorption, or
a  fibro-cartilaginous or osseous formation.  In the latter case
there is shortening of the  affected  muscle.  This degeneration
usually attacks the flexor muscles, 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 pro-
gressed very nicely, — so much so  that resolution gradually en-
sued, and, while  the public were applauding his splendid vocal
powers, Ricord used to join them enthusiastically, enraptured as
he was with the vigorous action of the arms and the triumph of
the iodide.
   In connection with the formation of gummy tumors in  the
muscles, another syphilitic affection,  termed  Myositis, has been
observed in a few cases.   This transformation is consequent
on a  subacute  inflammation of the muscular tissue.   It com-
mences gradually  with  moderate pain, especially at night, and
some constraint in  the  normal  movements of the  limb.  The
muscles enlarge slowly, become harder,  more elastic,  and their
contraction is difficult, painful  and  imperfect.  In the prog-
ress of the disease the. hardness of the muscles increases, and 
408
GONORRHOEA AND SYPHILIS.
approaches that of cartilage, and movement is impossible.  This
condition is followed by an atrophic shortening.
  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:
  " Eight years  ago a man contracted chancre, which did not
become indurated.  Two years later—that is, six years since — he
bad 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 gastrocnemius.
The limb became enormously enlarged, but  had entirely subsided
under the use  of the iodide of potassium, with plasters of am-
moniacum  and mercury."
  At the autopsy of a venereal  subject, Ricord found  in the
walls of  the ventricles of the heart  several points of tuber-
culiform  alteration, consisting  of a yellow substance of scirrhous
hardness at some points,  at others analogous to that of tuber-
cular matter in process of  softening.  These deposits he regarded
as possessing the characters of tertiary  syphilitic nodes or tu-
bercles, which are observed in the  subcutaneous or submucous
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 interior.
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 furuncu-
lar suppuration ; at other times  ossification occurs.  In some
instances,  extensive portions,  or even  the  entire   lengtli  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 irritation, pain, and 
TERTIARY SYPHILIS.
409
 partial paralysis.    They have  been found  in the epididymis,
 testicle, liver, lungs, brain,  bones, etc.*
   In fact, no organ or tissue in  the  human body can  escape the
 venereal infection.   Even the nerves, the teeth, the hair, and the
 nails are involved.    In the  syphilitic subject there is a tendency
 to the exudation of a low form of lymph or fibro-plastic material
 modified in character by the organ in which it occurs.  On the
 skin and in the mucous membranes its disposition is to soften
 and finally result in ulceration.   On the  bones it may proceed
 to  ossification,  or  produce caries.   On the tongue  and  other
 muscles it develops itself into hard lumps or tumors  when it is
 not modified  in  its  natural  progress  by  the action of medicines.
 In the earlier period these  nodules  appear to infiltrate the part
 they occupy, and are  comparatively soft; but  after  they have
 existed for a considerable time  they become harder, more  dis-
 tinct and separate  from  the neighboring  tissues;  and at a still
 later stage  they often  ulcerate.    These changes  are  frequently
 seen in the syphilitic  tubercles  or  tumors that appear  on  the
 tongue.f

        TREATMENT OF  TUBERCULA  GUMMATA.

   Experience has  at last demonstrated to the  satisfaction of
 every  practitioner who has  much to do with the  management

  * " A special kind of  exudation  is  seen  in  what is  termed gummata.
 Lobstein describes 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 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." — WedVs Pathological His-
 tology,  p. 235.
  Mr. Busk, 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 irregular 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 heterogeneous product, it rarely happens, if the case be
 properly treated, and the opening  of the tumor be avoided, that any exfoliation
 takes place."
  t In Guy's  Hospital  Reports for 1863, Mr. Wilks has communicated some
interesting remarks on this subject.
                   35 
410
GONORRHOEA AND SYPHILIS.
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
medicines in the  treatment of tertiary phenomena.   This con-
viction 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
severer  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
remedial 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
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 with the best advantage.  If the
patient have a capricious appetite  and impaired digestion,—if he
be troubled with constipation, with  restless nights, or with any 
TERTIARY SYPHILIS.
411
abnormal sensations of a serious character, and referable to any
of the vital organs or functions,—it will be important to relieve
him of these  annoyances before attempting the removal of any
specific venereal  symptoms.  But as soon as  the  constitution
has been suitably prepared  for the reception of  the salt in ques-
tion, its beneficial influence will  be realized in all cases of gum-
mata  that are amenable to any therapeutic agent.  We have
the experience and  testimony  of the  most distinguished men
now active in the medical and surgical ranks, all  over the civil-
ized world, to justify us in the belief that this  remedial  sub-
stance 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  tertiary
lesions, and hence the frequent failures.   In presuming  to sub-
mit this  remark, I  am willing  to include myself among those
who have erred  in  thus prescribing it.   The high encomiums
which, a  few years since, came over from European hospitals to
this country, respecting  the healing virtues of the potassium in
certain syphilitic  symptoms of long  standing, naturally excited
the hopes of medical men  in advance of any practical experi-
ence 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, bath-
ing, 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 symptoms.  In such
cases  the medical attendant, as well  as  the patient, is truly
unfortunate ;  but no maledictions sliould  fall upon the remedy 
412
GONORRHOEA AND SYPHILIS.
under consideration, although it fail to do good when adminis-
tered 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 un-
pleasant  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 coincident  with
the gummata.  Such cases afford the most  gratifying proof of
the excellent powers of the iodide ;  for while the gummata sub-
side under its action, the ulcers rapidly amend  or heal, and the
osseous affection ceases to torment.   Instances have been au-
thentically 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 situa-
tion 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 repu-
tation 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 
TERTIARY SYPHILIS.
413
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 purpose
of preventing relapses, as well as with a  view of recruiting 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  mercurial
 ointment for the purpose of encouraging absorption of the pur-
 ulent collection.   If fluctuation sliould  increase,  the contents
 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 integument m
 every direction, and great  ravages  among the different tissues
 will be likelv to occur.   If the  tumor be situated on the  scro-
 tum, 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  dressings  for these un-
 healthy sores.  The black  wash, the  yellow wash, the Peruvian
 balsam, and  a solution of the  potassio-tartrate 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 preference
  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 remedies.
  In most cases the  abnormal local action is of a  subacute type,
  and the ulcerations, that are almost certain  to supervene upon
  the opening of the gummata, present  a sloughing tendency, to
  arrest which, stimulants applied directly to  them will^be mcat
  appropriate.  In addition to those  above named for  daily u e
  the" nitric oxide  of mercury ointment will be found an exc lien
  preparation for nocturnal  use.   The occasional employment
   the undiluted  nitric acid will be  requisite if  the ulceration
   extend into the  soft parts.
                  35* 
414            GONORRHOEA  AND SYPHILIS.
   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 secondary
eruptions.   Cases are recorded in which  this salt has been taken
for many months for  the  cure  of pustular and tubercular affec-
tions of the skin without any  permanent advantage.   Some-
times 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  con-
tinuance 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
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 
TERTIARY  SYPHILIS.
415
to be entirely reduced in a few weeks.  In one instance lately
under  my  care, and  in which Dr.  S. D. Towsend 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 tertiary
syphilis, in which the effects of this  medicine have  almost uni-
formly been  such  as to  remind me of the expression of Ricord,
that it is "all-powerful."   And when I hear of failures and dis-
appointments connected with its administration, I always sus-
pect that it has been prescribed in cases not belonging to  the
 tertiary, nor yet the late secondary period, or that  it has been
 oiven in a manner or  under circumstances  that would  render
 any medicinal  agent nugatory. 
CHAPTER  XXXVII.
        SYPHILITIC  SARCOCELE, OR ORCHITIS.

  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 consecutive
manifestations,  and also after tertiary lesions had  existed for a
long time.   Thus, abstractly  considered, this glandular diffi-
culty belongs to no one period of syphilis exclusively.   Nor is
it strictly accurate to regard it as occupying a transition 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  periooteum  and bones; and it
may occur at any moment  intermediate between the extremes
here mentioned.  This irregularity as to the times of its devel-
opment 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 numer-
ous researches  of  Sir  Astley  Cooper have  placed these facts
beyond doubt.   In a majority of cases both  testicles  are  in-
volved in the morbid action simultaneously ; in others only one
testis is implicated.  The enlargement proceeds very gradually,
is attended with only a moderate degree  of  pain, and the indi-
vidual will  allow the part to be handled  without  complaining.
           (416) 
SYPHILITIC SARCOCELE, OR ORCHITIS.
417
For  some  time  the gland preserves  its smoothness and its
natural  pyriform  or ovoidal  figure;  but  as  the disease ad-
vances  it becomes  globular,  and  assumes  a  fleshy feel,  from
which circumstance is  derived the term sarcocele*  After  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 pre-
sents a somewhat irregular, lobulated appearance.  As the dis-
order 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 in-
tense pain ; but otherwise there is  merely a  dull, aching sensa-
tion,  accompanied by a feeling of weight in the  organ,  as in
non-specific orchitis.
   Instances are occasionally reported of the  disease terminating
in atrophy of  the gland.   This condition has been  erroneously
attributed to the physiological  influence of the  iodide  of potas-
sium.   The wasting away of the testicle  may sometimes be the
result of the  specific affection, or it may arise from neglect, or
from  improper management, or it  may be due  still more  fre-
quently to some peculiar diathesis inherent in the constitution.
   There is one feature appertaining to this variety  of sarcocele
which it possesses in common with nearly all the other consti-
tutional venereal affections, and that is a disposition  to recur.
Even if the  treatment have been entirely successful in removing
the engorgement, the  probability is that  after an interval  of  a
few months the same difficulty will return, although perhaps in
a mitigated  form.

   * From octo:.,  flesh, and uni-n, a tumor.
   + Mr. Acton is of opinion that syphilitic sarcocele never brings on suppura-
tion ; and the late Mr. Colles remarks that  he could not recollect any case of
what he considered  purely  venereal swelled testicle which went on  to sup-
puration,  although he had seen this occurrence take  place in some  persons
where  the debilitated and deranged state  of the  health appeared  to be the
exciting cause. 
418
GONORRHOEA AND SYPHILIS.
  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 bis testicle
by castration.
  In ordinary  cases of orchitis, virility  remains unimpaired;
but if both testicles are diseased, and  the  morbid condition con-
tinue  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,  subcuta-
neous, or submucous, chronic and unhealthy ulcerations, phage-
daenic  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 corre-
sponds with that of the common  chronic inflammation of this
body.  The glandular  structure of the organ exhibits a quan-
tity of yellow,  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 taken
place in  the part,  it can usually be restored to a healthy condi-
tion without difficulty.  Sliould it be very  painful and tender,
* Cooper, Brodie, Hamilton, Curling. 
SYPHILITIC SARCOCELE,  OR  ORCHITIS.        419
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 influ-
ence, 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 promoting the absorption of the plastic infiltration.
It will be a good practice, also, to  paint the  scrotum with the
compound tincture 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
objections 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  over-
balances 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 phenomena
 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 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. 
420
GONORRHOEA AND  SYPHILIS.
  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.

                SYPHILITIC EPIDIDYMIS.

  Syphilitic disease of this part may exist independently of any
organic lesion  of  the  testis  itself.   M. Dron  has furnished
accounts of quite a number of cases  he has met with at the
Venereal Hospital at Lyons.   Of the cases reported  by  him two
had syphilitic orchitis at the same time.
  When the head of the epididymis is not exclusively the seat
of the syphilitic  tumor, it is  always the part in which  it be-
comes most developed, and persists the longest.   Generally the
tumor does not exceed a nut or  an  olive  in  size, the largest
being equal to a small walnut.   Its  surface is irregular and
knobby, and its solidity increases with its duration.   It is always
easily  distinguished from  the testicle, and  it is usually very
indolent, so that the patient  himself  may not  be aware  of its
existence.   Sometimes,  however, the  disease is  attended with
more or less pain.  The functions  of  the organ do not appear
to be influenced  by the presence of the tumor, which is also
generally unaccompanied by lesions of any other portions of the
spermatic apparatus.  The period of its  first appearance cannot
always be determined, so little has it excited  the attention of the
patient.  In some cases the swelling or tumor is noticed within
three or four months after the existence of  a chancre, while  in
other instances it has been much later.  Left to itself  its  dura-
tion  seems to be  almost indefinite,  as it  is met  with  many
years after the occurrence of the primary disease.  The tumor
for the most part readily  yields to treatment, and a cure  is ac-
complished in two or three  months.   A  few  cases of pure
syphilitic  epididymitis, independent of any  coexisting lesion of
the testis, have come within my observation.   They  have not
been of a grave character, and have terminated by resolution.
The complaint occasionally shows a disposition to return.
   The iodide of potassium constitutes the most efficient, and in
fact about  the only remedy required.  Local applications are  of
no account. 
CHAPTER  XXXVIII.
     DISEASES OF THE PERIOSTEUM AND BONES.

  Syphilitic  diseases of the bones and of their investing mem-
brane,  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 mercury,
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  an ordinary rheumatism;  is
not  accompanied by redness,  swelling,  or  increased tempera-
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. 
422
GONORRHOEA AND  SYPHILIS.
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 opera-
tion  of trephining can  alone  give relief.  Surgical experience
has demonstrated this  fact.
   Syphilitic osteocopes are regarded by some  eminent  authori-
ties 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 per-
sons 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 peri-
osteum  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 enlargements, 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, however, as purely venereal  acci-
dents where no mercurial preparations have been administered.
They do not exhibit precise  uniformity in their appearance or
character, and have been separated by Ricord  into  three differ-
ent varieties, viz., the elastic, the phlegmonous, and the plastic.
Several nodes are frequently 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 out-
lines are not always well defined.  The central part is usually
more prominent 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.
Sometimes the nodes form without being preceded  by a painful
condition  in the  place from which they spring;  but in  most in-
stances, 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  occasion
but very little inconvenience; on  the contrary, they sometimes
prove extremely troublesome, and  are premonitory  of still more 
       DISEASES OF THE PERIOSTEUM AND BONES.    423

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 sup-
puration 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  sometimes  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 composition of the nodular deposits.   Mr.
Stanley states that he has found what was supposed to be osse-
ous matter to  prove  mere indurated  periosteum.    The peri-
cranium differs from  the fibrous investment  of the other  bones
in never becoming ossified.
   Sometimes  the morbid action which  originates in the  syph-
ilitic infection produces hyperostosis, or thickening and unusual
induration of the walls of the skull, and more or less irregular-
ity and roughness of  their surface, while at the same time there
is great  thickening and condensation of the  pericranium on
the one side,  and the dura matter on the other.   I  have  in  my
possession an interesting specimen of this abnormal condition
of the cranial bones.
   Rokitansky (vol. hi., p. 198)  states  that  upon a minute
examination  of a section of very  compact  syphilitic  skull,
numerous Haversian  canals  were discovered  lying far  apart,
and separate  groups  of unusually large and black corpuscles,
from which a  great number of rays diverged.  In a section of
a piece of syphilitic  skull, which  appeared porous externally,
but was in fact very compact, the Haversian  canals were  found
wide,  the corpuscles mostly large, and some of them placed at
right angles to  the canals.  In the neighborhood of particular
canals the innermost  lamella  was transparent, and  contained a
single  row of  corpuscles,  but it was  surrounded by a dark
stratum,  interwoven  with very  numerous  corpuscles,  which
were thickly  set  with rays.
  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 per-
fectly sound. 
424
GONORRHOEA AND SYPHILIS.
  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
serious  consequences, the cause  of all which  would  not be
suspected, 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  fur-
nish to  the investigating mind of the  intelligent practitioner
a clew to the  true nature of  the  case before him, and  he  will
form his diagnosis and regulate  his line of therapeutics accord-
ingly.
  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 wliich 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  temporal
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
removal.    In  this contribution three cases are related, from
wliich we learn that  at  a remote  period  or stage of syphilis,

         * London Medical Gazette, New Series, vol. xii., p. 1. 
       DISEASES OF THE PERIOSTEUM  AND BONES.    425

paralytic symptoms,  with defective  intelligence  and memory,
impaired vision, difficulty of articulation, and  epileptic seizures
may set in, and  ultimately disappear under proper treatment.
The means principally  relied upon by Dr. Reid consisted  in
shaving the head, extensive  blistering of that part, and mer-
cury.   In one of his cases, venesection, active purgatives, and
tartar-emetic were had recourse to.*
  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
a paralytic affection, with other cerebral disturbances of an
alarming  character.   He  could not stand upon his feet;  his
articulation was  imperfect;  his  memory and ideas generally
impaired; 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 wliich he did
not  recover.   He  lingered  several months  in an imbecile
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 iodide
of potassium; that is, twelve grains per diem, in syrup of iodide
of iron.
            * Labatt on Venereal Diseases, 1858, p. 196.
                    36* 
42G
GONORRHOEA AND  SYPHILIS.
  "The eruption was fading,and she seemed going on favorably
until June 15th, when she was found in the  morning hemiplcgic
on the right side.  Great difficulty in protruding the tongue and
in articulating; the  mouth drawn to the  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. Scolly speaks of the venereal poison often ' putting its
paw upon the dura  mater.'   It  would  seem most reasonable
to charge this  paralysis  to one of the freaks of constitutional
syphilis." *
  Miliary  syphilitic tubercles are  sometimes developed in the
bodies of the vertebrae,  in  the  sternum,  and in other spongy
bones.  They  not unfrequently soften, perforate the  bone at
numerous points in close proximity, and give to  it a honeycomb
appearance.

  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 na-
ture.  If the surgeon have any  doubt whether the inflammation
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 conclusion be formed
by obtaining from  the patient his syphilitic history.   It must be
admitted, however, notwithtsanding the contrary  is asserted, that
in some cases simple rheumatic affections and tertiary venereal
pains have many symptoms in common.   It  would be strange if
they had not.   Sometimes both diseases, rheumatism and ter-

  * 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 hemiplegia and  epilepsy arising from  syphilitic
affections of the cranial bones and their envelopes, and tubercular deposits in
the brain. 
       DISEASES  OF THE PERIOSTEUM AND BONES.     427

tiary syphilis, coexist.   Mr. Stanley makes the just and impor-
tant distinction, that while a rheumatic affection occasions gen-
eral 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, independent
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 to control,  through  the instrumentality of mer-
cury, than when its manifestations are situated in the superficial
tissues.   Indeed, in proportion  as  the venereal element pene-
trates the interior and  becomes  less accessible, the medicine in
question seems to be shorn  of its ability to do good ; whereas
the therapeutic action of the iodide  of potassium follows the
opposite rule;  that  is, its curative energy is most remarkable in
those very accidents over which  mercurial preparations exert no
beneficial  influence.  Hence, for tertiary  pains,  and all other
morbid phenomena  that follow in their train,  the  constitutional
management must  consist in the employment of  the iodide as
the principal remedy.   But  notwithstanding  the  frequent an-
nouncement of  these facts, there are to  be  found in the profes-
sion 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 sarsaparilla, will
ordinarily be a suitable  quantity.   This, however, may be in-
creased, 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 
428
GONORRHOEA AND  SYPHILIS.
made nearly black with the coating of iodine, and the  process
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
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 neighborhood
of the knee-joint.   As the epiphysis of the bone appeared to be
the original seat  of the complaint, he trephined at that part.
As  soon as the  outer shell of  bone was perforated, the  can-
cellous structure was felt to give way under the pressure of the
instrument, and some minute  and separate flakes of white mat-
ter 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

       * London Journal of Medicine, October, 1852. Also Vidal. 
        DISEASES  OF THE PERIOSTEUM AND BONES.    429

 Mr. Parker removed with the trephine a  second piece of bone,
 which was carious, and again penetrated  the medullary canal.
 Xo  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 periosti-
 tis ; 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 purpose of causing the absorption of
 the  morbid deposit, and thus greatly to diminish the chances of
 active inflammation and  its direct  ulterior  consequences, ex-
 foliation of the subjacent bone.   All these indications, as  re-
 gards the local disease, can be accomplished, and no permanent
 traces of  its visitation remain, and in the mean time the consti-
 tutional state of the individual  will  be  improved  by the same
 measures.  Persons who  have long  been troubled  with peri-
 ostitis, become exceedingly pale and chlorotic — a circumstance
 indicative  of  serious impairment  of the  composition of the
 blood.  The most important  deterioration consists in the dimi-
 nution 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 com- 
430             GONORRHOEA AND SYPHILIS.
pounds, the  potassio-tartrate  is the most valuable.   It exerts
a prompt influence in enriching the impoverished 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 im-
portant 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
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 treatment;
although in such a juncture  the  iron will be found more effica-
cious.   Whether a solution  of the potassium  or the iron be
ordered, it should  be  taken ia a large quantity of the compound
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 judicious if there be much local
inflammation.  But as soon as this has been  subdued,  the potas-
sium, together with some  chalybeate, should be substituted. 
DISEASES OF  THE  PERIOSTEUM AND BONES.    431
             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  suf-
 ficiently 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 accomplishing the ab-
 sorption of the fluid, which is  sometimes effected under very
 unpromising circumstances.   However strongly  he may be  in-
 clined 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  followed  by  most
 unpleasant consequences.   Should  the  practitioner decide  to
 puncture  the   abscess, as a last resource,  a very fine trocar,
 rather than a lancet, sliould be the instrument;  and every pre-
 caution should  be observed  to prevent the  entrance of air into
 the wound. The danger of caries  and exfoliation of the sub-
 jacent bone will thus be essentially lessened.
   A case now and then  transpires, in wliich the morbid growth
 has  been  of long  duration,  and after  undergoing a certain
 degree of diminution remains nearly  stationary, is of bony  hard-
 ness,  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 medical agents.   It is the result of
 the previous inflammatory action in the bone and periosteum,
 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 management of  these
conditions seem uncalled for. 
CHAPTER  XXXIX.
               INFANTILE  SYPHILIS.

  The transmission of the syphilitic materies morbi from parent
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 symptoms during the
infantile  period of  its existence.   The  development  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 exception 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 nine 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 was 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 tertiary
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 syphilitic taint, time
must  show;  but  that the  offspring  of such parentage should
have remained so  long exempt from  its manifestations, is not a
little extraordinary.
  The features which the syphilitic disease presents in the young
infant are quite different, in many respects, from those developed
in the adult.  Especially is this remark applicable to the morbid
appearances which show themselves upon the  external surface ;
and this imperfect resemblance offers one of the greatest difficul-
ties we meet with in clearing up the obscure  points, which  not
               (432) 
        DISEASES OF THE PERIOSTEUM AND BONES.    433

unfrequently baffle the judgment, in our  attempts to decide
upon the exact  pathological character of the symptoms under
review.   In  the adult  subject  the phenomena  are developed
with comparative regularity, and  are generally  recognized at
sight.. The origin or mode of infection in  the two classes of sub-
jects is different, and the lesion  which is  primary in the one, is
rarely ever met with in the other.  M. Caillault, a recent French
writer, considers the cutaneous phenomena of congenital syphilis
as constituting in point of fact the whole  disease of infants.*
This  view of the  subject,  however,  is untenable,  as we  shall
shortly see, and  as almost every physician  already knows.
   In  infantile syphilis the symptoms  belong almost exclusively
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 Malernite  nearly half a century ago, and in a  child thirty-
five days old.   There was  periostitis  on the superior and poste-
rior  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 cor-
rosive sublimate  were administered, and in three or four months
all the symptoms disappeared.
   The bones of  the nose in the new-born infant are occasionally
destroyed by the disease, and  a falling  in of the organ takes
place, which imparts to the features a most hideous deformity ;
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 oc-
currence 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 vene-

  * A Practical Treatise on Diseases of the Skin in Children from the French
of Caillault.  By R. H. Blake, &c. London Edition, 1863, p. 6.
                    37 
434
GONORRHOEA AND SYPHILIS.
real  taint when three weeks old.   But its  true  condition was
not understood  by the parents,  and  no apprehension  of 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 marriage 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 bad 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
is communicated  by the spermatic secretion of the father, who,
at a former period, may have bad 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 instance
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  answer to this inquiry,
I deemed it expedient to put this father upon  a  moderate  mer-
curial course, combined  with diaphoretics, 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 re-
sult 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 the conception.   By some writers
it has been supposed that in  these cases the mother must be
infected first, and the  foetus  afterwards; but facts  are every
now and then brought to  light disproving this theory, and estab-
lishing  exactly its opposite, namely, that the mother, who es-
 capes the infection at the time of copulation with an  individual
laboring under the  venereal diathesis,  may become  infected 
INFANTILE  SYPHILIS.
435
 from the foetus, the germ of wliich has  been poisoned by the
 semen of this same  individual.   This proposition may be con-
 sidered  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 at 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 pre-
 vious 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  especially on  the fact, says Mr. Parker,  no sexual mis-
 chief existed.  The wife  was carefully examined.  She had never
 had a vaginal  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 infan-
 tile syphilis, there is no difficulty in comprehending the influ-
 ence of a syphilitic mother in transmitting the same malady 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
venereal ulcers.  Inoculation in  this way, however, is probably
very infrequent.   The smegma, or sebaceous matter, that  cov-
* Lancet, May 29, 1858. 
436
GONORRHOEA AND SYPHILIS.
ers the whole surface of the child, operates as an  admirable
safeguard.   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 authorities.
I imagine that no  practitioner would, if called upon  for advice,
recommend a suckling child to the custody of a syphilitic 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 justly.   He
might as well countenance the deadly administration  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 opportunities
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 received 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  alow vital-
ity, and  that its existence is very seriously compromised.  Al-
though 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. 
INFANTILE SYPHILIS.
437
   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
 them exhibit, for the most  part, great  uniformity of symp-
 toms ;  and yet there is not, in every instance, an entire  assem-
 blage 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 spe-
 cific accidents or lesions is  delayed for several months;  the
 infant, meantime, being  to  all appearance  in perfect health,
 until some  incidental circumstance, such as dentition  or the
 process of weaning,  seems to  operate as an immediate exciting
 cause in bringing to  light the  latent diathesis.   Generally, how-
 ever, 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 emblem of old  age.  The inte<ni-
 ment of the face and of the whole frame is  wrinkled in conse-
 quence of defective nutrition.  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  consid-
 ers 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

   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.
                  37* 
438
GONORRHOEA AND SYPHILIS.
numbers of foundlings and other young infants,  in  whom tho
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
present before any actual eruption appears upon the external
surface, 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 abdo-
men.
  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
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 forehead
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 oc-
cupied by them.   These  blotches of eruption  are quite persist-
ent,  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 syphilitica.
  Syphilitic  maculae  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 connection  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, 
                           pi.vn.
Maculae
SypMiticas 
 
 
piviii.
-

Psoriasis Orbicularis Syphilitica, 
INFANTILE  SYPHILIS.
439
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 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 com-
pressed instinctively, as if  for the purpose of  avoiding constant
distress in the parts.  Isolated mucous patches are often observed
in the same localities as in the adult;  so also the lining  mem-
brane 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 disease, while
the skin remains intact, or nearly so.   The congestion and in-
flammation of  the pituitary  membrane  always interfere 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 breath-
ing becomes more laborious and obstructed, 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 downwards; 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-
purulcnt secretion, intermingled with mucus.  This  irritates 
440
GONORRHOEA AND SYPHILIS.
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
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 indifference, or
perhaps scarcely at all; they survive  but a few hours or days,
and then die of starvation, and without  exibiting 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 occa-
sionally met with in these young  subjects.   The external  erup-
tion is accompanied with extensive lesions within the mouth. If
ihe child be so fortunate as to be well fed, its general health will
frequently continue good for three or four months  after the 
LNFANTILE  SYPHILIS.
441
advent of the phenomena above described, even if no  treatment
be instituted.

  Erythema. — As yet we have barely mentioned this  exan-
them.  As it is generally the precursor or rallying point of other
venereal eruptions, it is  invested with an interest which would
not otherwise attach to it.   It may be  well therefore to dwell
upon its features for a moment.   Its presence  is of  grave  im-
port.  It denotes that there is a profound constitutional disturb-
ance, of which the  eruption  itself is  a mere sign or expression
not produced by any local or extraneous cause.  The eruption
may appear on any part of the body or limbs, but seldom comes
upon the face.   It assumes for the  most  part an acute form, but
apparently produces only  slight discomfort to the  child.   It
spreads out upon the surface  in  somewhat irregular circular or
oval patches of  various dimensions.
   At first the color is a vivid red, but in two or three days the
blotches reach their acme,  and the brilliant scarlet hue becomes
gradually  less  conspicuous,  and  a dingy red color prevails.
After the erythema has continued for six or eight days, a delicate
trace of yellow  often mingles with the coloration.
   If the eruption  exists upon the nates, around  the anal  re-
gion, inguinal folds, or genitals, the cuticle is very apt to be cast
off at an early day, and after  the desquamation has taken place
the derma shines as if polished or covered with a layer of var-
nish.  There is little or no serous  exudation, except about the
folds of the skin.   The cuticle is reproduced at irregular inter-
vals, and if the child nurses well, is kept cleanly, enjoys a salu-
brious  atmosphere, is  brought under the immediate action of
appropriate medicine, — that  is, mercury, —and  the venereal
diathesis is comparatively mild, it may resist  any further en-
croachments of the disease
   I have now under treatment a  female infant, nine months old,
which first exhibited, at the age  of five months, signs that it
inherited the venereal  diathesis.  The mother has never suffered
from the complaint, but she knows  the father has. At first,
erythematous blotches of moderate dimensions came here and
there upon the  extremities of the child.   They were not numer-
ous, but the mother suspected their  nature.   In a few weeks
small  isolated tubercles  supervened.    These  soon acquired a 
442
GONORRHOEA AND SYPHILIS.
pustular character, with hard bases and thick, dark, prominent
scabs;  presenting, in  short,  the  usual features of  syphilitic
ecthyma.   The mucous  surfaces were not  abnormal.   Tho
general aspect of the  child, when  I first  saw it, betokened  a
moderate  degree of  atrophy or stinted growth.  It lacked vi-
vacity, plumpness and color.   It nursed well but the nutritive
function was at fault.  That it was a genuine case of congenital
syphilis there was no reason to question.
  The  child was put upon the use  of the bichloride of mercury,
— one-sixtieth of a  grain  twice a day,—and  to the eruption a
weak nitric oxide of mercury ointment was  applied.    The erup-
tion  yielded very rapidly to the action of the medicines, and the
child has grown fat and in all respects improved in a satisfactory
manner.  The bichloride will  be continued in half the original
quantity for some weeks to come.
  But in a vast majority of cases a far different doom awaits the
syphilitic child.   The  morbid phenomena, instead of  diminish-
ing in  severity, become more and more intense; the erythem-
atous inflammation  bursts out  in new places, and spreads in
every direction; excoriations  of various extent and depth  are
formed; gangrenous  or sloughing ulcerations  are established at
different points; numerous  vesicles  or bullae appear about the
small joints of the extremities and discharge a foetid, sero-sanious
matter;  the  ill-developed nails turn yellow,  dry  up, and  are
detached ; abscesses supervene, and diarrhoea sets in ; and finally
coryza and laryngitis complete the picture,  and the child dies.
I have  seen not a few such cases within the last thirty years.

                    INTERNAL ORGANS.

  The Luxgs. — Indurated masses  or nodules  arc frequently
found in the parenchyma of the lungs in all stages of development
as a syphilitic lesion.  At first they are hard, — mere indurations;
they afterwards  soften,  suppurate,  and  yield a sero-purulent
fluid.  Their  course is usually rapid and always  fatal.  The
symptoms to which they give  rise  are similar  to those of pneu-
monia.   The pulmonary affection  is occasionally the only disor-
ganization manifest,  but in  most instances the skin, the throat,
and  other regions, are  occupied by some allied form of syphilis.
These nodules are formed during foetal life, and have been found 
INFANTILE SYPHILIS.
443
by M. Tierlinck to contain pus-globules  at  the seventh month.
It still remains a matter of question whether a true tuberculosis,
either in the young or in  the adult subject, can be produced or
even developed by the syphilitic element.
  As yet we have no means of positively detecting the peculiar
elementary characteristics  of these  syphilitic  deposits,  if  any
such  really exist.  The microscope brings to view fibro-plastic
material, cell-nuclei of various  sizes, oil  or  fat  globules, pus
globules, amorphous matter, &c.; but these  are  all found in
other morbid  products also.  In  the early stage of formation
 Mr. Wrilks, of  Guy's Hospital, found  nodules in the lungs of a
 syphilitic patient to consist of fibro-plastic tissue.  The disease
 in this instance consisted of rounded masses in the substance of
 the lung, quite circumscribed  and  firm, and presenting  an
 appearance different from the ordinary or inflammatory deposits.
    Several  writers  have  described  diseases  under  the  term
 "Syphilitic Pulmonary  Disease;" and one author tells us  that
 syphilis  displays itself in  the lung under the varied forms of
 bronchitis, pneumonia, or broncho-pneumonia.

    Hepatic  Affections.—It has  for along period been a  well-
  settled belief that  in constitutional syphilis the liver becomes
  involved;  and it is  now fully  demonstrated by  pathologico-
  anatomical facts that the  venereal  poison  is one  of the  most
  frequent predisposing causes of various morbid conditions of the
  biliary apparatus.  The  morbid  process manifests  itself in several
  different forms, as  simple interstitial hepatitis,  hepatitis  gum-
  mosa, waxy,  amyloid or  lardaceous degeneration  of the  liver
  There are  still other forms of  hepatic disease where the devel-
  opment of areolar tissue is widely extended throughout the livei
  and gives rise to  simple or  granular induration,  and  are
  described under the title of syphilitic cirrhosis.
     Of seventeen cases of syphilitic hepatitis ^n**J™0™
  the organ was reduced  in size four times, and once it did not ex-
    e  d wice the size of a man's fist; the volume was normal m seven
    a  es  and in six it was enlarged ; in five there was waxy degen-
   "  This latter  condition, resulting  fro*i  —1U011
   syphilis, may exist when the osseous system is not attacked.
   has been found even in newly born infants.
     In  the year 1848,  M. Gubler,  of France, presented  to the 
444
GONORRHOEA AND SYPHILIS.
notice of the profession a very important  paper demonstrating
the occurrence of a peculiar change in the liver in a great num-
ber of  new-born children affected  with  hereditary syphilitic
phenomena;  and   the  pathological  researches  of  Cullerier,
Depaul, Lebert, Trousseau, and many other observers, concur in
proving that while various  syphilitic  lesions  are developed in
the skin and mucous  membranes, the liver  is profoundly dis-
organized in  different ways ; but the  most frequent abnormal
conditions appear to be hypertrophy and  induration; and yet,
strange to say, Mr. Wilks  informs us that although he has seen
fibrous deposits in  the  livers of children who have had heredi-
tary syphilis, he has not met with  this enlargement and hard-
ness of  the organ.  The change here  spoken of is regarded as
similar to the lardaceous  or  waxy  liver.   In extreme cases  of
this extraordinary  formation it resists pressure, and when torn
by the fingers its surface receives no indentation from them, and
the elasticity of the organ is  such that if a wedge-shaped piece
taken from its thin edge  be  pressed, it escapes like a cherry-
stone and rebounds from the ground.  When cut into it creaks
slightly under the  scalpel.   Sometimes the change is universal,
at other times partial.
   Microscopical  examination of the diseased  tissue reveals the
presence of  a great amount of fibro-plastic material.
   A remarkable fact connected with this  syphilitic condition  of
the liver is, that there is never any jaundice  even when  the
entire organ is diseased.
   Gubler regards the special change in  the  liver above spoken
of as a lesion of the tertiary order, although no tertiary phe-
nomena, properly so called, are observed  to coexist with it; and
further, it has been found that the iodide of potassium will not
cure it, while the proto-iodide of mercury has been found to be
the specific for it.   The opinion of Diday  is quite curious,  and is
at variance  with that of Gubler.   Diday  believes (p. \)o) that
the induration of the liver in new-born children is exactly anal-
ogous to the induration of a chancre in the adult, and is due to
the transmission  of the  poison  furnished  by the blood  of the
mother, determining in its course the  same organic reaction, of
which  induration  is the  expression, which the  poisonous pus
absorbed during coitus induces around the chancre, and then in
the first lymphatic which it traverses.  On this theory induration 
INFANTILE  SYPHILIS.
445
of the liver ought not to occur when the infection proceeds from
the father ; and such, it is averred, is the fact.*

   Treatment. — So  far  as mere pharmaceutic agents are con-
cerned, the treatment may be summed up in few words, namely,
mercury  and the iodide  of potassium.   The  same may be said
in  regard to  the  treatment  of syphilitic  lesion  of  the  lungs,
although in the latter malady no  therapeutic preparations are
available for good.   The form of mercury which  I prefer is the
bichloride, — from one-sixtieth to one-twentieth of a grain once
or twice  per diem, as in the subjoined formula: —

   R.  Hydrargyri Bichloridi,.........-  gr- j-
       Syrupi Tolutani,.............3 ss-
       Aquas Fontanae,.............S viiss.  M.
   Give a teaspoonful, once, twice, or thrice daily.

   In regard  to the duration  of  the  mercurial  treatment  no
 positive  rules can  be prescribed.   The age of the  child, the
 severity  of the symptoms, and the  apparent  influence of the
 remedy, will  serve,  in a  good  degree, as  a rational  guide both
 as to the daily amount that  should be  administered  and the
 period during which it should  be continued.    It should be pro-
 longed for two or three months, with occasional intermissions of
 a few days, after the syphilitic manifestations have disappeared.
 It must  not be concealed, however, that the prospect of perma-
 nent benefit to the little patient is very slight, compared with
 the  many probabilities to the contrary.

   * Testelin, a German  writer, comes to the following conclusions respecting
 syphilitic affections of the liver.  (1.) In a majority  of cases the high mortality
 of sucking children, affected with hereditary syphilis,  depends on specific^dis-
 ease of the liver.  (2.) This morbid alteration, characterized in the dead body
 by the presence of fibro-plastic elements in the parenchyma, reveals itself dur-
 ing life by disturbance  of the digestive  canal coexisting with the ordinary
 signs of hereditary syphilis, and by a considerable enlargement, of the liver
 demonstrable by palpation or percussion.  (3.) In most cases of  syphilitic
 affection of the liver death is caused  by a  suddenly supervening of pentoiuto.
 (4.)  In rare cases death can also be caused by passive hemorrhages, which
 may depend partly on the crasis of the blood, partly on the disturbance of the
 circulation occasioned by the liver affection.-New Sydenham Society s 1ear-
 Book of Medicine and Surgery for 1860,  p. 238.
                   38 
446
GONORRHOEA AND SYPHILIS.
  Peritonitis. — Several years ago, Professor Simpson reported
a number of cises of this disease which proved  fatal in children
whose mothers were suffering from constitutional syphilis, and he
considered the peritoneal inflammation as due  to the venereal
element.  Gubler states  that in some cases of infants  in whom
induration of the liver was found, evident traces of inflammation
of the peritoneum were also detected.

  Thymus  Gland. — Numerous instances of   suppuration of
this organ in  children of syphilitic parents have been reported
by various observers.    Externally the gland presents no abnor-
mal features ;  but, upon cutting it open and squeezing it, minute
drops of purulent matter appear upon the incised surfaces.  In
most of the subjects thus  examined, the skin, lungs,  and liver
likewise presented unequivocal evidence of syphilis.

   Diagnosis. — By studying the specific accidents, the physician
will soon be convinced that the child has upon it symptoms and
appearances not belonging to any non-venereal malady.
   The child may be born at the normal period of gestation.   It
may, possibly, be plump and hearty, and no signs of disease 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 charac-
terizes the affection, but they  feed  and thrive as well as if no
cutaneous eruption were upon them ; nor have they any corre-
sponding abnormal state of  the buccal  and nasal mucous mem-
brane.   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
 reason that they do not suffer from cutaneous irritation, how-
 ever extensively the skin may be covered with specific eruption.
  ' Strophulus confertus is  quite  a  common  eruption  among 
INFANTILE  SYPHILIS.
447
infants 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 appear-
ance of the skin and of the patient has nothing in common with
the features observed in a syphilitic papular eruption at this age.
Besides,  strophulus like  simple  eczema, occasions 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 assistance as with it.
   It has been sufficiently shown  that a  venereal complaint de-
veloped upon the skin of an infant is  almost without exception
associated  with disease within the mouth, and with constitu-
tional derangement of a very grave character.    Let this impor-
tant 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
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 affections
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 
448
GONORRHOEA AND SYPHILIS.
for  suspicion that the complaint is venereal.   There is a pe-
culiarity in the anatomical character of the squamae.   They are
thicker, and in many places, as  on  the  head, the face, the but-
tocks, and about the root£ of the nails,  are more like thin, lam-
inated 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  his-
tory of the parents, he  sliould 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 patho-
logical chain that connects the parental malady with that of the
offspring, as cause and effect.
  Notwithstanding the  utmost diligence to gather the  elements
on which a just diagnosis can be established, a  case will some-
times present itself that will greatly embarrass the  shrewdest
practitioner.   The mother, for  instance, may never have had
any venereal  trouble.  The  husband may be able to say the
same for himself; or he may have had the primary disorder ten
or fifteen years antecedent to the birth of the  child, and may
never have  had constitutional  symptoms.  Or, instead of the
liusband, an alien may unlawfully have stepped  in  and contrib-
uted 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 him-
self against the many  stratagems  and other sources of error
that may beset his path  when he is called upon to give his opin-
ion, 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 wliich
to reach the manifestations inherent in the child, has become
obsolete, and is justly discountenanced every where.
  It matters but little  whether  the mineral be conveyed into
the child's system through the cutaneous surface or through 
INFANTILE  SYPHILIS.
449
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
iatter 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 regards
their function in the infant; and I confess that I am inclined to
accept  this theory.   So long as the mother's  milk 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 mention  in this con-
 nection, is  that the  function of the maternal mammary glands
 is postponed until the time and occasion arrive when this func-
 tion can  be turned  to useful account.  The  lachrymal glands
 furnish still  another example of tardy functional activity or
 development.   The  infant  will  cry right  heartily from the
 moment  of its  birth,  but shed  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
                   38* 
450
GONORRHOEA AND SYPHILIS.
 of the ointment is to be spread  on one end of a flannel  roller,
 wliich 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.
  There  is another  region upon which  it may sometimes be
 more convenient to  apply the  ointment than upon the legs or
 thighs, and that is the lateral  surfaces of the chest, near the
 axilla, by means of a flannel  roller, the portion  next the skin
 being covered with the ointment, which should be fresh-made,
 and renewed daily.
  If the remedy in question should produce much irritation  on
 the part before it has had time to exert its anti-syphilitic power,
 it should  be diluted with rose ointment.
  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, 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.
  The hydrargyrum cum creta  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  continued  for
 five or six weeks after the symptoms have disappeared.  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 consti-
tutional disturbance  is  displayed  the  treatment  with mercury
should be suspended, and the  cautious use of the  iodide  of 
INFANTILE  SYPHILIS.
451
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  preg-
nancy, requires no modification whatever of the remedial course
that would be appropriate under  other circumstances.  This
proposition, or statement, is fully sustained by the experience
of the best and most reliable  observers, with scarcely a dissent-
ing  voice.   The opinion was  formerly  extensively diffused
among the  members of the profession that the  administration
of mercurials was injurious to women during utero-gestation;
and also that  the class of medicines here referred to had  a  ten-
dency to cause abortus, or the death  of the foetus.  Now, how-
ever, 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, instead of producing an arrest of
foetal development and  abortion, the use  of mercury is  calcu-
lated to  prevent these evil consequences. 
FORMULAE  OF  REMEDIES.
                        FOR  GONORRHOEA.

  R.   Bals. Copaibae,..............S iij.
       Spiritus Athens Nitrici,...........§ ss.
       Tincturae Kino...............§ ss.
       Misturae Camphorae,............S ij.
       Morphia? Sulphatis,   ............grs. iij.  M.
  Dose. — One teaspoonful three times a day.

  R.   Bals. Copaibae,..............§ iiss.
       Spiritus JEtheris Nitrici,...........§j.
       Tinctura? Kino,..............§ iss.
       Pulveris Gm. Acaciae,............3 ij.
       Tinctura? Opii,..............§ ss.
       Aquae Fontanae,..............§ ij.  M.
  Dose. — One teaspoonful three times daily.

  R.   Pulveris Cubebae,    .............§ vj.
         "    Aluminae,.......     .....3 vj.   M.
  Div.  in chart. No. xxiv.
  Dose. — One powder three times a day in a gill of water.

                  INJECTIONS  IN GONORRHOEA.

  R.   Zinci Sulphatis,..............
       Plumbi Acetatis, aa,.............gr. xv.
       Tincturae Catechu,.............
               Opii, aa,.............3j.
       Aquae Rosarum,..............g viij.  M.
  Injection. — To be used three times daily.

  R   Vini Rubri,...............§ vj.
       Acidi Tannici,..............grs. xviij.  M.
  Injection. — For the male urethra.  For the vagina the quantity  of tannin
may be doubled

  R.   Zinci Chloridi,...............gr. iv.
       Aquae Fontanae,..............§  vj.   M.
  Injection. — To be used two or three times daily.
             (452) 
FORMULAE OF  REMEDIES.
453
  R.  Hydrargyri Acidi Nitratis,..........gtt. ij.
       Aquae Fontanae,..............§ vj.  M.
  Injection. — In gonorrhoea  or gleet.  To  be used once, twice, or thrice
daily.  Few patients  can tolerate this injection stronger than is here pre-
cribed.

  R.  Vini Opii.................
       Liquoris Plumbi Subacetatis,  aa,.........3 ss.
       Aquae Distillatae,..............§ vj.  M.
  Injection. — To be used three times a day, in gonorrhoea or gleet.

           FOR CHORDEE AND  PAINFUL  ERECTIONS.

  R.  Take spirits  of  camphor, about thirty drops, every hour, in a wine-
glass of sweetened milk, until  three  or four doses are taken, if necessary.

                                GLEET.

  R.  Tincturae Ferri Sesquichloridi,.........§ ss.
       Aquae Fontanae,..............§ ij.  M.
  Dose. — One teaspoonful thrice daily, in a gill of cold water.

  R.  Copaibae,................§ ss.
       Tincturae Cantharidis,............§ ij
           "     Ferri Sesquichloridi,.........§ j.  M.
  Dose. —Thirty drops thrice daily, in a gill  of sweetened water.

  R.  Tincturae Cantharidis,............§ j
       Quiniae Sulphatis,   .............3 ss.
       Tincturae Ferri Sesquichloridi,.........3 ij-
       Acidi Sulphurici Diluti,...........3 ss.
       Aquae Fontanae,..............5 vnj-  M.
  Dose. — One ounce three times daily, in an equal quantity of water.

  R.  Morphise Sulphatis,.............gr-j-
       Sacchari,................3 nj.
       Misturae Camphorae,.............
       Mucilaginis Acacia?,  aa............3 ]j-
       Olei Terebinthina?,..............3 ij.   M.
  Dose. — Two drachms thrice daily.   Injections the same as in gonorrhoea.

          VEGETATIONS, CONDYLOMATA,  AND  WARTS.

                                  WASH.

  R.  Liquoris Soda? Chlorinatae,..........§ss-
       Aquae Fontanae,..............3V-   -1-
  Ft. lotio. 
54
GONORRHOEA AND  SYPHILIS.
                              for  warts.

  R.  Pulveris CEruginis,.............
           "   Sabinae, aa,.....•.......3j-   M.
  Apply a small quantity every three or four days.

  R.  Acidi Chromici,..............3ij-
       Aquae Fontanae,..............3 x.   M.
  To be apphed in the same manner as a  strong  solution of nitrate of silver,
once in three or four days.  It produces but little pain, and is usually effectual
in destroying venereal warts.

  R.  Zinci Chloridi,    ..............3 ij.
       Aqua? Fontanae,..............3j«  M.
  To be used like the preceding.

                  GONORRHOEA  IN THE FEMALE.

  R.  Copaiba?,................
       Mucilaginis,...............
       Pulveris Cubebae, aa,............§ j.
       Spiritus ^Etheris Nitrici,...........§ iss.
       Misturae Camphorae,   ............§ viij.   M.
  Dose. — A tablespoonful in half a gill of sweetened milk, three or four
times a day.

  R.  Tinctura? Lyttae,..............
       Tincturae Cubebae, aa,............§ ij.
       Misturae Camphorae,............§ iv.
       Morphiae Sulphatis,.............gr. iv.   M.
  Dose. — One drachm thrice daily, in half a gill of sweetened milk.

                             INJECTIONS.

  R.  Tannine?.................^ ij.
       Potassae Chloratis..............3j.
       Aquae Fontanae,..............§ xvj.   M.
  Inject an  ordinary female syringeful at a time, and  repeat the operation ad
libitum.

  R.   Infusionis Cinchonae Rubrae,..........§ x.
       Acidi Nitrici................3 ss.   M.
  To be used as an injection repeatedly during the day.

  R.   Tincturae Iodinii  Comp.,...........3 S8<
        Aquae Fontanae...............§ viij.   Jfl.
  Inject a syringeful three, four, or five times a day. 
                    FORMULAE  OF REMEDIES.                455

 R.  Aluminae,................3j.
      Aqua? Fontanae,..............Sxij.  M.
 Injection. — To be used freely.

 R.  Zinci Sulphatis,..............
      Acidi Tannici, aa,   .............9 j.
      Aqua? Fontanae,..............§ x.  M.
 Injection. — To be used freely.

                             CHANCRES.

           caustic applications. — (abortive treatment.)

  I use the following substances, and give preference to them as they are here
arranged: —
      1.  Concentrated Nitric Acid.
      2.  Acid Nitrate of Mercury.
      3.  Chloride of Zinc Paste.
      4.  Solution of Chromic Acid.

              SLOUGHING  CHANCRES, OR  ULCERS.

  R.   Potassa? Chloratis,.............§ ss.
       Aquae Fontana?...............5 viij.
       Acidi Hydrochlorici,............gtt. xx.  M,
  Signa. — Lotion.   To be constantly applied with lint, until healthy action is
produced, after which a somewhat weaker solution may be employed.  Of late
I have used the chlorate of potash solution to sloughing and  atonic ulcers with
the most gratifying results.

                               SINUSES.

  R.   Tinctura? Iodinii,..............  3 J-
  Inject into the sinus a small quantity every four or five days, if necessary.

              MUCOUS  PATCHES ON  THE  TONGUE.

  R.   Extracti Cicuta?,..............3 ss.
       Hydrargyri Chloridi Corrosivi..........gr- "•
       Aquae Fontana?,..............3 VJ.  *  •
  Signa. — Mouth Wash.   To be used three or four times daily.

                              GARGLES.

              for  sloughing ulcers within the mouth.

  R.   Oxymellis ^Eruginis,..........gj  vel g ij.
       Aquae Fontanae,............3 VJ-
  Signa. — Gargle.   To be used three or four times daily. 
45G
GONORRHOEA  AND SYPHILIS.
  R.  Potassee Chloratis,............     3 iij.
       Acidi Hydrochlorici,............gtt. xx.
       Aquae Fontanae,..............§ viij.   M.
  Signa.—Gargle.  I know of no gargle or mouth-wash superior to this in
sloughing ulcerations of the tongue, or elsewhere within the buccal cavity   It
occasions but very Uttle smarting at the time of using it, and may be repeated
many times in the course of the day.

  R.  Acidi Hydrochlorici Diluti,..........3 ij.
       Decocti Cinchona? Corticis,..........§ x.  M.
  Signa. — Gargle.  To be used freely.


                 FOR  TUBERCLES  ON THE FACE.

  R.  Pulveris Camphorae,   ............3j.
       Hydrargyri Oxidi Rubri,...........9ij.
       Unguenti Rosarum,.............§ ij.  M.
  A small quantity to be applied at night.   In the morning  the ointment may
be removed with soap and  water, and  the  following lotion of acid nitrate of
mercury immediately applied with a camel's-hair pencil: —

  R.  Hydrargyri Pernitratis Liquoris,  ....     ....  gtt. xxx.
       Aquae Destillatae,..............§ vj.  M.
  Signa. — Lotion.  To be applied freely to the tubercles.

                                  Or,

  R.  Hydrargyri Cyanureti,............gr- vj.
       Aquae Destillatae,..............§ vj.   M.
  Signa. — Lotion.
  This lotion should be smeared over the tubercles with a camel's hair pencil,
once or twice a day.  If it produces much smarting, cold water should be used
freely to subdue it, and the wash should be employed less frequently.   It some-
times proves efficacious in removing the  tubercles from the face without occa-
sion for any other topical remedy. 
INDEX.
PAGE
Abbott, Dr. S. L., secondary syphilis communicated to an infant
       attendant, ...          .
Abrasions, superficial, on the tongue,
Accidents from iodide of potassium,
Acid, chromic, as an escharotic,
      nitric, as an escharotic, ....
            in sloughing phagedaena,
            sloughing ulcers,
            danger in applying it to the pharynx,
Acid, Nitrate of Mercury as an escharotic,
Alopecia.......
Amaurosis, syphilitic,.....
Ammonia, carbonate, in phagedaenic 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,
              between exposure and the appearance of chancre
Babington, method of prescribing mercury,  .
Balanitis,.......
          pseudo,  .•••••
by an
         causes of,
         treatment,
Baldness,  .
Balsam of copaiba,
                  eruptions produced by,
                  useless in vaginal gonorrhoea,   .
                  first  employed by Professor Chapman, .
Behrend, 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 ulcers,  .
Bladder, irritable,......
                 treatment,  .     .              •
     300
     371
     337
     167
165, 196
     245
245, 376
     377
166, 196
     366
  .   399
     247
  .   339
     279
  .   101
     102
  .   219
     193
  .   213
      72
      73
      74
      75
     366
      36
  24, 306
  .  176
      36
  .  244
     208
  .  291
     291
 349, 378
     108
  .  110
39
(«7) 
458                            INDEX.
                                                                     PAGE
Blennorrhagia,...........13
              causes of,     ........   14
              diagnosis,.........24
              usual period of latency,.......26
              symptoms,........26
              contagion,.........28
              treatment of, in the male,......31
              cathartics in,.........31
              hot fomentations,     .......      32
              injections of nitrate of silver,......32
                                         fatal effects of,  in, .     .      35
              capules of copaiba,.......40
              cubebs,     ...          .....42
              various injections,........53
              treatment at Chelsea Hospital,.....52
              in the female,.........158
                           diagnosis,......170
              in young female children,......172
              situation of the complaint in the adult female,   .     .     174
              varieties and symptoms,......174
              treatment,    .          .......175
                        local,........177
              of the uterus,  .........  181
Blisters in gleet,..........64
Blood in syphilis,...........202
       contagion from syphilitic,........287
Boeck, Professor, on syphilization,      .......  204
Bones and periosteum, diseases of,......          421
Boston  Society for Medical Improvement, on contagiousness  of second-
  ary syphilis,...........292
Bougie,.............67
Bromine and its compounds,........349
Bubo......          .......254
      on same side as chancre,........254
      from indurated chancre, rarely suppurates,  .    .    .    .217, 255
      true syphilitic, usually indurated,......255
                   denotes the system is poisoned,     ....  255
                   treatment,........259
                   Vidal's opinion,.......259
                   patient should keep  still,.....259
                   counter-irritants,.......260
                   Malapert's  method of blistering, etc., .     .     .     260
                   method at Paris Hospitals,.....260
                        ''    Guy's Hospital,.....260
                   compression  objected to,.....262
                                fatal results from,  ....     262
                   indolent or chronic,.......262 
INDEX.
459
                                                                    PAGE
Bubo, true syphilitic, sloughing,.......264
Buchu in blennorrhaea,.........46
Buckingham, Dr., anomalous cases,.......20
Busk, Mr., on composition of gummy tubercles,......409
Calomel to mucous tubercles,........353
Camphor in painful erections,........57
Castration in spermatorrhoea,........138
Cazenave on contagiousness of  secondary syphilis.      ....  292
Cerebral syphilitic affections,   .     .......424
Chancre, indurated,.........189, 216
         microscopical examination of,......189
         Hunterian,  rarely met with,.......189
                    never forms on the glans penis,       .    .     .     192
                    rarely on os uteri,  .......  191
                    period of incubation,......192
                    abortive treatment,     .    .     .     .     .     .193
                    views of Dupuytren, .     .     .     .    .     .     194
                            Vidal,.......194
                    local applications,    .....     196, 229
                    constitutional treatment,     .....  199
         average time for curing indurated,     .     .     .    .     .     219
         masked or  concealed,........232
                 rarely met  with,    .......     233
                 produces great mutilations, ......  233
                 treatment.........234
                 on  os uteri, and vagina,    ......  233
                 treatment,    ........     235
         inflammatory,..........237
                     how induced,       .     .     .     .    .     .     237
                      treatment, '.     .    .    .     .     .     .     .  237
                      Mr. Key, sarsaparilla  and limewater,   .     .     238
                      opium,     ........  238
         phagedaenic,     .........     240
                    progresses rapidly,    .    .     ■     .     .     .241
                    seldom produces constitutional  syphilis,  .     .     242
                    treatment,........242
Chancres, in women,..........251
Chordee,............56, 58
        treatment,   ..........      56
                 lupulin,.........57
                 camphor,    ........      57
Choroiditis, syphilitic,..........399
Circumcision,    ........•••       <°
             citrate of iron, and quinine,......218
Cod liver oil, as a tonic,.........334
             chocolate, and jelly,       .......334 
4G0
INDEX.
	PAGE
	91
350,	364
286,	292
.	292
	42
23,	306
	222
	52
	375
	292
	292
	424
.	425
	103
Compression of the testis,      ......
Condylomata,     .........
Contagion of secondary syphilis,     .....
Coote, Holmes, on secondary without primary symptoms,
Cubebs in gonorrhoea,........
         eruptions produced by,......
Cullerier, of Paris, on bichloride of mercury,   ....
Davis, Dr. C. A., treatment of blennorrhagia,
Deafness, syphilitic, case of,    ......
Diday, on contagiousness of secondary syphilis,
Discussion at Boston Society for Medical Improvement,
Dura Mater, syphilitic tumors on,   ......
             iodide of potassium for,   .....
Eczema praeputialis,  .........
                  diagnosis of,        .    .     .     .     .     .    .104
                  treatment of,    .......     105
Egan, Dr., on the use of mercury,.......199, 211
Emunctory organs,..........206
Epididymitis.............84
Erections, involuntary and  painful,  .......      56
Ergot in spermatorrhoea,.........135
Erichsen, Professor, on simple and mercurial treatment,   .     .     .     299
Eruptions, papular,..........310
                  diagnosis,   ........     311
                  treatment,........314
          squamous,........318, 325
                    treatment,........333
          from iodide of potassium, .......     337
          tubercular,   ..........  342
                    treatment,      .......     345
          pustular,..........355
Erythema syphiliticum,........306> 441
Escharotics to chancrer,                .    .          .     .     .    .196
Excoriations,...........113
Exostosis syphilitic,........         .431
Ferruginous remedies and iodide of potassium in the constitutional treat-
  ment of nodes,........_          429
Fissures, or  rhagades, on the tongue,.....            372
Fomentations in blennorrhagia,      .....          ,32 178
Francis, Dr. J. W., on bichloride of mercury,     ...            221
French Council  of Health, statistics  of different methods  of treating
  syphilis,......         ....  c  208
Frike. of Hamburgh, a non-mercurialist.     ...            207
Fumigations...........316,400
Gamberlini,  Dr., of Bologna, on iodide of sodium,      ...       341
Gargles,............381
Gleet>...........     .     28,60 
INDEX.
461
                                                                      PAGE
Gleet and matrimony..........      29
      microscopical appearances,  ....          ...    62
      treatment,..........      63
      blisters,...........64
      injections,......         ...      65
      constitutional treatment,    ........    69
Gonorrhoea, causes,  ..........      14
            diagnosis,  ..........    24
            period of latency,   .......      26
            treatment of, in the male,  .......    31
            in the female,........168
            diagnosis,..........170
            situation, varieties, and symptoms,      ....     174
            treatment,   .........   175
Grassi,  M., analyses of  syphilitic blood,......202
Gummy tubercles,..........403
                   diagnosis,    .......     404
                   cases,      .     .     .     .     .    .    .     .     .   404
                   giv-e  rise to the " horse-shoe," or serpiginous ulcer,      405
                   have been found in muscles,              ...   407
                                  in the heart,                         408
                                  in tendons,.....408
                                  in the epididymis,     .    .          409
                   testicle, liver, lungs, brain, etc.,      ....   409
                   their composition,      ......     409
Hancock  on buchu in blennorrhagia,.......46
Hebra  and Sigmund, of Vienna, on mercurial inunction,  .    .     .     214
        on communicability of secondary syphilis,.....286
Hemorrhage, urethral,     .....••■•      58
Hepatic syphilitic  affections,.........290
Heredito-syphilitic iritis,.........398
Herpes praeputialis,..........96
                    symptoms,.......96
                    treatment,........101
Hosack, Dr. David, on bichloride of mercury,.....221
Hyoscyamus and camphor in spermatorrhoea,.....13/
Incubation of  the  venereal poison,.......I92
Infantile syphilis,..........
Infrequency of indurated chancre,.......
                                                                    S2 178
Injections of nitrate of silver,.......0^,1 <o
           obiections to those of high power......
                                                                        35
           fatal effects from,.........
                                                                       179
           in blennorrhagia,     ...         •     •
                         .                                              41
           of balsam copaibae,......
                       .                                                44'}
Internal organs syphilitic,........        "
......                                         .        000, 000
Intoxication, iodic,      ...••••                 1-0.
Iodine, tincture of, as an injection,.....
                       39* 
462
INDEX.
                                                                     PAGE
Iritis, syphilitic,...........391
      diagnosis,     ..........     393
      treatment,   .               ........395
Iron, arseniate,..........99
     citrate of and quinine..........218
     iodide of,..........346
     potassio-tartrate........218,229,347,354
                      in phagedaenic ulcers,.....243
Irritability of the bladder,.........108
                         treatment,      .     .     .     .     .     -     110
Jackson, Dr. James, on lupulin,........135
       226
       264
       384
       205
       428
15, 17, 170
       311
       311
       312
       223
       223
       247
       442
        57
       134
       307
       442
243,
Johnson, Dr. James, on sarsaparilla,.....
Key, Mr., iodide of potassium in sloughing buboes,
Larynx, syphilitic,   ........
Lawrence, Mr., of London, on syphilization,  .
Lee, Mr., of London, trephining in certain cases of syphilitic ostitis,
Leucorrhoea as a cause of gonorrhoea,     ....
Lichen, varieties,  ........
        diagnosis,   ........
        passes into tubercle,       .....
Locher, of Vienna, use of bichloride of mercury,
London Lancet, on     .......
Lotion of chlorate of potash,   ......
Lungs, syphilitic,  ........
Lupulin in chordee and erections,.....
        in spermatorrhoea,   ......
Macula syphilitica,.......     .
Marsden, Dr., treatment of secondary eruptions at the Royal Free Hos
  pital, London,   ...........  319
Massachusetts General Hospital, cases of venereal disease arising from
  infantile syphilis,  ..........     288
Menstrual fluid exciting gonorrhoea,     .     .     .     .     .     .    14, 170
Mercurial fumigations,........316, 400
Mercurial inunction for curing venereal symptoms,      .     .     .     .214
Mercurial inunction in orchitis,........87
Mercury,............206
         should be taken on a full stomach,    .    .     .     .     .     213
         not useful for sloughing or phagedaenic ulcers,  ....  210
         bichloride,..........221
                   one hundred years ago,......223
                   a favorite of Dupuytren,   .....     224
McGrigor,  Sir James, reports  cases  in British army  cured without
  mercurv,    .     .     .    .    .    .    .     .          .    .     .  207
Methods of treating syphilis,........206
Miliary tubercles,...........426
Milton, Mr., blisters in gleet,........64
Mouth and throat, secondary lesions,.......370 
INDEX.
463
                                                                     PAGE
Mucous tubercles,..........350
                 treatment,.........353
Myositis,............407
Nitrate of silver, injections in blennorrhagia,      .     .     .     .     33, 53
                  as a caustic to chancres,.....196
Nitric acid, to sloughing ulcers........245, 376
Nodes,............422
        intra-cranial,..........425
        diagnosis,     ...•..-...     426
        constitutional treatment,........429
        local treatment,.......•          430
Nose, syphilitic diseases of,.........386
                           treatment,     ......     388
Nurses, inoculability by  syphilitic children, and vice versa,      .     286, 291
Ointment, mercurial, for curing venereal symptoms,     ....  214
Ophthalmia, gonorrhoeal,.........140
                        etiology of,.......142
                        from  metastasis,......142
                        diagnosis,      .......  146
                        treatment........147
                                    treatment,     .     .     .    .     153
Opium, in irritability of the system,.......238
Orchitis,............82
         statistics by Sigmund,........8^
         symptoms,..........°4
         treatment...........°°
         mercurial ointment,........°'
         iodide of potassium ointment,.......87
         extract of  belladonna,.......
         tincture of hyoscyamus,....... •    .89
         syphilitic,........'.   '     '     416
                    belongs to no particular stage of syphilis,     .    .  416
                    diagnosis,........^18
                    pathological appearances,.....418
                    treatment.........41°
Ormerod on iodide of potassium, and mercury,  .    .    •    •     •     340
Os tinea?, chancres on,        ........'
                  infrequency of,......iyi» Z6b
                                                                      421
Osteocopes, syphilitic,........
            diagnosis and treatment,.......
     » ,                                                                 56
Painful erections,  •     •     •    \         '    '    '                42q
Pains, tertiary, iodide of potassium in,
       urethral,.......'
                treatment,      .........
 ^   .„                                               ....   166
 Papillomata,.......                             „
             treatment,......... 
464
INDEX.
                                                                      PAGE
Papular eruptions,...........310
                   diagnosis,........311
                   treatment,........314
Paralysis from intra-cranial syphilitic nodes,.....425
Paraphymosis,...........79
              treatment,.........79
Peaslee, Professor E. R., on nitrate of silver as a caustic,     .          .  196
Penis, bony hardness of,.........56
Period of latency between primary and secondary symptoms, .     .     .  267
                 longest recorded,    .......     270
                 shortest     "........270
Periosteum and bones, syphilitic,......          421
Pharynx, sloughing ulcers,........     .  374
                          treatment,......376
Phymosis,............   76
           treatment,..........76
Porte caustique, danger of using,  ........  136
Potassa fusa as an escharotic,........196
Potassium, bromide of, in  spermatorrhoea,    ......   137
           chlorate of, as an injection,     .    .          ...     179
                   in stomatitis,  ........  230
                   strong  solution  of,  as  a dressing for sloughing
                      ulcers,.......243, 247
           no standard dose,.........339
           singular effects of,.......  337
           in tertiary syphilis,.......405, 410
Potassio tartrate  of iron,     .                    .               .     .218
                       in phagedaena,......     243
Pregnancy and syphilis,.......          .     .451
Prepuce, its uses,    ..........      72
Prostitutes, cause of their sterility,........  181
Puncturing the tunica vaginalis testis, and epididymis,    ...      90
Purpura co-existing with rupia,    ........  358
Pustule plate,...........     351
Pustules, syphilitic,.........     .  355
                   treatment,.......          361
Rectum, syphilitic stricture of,........353
Reeve, on intra-cranial affections,.......425
Reid,   •'      "        "       ........424
Relapses in gonorrhoea..........47
Rest, its importance in gonorrhoea,......32, 39, 186
Rheumatism, gonorrhoeal,.........156
                         diagnosis........158
                         treatment,.......158
Rhus glabrum in  stomatitis..........230
Ricord, on experiments without mercury,......     208
Rokitansky, microscopic examination of syphilitic skull,      .     .     .  423 
INDEX.
465
                                                                    PAGE
Roseola syphilitica,..........306
                   sometimes assumes the annulate form,     .     .      307
                   diagnosis,     ........308
                   treatment,........309
Royal Free Hospital, London, treatment of secondary eruptions,  .     .   319
Rupia syphilitica,  ...........   356
                 two varieties,      .......      358
                 treatment,.........361
                 iodide of  potassium,    ......      363
Salivation never necessary,........212, 222
          or stomatitis,  .........      229
          chlorate of potash in,   .......     .   230
          muriatic acid in,     ........      230
          rhus glabrum in,.........230
 Saponaria officinalis,.........226
 Sarcocele.............416
          treatment,     .........      418
 Savin and burnt alum as  an escharotic,.......165
 Scrofula and syphilis,.........401
 Secale cornutum in spermatorrhoea,.......135
 Secondary syphilis,..........      266
           symptoms without primary,.......281
 Seminal fluid may communicate syphilis,......287
 Sigmund on mercurial  inunction,........214
          on communicability of secondary syphilis,   ....     286
 Simpson, Professor, on syphilitic peritonitis.......446
 Sinuses, injections of tincture of iodine for......265
 Skey, Mr., his method  of treating gonorrhoea and gleet,      ...    55
 Skull, thickening of,..........423
 Smith, Dr. J. L., on syphilis from a nursling to a nurse,     .    .    .291
 Sodium, iodide of,..........340
                                                                      1 fi8
 Speculum uteri,...........
 Spermatorrhoea,..........
                                                                      123
                causes, .         ........
                pathological appearances,.....128
                                                                      1 98
                treatment,.........A^°
                                                                      325
 Squamous eruptions,.........
 Sterility, causes of in prostitutes,........181
 Svphilis............
          secondary,..........
          time between exposure and symptoms,     .                   I92
          blood in............202
          u    a-*                                            .         432
          hereditary...........
          infantile............
                                                                      436
          prognosis..........         ^
          symptoms,..........
          infantile diagnosis,........ 
4GG                             INDEX.
                                                                      PAGE
Syphilis, infantile, treatment,........448
                  communicated by vaccination,     ....     287
Syphilodermata,...........273
                "Wilson's nomenclature,......275
                "NYillan's system,........276
                diagnosis,........276
                color of skin,     ...•••••   276
                insensibility of skin.     ......     279
                cicatrices..........280
Syphilization, artificial..........208
                      diseases from.  .......   205
Swan Alley sore,..........252
                 not contagious,  ........   253
                 treatment,........252
Tendons, nodes or gummata in.........408
Tertiary pains............427
         syphilis,  .....••••••   401
                in young children,......•     433
Testelin on syphilitic hepatic diseases,   .......445
Testicle, swelled,    ..........      82
                 compression,     ........    91
                             best time for,.....92
                             Ricord's opinion,   .....    92
Thymus gland, syphilitic,.........     446
Tincture of benzoin comp. for sloughing  ulcers,    ....   349, 378
            iodine as an injection in vaginal blennorrhagia,    .    .     179
Todd, syphilitic diseases of dura mater,      ......   424
Tongue, syphilitic diseases of,                      ....     370
                            treatment,......375
         swelled in stomatitis,   ........     231
Transmission of infantile syphilis,      .......   290
                                 Trousseau on,      ....    390
Travers on sarsaparilla,     .........   226
Trephining in certain cases of chronic ostitis,  .....     428
Tubercula  gummata,    ..........   403
                    diagnosis,      .......     404
                    cases,.........404
                    produce horse-shoe  or serpiginous ulcers,   .     .     405
                    treatment,........   409
Tubercles,  lupoid,..........344
Tubercule muqueux,..........351
Tumors, mucous,-..........351
                 treatment,.........354
         intra-cranial, syphilitic,.......424
Tunica vaginalis, puncturing,........90
Turenne, M., on artificial syphilization,......203
Tyrrell, Mr., scarifications in gonorrhoeal ophthalmia.....148 
INDEX.
467
                                                                    PAGE
Ulcerations about the toes and the nails,......365
           on the tongue,.........3/0
           sloughing, in the mouth,......374
Ulcers, serpiginous,..........341
       phagedaenic,.........244, 343
                   strong  acid  solution of chlorate of potash, as a
                     constant dressing in,.....       247
Urethral blennorrhagia in the female,......184
                      symptoms and treatment,.....185
         hemorrhage,.........*°
         pains,........' ...  118
Urethral pains, treatment,.........Hy
Uterus, blennorrhagia of,.........lox
                        treatment,.......182
                        injections,.......183
Vaccination the medium of communicating syphilis,  ....     287
                                                                     180
Vaginitis, chronic,...........
          in \oune children,........1'2
                                                                     162
Vegetations,............
            anatomical structure,.......I"3
            Vidal's opinion of their venereal origin,    .    •     . -    .  164
            Acton's,  "               "       »     .    .    .    •     164
            treatment...........16°
 Velpeau on transmissibility of secondary syphilis,    ....    286
Venereal disease in cats, horses, monkeys, etc.,.....203
Veratrum viride in gonorrhoeal rheumatism,.....1"°
Vidal, on contagiousness of secondary syphilis,.....292
Victor de Meric, interval between primary and consecutive symptoms,    267
Vienna paste  as an escharotic.....
 Virility unimpaired in orchitis,........
 Waller, produced syphilis with the blood,......
 Warts, or morbid excrescences,........
 Weltz, Dr. Robert, on syphilization,......
 Wilks, Mr., on syphilitic liver,........
 Williams, Dr. H. W., on gonorrhoeal ophthalmia,.....1"
           ...io-                                       .     340
 Willis, on iodide of potassium,.......
 Wilson, Erasmus, on mercury,.......
 Women, chancres in,..........
                       syPhUis>  '.......165  183
 Zinc, chloride of, as  an escharotic,......
pregnant, and syphilis,
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