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THE
MODERN TREATMENT
SYPHILITIC DISEASES 
 
THE
      MODERN TREATMENT
                  OF

SYPHILITIC  DISEASES,

                  BOTH

      PRIMARY  AND  SECONDARY;

                COMPRISING

 THE TREATMENT OF CONSTITUTIONAL AND CONFIRMED SYPHILIS
        BY A SAFE AND SUCCESSFUL METHOD;
                  WITH
  NUMEROUS CASES, FORMULA, AND CLINICAL OBSERVATIONS.

                  by      \y
        LANGSTON  £ARKER,
          SURGEOX TO THE QUEEN'S nOSHTM^MIttnlCOHAM.
 FROM THE THIRD, AND ENTIRELY RE-WRITTEN LONDQN EDITION.
       PHILADELPHIA:
BLANCHARD AND LEA.
           1854. 
W(5A
  l<2 54 cu
      WM. S. TOTJNG, PRINTER,
REAR OF TEE FRANKLIN HALL, 50 NORTH SIXTH STREET. 
PREFACE.
   I  have now devoted nearly twenty years to the thera-
peutics of Syphilis, more especially in  its Secondary and
Constitutional forms.   During that period, without taking
into consideration the extended field of observation, which
a  large hospital  constantly  presents, I  have  personally
treated more than eight  thousand cases.  The results of
my experience  are recorded in  the following pages.   The
present Edition must be looked upon  more in  the light of
a  new work, than a new edition, as  every line has  been
carefully revised, and re-written where  my opinions have
undergone any change; again, as will be seen, great addi-
tions have been  made, amounting to considerably more
than one half  of the entire  work.  My cases  have been
tabulated, and kept according to the annexed plan: I have
selected from them, and distributed, through the following
pages, such as I thought were more than usually interest-
ing from their nature, their rarity, their marked illustra-
tion  of doctrine,  or of  difficulty,  or  peculiarity in treat-
ment. 
PREFACE.
Mode in which the Cases alluded to have been registered.
1.	2.	I 3.	4.	5.
Name, Date, Age,	Disease.	j Habit of Body.	History and Ante-	Causes.
Occupation, &c.		i	rior Duration.	
6. Primary Symp-toms.	7. Pathology. — Ex-amination by Spe-culum or Bougie. ,	8. Treatment of Pri-mary Symptoms.	9. Symptoms accom-panying the Spe-cific Disease.	10. Consecutive Symp-toms.—Bubo, Phy-mosis, &c.
11.
Constitutional
 Symptoms.
12.
Recurrence of
 Symptoms.
13.
14.
Treatment of Consti- Accidents occurring
tutional Symptoms.
during Treatment.
Result and Re-
   marks.
20, COLMORE ROW, BiRMINGHAiM ;

         December, 1853. 
CONTENTS.
                               CHAPTER I.
           ON THE SIMPLE, OR NON-MERCURIAL TREATMENT OF SYPHILIS.
                 .                     ,                              PAGE
 Modem history of syphilis—Doctrines of Hunter, Ricord, Mr. Car-
   michael, and  Broussais—Objects of the simple  or  physiological
   treatment  without  mercury—Diet in syphilitic diseases—Cura
   famis, as practised  in  Sweden and Denmark—Cases illustrative
   of the effects of diet in syphilis—Modification in treatment neces-
   sary in relation to the age, habits, and constitution of the patient
   —Position of the patient, rest in bed, the warm bath—Dr. Roe's
   practice—Local surgical treatment—Local bleeding condemned
   —Non-mercurial treatment not  always successful—Opinion  of
   the Congress  of Surgeons  at  Nantes in reference to it—The au-
   thor's opinions and practice in reference to this point .    .     .     17—27


                              CHAPTER II.
             ON THE MERCURIAL TREATMENT OF SYPHILITIC DISEASES.
 Circumstances which indicate its employ—Particular indications for
   the use of mercury—When not to be  used—The  nature of the
   induration in which it is indicated—In what  manner mercury is
-  to be employed—Treatment  by internal administration, by fric-
   tion, by moist fumigation—Change of form advised—Discontinu-
   ance  oF mercurial treatment.......28—38


                              CHAPTER III.
   ON INOCULATION, AS APPLIED TO THE DIAGNOSIS AND TREATMENT OF SYPHILITIC
                                 DISEASES.
 Inoculation practised by Hunter—The practice revived by M. Ricord
   —Experiments of M. Ricord on the inoculation of chancre, of the
   Author, of Dr.  Egan—Inoculation only of value when positive—
   Phagedenic sores not to be inoculated—Inoculation  of buboes—
   Reason why not often successful—Inoculation with the matter of
   gonorrhoea—The real  position of inoculation in reference  to the
   therapeutics of syphilis—Inoculation of secondary diseases—
   Cases illustrative of the contagion of secondary syphilis—Opi-
   nions of M. Cazenave—Experiments of M.  Waller, of Prague,
   on the inoculation of secondary symptoms  .    .     .     .    .    39—48 
xii
CONTENTS.
                             CHAPTER IV.
OF BALANITIS—INFLAMMATION OF THE GLANS PENIS--EXTERNAL OR FALSE GONORRHOEA
                      —CHANCROUS EXCORIATION, ETC.
                                                                     Page
Symptoms  of balanitis—Causes—Occasionally of_ pure  venereal
  origin—Sometimes due to natural organization of the penis in
  the male, or various morbid conditions of the vagina and os uteri
  in the female—Illustrative cases of both classes of causes, treat-
  ment, complications, relapses......-     49—58


                             CHAPTER V.
                             OF GONORRHOEA.
Varieties of—Seats of—Causes of—Diseases which resemble it—
  A disease distinct from chancre—Pathology of—Symptoms of—
  Differential  diagnosis  of—Stages of—First  stage  of—Abortive
  treatment of, at this period—Second and third stages of—Anti-
  phlogistic treatment of—Frequently more  than  a urethritis —
  Specific remedies in,  copaiba, piper cubebae—Particular forms
  for their exhibition—Other remedies — Mercury—Injections —
  How to  be used—Forms  for—Terminations'  of—Gleet—Local
  symptoms  of—Constitutional  effects  of—Complications  of—Mi-
  croscopical examination of the discharges in—Treatment of, by
  injections in diseases anterior to the bulb, by injections in dis-
  eases of the prostatic and membranous portions of the urethra, by
  bougies,  by blisters; by internal remedies.....59—83


                             CHAPTER VI.
    Of DISEASES WHICH SUCCEED TO, OR COMPLICATE GONORRHOEA IN THE MALE.
Alteration in the natural elasticity of the urethra—Stricture—Ab-
  scesses  in  the perineum, and vicinity of the anus—Gonorrhoeal
  rheumatism—Its two forms—Gonorrhoeal diseases of the eye—
  Gonorrhoea] ophthalmia—Treatment of—Local remedies—Specific
  remedies—Mercury—Restoration of the urethral discharge—Go-
  norrhoeal  iritis—Gonorrhoeal  diseases  of  the testes  and their
  envelopes—Orchitis, how and at what period it occurs—Causes
  —Differential diagnosis—Illustrative cases—Treatment—Chronic
  enlargement of the testis—General  weakness and  irritability of
   the sexual and urinary organs a consequence of gonorrhoea—Ge-
   neral remarks on the treatment of such diseases     .    .    .     84__97


                             CHAPTER VII.
                       OF GONORRHOEA IN THE FEMALE.
 Its nature—Seat—Pathology—Use of the speculum—Internal treat-
   ment—Local treatment—Treatment of the more chronic forms—
   Forms for topical applications—Complications—Differential diag-
   nosis—Difficulties in treatment  .     .    .    .     .     .    .    98__104 
CONTENTS.
Xlll
                            CHAPTER VIII.
OF THE SECOND CLASS OF PRIMARY  SYPHILITIC DISEASES—ULCERS, THEIR VARIETIES
                           AND CONSEQUENCES.
                                                                   PAGE
Classification of primary venereal sores—Their varied aspect fre-
  quently dependent  on their seat—Diagnosis  of—Is a  primary
  venereal sore always a local  disease ?-r-Is a so-called  chancre
  ever the first evidence of a constitutional taint?—Abortive treat-
  ment of primary sores, by escharotics—Local treatment—Consti-
  tutional treatment—Diet—Mild local treatment recommended—
  The Author's views on the use of caustics—Those recommended
  —How to be used—When their use  is contra-indicated—Phimo-
  sis—Primary inflammation—Question of the propriety of mercu-
  rial treatment considered—Local treatment of the  second stage of
  chancre—The indurated primary ulcer—Its treatment—Persistent
  induration of the cicatrix........105—118

                             CHAPTER IX.
                         CHANCRES  IN THE URETHRA.
 History of—Symptoms— Diagnosis—Complications—Prognosis—
   Consequences—Treatment—Illustrative cases  ....  119—127


                             CHAPTER  X.
                              OF PHAGEDENA.
 General account of phagedena—Causes—Situation—Local treat-
   ment  by caustics—Other  local  remedies—The inflammatory
   forms—The gangrenous forms—Illustrative cases of the success-
   ful treatment of, by the mercurial vapour-bath  ....  128—133


                             CHAPTER XI.
                     OF VENEREAL ULCERS IN THE FEMALE.
 Situation of—Nature of—Rarely inoculable when seated on the os
   uteri—Illustrative cases........134—135

                             CHAPTER XII.
                                OF BUBO.
 Three kinds of—Primary, secondary, and constitutional Nature of—
   Inoculation as a test of the nature  of—Causes—Abortive treat-
   ment—Blisters—Mercury—Antiphlogistic  treatment—Malapert's
   abortive treatment—When most efficacious—Author's objections
   to its use—Indolent bubo—Terminations—Treatment when fluc-
   tuation is evident—Ulcerated  bubo—Sloughing  bubo—Chronic
   indolent bubo—Removal of loose  portions of integument—Treat-
   ment of sinuses—Iodine—Causes which favour the occurrence of
   bubo—Premonitory symptoms and their treatment—How a bubo
   should be opened      .             ......136—149 
xiv
CONTENTS.
                             PART II.
               CONSTITUTIONAL OR SECONDARY SYPHILIS.

                            CHAPTER XIII.
                 OF CONSTITUTIONAL OR SECONDARY SYPHILIS.
General account—Phases—Prevention—Complications—General
  treatment...........

                            CHAPTER XIV.
           OF THE CAUSES OF SECONDARY OR CONSTITUTIONAL SYPHILIS.
Primary discharges and ulcers a cause—Inoculation or contagion a
  cause—Hereditary transmission a cause—The  treatment of the
  primary sore a cause—A peculiarity of constitution a cause      .  155—164


                            CHAPTER XV.
                  ON THE DIAGNOSIS OF SECONDARY SYPHILIS.
Sometimes difficult and uncertain—Illustrative case, where the na-
  ture of the disease in the father was discovered by the health of
  the children—Illustrative  case of a secondary  ulcer closely re-
  sembling lupus—Rules to guide the practitioner in forming a cor-
  rect diagnosis..........165—170


                            CHAPTER XVI.
               OF THE PROGNOSIS OF CONSTITUTIONAL SYPHILIS.
Rarely, though sometimes fatal—Its influence  in developing other
  latent diseases—Question of its perfect curability considered    .  171—172


                           CHAPTER XVII.
           OF THE STATE OF THE BLOOD IN CONSTITUTIONAL SYPHILIS.
Microscopic appearance of—M.  Grassis' researches—M. Waller's
  experiments on inoculation with syphilitic blood—Condition of
  the blood disc    .         ........173—174

                           CHAPTER XVIII.
OF THE PARTICULAR SYMPTOMS OF CONSTITUTIONAL SYPHILIS — OF  SYPHILITIC DIS-
                           EASES OF THE SKIN.
The  syphilitic exanthemata—Squamse—Vesiculse—Pustulae—Pa-
  pulse—Tubercula—Maculae—Constitutional  or  secondary vene-
  real ulcers..........     .  175—190

                           CHAPTER XIX.
Of syphilitic tumours of the skin, and subcutaneous cellular'tissue  191—193
     PAGE

150—154 
CONTENTS.
XV
                            CHAPTER XX.
On syphilitic affections of the appendages of the skin—Alopecia—
  Loss of the hair from syphilitic causes.....194—195

                            CHAPTER XXI.
On syphilitic'diseases of the nails.......       196

                           CHAPTER XXII.
     ON SYPHILITIC WARTS, EXCRESCENCES, VEGETATIONS, CONDYLOMATA, ETC.
Their  seat—Causes—Primary and secondary forms—Contagious
  character—Local and constitutional treatment  ....  197—204

                           CHAPTER XXIII.
  CONSTITUTIONAL OR SECONDARY SYPHILITIC ULCERATIONS OF MUCOUS MEMBRANES.
Syphilitic affections of the mouth—Of the throat—Varieties of ulcers
  of the throat—Local treatment of......205—208

                           CHAPTER XXIV.
Syphilitic diseases of the nostrils and nasal fossae ....  209—210

                           CHAPTER XXV.
                   ON SYPHILITIC DISEASES OF THE TONGUE.
The iodic tongue—The mercurial tongue—The syphilitic tongue—
  Rules to guide the practitioner in forming a correct diagnosis    .  211—214

                           CHAPTER XXVI.
On syphilitic ulceration  of the larynx......215—216

                           CHAPTER  XXVII.
                        ON THE SYPHILITIC TESTICLE.
Symptoms—Diagnosis—Pathology—Influence on Virility—Treat-
  ment............  217—221

                          CHAPTER XXVIII.
               ON SYPHILITIC DISEASES SEATED IN THE MUSCLES.
Syphilitic tumour in the muscles of the fore arm  ....  222—223

                           CHAPTER XXIX.
SYPHILITIC DISEASES OF THE PERIOSTEUM AND BONES—OSTITIS, PERIOSTITIS, CARIES,
                         NOCTURNAL PAINS, ETC.
Pains in the bones due to syphilis and not to mercury—Illustrative
  case of long-continued pain cured by trephining—Nodes—Causes
  of—Pathology—Termination—Treatment—Differential diagnosis
  —Prognosis—Treatment—Comparative effects of mercury and
  iodine—Local  treatment—Abscesses over  bone  not to be laid
  freely open...........224—233 
xvi
CONTENTS.
                            CHAPTER XXX.
    ON SYPHILITIC DISEASES OF THE LUNGS—SYPHILITIC CACHEXIA—SYPHILITIC
                               CHLOROSIS.
                                                                    PAGE
 Nature of the wasting from a syphilitic taint—Not a true tuberculo-
   sis—Close resemblance between syphilitic ulceration of the wind-
   pipe  and laryngeal  phthisis—Illustrative  case—Rarity  of  the
   syphilitic tubercle in the lungs.......234—236


                            CHAPTER XXXI.
    ON THE TREATMENT OF SYPHILIS IN PREGNANT WOMEN, NURSES, AND INFANTS.
 Modes in which the ovum, foetus in  utero,  or infant becomes dis-
   eased—Cullerier's diagnosis of symptoms in  nurses and  infants
   —Illustrative case—Primary diseases in the infant rare—What
   diseases  are really primary—Symptoms  of infantile  syphilis—
   Period at which  such  symptoms commonly first appear—Treat-
   ment of pregnant women—Of the  parents of children born dis-
   eased—Of the infant   .........237—245


                           CHAPTER  XXXII.
   ON THE EMPLOYMENT OF  PARTICULAR REMEDIES IN THE TREATMENT OF CONSTITU-
                             TIONAL SYPHILIS.
The mercurial vapour-bath.........246
The chloride of mercury..........252
The bichloride of mercury.........252
The iodide  of mercury..........  253
The biniodide Of mercury.........254
The bicyanide of mercury.........254
The iodide  of potassium..........255
The iodide of sodium..........258
The iodide of iron...........258
Sudorifics, vegetable decoctions, and  infusions.....259
Opium   .             ..........260


                          CHAPTER XXXIIL
CLINICAL OBSERVATIONS ON THE TREATMENT OF  SECONDARY CONSTITUTIONAL AND CON-
    FIRMED  SYPHILIS, BY THE MERCURIAL VAPOUR-BATH, AND OTHER REMEDIES.
Cases from No. 29 to No. 65........262__304
General Index..........305.__3 j j
Index to the Cases.........313__^i& 
                       THE

         MODERN  TREATMENT

                        or

SYPHILITIC   DISEASES.
      PART I.

PRIMARY SYPHILIS.
                       CHAPTER  I.
     ON THE SIMPLE OR NON-MERCURIAL TREATMENT OF SYPHILIS.
   The modern history of Syphilis, both as regards its pathology
 and therapeutics, dates from the time of John Hunter, whose trea-
 tise on the venereal disease appeared  in 1786.  The doctrines of
 that surgeon have influenced surgical opinions and  practice even
 to the present day.  Hunter regarded syphilis and  gonorrhoea as
 varieties of the same disease, and, looking upon  mercurial inunc-
 tion as the grand panacea for  both, submitted both to the same
 treatment.  This was opposed in his  own day by Benjamin Bell,
 of Edinburgh; but so powerful for good or evil are the doctrines
 of a great man, that even  up to  the period of Sir A. Cooper's
 appointment to Guy's Hospital, patients suffering from gonorrhoea
 were compelled to rub in so many drachms of  mercurial ointment
 till a profuse salivation was  induced.   Even the late Professor of
 Surgery in the University of Edinburgh1 charges a father as being
 unnatural, who, having a son suffering from syphilis,  would submit
 him to any treatment except a mercurial one.2
  1 Sir C. Bell; see his "Institutes  of Surgery."
  2 " Les extremes se touchent," says the French proverb.  The present professors
in the University of Edinburgh now entirely repudiate mercury in the treatment of
all forms of syphilis, both primary and secondary. We apprehend this doctrine to be
      2 
18
PRIMARY  SYPHILIS.
  Hunter  proved  the  existence of a  specific  "morbid  animal
poison," or " virus," by inoculation, which doctrine, revived in the
present day  by M. Ricord, has  added little to what  Hunter had
already taught on this subject.  When the physiological school of
medicine and surgery arose in France, its founders and partisans,
reviving the  idea of Bru (Methode nouvelle de traite les Maladies
veneriennes,  Paris, 1789,) denied the existence of a special poison,
or virus, altogether, attributing the phenomena, or pathological
symptoms,  called  "syphilitic"  to certain modified conditions of
ordinary irritation. Richard des Brus (De  la  non-existence du
Virus venerienne, Paris, 1826,) and the learned M. Jourdain (Traite
complet des  Maladies veneriennes,) may be  named as  the most
strenuous supporters of physiological doctrines so far as they re-
late to the  pathology of syphilis.
  An eclectic or mixed doctrine was taught in  this country first
by the late Mr. Carmichael, of Dublin, in which it was shown that
many primary  sexual ulcers were due to the  action of a specific
virus, and were best combated by specific remedies: whilst, on the
other hand, a great number of these  ulcers were due to the ordi-
nary forms of irritation,  and required no specific treatment for
their cure.
  In 1813  Mr. Carmichael first  drew the attention of the profes-
sion in this country to the treatment of  venereal diseases without
mercury, limiting the employment of this medicine to certain forms
of primary and constitutional infection.  Mr. Carmichael incul-
cated the  employment of mercury "in  alterative doses" in cases
of the "simple  primary  ulcer  of the  papular  venereal disease
which  did not yield to  rest, the antiphlogistic treatment, and
astringent washes, and to produce its full effects in the true Hunte-
rian chancre, with hardened edge and base."  In the constitutional
forms of disease this surgeon had recourse to mercury in alterative
doses, " when the papular  and pustular eruptions became scaly, and
obviously on the decline, and had not yielded to sarsaparilla, anti-
monials, and  the  hydriodate of  potass,"  to produce its full effects
in iritis, in nodes when iodine had failed, and for the scaly erup-
tion, the lepra or psoriasis which attends it, and the deep exca-
vated ulcer of the tonsils.
as pernicious  as  the one previously inculcated by the late Professor of Surgery. Sy-
philis is modified and complicated in a variety of ways by the age, habits, and con-
stitution of the  patient; and  that treatment  can only be rational, successful and
safe, which is eclectic, and founded upon the actual nature and peculiarities of each
individual case. 
SIMPLE TREATMENT.
19
  It will be perceived that this  practice is materially different
From that employed on many parts of the continent, in Paris, Ham-
burgh, Vienna, Sweden, and other places, where many surgeons
treat venereal diseases, in all forms, without the exhibition of any
mercurial preparation.
  Various plans of treating syphilis without mercury have been
practised  by surgeons in  all parts of the world  prior to the  time
of Broussais,  although that treatment, which is denominated  at
the present day " simple," dates its origin more immediately from
the doctrines of J;hat pathologist   Broussais, considering syphilis
as a mere irritation without any specific character, promulgated in
1815 the following opinions on its nature and treatment:1
  " That syphilis is an irritation affecting the exterior of the body.
That it is at first a local disease, but  becomes subsequently con-
stitutional; that, to prevent the latter, the local disease must  be
treated by antiphlogistics, more particularly by frequent  and full
local blood-letting.
   " That confirmed op constitutional syphilis may be cured by ab-
stinence and  an antiphlogistic treatment; but this method being
tedious, mercury and  sudorifics  are generally  preferred.  That
mercury and sudorifics cure syphilis by producing revulsion  upon
the  exhalant capillaries:" hence, by Desruelles2 and others, this
is termed the " revulsive treatment."
   " That the remedies termed antisyphilitic should be administered
internally with caution, otherwise they commonly produce gastro-
enteric affections, which exasperate the primitive disease; the  re-
vulsive action of the remedies  is thus  prevented, irritation is  set
up in the viscera, which terminates ultimately in their disorganiza-
tion.                                                    ,
   " When the remedies termed antisyphilitic have produced gastro-
enteric irritation or inflammation,  and the syphilis is not cured,
the latter only amends with the affection of the stomach and bowels,
and a  long perseverance in a strict  antiphlogistic regimen.  If
the  abdominal viscera are disorganized  or  the patient too much
weakened, the cure is impossible.
   " Mercurial preparations applied topically to external syphilitic
irritations or sores, exasperate them always when they are intense,
.irritable  or inflamed.  They cure them  only when they are  indo-
lent, by opposing irritation to  irritation.  This fact is also appli-
cable to all visceral inflammations, <fec.  •
1 Examen des Doctrines M£dicales.
a Traite" des Maladies vene"riennes; Paris, 1836. 
20
PRIMARY  SYPHILIS.
   "Scrofulous subjects are more difficult to cure of syphilis  than
others.   Those  predisposed to  visceral irritations should,  when
suffering from venereal affections, be treated on the antiphlogistic
plan, both externally and  internally.   If  treated  internally by
mercurials, the viscera are excited, and sometimes the  syphilis it-
self is not cured."
   Such  are the principles  laid down by Broussais, for although
the non-mercurial treatment of  syphilis had been occasionally re-
sorted to, it was left to Broussais to lay down the simple treatment
as a system.   In the aphorisms of this pathologist many opinions
are promulgated in reference to syphilis, which are contradicted by
all ancient and modern experience, and  even by the most candid
of the followers of the physiologic school.   We do not consider
syphilis a mere irritation, independent  of any specific character,
as the researches of Ricord and others amongst the moderns suffi-
ciently prove.  It is a specific  disease, inasmuch  as many of its
forms may be propagated by inoculation, and thus diseases of a
precisely similar character produced.1  It is a disease of irritation,
inasmuch as all  venereal  sores are accompanied by a greater or
less  degree  of  inflammation; the intensity of this inflammation,
and  consequently the  violence of the  disease, depending  on  the
constitution of the patient, the circumstances in which he is placed,
his habits of living, and the local treatment of the syphilitic sore.
   The simple or rational  treatment is directed towards the remo-
val of all the local and constitutional irritation which accompanies
a venereal sore, by which the sore itself in many instances heals,
and  the disease is cured.   Where it becomes necessary to employ
mercury, it will invariably be found  advantageous  to  administer
the remedy in accordance with the principles of the simple treat-
ment.   This proposition is illustrated  by the practice  of the late
Dr. Wallace, of  Dublin, who states that the  most  appalling forms
of syphilis which he has met with have  resulted from the injudi-
cious application of  mercurial preparations to venereal sores in a
state of irritation or inflammation.
   In all venereal affections, whether primitive or  secondary,  the
diet should be light  and unstimulating, and  directly proportionate
to the degree of irritation  accompanying the disease, to the age
and idiosyncrasy of  the patient.  It is difficult (says M. Cullerier)
to conceive why the regulation  of d'iet, so  important* in all other
diseases, whether acute or chronic, should have  been totally neo*-
      ? See Ricord; Traite pratique des Maladies v6neriennes; Paris, 1888. 
SIMPLE TREATMENT.
21
lected in the management of syphilis.   The  patient  should  be
placed upon the lowest possible diet when the local venereal affec-
tion is accompanied by much inflammation or irritability, when the
affections are numerous in the same individual, if the disease  be
constitutional, the principal viscera in a state of excitement or irri-
tability, and the subject young and vigorous.  This regimen should
be still more closely adhered to if the affection occur in spring or
autumn, and is yet more strongly indicated if the patient be sub-
jected to a mercurial course.1  Desruelles recommends a milk diet
if the patient be weak and the viscera unsound.2
   On this point no fixed rules can be laid down; they must be dic-
tated by the circumstances of the case, and call for the exercise of
much judgment on the part of the practitioner.  It may be easily
conceived that the severity of the regimen must vary according to
the constitution of  the patient we  have to treat.   Some  subjects
are soon weakened or rendered irritable by abstinence, or quickly
placed in conditions favourable to the action of remedies;  others,
again, are not so readily brought into such states;  and in some in-
stances it becomes necessary to resort to general blood-letting and
the warm bath.3   It constantly happens that primary ulcers which

  1 See Desruelles on this subject, op. cit., p. 249.
  a In  Sweden and Denmark, venereal diseases  are treated systematically by diet
alone, and to this plan the name "cura famis" has been given.  It consists in sub-
mitting the patient to a very severe regimen, and the administration of the extracts
of bark and conium as medicines.  The regimen of the patient during the first six
weeks consists of five ounces of roast meat without gravy or condiment of any kind,
and six ounces of white bread soaked in water; this quantity is divided into two or
three portions, but it is the whole quantity allowed for one day's consumption.  The
extract of conium is given, in doses of four or six grains night and morning.  At the
end of  six weeks the patient resumes his ordinary diet.  All kinds of venereal dis-
eases may be treated on this plan, whether recent or inveterate;  but it is particu-
larly indicated where mercury has been used without success, or where syphilis
exists in a gouty or scrofulous constitution.  A decoction of the root of the "smilax
china" is given for drink to the extent of two pints in the day.   (Expose" de la M6-
thode pour guerir les Maladies veneriennes d6g6n6re"es, par Osbeck; Stockholm, 1811.)
  The commission appointed to examine into the merits of this plan of treatment,
decided that the cure was due to the regimen alone, and the medical treatment had
little or no effect.   The Swedish physicians restrict the "cura famis" to cases of
constitutional,  inveterate, or protracted syphilis.  In primary syphilis it is consi-
dered injurious, and is supposed to favour  the development of constitutional  dis-
ease  by rendering absorption  more active.—For a further account of this mode of
treatment, see  Bibliotheque M6dicale, tomes 60 et 61.—Journal de Hufeland, Juin,
1817, " Quelques notices sur les Institutions Medicales de Stockholm, et  sur le traite-
ment par la Faim, usite dans les hopitaux de cette ville."—Gibert; Manuel des Ma-
ladies veneriennes; Paris, 1837.
  3 Lucas Championniere; La The"rapeutique de la Syphilis, p.  115. 
22
PRIMARY SYPHILIS.
resist all modes of treatment when the  patient pursues  his ordi-
nary occupation, and lives in his usual way, heal rapidly  when the
patient is confined to bed and lives low.  I have verified  this hun-
dreds of times,  both in hospital and private practice.  I introduce
two cases by way of illustration.

                            Case I.
Secondary venereal ulceration of the throat of many months' standing; failure of
  the ordinary remedies whilst the patient used her ordinary diet; rapid cure by
  the same remedies and abstinence.
  A healthy-looking female, set. 26, was sent to me from the country
for my opinion respecting her throat, which had been the seat of
venereal ulceration for some time past, and for which she had taken
mercury under  various forms without benefit.   During this treat-
ment  she had  followed her  usual occupations and  lived in  her
usual  way.   There were three deep ulcers  on the soft palate, and
one on the  left  tonsil; the remaining portion of the throat being
generally of  a  vividly red colour.
  I advised her to leave off  animal food, stimulants of all kinds,
and take as little food, and that only in the shape of tea  or gruel,
as she could be comfortable under.  She was ordered the third of
a grain of  tartrate of antimony three times a day, and mercurial
frictions to the  axillae.  All the ulcers had healed in a fortnight.
  I detail  a second case in illustration, where a totally opposite
effect was produced  in a protracted case by abstinence  and low
diet, and this is by no means  uncommon.

                           Case  II.
  A gentleman, get. 46, in the habit of living  well, contracted a
primary  sore, which was  succeeded by  a well-marked  attack of
syphilitic lepra, which affected the hands, the face, the abdomen,
and other  parts; for this secondary disease he placed himself
under my care,  and was treated by the mercurial vapour bath; the
scaly  eruption  had disappeared in about three weeks;  two livid
blotches, however, remained, one on the face and one behind the
ear, which ran on into deep, dirty ulcers, affecting the whole depth
of the skin:  these not amending, I recommended abstinence from
all specific treatment for a time, change of air, and  attention to
the general health.   As the weather was fine, the patient went to
the coast, where he consulted a gentleman, who recommended the
use of Zittman's decoction, a vapour bath daily, and  a  very low
diet.  In six days the sores  had spread frightfully; the  patient
was so  reduced that he could not stand, and  a copper-coloured 
SIMPLE  TREATMENT.
23
mottling broke out over  the whole body.   A second practitioner
was now consulted, who advised a full diet, three or four glasses of
port wine daily, and  small doses of blue pill with the hydriodate
of potass: under this treatment the sores healed, and the patient
recovered his health; some small scaly blotches still remained on
his return to me, which disappeared under the use of the compound
decoction of sarsaparilla, small doses of the bichloride of mercury,
and the mercurial vapour bath.
  Age, previous habits of living, and constitution, most materially
modify the treatment both of primary and  constitutional syphilis,
especially in relation to diet and general management.
  In  all local and constitutional venereal ^flections, our first duty
should be to examine the general condition of the system of the
patient, to ascertain the state of the viscera of the chest and ab-
domen, and to place him upon such a regimen as may be most like-
ly to  diminish the irritability of the system generally, or of any
one organ in particular.   The  bowels  shouH be kept free by the
exhibition of mild, unirritating purgatives, suited to the gastric
constitution of the patient.
  General bleeding  may be  employed  as a preparatory measure,
when the circulating medium of the patient is too active, or the
inflammation accompanying the local  disease acute, and  the pa-
tient  young and plethoric.
  The simple treatment attaches much importance to the position
of the patient, in the cure of venereal affections;  hence, when-
ever it is practicable, the patient should be confined to bed.   This
has the advantage of  keeping the skin warm and promoting per-
spiration, points of great importance, whilst the  recumbent  posi-
tion favours the return of blood upwards through the pelvis, and
tends to  mitigate any inflammatory action or tendency,  'this po-
sition also renders the application  of  dressings much easier, and
places the patient in a more advantageous condition for the action
of remedies.  In buboes, posthitis, acute or subacute gonorrhoea,
ulcers on the genitals, vegetations about the anus, affections of the
skin, &c, the* recumbent position in bed, if not indispensable,  most
materially facilitates the cure.
  The warm bath is  a modifying  agent of great  utility.  In a
great variety of venereal  affections the  patient may use it  daily
with advantage.  The hip-bath, in many cases,  from the situation
of the venereal affection, may supersede the necessity of immersing
the whole body.  The patient may be  directed to remain in the 
24
PRIMARY SYPHILIS.
 bath an hour, or two, or more, according to circumstances.  Baths
 medicated with gelatin, starch, bran, or the decoctions of  poppy,
 henbane, or  belladonna,  may  be employed.   General  and local
 bleeding, low diet, aperients, the warm bath, with  repose  in  the
 recumbent position, constitute  the  general simple  treatment of
 syphilis; and so efficacious are these means in mitigating the irri-
 tations accompanying primitive or secondary syphilitic  affections,
 that, of themselves, they frequently work a cure.  Where  a mer-
 curial, or other specific treatment is adopted, the simple general
 treatment, pursued at the same time, will be found most materially
 to assist it, whilst by keeping the constitution in a state free from
 irritability, it prevents the accidents to which a mercurial  course
 frequently gives rise.
   As a good example of the mode in which  the simple  treatment
 may be employed, we may refer to the  practice adopted  by Dr.
 Roe, of the  39th regiment, as  recorded in  Dr. Graves' 'Clinical
 Medicine:' "The patients on their admission were purged with
 Epsom salts  and tartar  emetic, and were ordered to apply a piece
 of lint wet with a solution of  the sulphate of copper to  the sores,
 and to renew the application every third hour, using a wet linen
 roller to keep the parts clean, and retain the dressings.   Milk diet,
 aperients every third day, the parts frequently bathed  with cold
 water, particularly if pains existed in the groin.   The chancres
 were occasionally .touched with nitrate of silver, or sprinkled with
 red precipitate, to expedite the cure.   No mercury, except as an
 aperient.  Perfect rest in bed."
   We shall now indicate some general rules for the surgical treat-
 ment of syphilitic affections, considering the particular  treatment
 with each separate form of disease.  The best antisyphilitic is fre-
 quently a dressing  methodically made, it being in  vain that we
 attend to the constitutional treatment of our patient, at the same
 time irritating or neglecting the local disease.
,  Syphilitic sores should be daily cleansed, by a soft sponge  and
 tepid water, from the discharges which their surfaces secrete;  this
 should be done without creating any irritation or pain, and care
 should be taken not fro disturb any parts undergoing a  process of
 cicatrization.  Syphilitic  ulcers, perhaps, more  than   any other
 kind, are liable from slight causes to become irritable, and  assume
 a phagedenic character.  The dressings to these ulcers  should be
 of the simplest kind; mild astringent and anodyne solutions gene-
 rally succeed better than the various  kinds of  ointments, particu- 
SIMPLE TREATMENT.                  25
larly those which contain mercury.  The testimony of all modern
authors is decisive upon this point.  Strong aqueous solutions of
opium, weak solutions of nitrate of silver, the sulphate of copper,
port  wine, and water, or the black or yellow washes made very
weak, are some of the most suitable applications to primary syphi-
litic  sores in their  early  stages.   These generally agree better,
are more convenient, and cleaner than ointments; should the latter
be preferred, the Unguentum Zinci, or the Cerat Plumbi Acetatis
with  or  without opium, will be  found proper.  Sometimes  cold
water, or soft dry charpie, or lint, agrees better than anything else.
When a  primary sore becomes painful under any local application,
when its secretion is  increased, when it inflames, or its edges get
red and  hard, or the  ulceration spreads in depth or  extent, the
local application does not agree, and must be changed.
   In the treatment of almost every form of primary syphilis, more
particularly that of the ulcerated kind, local bleeding by means  of
leeches should be  adopted with extreme  caution.  If leeches are
applied in  the vicinity of an inflamed chancre, the  bites will very
probably become inoculated with the virus, and fresh chancres be
consequently produced.   If, again, as some writers recommend,
leeches are  applied in the centre of a venereal sore, with a view
of diminishing the inflammation which surrounds  it,  the tissues
become poisoned to  the extent in which  they have been divided
by the bite of the  leech, and hence an extension  of the ulcer  in
depth will take place.  Even  in incipient  bubo, swelled testicle,
and other of the consecutive symptoms of primary  syphilis, an ex-
tensive experience has taught us that local  bleeding is not  es-
sentially attended  with very^ marked benefit.  We  have other
plans of  treatment to recommend, less tedious and more certainly
successful.
   In  inflammation of the testicle, and of the glands of the groin,
if leeches are  employed they are more efficacious placed directly
upon  the most painful part of the tumour, than in the course  of
the spermatic vessels, or around its base.  M. Gama, chief surgeon
to the military hospital of Val  de Grace, observing the compara-
tively trifling effect of local  bleeding on buboes, &c, as it is gene-
rally employed, practises with more success what he terms " saignee
permanente."  Instead of applying a large number of leeches  at
once,  as twelve, fifteen, or more, he uses four or six, and when the
bleeding begins to diminish, reapplies the same  number, so as  to
keep up a constant flow of blood from the part for  many hours.
   Irritation is frequently kept up by the mere contact of two in- 
26                  PRIMARY SYPHILIS.

flamed surfaces, notwithstanding an appropriate treatment, in all
other respects,  may  be methodically  practised;  hence,  certain
forms of superficial primary syphilis, or of balanitis,1 and posthi-
tis,2 are kept up by the contact of the glans penis and prepuce, and
some  gleets protracted from the contact of the two sides of the«
urethra.   Fricke, of Hamburg, first  established this fact, which
has been verified in the practice of  Desruelles and Ricord; the
latter has frequently succeeded in curing obstinate gleets by intro-
ducing a small portion of lint into the  urethra, dry, or soaked  in
a mild astringent solution.   The prepuce and  glans, when either
is the seat of irritation or ulceration, should always be separated
by the introduction of fine linen, or lint.   The continued  contact
of the glans and prepuce, when inflamed or ulcerated, frequently
occasions their total or partial adherence.
  Parts affected with syphilis which are deeply seated, or covered
by folds of integuments or mucous membrane, should be  daily
cleansed by tepid anodyne or  astringent injections, according  to
the character of the  accompanying  irritation.  These injections
should be practised quietly, without force, and without creating pain.
  Abscesses should be opened early, more particularly if the pre-
sence of matter occasions much pain, or take place under fasciae  or
tendinous expansions, where the pus cannot readily make  its way
to the surface.   Long and deep sinuses  should be laid freely open,
or if  it be practicable, a counter-opening may be made.
  All parts  in a state of natural or acquired strangulation which
offer  impediments  to the cure of syphilitic diseases should  be
quickly relieved; this becomes  necessary in natural or acquired
phymosis or paraphymosis.   The circumstances which contra-indi-
cate this practice will be mentioned  under the article on the par-
ticular diseases  themselves.
  The non-mercurial, simple, or physiological treatment of syphi-
lis, then, consists in the employment of the means already passed
in review, both  local and constitutional,  without having recourse
to mercury  as a specific therapeutic  agent  in  their cure, and this
may be adopted both in the primary and secondary forms of dis-
ease.  It will be found, however, that  the primary are very much
more easily cured than the  secondary  upon such a plan.   It can-
not  be concealed, that the non-mercurial treatment does not  al-

  1 Balanitis, BaKavog, glans; inflammation of the glans penis.
  2 Posthitis, from mo-rtj, preputium, inflammation of the prepuce; the term bala-
no-posthitis, where both glans and prepuce are inflamed, is employed by some mo-
dern writers on syphilis. 
SIMPLE TREATMENT.
27
   ways succeed in the cure of primary syphilis; and that, in a great
   number of cases, the cures are  more apparent than real, the sores
   breaking out again when the patients return to  their  customary
   diet and occupations.  Matters go on very well whilst a patient is
m  'limited to a rigid diet, and  confined  to  bed, and watched in  the
   wards of a hospital, but in  private practice  this cannot be done;
   and hence  it has been  found  by military surgeons, that whilst
   they could  cure the privates, they could not cure the  officers on
   the non-mercurial plan.   In the French memoirs of military sur-
   gery,1 the medical officers of the military hospital  of Toulon state
   that,  although the non-mercurial plan is useful in  allaying the ir-
   ritation, or inflammatory symptoms which accompany primary ve-
   nereal sores, yet they  were compelled to  resort to  mercury to ob-
   tain radical cures.  Fifty-two surgeons  met at Nantes,  in  July,
   1835, to discuss this question: they had five discussions; two only,
   one of whom was M. Devergie, declared  themselves  in favour of
   the physiological, or non-mercurial treatment of syphilis.2
      As a general rule or principle, I never employ mercury,except
   as an aperient, in the ordinary forms or earlier stages of primary
   venereal  sores,  except such sores have been tested  by inoculation,
   and yielded a characteristic pustule.  The immediate local or spe-
   cific effect of the syphilitic virus produces a degree of irritation or
   inflammation on the parts to which it  is  applied, during  the  con-
   tinuance  of  which mercury is, to say the least, injurious, except as
   an aperient;  and it is  not till rest, low diet, mild opiate or astrin-
   gent  washes, and  the  other remedies just noticed, have failed in
   producing a cure, that  mercury is to be thought of as a specific
   agent.  When, however, all these have failed, and the case has as-
   sumed a perfectly chronic  character, mercury may be used with
   every prospect  of a beneficial result,3 and this is certainly the re-
   sult of modern experience on this subject.
     ' Recueil de Me"moires de M^decine et Chirurgie Militaires, torn. xxxv.
     3 Proces verbaux des stances tenues par les Medecins de Nantes, pour discuter la
   valeur des doctrines nouvelles relativement a la nature et au traitement de la Sy-
   philis; Nantes, 1835.
     3 Desruelles, of Val-de-Grace, concluded from observations made on 8810 patients,
   that the non-mercurial treatment must be considered as the base of all rational prac-
   tice ; "but," says he, " should the ulcers continue without disposition to heal for twen-
   ty or thirty days, mercury should be employed to effect a cure."—The same doctrines
   are taught by Dr. Egan, of Dublin.  (Syphilitic Diseases, their Pathology, Diagno-
   sis, and Treatment, &c, &c.; London, 1853, pp. 330-331.), And this is the result
   of my own experience, drawn from the personal treatment and examination of more
   than 25,000 patients, in hospital and private practice, during the last twenty years,
   many of them tabulated and noted according to the plan alluded to in the Preface. 
28
PRIMARY  SYPHILIS.
                          CHAPTER II.

       OF THE MERCURIAL TREATMENT OF SYPHILITIC DISEASES.

   In this chapter I shall point out the circumstance which modern
experience has indicated for the use of mercury; for although this
remedy cannot be considered in any measure as a specific against
syphilis in  any of its forms, still there are numerous cases in which
it is the most  powerful and  certain therapeutic agent we can op-
pose to them.
   Why is mercury to  be employed in the treatment of  syphilis?
When is it to be  employed?  In what manner is it to be employed?
What are the states  of the constitution and of the sore which are
to guide us in pursuing its use or giving it up?  And when is it to
be discontinued?  These are the practical questions which suggest
themselves to  us in reference to the use of mercury in  venereal
diseases, and to them we shall give the answers that modern ex-
perience has sanctioned.
   Mercury is employed with the intention of healing  a syphilitic
sore, and to diminish the chance of secondary symptoms.1  When

  ' Wallace; on the Venereal Disease and its Varieties, p. 100;  Lond.,  1838.
  This  statement requires some  comment.  That mercury, however administered,
will not infallibly prevent secondary symptoms, is a fact as certain, as that secon-
dary symptoms do occur.  One reason why mercury is not more  successful  under
this point of view, is owing  to the manner in which it is given, and the  irregulari-
ties of the patient during its exhibition.  That mercury should fulfil its intentions,
it is necessary that it should be employed properly and fully, or  not at all.  Mr.
Judd's  experiments show that dabbling with mercury increases the number of se-
condary diseases, whilst properly conducted courses have a different effect, (On Ure-
thritis and Syphilis, p. 537 ;) and that its use should be limited to that  description
of sore which is really syphilitic, i. e., that it either presents a well-marked indura-
tion, or has yielded a characteristic pustule when tested.  This being  settled, the
mode of its administration should be considered, and the patient should be subjected
to those rules of diet and regimen, which have already been laid down in the chap-
ter on  "Non-mercurial Treatment."  It is owing to a neglect  of these precautions
that secondary diseases so frequently follow mercurial treatment, which under other
circumstances would not happen.  The particular modes of its employment will be
considered further on. 
MERCURIAL TREATMENT.
29
  (says Cullerier) the local applications before mentioned are insuffi-
  cient to produce the  cicatrization of a chancre, the  patient must
  be placed upon a general  mercurial treatment.1   The rapidity of
  the complete cure of several varieties of venereal sores  is enor-
  mously in favour of the mercurial treatment, whilst the number of
-  secondary affections is, by it, much diminished.
     There are several circumstances which particularly indicate the
  presence of mercury in primary syphilis.  1.  When a sore remains
  long open, and shows no disposition to heal under the non-mercu-
  rial plan detailed in the last chapter.   2. When  secondary symp-
  toms  appear  before  the  primary disease is cured.   3.  In  well-
  marked indurated chancre, more especially if this have been tested
  by inoculation.2   4. In all  primary sores which  have  yielded  a
  characteristic pustule  by inoculation;  the indications for the em-
  ployment of mercury in the two  last-mentioned classes of  cases is
  still more pressing, if the primary sores be accompanied  by bubo.3
  5.  In certain cases of rapidly spreading ulceration, hereafter to be
  described.
     Mercury is not  to be  used during a state of fever or local in-
  flammation which is present during the first days of venereal ulcers,
  nor till our patient is  prepared for it by appropriate diet and medi-
  cines.  When the fever and local inflammation or irritation which
  commonly attend primary venereal  sores are removed, when  the
  process of  ulceration has stopped, and the sore remains indolent

     1 Recherches pratiques sur la The"rapeutique de la Syphilis, ouvrage fonde sur les
  observations recueilles  dans le service, et sous les yeux de M.  Cullerier, par Lucas
  Championniere;  Paris, 1836.
     ■ The term  induration, as limited to a primary sore, is to be understood to mean
  a cartilaginous hardness of a whitish colour which immediately surrounds the sore,
  on the top of which the ulcer is sometimes seated, or in which it is dug out, the
  redness or inflammation accompanying the one  is generally on the outside of this
  white  hardness, which  is movable under the skin; this appearance of induration
  sometimes does not come on at first, but makes its appearance  during the progress
  of a sore, and in other instances the induration  appears on the site of the cicatrix
  after the sore has healed, but under which circumstances  it is prone  to ulcerate
  again.  Specific induration must not be confounded with the  swelling, oedema, or
  inflammation which accompany other ulcers of the penis, nor again with  a thickened
  condition of the edges of a sore, which is frequently produced by improper local
  treatment, or appears when simple ulcers become indolent.
    ' "In such cases," says M. Ricord, "six months never elapse without secondary
  symptoms manifesting themselves, unless a specific treatment be employed."  It is
  also the experience of M. Puche, who has verified its truth in hundreds of instances,
  without an exceptional case.  "This is a universal  law which  there is no means of
  eluding, but by mercurial treatment."  (See Ricord's Letters, by Stapleton, p. 51.) 
30
PRIMARY SYPHILIS.
under the use of topical applications; above all, when its  edges
are elevated and hard, mercury may be employed with the full ex-
pectation of realizing its most beneficial results.
  When a certain degree of induration accompanies a chancre, or
persists after its apparent cure, recourse may be had to mercury,
and, " as the  mineral  is frequently injurious in some other  forms
of syphilis, so it is of use here."  Mercury may be employed  in
the absence of fever  and local  inflammation, when the sore has
become indolent, and puts on no  disposition to heal under ordinary
local dressings.   Dr. Wallace resorted to mercury, in most cases
of primary venereal sores, when the process of ulceration has been
arrested by the nitrate of silver, or other caustics, when the sore
had become indolent,  or not assumed  a disposition to heal.  This
author, recognising the  grand principles above detailed, that we
are not to employ mercury in the earlier stages of chancre, whilst
the constitution and sore are irritable and are still suffering from
the more immediate  effects of the venereal poison, says "great
mischief frequently results from the topical employment of mercury,
as well as other stimulants, during the  stage of ulceration or de-
struction of  primary  syphilis,  by producing  morbid  excitement
followed sometimes by indolent and sometimes by irritable action,
with their concomitants and consequences.   The  most appalling
forms of this  disease, which ever came under my observation, were
caused  by the injudicious application of the red  precipitate, or
other powerfully stimulating dressings, and it has therefore long
been a principle with me strictly to avoid all mercurial and stimu-
lating  dressings during the ulcerating stage of syphilis.  It is also
in general highly improper to administer mercury internally during
this stage; for if used at this period it may, instead of producing a
salutary and  specific influence, increase the inflammation, or excite
a state of irritable or indolent action, after which the  system will
become quite insensible to ordinary doses of this medicine; and if un-
der such circumstances larger doses of mercury be employed, a pe-
culiar  and complex state will most probably result, determined in
its character  by the combined influence of the disease, the remedy,
and the constitution of the patient, a  state in which mercury acts
as a poison, or in other words-not  only aggravates all the  symp-
toms, but perhaps excites a new train of peculiar morbid action."1
   In what manner is mercury to be employed, when indicated  by
1 Op. cit., pp. 109-110. 
MERCURIAL TREATMENT.                31
the before-mentioned conditions?  It may be used in three ways:
by  internal administration,  by friction,  or moist fumigation.  I
have little faith in the internal administration of mercury alone
for the fulfilment of the intentions just stated, and never depend
on it alone, unless combined with the moist mercurial fume. "You
may patch up the disease,',' says Sir B.  Brodie,1 " by giving  the
remedy internally, but it will return over and over again."   The
advantages of administering mercury by the mouth are the facility
with which such  a  plan may be followed, this, however, being
vastly  counterbalanced  by its  disadvantages, which are, the  un-
certainty of its result and  its operation on the patient;  it is more
commonly followed or accompanied by the evil effects of mercury,
and less frequently followed by the cure of the disease  than' the
other methods.  In this country the Hydrargyrum c. Creta, the
Pil. Hyd., or the Chloride of Mercury, are the remedies generally
used.  On the continent the  Bichloride and the Biniodide.3
   The treatment by friction is much more certain than by the in-
ternal administration of mercury.  This method consists in rubbing
in before the  fire each night, till the  proper effect is produced,
from a  scruple to a drachm  of  the  stronger Mercurial Ointment.
These frictions may be made on the inside of  the thighs, in  the
popliteal space, on the soles of the feet, or in the axillse.  Frictions
in the axillae  are  of service  in obstinate  ulcerations  of the throat.
I very frequently employ them with complete success in this situa-
tion.   Cullerier records the histories of  two cases cured by mer-
curial friction in the axilla?,  which had resisted its employment in
other parts.   Sir B. Brodie  (Lectures on Pathology  and  Surgery,
p. 243,) prefers this method, which was that of the late Mr. Pear-
son of the Lock Hospital, to all others; he believes that  surgeons
have gone back  in their treatment of  syphilis.  Mr. Hunt (On
Syphilitic Eruptions with especial reference to the use of  Mercury)
■is of the same opinion.  In reference to the treatment of infantile
syphilis,3 it is clear that frictions are much more  safe  and effica-
cious than treatment by the  mouth.  "Very few of those  children
ultimately recover to whom  mercury has been given  internally;
but I have not seen a single case  in which the  other method of
treatment has failed."4  The frictions must be  continued every
  1 Lectures on Pathology and Surgery, p. 242.
  » See the Chapter "On the Employment of particular Preparations of Mercury,"
for details on these points.
  » See the Chapter on this subject.
  4 Sir B. Brodie; op. cit., p. 245. 
32
PRIMARY SYPHILIS.
night, or every other night till the gums swell, and the secretion of
saliva  is slightly  increased;  the  intervals between  the frictions
must then be lengthened, but  the effect kept up till sometime after
the sore has healed, and its specific induration gone.   We cannot,
with Chelius1 and  others, limit the number of frictions to nine, or
twelve, or  any specific number, they must be "continued  till  the
effects above mentioned are produced.  That mercurial  treatment
by friction or by  the  mouth  should succeed, it  is absolutely es-
sential that the patient should be  confined to a warm room,  and if
possible to bed; exposure during a mercurial course sometimes en-
tirely destroys the effect of the remedy.  It is owing to an obser-
vance of these rules that patients in the hospital get cured, who
are made to observe  them, whilst  private  patients  who neglect
them  or cannot observe  them, are  not so  fortunate.   The diet
during this treatment should be light, nutritious, and unstimulating;
the older and more weakly the patient the better the diet; should
he be young and  plethoric, he should  combine  the  hunger cure
with the frictions.   The treatment by friction is milder, safer, and
more certain than that by the internal administration of mercury;
but it is liable occasionally, though not so frequently, to produce
the evils already alluded to when speaking of the use of that class
of remedies.   In certain cases, frictions of different  preparations
of mercury have been  made on the gums and upon the tongue.   I
have tried  them, but at best with little  success.
  Mercury, when indicated in the treatment of venereal diseases,
may be employed  by way of fumigation, in the manner alluded to
by me in the second edition of this work, and more fully detailed
in a separate publication in 1850.2 There is no doubt but that the
dry method of fumigation, introduced by Lalouette in 1786,3 and
subsequently practised both in  this country and  on the continent,
was exceedingly efficacious in the treatment of a great number of
venereal diseases intractable or incurable under ordinary methods.4

  1 A System of Surgery, by J. F. South.
  a On the Treatment of Secondary Syphilis, &c.; Churchill,  1850.
  ' Nouvelle methode de traiter les Maladies veneriennes, &c.; Paris, 1776,  publiee
par ordre du roi.
  4 "I have reason to speak in the highest terms of the Cinnabar fumigation, which
I have never,found to fail in arresting the rapid ulceration that we often find so for-
midable in the throat  and on the penis; usually  one or two applications are suffi-
cient to change entirely the character of  the sores, and to convert the destructive
state into a process of  healing."  (Mr. Vincent's Surgical Observations, p. 350.)
  "So late as the year 1814, it was the practice in  Stockholm, to heal primary symp- 
MERCURIAL TREATMENT.
33
The old manner of applying it, however, by vaporising the mercury
from a heated piece of iron or hot cinders, was so uncertain that
sometimes no effect was produced, at  others too much.  The plan
which I suggested of vaporising the  mercury from a tin plate by
the heat of a large spirit lamp, and mixing it with a small quantity
of common steam, so that the patient  is exposed to a gradually in-
creasing temperature, divests fumigation of all its antecedent evils;
and I believe when this method is combined with the internal  ad-
ministration of very small doses of this remedy, that this is by far
the least hurtful, and most certain way of employing mercury that
can be adopted.1
  In a great number of  primary diseases I prefer  the treatment
by fumigation, combined with the internal administration of a twen-
tieth of a grain dose of the Bichloride  or Biniodide,  and a milk
diet.  In  indurated  chancre and primary phagedenic sores,  the
treatment does not fail, neither is it attended with accidents, such
as diarrhoea or salivation, once in a hundred times; it is as certain
and  as little hurtful as any treatment can possibly be.
  Between the years 1846 and 1850 I personally treated fifty-eight
cases of indurated chancre in this way; none of the  patients were
confined by the  treatment, though I admit  this would  have been
better could it have been accomplished, but in a great  majority of
syphilitic cases this is impossible; it is therefore our  duty to frame
some treatment  that will be efficacious without such an important
auxiliary.   Diet can be  observed, but rest in bed or confinement
to a warm room cannot with a great mass of private patients. One
case only out of the fifty-eight, up to  the present period, has been
followed  by secondary symptoms, and that in the form of slight
lepra with superficial ulceration of  the throat, which occurred in

toms by most free inunction, and under this system, it was calculated that the num-
ber of cases of secondary affection of the bone was no less than 54 per cent.   In 1814
this treatment was  changed, and a milder method adopted, by fumigations and by
diet;  and the result is stated to  have been so eminently successful, that the College
of Health reported that the cases of diseased  bones were reduced from the large
number mentioned to about 6J per cent.  It is also added, as a consequence, that,
instead of there being six hospitals for the reception of venereal patients, there is
now only one in all Stockholm." (Williams' Elements of Medicine, vol. ii. p. 134,
quoted in "Brit, and For. Medico-Chirurgical Review," No. 18, July,  1851.)
  1 " Mr. Langston Parker's work certainly contains strong evidence in favour of the
merits and the advantages of this method over any other mode of obtaining the the-
rapeutic effects of  mercury in  this disease."   (Edinburgh Medical and Surgical
Journal, No. 193, October, 1852.)
       3 
34
PRIMARY SYPHILIS.
three months after the primary disease.  In five of these cases the
sores were situated at the orifice of the urethra, and in one accom-
panied also  by phymosis, the glans and prepuce were as hard as a
scirrhous mamma; nevertheless the cure was perfect and the health
unimpaired, although the patient was nearly 50 years of age.
  In primary ulcerative (not sloughing) phagedena, I have not as
yet seen one single instance of failure.  Salivation rarely accom-
panies treatment by moist fumigation, and this is prevented by the
profuse  sweating which the process occasions.  If patients use an
ordinary vapour bath whilst taking mercury internally, or employ-
ing it by friction, salivation very rarely takes place.
  During  the employment of mercury, the states of the sore, of the
constitution, of the mouth and breath, are to be carefully watched,
since each of them may assume certain conditions which would ren-
der the  further use of mercury injurious.
  The state of the sore whilst the patient is taking mercury should
be frequently  examined, and topical applications suited to  its con-
dition employed.  At one time it may require anodynes, at another
astringents,  or again slightly stimulating applications may become
necessary.   During the mercurial course, also, the diet should be
mild and  unstimulating, and the condition  of the stomach and
bowels carefully attended to.  Dr. Wallace  recommends the mas-
tication and deglutition of  grains of allspice or pepper during the
day, and covering the abdomen with two or three folds of flannel.
A nightly draught or pill of some preparation of opium with cap-
sicum1 may be employed with advantage, even  during the period
the patient is using mercurial frictions; the former not only prevent
those attacks of pain, griping, and diarrhoea, which sometimes come
on during a mercurial course, and  materially retard the healino-
process, but they contribute directly to  the  therapeutic effects of
the mercury.
  It is from a want of attention to these circumstances that persons
are so frequently placed upon the mercurial plan without beinc
cured.  This arises from their neglecting the modifications of to-
               1 R.  Pulv. opii, gr. j;
                    Pulv. capsici, gr. ij;
                    Conf. aromat. q. s.  ft. Pil.
                Omni nocte  sumend.
                       or,
                R.  Liq. opii sedativ., n^ xx ad xxx;
                    Tinct. capsici, Tn_ xxx ad l ;
                   Aquae cinnamomi, ijj.  M. ft.  Haust. h. s. s. 
MERCURIAL TREATMENT.
35
  pical applications, and not observing the dietetic regimen suited to
  their state.
    The condition of the sore is very frequently an indication of the
  effect  of  mercury upon  the constitution, and  points out clearly
  whether it is agreeing with the system or not.  From this circum-
  stance, we recommend a frequent examination of the local disease
  during the time the patient is using mercury.   " It will be found a
  most  important rule in practice  to omit all mercurial treatment
  whenever there appears an increase of inflammation or sensibility
  to arise in the  local disease during  the employment of mercury;
» for a perseverance in its use, under such circumstances, will almost
  inevitably tend to some  destructive  action, determined  in its cha-
  racter by the constitution of  the patient.   In  such cases we must
  have  recourse  to emollient and anodyne applications, purgatives,
  rest, abstinence, and diaphoretics, witbor without narcotics, and, as
  soon as the morbid actions which have supervened  have been re-
  moved, mercury if necessary may be again resumed, to be suspended
  afresh in  case of a return either of inflammation or irritability."1
     The state of the constitution as well as of the sore demands great
  watchfulness during the administration of mercury for the cure  of
  primary venereal sores.   It is quite certain  that venereal sores
  which have resisted all other modes of treatment daily heal under
  the use of mercury, whilst the remedy produces no sensible effect
  upon the  economy either by causing salivation or  mercurial fever,
  more especially when moist fumigation is used.  We therefore insist
  upon the  principle, that  the greater the degree of excitement or  of
  deviation from the healthy condition of any of the functions of the
  body which mercury produces, the greater is the danger of its action
  being followed by deleterious effects, or of its ceasing to influence
  in  a salutary manner the symptoms of syphilis.
     It  is not  necessary that mercury should produce  salivation  in
  order that its benefits, in curing primary syphilitic ulcers or dimi-
  nishing the chance of secondary symptoms, may be realized.   What,
  then, are  the rules to guide us in these circumstances?  How long
  is our patient  to be submitted to  the use of mercury, and when is
  it to be discontinued?   Is the healing of the sore  without a thick-
  ened condition of the cicatrix our rule for the discontinuance  of
  mercury?  I think not;  the disappearance of a symptom is  not the
  cure of a disease; and, as M. Ricord has very justly observed, " that
   to  continue specific treatment only until the symptoms disappear is
                        1 Wallace; op. cit., p. 119. 
36                  PRIMARY SYPHILIS.

the method by which we may be almost sure of their return."   A
change in the form of mercurial  remedy exhibited is frequently
very efficacious, particularly in syphilitic diseases of the skin, or in
rebellious forms of ulceration.   I have seen the mercurial  fume
bath succeed after a complete treatment by inunction and blue pill
had failed, and  the Bichloride in small doses beneficial, when blue
pill and calomel had been taken without success.  "A gentleman
was  treated by me for a  scaly eruption, which  yielded in three
weeks to  the moist fumigation.   At this period some large red
blotches  appeared  on the  face and abdomen, which  ran into foul
sores.  The vapour had no effect on them; but they yielded quickly
to small  doses of blue pill and the iodide of potass.  These had
hardly healed when a second scaly eruption  made its appearance,
different  in character to the  first, which  spread under the use of
blue pill  and iodide of potass, but  which very quickly disappeared
when the vapour, with one-twentieth of a grain dose of the  Bichlo-
ride was  used.  No return of symptoms since."   The old rule was
to continue the  remedy, after the disappearance of the symptoms,
for as long a period as it had taken to cause the disappearance of
them; this, though not infallible, is certainly not a bad guide  in
practice.   Salivation certainly is  not a test  of the eradication of
disease, and, if it occur suddenly or prematurely, rather gives pro-
mise than the reverse of a secondary attack.  In fact, there is no
certain rule that can be laid down on this  point.   The late Dr.
Colles inculcated that mercury should be continued for a few days
after all  hardness  of the cicatrix  had been removed, and thinks
moderate ptyalism  should be kept  up for a month.  Mr. Judd men-
tions twenty-five to thirty days; M. Ricord  advises a " daily dose
to produce a sensible or physiological effect for six months."  This
is certainly wrong: the constitution becomes habituated to a remedy
persevered in in this manner, and I have occasionally seen a fresh
outbreak occur during a prolonged course of this kind.  As it has
been incontestably proved by the observations of all writers  on
syphilis,  that secondary symptoms will  occur in certain  cases and
constitutions, whatever mode of treatment be adopted for the cure
of the primary sore, it must be clearly evident that it cannot  be
logical practice to  submit a patient, from whom all symptoms have
disappeared, to the influence of a mercurial treatment for a lono-
period of time, to eradicate a disease the existence of which is con-
jectural; whilst on the one hand there are no symptoms to combat
and on the other, if the poison be  latent, we  have no data to prove 
                   MERCURIAL TREATMENT.                 37

that such a treatment will  destroy it.  The rule 1 invariably act
upon is to continue the specific remedy for two or three weeks after
the primary disease has disappeared, with all induration of the ci-
catrix; to advise the  patient when he leaves me to live  regularly,
take a smart aperient from time to time, a vapour bath once or
twice  a week; and to avoid all causes, such as cold,  &c, which are
likely to interfere with the general health, since it has been shown
by Cazenave1 and others that accidental causes affecting the gene-
ral health very frequently determine  an outbreak of syphilis, and
hence in confirmed cases regular attacks occasionally supervene in
spring and autumn.
   The state of the mouthy should be carefully examined  before re-
sorting to a course of mercury;  sometimes a stomatitis may be pre-
sent before the administration of this remedy, and  we might thus
be deceived in its effect, mistaking the inflammation of the mouth,
which was previously in  existence, for one which is the result of
mercury.  It is quite certain that many morbid  conditions of the
mouth and  breath so  closely resemble those produced by mercury
that, without an  examination of the mouth before  resorting to. a
mercurial course, we  might be led into  great error.
   When the breath becomes fetid, and the  gums tender, the mer-
cury must be  discontinued, or very much diminished in quantity.
The patients should  use  slight astringent  gargles, with  mineral
acids,  and lozenges of the chloride of  lime.2
   M. Desruelles, surgeon  to the military hospital of Val de Grace,

  1 Traite" des Syphilides;  Causes des Syphilides, p. 529.—See  also a remarkable
case, and the remarks on it by Sir B. Brodie, (Lectures on Pathology and Surgery,
p. 247,) which fully bear out what I have said  on this subject.
                *  R. Soda? chlorid. solutionis (Beaufoy's;)
                    Tinct.  myrrhae aa ^ss;
                    Aquae, 3jv.            M. ft. garg.

                  R. Aquae destillatae, §vij ;
                    Aluminis et potassae sulph., Qij ;
                     Mellis rosarum, ^j.    M. ft. garg.
  Lozenges of Chloride of Lime.—
                     Calcis chlorid., giv;
                     Sacchar. alb., lb. j ;
                     Amyli, §iv;
                    P. gum. tragacanthae, gij.
                  M. Aquae aurantii quantum sufficit.
  The mass is to be made into lozenges of three  grains each.  Their use principally
in removing the mercurial fetor of the breath. 
38                  PRIMARY SYPHILIS.

having the charge of the venereal department of that establishment,
and a partisan of the simplest or physiological treatment of syphilis
without mercury, entertains the following  opinions as to  its use,
and gives certain rules for its  exhibition.   Certain chancres, says
he, of a phagedenic or Hunterian character with a hard base, which
leave behind them in healing an indurating cicatrix, are more fre-
quently followed by secondary symptoms, when treated  without
mercury, than if this remedy had been given.
  When venereal sores become stationary, or do not heal under
the simple treatment, and the exhibition of mercury is not contra-
indicated by the inflammatory or irritable condition of the sore, or
certain states of the constitution, mercury may be advantageously
used.  Mercury is not to be employed when any of the viscera pre-
sent symptoms of irritation, when the patient applies immediately
after having contracted his disease, or when the sore heals quickly
under the simple treatment.
  Mercury may be given when the local inflammation accompany-
ing a venereal sore has been subdued, and the patient is prepared
for its exhibition by diet and aperients, the sore remaining indolent,
of a bad aspect, and not healing or appearing to be influenced by
the simple treatment.   This  remedy may be also employed if the
sores are  complicated  with  inflammation  or  enlargement of the
glands of the groin, or if any affection of the skin, as papular or
other eruptions, make their appearance during the simple treatment,
and there is reason to believe the constitution affected.
  In many secondary affections, although generally trusting to the
simple  treatment, Desruelles thinks the employment of mercury,
particularly of the iodide, may be of service.   He  merely states
that if secondary symptoms appear in an  individual who  has for
the primary form of the disease been treated fully by mercury, nt
is better  to employ the simple treatment, sudorifics, and attention
to the  general health, than to have recourse again to the  employ-
ment of mercury.  In secondary syphilis, which succeeds to a pri-
mary affection treated without mercury, this remedy is almost al-
ways necessary.   A mild mercurial course in  such instances is ge-
nerally more efficacious than any other. 
INOCULATION.
39
                        CHAPTER III.

 ON INOCULATION, AS APPLIED TO THE DIAGNOSIS AND TREATMENT OF
                       SYPHILITIC DISEASES.

   Both before and since the time of Hunter inoculation has been
 employed for the purpose of testing the character of syphilitic dis-
 eases; and at the present day M. Ricord has deduced from an ex-
 tended series of experiments certain conclusions of great value and
 importance, which he has given  to the world  in  his great work,
 'Traite  pratique des Maladies  veneriennes, ou Recherches cri-
 tiques et experimentales  sur  l'Inoculation, appliquee a l'etude de
 ces maladies."
   M. Ricord establishes, in  the first place, that a chancre, where-
 ever it may be seated, is  produced by  a specific matter which  is
 secreted by a chancre only,  which matter produces a similar con-
 tagion.
   This specific matter is only secreted from the surface of a chan-
 cre during its first stage, that is, during the period of ulceration,
 or when the sore is indolent or stationary.   At these periods only
 does  a chancre secrete a  specifio  matter capable  of producing a
 similar disease by inoculation.   When the sore begins to heal and
 a process of reparation has commenced, it is merely a simple ulcer,
 does not furnish a specific secretion, and is not  capable of propa-
 gation by inoculation.2
   If matter be taken from a chancre during the period of ulcera-
 tion, and introduced under the epidermis by means of a lancet, it
 produces the following effects:  During the first twenty-four hours
 the puncture becomes more or less inflamed; from the  second to
 the third day it  is accompanied with slight tumefaction, and  pre-
 sents the appearance of a small  papula surrounded with a red areola;

  1 Paris, 1838.
  2 It would appear that these views were likewise entertained by Dr. Wallace, who
 divides chancre into two distinct stages or phases, the first one of ulceration, the
 second one of reparation; he particularly insists upon the impropriety and danger of
administering mercury during the first stage, that  of ulceration. 
40
PRIMARY SYPHILIS.
from the third to the fourth day the disease  assumes a vesicular
form, the epidermis being raised  by a  fluid more  or less opake,
presenting at its apex a small  dark point; from the fourth to the
fifth day the contents of the vesicle become purulent, the apex of
the pustule depressed, resembling very much the pustule of small-
pox.  At this period the areola, which had progressively increased,
begins to diminish  or  altogether  disappears,  particularly if the
disease does not increase:  after the fifth day, however, the subja-
cent and surrounding tissues, which hitherto had undergone little
or no modification, or were merely slightly (edematous, become in-
durated by the extravasation of a plastic lymph, which communi-
cates to the touch the resistance and elasticity of cartilage. After
the sixth 'day the contents of the pustule thicken, the pustule itself
shrivels up, and is  covered with crusts.  These enlarge towards
their base, and forming by successive strata, at length assume the
form of a truncated cone with a depressed apex.  If these crusts
are detached,  or  if they  fall  off, we find  under  them an ulcer
with the hard  base  of which we have spoken, extending through
the whole thickness of the skin.   The surface of this ulcer, of a
deep red colour, is foul, covered with a thick adhesive pultaceous
matter, almost like  a false membrane, which cannot be removed
by any attempt to clean the sore.   The edges of the ulceration
at this period appear as though it had been dug out from the sur-
rounding parts by a sharp circular  instrument.   The immediate
vicinity of the sore  is surrounded by a red, dark, or livid margin,
more elevated than  the surrounding parts,
  Such is the regular course which the inoculation of the syphilitic
virus generally runs, when the  inoculation is positive; but do all
sores, which from their aspect  and history we should repute sy-
philitic, invariably yield  a characteristic when inoculated  or run
the course described?   They do  not.  The indurated chancre, I
may say, invariably does this; but other sores undoubtedly syphili-
tic, proved by the secondary diseases to which they have given rise,
do  not very frequently yield any result when tested by inocula-
tion;  and at other times, when the result is positive,  they do not
always run the course indicated; at other times the pustule shrivels
up, and dies off in three or four days, or  again an irregular abscess
forms.  All these effects I have repeatedly verified and shown in
the wards of the Queen's Hospital.  I have never seen any reason
to change the  opinion I gave on this subject in the second edition 
INOCULATION.
41
of this work, and which  I am much gratified to see quoted and
supported by Dr. Egan, of Dublin.1
  Inoculation is only valuable when positive, and I must caution
the young surgeon against assuring his patient, that his primary
disease will not be followed by a constitutional taint, because it has
not yielded a characteristic pustule when inoculated.  That inocu-
lation should succeed it should be^carefully performed.   I always
raise the epidermis with  a new or carefully cleansed lancet, and
introduce the virus on  the tip of a new vaccine point; this should
be done two or three times, if the first puncture does not succeed.
Primary venereal sores of a phagedenic character should never be
inoculated.
  The ulcerations completely destroyed or arrested on  the third,
fourth or fifth day from the application of poison are not liable to
secondary inflammation.   It is not before the fifth day that the in-
duration of chancres commonly commences, and it is the indurated
chancre that is most  frequently followed by secondary symptoms;
this induration seems to indicate that the affection  has  become in
some measure already constitutional; as long as there is no indu-
ration we may suppose the disease to be merely local.
  The varied appearance which primary venereal  sores present
(says M. Ricord) has given rise to arguments against the identity
of the venereal virus, and  has led to the promulgation of the theory
of a plurality of venereal poisons.  Inoculation, however, sets this
matter at rest, for whatever may be the actual character of the sore
from which we take  the pus,  provided  it be taken during the first
stage of chancre, that of ulceration or indolence, we obtain by inocu-
lation when successful  a regular pustule when the matter is intro-
duced beneath the epidermis or epithelium; an ulcer when it is ap-
plied to a denuded surface; and  an abscess when introduced into
the cellular tissue, or into the lymphatic system.
  The various characters of  chancres  or primary venereal sores,
are due to  circumstances  which  are foreign to  the  specific cause
which produced  them;  these are  principally the particular consti-
tution of the patient, his mode of living, the influence of any ante-
cedent or present disease with which he may happen to be affected,
the situation, and not least the local treatment of the sore.  It is
from one or many of these circumstances that we see phagedenic
ulcers in subjects who  have contracted their  disease from others
affected with ulcers of  the simplest character.
      *           ] See  his  work already quoted, p. 27. 
42                  PRIMARY  SYPHILIS.

  The first stage of chancre, i. e. of ulceration or indolence, is the
only one during which the disease is susceptible of propagation by
inoculation; the period of this  stage is not limited, but may ex-
tend over a long period of time, frequently many months.
  The researches of M. Ricord  on the  nature and differential di-
agnosis of buboes are of equal interest with those which we have
detailed on the subject of primary sores.  According to this au-
thor,  buboes are of two kinds,  simply  inflammatory or virulent:
in the  first instance, succeeding to gonorrhoea, balanitis or any
other primitive affection; and in  the second, from the consequences
of the direct absorption of specific matter from a chancre.   To
the pathology of bubo we shall return in the chapter particularly
devoted to its consideration, in this place  merely detailing the
results obtained by inoculation from buboes in a condition of ul-
ceration.
  M. Ricord deduces from his experiments upon buboes in a con-
dition of ulceration the following conclusions: that a virulent
bubo, or one resulting from the absorption of the specific pus  from
a chancre, is a  disease precisely similar to chancre, merely differ-
ing from it in its seat, and the anatomical organization of the parts
affected; that this species of  bubo is the only one capable of pro-
ducing  a pustule by inoculation; that the symptoms hitherto  indi-
cated by authors, with the view of establishing the differential di-
agnosis between a true virulent bubo and one merely inflammatory,
are of little value, inoculation being the only certain and pathog-
nomonic sign.
  It must be evident, and indeed the fact has been admitted by all
observers, that very few buboes can be  inoculated in proportion to
the  number of the primary venereal sores  that are followed by
such a result.   The  late Dr. Wallace, of Dublin, is said to  have
succeeded only three times in many hundred experiments.  Dr.
Egan, also, frequently failed  in producing the  characteristic pus-
tule; the same has happened to myself,- and must have done to all
other surgeons who have tested  buboes  in this way.   Whether we
test the pus that first escapes when a bubo is opened, or that from
the bottom of the abscess " the deeper layer," the result is in many
instances negative, and yet the bubo may be of  a purely syphilitic
character.  This may be very easily explained by  the  fact, that
the virus absorbed  from the chancre by the lymphatics is modified
in its passage through them, and the first lymphatic gland or glands
they enter, by becoming mixed with the ordinary products aad con-
tents of the gland itself. The virus acts as an irritant on the lining 
INOCULATION.
43
membrane of the lymphatics, which causes them to swell and  in-
flame whilst the morbid poison is passing through them.  "On ex-
amining glands which become enlarged from the result of irrita-
tion from a neighbouring ulcer, we find them to be soft, and readily
yield on section, a dirty, turbid fluid.  If we examine this fluid
under a magnifying  power of 250 diameters,  we  find it  to  be
crowded with the cell elements of the gland, some of which are
considerably enlarged. It would appear, that under these circum-
stances, the cell elements  not  only increase in  number, but that
some of the latter assume a power of development which they
never present in a state of health."1  If this condition go  on to
suppuration, the specific irritant must be so mixed up with pus and
the altered secretions of the gland, as to be with difficulty met with
sufficiently pure to produce a characteristic syphilitic pustule when
tested by inoculation; and this is the true explanation why syphi-
litic  buboes are not so frequently inoculable as primary sores;
he^-e, as in primary sores, inoculation is only of value when  posi-
tive.  Let no  man  say a bubo is not syphilitic because it cannot
be inoculated.
  With reference to the test of inoculation  itself, some degree of
difference of opinion exists.  Whenever inflammation  and  suppu-
ration of the cellular tissue, or  lymphatic glands of the groin, is
owing to any other cause  than  the occurrence of chancre, the pus
secreted furnishes no result from inoculation, at whatever periods
and under whatever circumstances the test may be made. Neither
does it follow, of necessity, that buboes succeeding to true chancres
will furnish a specific pus;  and consequently, by inoculation, a cha-
racteristic pustule.  That this  may occur, it is necessary that the
bubo shall not merely be owing to a simple sympathetic inflamma-
tion, but that  actual absorption of the specific matter of the
chancre shall have taken place. When absorption of the matter
from a chancre on the genitals  takes place, it is generally confined
to the superficial glands of the groin; and most  frequently the
syphilitic poison is conveyed to one gland only,  although many of
the glands in the immediate vicinity of  the latter, both superficial
and  deep seated, are inflamed, and  suppurate at the same time, so
that the  matter taken from one gland shall be purely syphilitic,
and  give rise, by inoculation, to  the characteristic  pustule, while

  1 Leucocytbemia, or white-cell-blood, in relation to the Physiology and Pathology
of the Lymphatic Glandular System, by John Hughes Bennett, M. D.; Edinburgh,
1852. 
44                   PRIMARY SYPHILIS.
those in its immediate neighbourhood shall be  affected by simple
phlegmonoid inflammation, the pus from which  shall, when  tested
by inoculation, give a negative  result.1
  It may be very readily conceived that the irritation  produced
by the passage of the syphilitic poison through a lymphatic vessel
and ganglion may excite in the  neighbouring organs an inflamma-
tion which is  not specific, but  merely phlegmonous, and this  ap-
pears to  be  the true nature of the case.  M. Ricord opened a bubo
which had succeeded to a chancre, the  pus from which  produced
no result by inoculation. In the centre of the abscess he discovered
an enlarged lymphatic gland, presenting an evident  fluctuation;
this was  punctured and  tested by  inoculation, the characteristic
pustule of chancre was obtained.
  Discharges  from the urethra are of two kinds, resulting either
from the existence of a true syphilitic  ulcer in some part of  the
passage, or  owing to gonorrhoea properly so called.  Chancres, or
syphilitic ulcers  of the urethra, to the consideration of  which we
shall return in a particular article, are in all respects, except situa-
tion, of the same character as other  primary sores, and give rise
to the same results when the matter is tested by inoculation.
  The matter of gonorrhoea, applied  upon a mucous surface, pro-
duces an inflammation and discharge of  the same character. In no
instance can it produce a true syphilitic sore, although by remain-
ing  in contact with a mucous surface for a certain period of time
it may occasion a greater or less degree of excoriation, but is not
capable of producing a specific ulcer,  as the researches of Ricord,2
Hernandez,3 Dr.  Egan, and myself incontestably prove.
   The diseases which are consecutive  to gonorrhoea, as sympathetic
buboes, &c, do not secrete pus capable of producing a specific ulcer
by inoculation, neither do secondary or constitutional  symptoms
generally succeed to a simple gonorrhoea.4  M. Ricord thinks that
in the rare  cases where secondary symptoms have been said to have
followed a simple  gonorrhoea, that  the  diagnosis of the primitive

  1 See Ricord; op. cit., pp. 142 et suivantes.
  2 M6moires, sur quelques Faits observes a l'Hopital des Ve"n6riens, par P. Ricord.
Memoires de l'Aeade"mie Royale de Medecine, tome 2me.
  ' Essai analytique sur la Nonidentite" du Virus  gonorrhoique et syphilitique par
J. F. Hernandez; Toulon, 1812.
  4 Such is M. Ricord's statement.  Secondary symptoms  of mild character do suc-
ceed to discharges from the urethra, where there is no reason to suspect the exist-
ence of ulceration.  We shall in subsequent pages have to instance some examples
of this. 
INOCULATION.
45
disease has been inexact, that the diseased surfaces have not been
properly examined, and the cases have been concealed chancres of
the urethra, and not gonorrhoea.   It is also  extremely probable
that such were the forms of disease which embarrassed Dr. Wallace,
who says that he had met with some forms of  discharges from the
urethra which were beneficially influenced by mercury, and which
he was unable to cure without its exhibition.
  The pus of gonorrhoea, tested by  inoculation, gives no result: it
may be followed by  inflammation, but never  produces a specific
sore; injected into the urethra, it produces a disease like  that of
which  it is  the .product;  applied externally between the  glands
and prepuce, it occasions inflammation and discharge, balanitis, or
external gonorrhoea;  a similar  effect follows its application upon
other mucous surfaces.
  We would here inquire what is the real position inoculation oc-
cupies in reference to the therapeutics of primary syphilis.  Ino-
culation, pushed to its greatest  extent by M. Ricord, has proved,
beyond a question, the fact which English surgeons had  always
acted upoB, though, we must admit, not upon such good grounds
as they do now, that syphilis is a specific disease, and not the result
of the ordinary forms of irritation.  M. Ricord has proved that
certain sores, when tested  by inoculation, produce a pustule run-
ning through certain stages, and terminating in a  specific ulcer
capable of being propagated, ad infinitum, by  the same means.  It
has, however, only been shown that certain ulcers produce a cha-
racteristic pustule by inoculation, and  therefore  should be those
only which  are truly  specific; yet we find  other sores, the result of
sexual intercourse, succeeded by secondary symptoms of the worst
kind, and also yielding magically,  in some  instances, to mercury
when all other remedies had failed, the old Hunterian test of true
syphilis.
  In the  present state of science  all we can say is, that  certain
ulcers, the result of sexual intercourse, and not distinguishable,
by their external characters from other ulcers, equally the result
of sexual intercourse, yield a characteristic pustule by inoculation;
but the ulcers which  do not yield  the characteristic pustule are
equally liable  to  be followed  by  secondary  symptoms, and are
equally benefited, under many circumstances, by mercury.
  The results of inoculation in all forms of secondary or constitu-
tional diseases have led to the  opinion  that the pus of a constitu-
tional syphilitic sore  is not inoculable:  that it is not generally so
may be demonstrated any day in a  large hospital; but, if not ino- 
46                   PRIMARY SYPHILIS.

culable, generally, is  secondary syphilis never contagious?  does
it never  pass from the  diseased to the healthy body without the
intervention  of primary disease? It certainly does.  I have  seen
and treated several cases  of this kind where a secondary disease,
and no primary, has been communicated to the wife by the husband.
Biett, Cazcnave, Lagneau, names of the highest authority on this
subject, have recorded examples.  Lagneau records the case of an
infant  to  whom pustular syphilis was communicated, who  slept
beside its mother suffering from a similar disease.  Biett gives  a
very similar  instance.   Three very instructive and well-observed
cases have been published by Dr. Stark.1  Todd2 mentions the case
of an old  woman of  seventy, who spoonfed  her grandchild, which
was affected with syphilis, and died a fortnight after birth.  Three
days after the woman had a rash on her arms, then excrescences
on the labia, elevated  blotches on the breast and back, and an
ulcer  on  each  tonsil.   She speedily recovered  under  mercurial
treatment. This case is referred to by Mr. South in his translation
of Chelius' Surgery.
                           Case III.
Syphilitic lepra, with alopecia in the husband; the same disease communicated to
            the wife;  cure of both by moist-mercurial vapour.
  A gentleman contracted a superficial primary sore, which healed
without leaving a mark  or induration  behind it.  Being appa-
rently in good  health, he married.  Three or four months  after
his marriage  he perceived on his body numerous red, smooth, ele-
vated scaly blotches;  very  shortly his wife broke out with an
eruption of similar character;  and the hair came off rapidly in
both patients.  In this state they were sent to me.  Neither had
any primary disease, and  the lady had never had  the slightest ir-
ritation in the genito-urinary organs.  I examined them both fre-
quently and carefully, and I am positive  the wife had  never suf-
fered from sore, excoriation, or discharge. I placed them both on
a rigid diet, and the use of the moist vapour of the bisulphuret of
mercury.  In about six weeks they were both apparently well, and
have remained  so for three years.
                          Case IV.
  A gentleman, who had suffered  both from primary and  secon-
dary syphilis, married, after having been free from all symptoms
  1 Edinb. Medical and Surgical Journal, April, 1851,  p. 365; cases which appear
to prove that secondary syphilis is capable of being communicated to the Healthy
by James Stark, M. D.
  1 Dublin Hospital Reports, vol. ii. p. 182. 
INOCULATION.
47
for twelve months.   Soon after this he had another eruption and
sore  throat; his wife became affected with the same eruption, ex-
cavated ulcers of the tonsils, and was prematurely delivered of a
dead child in the sixth month of her pregnancy.  Both  patients
lost their hair and eyebrows.  On account of the obstinacy of some
of the symptoms in  both these cases,  they were sent to  me from a
distance to be treated by the moist vapour of mercury, under the
use of which they both perfectly recovered.  In this case the lady
was  more than once carefully examined: she was free from all evi-
dence of any form of primary disease, and never had suffered from
the least irritation in the parts.
   There can be no  doubt that in  both these  instances the  secon-
dary taint was  communicated from the husband to the wife.  It
will be remarked that  both were affected precisely with the same
symptoms,  both had the same character of skin disease, and both
lost  their hair and eyebrows, a very strong conviction to my mind
of the mode of contagion.  If the husband communicate a primary
disease to the wife,  and the primary  disease in both be followed
by secondary symptoms, it amounts almost to a certainty  that the
symptoms which accompany the constitutional taint will  differ in
each; but where  secondary diseases are communicated they are
generally, as far as  the  skin is  concerned, alike, as the two cases
detailed sufficiently prove, and as Dr. Wallace had already  re-
marked, that all forms of syphilis produce their like.
   In illustration of  the first proposition of the constitutional symp-
toms being different, when primary diseases are communicated, I
bring forward  a case.
                           Case V.
   A man, S. H—, and his wife, were  admitted  into the Queen's
Hospital at the same time, under my care, for a syphilitic  eruption
on each. The husband  had a papular eruption, the true venereal
lichen, and the wife  a well-marked pustular disease.  Twenty-three
weeks before their  admission the husband contracted chancre, and
three weeks after his wife had primary symptoms, an ulcer on the
inside of the right  labia, with redness and tumefaction of the os
uteri.
   The husband here contracts primary disease, followed by secon-
dary disease in the form of a papular  eruption; he communicates
the primary disease to  his wife, who  suffers from a pustular erup-
tion.  If he had communicated the  secondary form, her  skin dis-
ease would also have been papular.
   M. Cazenave, whilst  admitting  the  rarity  of  the contagion of 
48
PRIMARY SYPHILIS.
secondary symptoms, says, "that it is impossible to deny its occur-
rence, but that  certain local  circumstances are indispensable to
such  a result, these  are a humid or moist  secreting  surface and
prolonged contact," (Traite  des Syphilides, p. 385;) and hence we
see that these conditions are fulfilled in persons habitually sleep-
ing  together, as husband  and wife, mother and child, &c.  &c.
Whilst these secondary symptoms are  rarely capable of propaga-
tion by inoculation, they are frequently contagious under the  cir-
cumstances mentioned, which the facts adduced  sufficiently  prove.
  From these facts I make a few simple deductions, which young
surgeons would do well to note.
  1.  That  it is wrong  for  one  person affected with a secondary
venereal taint to sleep with a healthy individual, especially if  the
former be affected with a  form of disease  in  which there is  a
breach of the surface.   This remark applies to husband and wife,
and diseased children and healthy nurses, or the reverse.
  2. A diseased child should never be suckled by a healthy nurse,1
neither  should a healthy child  be  placed with  a diseased  nurse.
We cannot be too careful  in examining wet  nurses, before their
introduction  into families;  they are most commonly the  mothers
of illegitimate children, and therefore the greater need for caution.
Not only the external parts, but the vagina and os uteri should be
examined before a positive opinion  as to the health of the woman
be given.2

  1 See Clinical Lectures, (No. 7, p. 332,) by Dr. J. H. Bennett, of Edinburgh, for the
details of a case, where two nurses recovered compensation from a surgeon from a
circumstance of this kind.
  a See Mr. Whitehead's (of Manchester) Cases, p. 368. Mr. Whitehead,  by the
way, is a firm believer in the contagion of secondary syphilis.
  M. Waller, of Prague, published in 1851, an account of  his researches on the
contagion of secondary  syphilis.  This  paper is republished  in M. Cazenave's 'An-
nates de la syphilis,' 1850-51, t. iii. p. 174,  &c.  The results at which M. Waller
arrives are the following:
  1.  Inoculation with the pus of a primary venereal ulcer  produces, under certain
        circumstances, a primary ulcer of a light character; inoculation with the
        secretion of secondary syphilitic ulcers never produces ulcers having the
        characters of chancres.
  2.  Inoculation with the secretion of  secondary syphilitic ulcers, on healthy sub-
       jects, produces in them secondary syphilis.  Both primary and secondary
        syphilis, then, may  be propagated by inoculation; the  pus  of  primary
        syphilis produces primary syphilis, the  pus or secretion of secondary sy-
        philis produces secondary syphilis.   (See p. 187, of the translation by M.
        Axenfield, in the third volume of Cazenave's 'Annales.')
  It is singular how closely the results of these experiments coincide with the facts
already detailed by me in the cases which I have related. 
BALANITIS.                          49
                          CHAPTER IV.

OF THE FIRST CLASS OF PRIMARY SYPHILITIC DISEASES1—GONORRHOEA,
         ITS VARIETIES, COMPLICATIONS, AND CONSEQUENCES.
                            OF BALANITIS.
 INFLAMMATION OF THE GLANS PENIS—EXTERNAL OR FALSE GONORRH03A—CHANCROUS
                            EXCORIATION, ETC.

   This disease is characterized by more or less redness, and a mu-
 co-purulent discharge from the surface  of  the glans penis, with or
 without excoriation.  Balanitis rarely occurs alone, but is more fre-
 quently complicated with a similar  condition of the internal sur-
 face of the prepuce (posthitis.)   It is then termed balano-posthitis.
 As it  is rare to see  the affections separate, I shall consider both
 under the  title of balanitis.
   This affection  may have  a purely venereal origin,2 or  may suc-
 ceed  to intercourse with women  labouring under leucorrhcea, or
 other simply inflammatory affections of the vagina, when this part

  1 Synonyms.  Affections non virulentes.—Ricord.   Maladies primitives a forme
 erythe"mateuse.—Desruelles.   Catarrhal primary syphilis.— Wallace.
  3 "It is denied by many that the present variety of disease ever arises from the
 venereal poison, or that it even leads to secondary symptoms ; and it is affirmed to
 be the consequence of numerous causes of common irritation.   Now it must be ad-
 mitted, that causes of common irritation often produce excoriations of the glans,
 corona, and  prepuce, for this is a daily occurrence.   It is also notorious that such
 excoriations may be produced without sexual intercourse, from acrimony of the na-
 tural secretions of the part, &c. But I have often had equally conclusive proof that
 the present variety of disease may arise from the application of secretions containing
 the venereal poison."  (Wallace, p. 222.)  Vidal  (de Cassis) p. 119, is of the same
 opinion, and states that in several instances the pus of a balanitis, where there has
 not been the least breaking of the skin, has produced the characteristic pustule of
 chancre when inoculated.  These,  I believe, are rare cases, but they do  happen.  I
have seen and treated one case, where I believed the disease to be nothing more than
balanitis; but the wife had secondary symptoms, scaly blotches,  and nodes.  Dr.
Wallace has recorded another.  As these forms of disease, which are purulent in the
commencement, frequently run on into ulceration, a very cautious opinion should
be given.
        4 
50
PRIMARY SYPHILIS.
 is covered with secretions of a more or less irritating character.
 The menstrual  discharge will also  frequently occasion balanitis,
 and I have frequently seen great anxiety arise to married men who
 have suffered from balanitis, the result of intercourse with their
 wives in one or other of the above-mentioned states.  Balanitis
 sometimes owes its origin to a natural conformation of parts, and
 hence subjects with a natural phymosis, or small preputial opening,
 may be considered as predisposed to it.
   The treatment of uncomplicated  balanitis is extremely simple.
 When the  glans can be denuded, and the inflammation is not very
 acute, the solid  nitrate of  silver may be passed slightly over the
 surface, covering it with  a piece of fine soft linen, and then bring-
 ing the prepuce forwards over  the  glans.  The 'penis should be
 covered with linen compresses soaked in cold water, or the liquor
 plumbi diacetatis dilutus, and the linen between the prepuce and
 glans renewed twice in the day; at each renewal of the linen, the
 parts should be washed with an  astringent lotion.1   It will be oc-
 casionally found that lotions of  all kinds tend to keep up' the irri-
 tation.  When  this is the case, the surface of  the glans should be
 thickly dusted with an astringent powder:2 this tends  to allay the
irritation, by absorbing the acrid  secretions, and preventing any
friction between the glans and prepuce.  If the inflammatory symp-
toms accompanying balanitis run high, and are complicated with
phymosis, aperients should be administered, and the patient kept
quiet, and  live low.   Injections of the nitrate  of silver, or an
aqueous solution of  opium, may be thrown up between the glans
and prepuce.  In  cases where balanitis, thus complicated, termi-
nates in gangrene, or this is threatening,  Ricord recommends the
free exhibition  of opium, either  by the mouth, or united with cam-
phor in form of enema.   Desruelles speaks  highly of continued
injections or irrigations  in  balanitis, or balano-posthitis, resorted
 to when these  diseases are  complicated with  phymosis.   To ac-
 complish this, a small cannula may be fitted to one of  Weiss' self-
acting enema syringes; the cannula, which should be made of caout-
chouc or elastic gum, is to be passed between the  glans and  pre-
 puce, and thus, without removing it, a continued stream of  some

                  1 R.  Plumbi diacetatis, jj;
                      Aquae destillatae,  ^viij.  M. ft. lotio.
                  1 R.  Plumbi subcarbonat.,
                      Pulvis cinchonae, aa ^j;
                      Acid, tannic, gr.  v.      M. ft. pulvis. 
BALANITIS.
51
narcotic or astringent injection1 may be thrown gently up for some
minutes together.2
   The causes of external gonorrhoea are to be sought for in the
natural conformation of  the  penis  on the part of the  male, and
various morbid conditions of the vagina on the part of the female.
A natural phymosis predisposes the patient to contract this form
of disease;  for instance,  a person having natural phymosis coha-
bits with a female having various morbid discharges  from the va-
gina; the discharge gets  under the prepuce, and is there retained,
as the patient cannot withdraw it to wash the part; the discharge
excites  inflammation of a more or less active character, which would
all have been avoided if the  glans could have been retracted and
the  part washed with a little soap and water.   The secretion of
the glandular odoriferse, as they are termed, also of itself produces
a  form  of balanitis, without even exposure to impure  connexion.
This secretion, which, in some persons, is extremely abundant and
.offensive, is retained by the  elongated prepuce  on the base and
surface of the glans, there irritating and  inflaming the  parts, and
ultimately producing adhesions between the glans and prepuce.'
Sometimes, when there is a very narrow preputial opening, and the
discharge cannot make its way out, large collections of  matter are
formed, and the  patient,  unless an operation is performed, is only
relieved by gangrene, or sloughing of the whole prepuce.   I have
been called to several cases where such a termination  has taken
place.
                           Case VI.
   I was sent a short time since to see a young gentleman, about 17
years of age,  whose disease  occasioned the utmost  alarm to his
friends.  On examining the patient, I found the penis enormously
swollen and dark coloured, and a djstinct gangrenous spot, about
the  size of a  shilling, situated near its  extremity,  under which
fluctuation was evident.   The prepuce was  long, so swollen, de-

               1 R.  Decoct, papaveris, h. ij;
                    Aluminis ust., gr. xx.  M. ft. injectio.—Desruelles.
   Simple tepid water, with alum in the proportion of eight or ten grains to the pint,
forms an exceedingly useful injection, particularly where large quantities are used.
                " R. Cerati simplicis, vel mellis,
                     Olei olivse, aa §j;
                     Hydrargyri chlorid., ^ss;
                    Ext.  opii, 3J.           M.
   The above preparation may be introduced between the glans and prepuce by means
of a camel-hair pencil; a remedy of great value. 
52
PRIMARY SYPHILIS.
formed, and oedematous, that it was  impossible to make out the
situation of the preputial opening.  I was convinced that it was a
case of balanitis with occlusion of the preputial opening.   I made
a deep incision through the black spot into a collection of matter
between the glans and prepuce, after which, with ordinary treat-
ment, the patient speedily recovered.

  The chief causes of balanitis are to be sought for in the condition
of the female vagina.  " In examining the vulva, vagina, or neck of
the  uterus,  in females labouring under discharges which have pro-
duced balanitis or gonorrhoea in the  male, we  have observed the
mucous membrane covered with papulae or follicles, more or less de-
veloped, constituting a papular vaginitis, or uterus vaginitis, some-
times assuming the form of small spots, in size not larger than a pin's
head, isolated, or  more or  less confluent.   On the same  portion
of the mucous membrane we have distinctly seen patches more or
less numerous, and varying in extent, which have a striking ana-
logy with the  suppurating surfaces of the skin on which a blister
has been applied.  Again, in some forms of blennorrhagia in the
female, we find the mucous membrane of the vagina of a uniformly
red colour.  At other times the redness occurs in isolated patches
with swelling, heat, and pain, unattended by any secretion. Other
cases of this kind give rise to a morbid  secretion, the colour and
consistence of which are variable. The differences in the charac-
ter  of the secretions appear to have no  reference to the causes
which  have produced them.  The discharges from  the  urethra,
vulva, vagina, and uterus, are very Various; but the difference has
not appeared connected with any one particular lesion more than
another. The acute stage generally, whatever may be the particu-
lar  lesion,  causes at its commencement a secretion almost wholly
serous,  or  only consisting of mucus more abundant than usual,
which afterwards becomes opaque, purulent, or  of a darkish yellow
colour, sometimes green, sometimes mixed with blood.  The chronic
stage often gives rise to a milky secretion of a thickish consistence,
similar to that of cheese, or simply to a mucous flux.  The  chronic
discharges  also may put on a rusty appearance,  and become tinged
with  larger  or  smaller  quantities  of blood.   These secretions,
whether in the acute or  chronic  stage, may have no smell, or  on
the contrary, may have a very unpleasant odour, particularly where
the mucous papulas exist. The smell is often so decided, that it is
characteristic in a great  number of cases.   The only differences 
BALANITIS.                      53
which result from the particular seat of the blennorrhagia are, that
the secretions which come from the uterus are always more mucous,
thready, and collected into flocculi; whereas those which  escape
from the urethra, vulva, or vagina, present a less tenacious charac-
ter than the others.1
   These forms of  vaginitis  sometimes occur in patients  of the
highest respectability, and are capable of producing balanitis  in
the  male.   I have  seen  one or two instances where an inflamed
and irritable  condition of the vagina in the female, during the
latter months of pregnancy, has produced balanitis in the husband,
and where a great deal of  family distress has been  occasioned by
the circumstance.

                          Case VII.
   A lady, whom I welf knew, the  mother of seven children, in her
eighth pregnancy suffered  from a white discharge, with swollen
labia and much irritation.  Her husband became affected with in-
flammation  of the  glans and prepuce, swelling of the penis, an
abundant offensive discharge, and ultimately phymosis, the inflamed
surfaces  ulcerated  to some extent.  The case was obstinate, and
occasioned much family  annoyance. What  is, however, very re-
markable, and proved the  nature and origin of the disease, was
that with the accouchement the disease of the lady disappeared,
and intercourse no longer affected the  husband.  In  the ninth
pregnancy the same symptoms occurred again in the wife, and pro-
duced a similar obstinate disease in the husband.

   The forms of disease on  the part of the female I  have just enu-
merated  will produce external gonorrhoea, and also gonorrhoea
properly so called.   Both  gonorrhoea and  ordinary leucorrhcea
recognise the  same pathology, i.  e., a vaginitis assuming various
forms, accompanied by discharges  also of varied character;  yet, in
one instance, we see gonorrhoea in both its forms, external and in-
ternal, constantly produced in the male; whilst in another, cohabi-
tation takes place almost with impunity, as far as contracting dis-
ease is concerned.  Hence it has been attempted to establish a dif-
ferential diagnosis  between the two, in which  all have  equally
failed.  Hunter, Clarke,  and  Churchill, have failed in  doing so,
and since the speculum has been so much employed no additional
light on the subject has as yet been given.
1 Acton on Venereal Diseases, pp. 172-3. 
54
PRIMARY SYPHILIS.
   We must decide, in these  instances, by the effects produced, by
the facts before us, and not on the grounds of any a priori reason-
ing.  When we see that blennorrhagia, or the various  forms  of
vaginitis with muco-purulent discharge  in the married female, on
the one hand, exist for a longer or  shorter period, for months, or
even years, without producing  the  slightest affection  on the part
of the husband, or on that of any child which may happen  to be
born  during  the  continuance of the disease, and observe, on the
other hand, forms of vaginitis  precisely similar to those which I
have mentioned, producing balanitis, gonorrhoea, and  all their at-
tendant consequences, we must be  disposed  to  admit something
specific in the latter case, some  form of morbid poison which does
not exist in the first.
  " Between the muco-pus of a pure gonorrhoea and the  pus or muco-
pus of other  discharges, there  is a  difference precisely similar to
that which exists between the pus of chancre producing a character-
istic pustule by inoculation, and the pus of other sores consequent
upon sexual intercourse, which do not give this result, although no
chemical or physical circumstances are capable of showing in what
this difference consists."1
  The symptoms of balanitis are heat, itching, and redness of the
glans penis and the inner surface of the prepuce, the redness being
disseminated  in patches, as though the surface of the part had been
slightly scalded with drops of hot water sprinkled over it.  These
symptoms are accompanied by a muco-purulent discharge from the
preputial opening, and if the glans can be denuded, its whole sur-
face and  that of the prepuce are covered with  an adhesive flaky
matter looking like curd.   This is  the  condition if the glans can
be denuded;  if it cannot, all we generally  observe is a muco-puru-
lent discharge from the preputial  opening, though not from the
urethra, with heat and swelling at the  end of the penis.   In fact,
the balanitis  itself is the most common cause of our not beino* able
to denude the glans penis; the inflammation produces the phymosis,
which was not present till the balanitis was contracted.  Ao-ain,
the phymosis may be congenital.
  Discharges from the end of the preputial opening, however, with
a natural or acquired phymosis, are not all dependent upon balani-
tis, as I  have described it.   They  may result, and commonly do
result, from a chancre or ulcer, situated either on the glans or pre-
1 Baume"s precis sur les Maladies veneriennes, vol. i. p. 208. 
BALANITIS.
55
 puce, and producing the inflammation with the discharge from the
 preputial orifice.   If an ulcer of any standing be the cause of the
 mischief, we  can  generally detect it from a partial induration felt
 at the same part of the prepuce under the skin, and a peculiar sore-
 ness and tenderness existing in this part, when the penis is pressed
 or  rolled between the fingers.  These would be the distinctive
 symptoms to  guide us in a differential diagnosis between phymosis
 with chancre, and phymosis the result of pure balanitis, since  both
 diseases would be characterized by the  same, or pretty nearly the
 same, general symptoms; viz., swelling and heat of the end of the
 penis, with phymosis and discharge from the preputial opening.
 A balanitis might again exist with a pure  gonorrhoea; this is  very
 common, but  in this instance the discharge from the urethra can be
- seen.  I mention these complications of  balanitis, because their ex-
 istence  in balanitis would materially modify the  treatment.
    Balanitis is in many, if not  in most instances, complicated  with
 phymosis, and the question naturally arises whether this is to be re-
 lieved by an operation or not.  If the  phymosis be a congenital
 one, and the  patient have contracted a balanitis, in most instances
 the operation should be performed, as the continuance of the  phy-
 mosis predisposes the patient to a number of those inconveniences
 mentioned before, adhesions between the glans and  prepuce, and
 thickening of the latter from chronic inflammation.   If the  phy-
 mosis be an acquired one, produced by  the  disease, the operation
 should not be performed.  Poultices, cold lotions, purgatives, and,
 above all, the calomel and opium pommade, will in a few  days, in
 almost every case, enable us to retract the prepuce.   An operation'
 in the latter  case is  unwarrantable, whilst in the former  it is not
 only justifiable, but highly advantageous.  We shall  have  more to
 say of  the operation for phymosis when  speaking of primary
 venereal sores complicated with it; but in cases of uncomplicated
 balanitis, the rules I have given are safe, and have been proved by
 myself time after time in practice.  Balanitis may, if neglected or
 badly treated, continue for an indefinite period of time, may run
 on into  conditions of superficial ulceration, may produce adhesions
 of the prepuce to the glans, either partial or total, thickening of the
 prepuce, and, according to  Roux, cancer of  the  penis.  Again, it
 commonly produces enlargement of the  glans in the groin, and oc-
 casionally bubo.  I have seen the latter in one or two instances.
   Secondary  symptoms may succeed to simple balanitis, and some
 modern authors have recorded examples of the fact.   If balanitis 
56
PRIMARY SYPHILIS.
or chancrous excoriation.is  suffered to continue for an  indefinite
period .of time, a thickening of the diseased surface always occurs,
and a chronic suppuration is established from the abrasion  cover-
ing the thickened part.  In this state of things secondary symptoms
will occur in the male, and may be produced in  the female, when
cohabitation is permitted under such circumstances.   I have seen
eruptions accompanied by a node  on the forehead, loss of the hair,
and other symptoms of constitutional syphilis produced in the wjfe,
where this species of  abrasion, with thickening, were the'only
symptoms in the husband. Some cases have been brought forward
in which  constitutional symptoms, characterized by copper-coloured
patches and papulae, succeeded to balanitis or discharge from  the
external  surface of the glans and from the prepuce, without ulce-
ration or breach of surface.  In the cases mentioned, this external
gonorrhoea was followed by the falling off' of the hair,  and erup-
tions precisely similar to those which follow primary venereal sores,
and these complaints were curable only by mercury.  In the first
case, the  patient had never before any venereal affection  till he
contracted  a balanitis  characterized by redness,  heat, and itching
of the external surface of the prepuce, to which succeeded a puru-
lent discharge.
  This form of disease is considered by many modern writers as a
variety of gonorrhoea, differing from the  urethral variety merely
in its seat.   In the cases already  alluded  to, this external  gonor-
rhoea or  balanitis was followed by falling  off of the hair and erup-
tions  precisely similar to those which  succeed to venereal sores,
and were curable only by mercury.  In one case, the patient had
never before had any venereal affection till he contracted a bala-
nitis  characterized by redness, heat and  itching of the external
surface of the glans penis and neighbouring portion of the prepuce,
to which succeeded a purulent discharge,  without any kind of ex-
coriation or wound.    This was  succeeded "by copper-coloured
patches on  the forehead and chest; and a female, with whom  this
patient cohabited, became affected with heat and swelling of the
genitals,  pain in  making water,  and, two months after, an erup-
tion on the inside of the thighs, the nose,  and the forehead.  The
female was declared  diseased; put on the use of mercury, with sar-
saparilla, and recovered.   The patient (the male) took to himself
a second mistress, still suffering from the affection (balanitis,)
which he did not consider syphilitic, the first mistress having mar-
ried after  recovery.   The second mistress soon became affected 
BALANITIS.
57
with the same symptoms  as  the  first, and, two  or  three  months
after, a constitutional  affection made its appearance, which ulti-
mately assumed a pustular form.  The prospect of an advantageous
marriage presented itself, and our patient now separated from his
second mistress and married.  In a short time the wife was affected,
as her temporary substitutes had been before, and subsequently
with eruptions of a like character.  The patient and his wife now
put themselves under  medical care; and the  surgeon stated that
the only disease  in the genitals with which the husband  was af-
fected was  redness of the glans  penis, with  purulent discharge;
no ulceration, breach  of  surface, or trace of cicatrix. The  pa-
tients were  put upon mercurial treatment,  and both perfectly re-
covered." .  These primary  forms of  disease in the  glans  and
prepuce, marked or characterized by  discharges, without ulcera-
tion, have of late been supposed to  be  precisely  identical  in their
character with gonorrhoea, differing from it only in their seat.  We
are inclined, from  observation, however, to  believe, in many in-
stances this analogy is not  correct, though it may hold good in
some, since  what appears  a mere  catarrhal affection in the  first in-
stance," frequently degenerates into  ulceration more or less exten-
sive.   Many modern surgeons of experience in the matter we are
now considering, state that simple balanitis may produce a chancre,
and thus induce  secondary symptoms.
   A very marked example of this  occurred  in  a  patient in the
Queen's Hospital; he was admitted for simple balanitis.  On  ex-
amining him a few days  after, I was  surprised  to  see a  crop of
small ulcers on the prepuce.  I have in private  practice, not only
in one," but  in several instances, seen a superficial sore appear be-
fore a patient was well of the balanitis, and this sore followed by
a bubo; in these instances a fresh infection was impossible.  The
distinctions are  perhaps  not very clearly defined between a pure
catarrhal  inflammation of the glans and prepuce, and those very
mild forms of syphilis which  some writers have termed superficial.
Dr. Wallace has recorded a case bearing upon this point, which, in
a practical point of view, is so instructive, that I shall introduce it
here.
   "A lady was brought to Dublin on  account of an eruption, and
a state of general ill health.  She had  been some months married,
and was pregnant.  The  eruption  did not appear of a doubtful
character.   It was  a syphilitic  eruption, of a rubeoloid form, and
was  accompanied by its  almost constant attendants, a superficial 
58
PRIMARY SYPHILIS.
disease of the fauces and a condylomatous state of the pudenda
and of the orifice of the anus.   There were, also, small condylo-
mata  in  the  axillae.  I communicated  my opinion to the husband
of the lady, who had accompanied her to town, and he denied that
he had ever  had any venereal  disease; but he at  the  same time
admitted, that some months before his marriage  he  had got, in
consequence of a suspicious intercourse, what he called a chafing;
that he  had  consulted  Mr. M., who directed for him a wash, by
which the disease was removed; that he had been assured by this
gentleman that  the complaint was  not venereal, and did  not re-
quire mercury; and that he had  taken the precaution of submitting
himself to examination before marriage, with the view of  making
his mind sure that he had no  venereal taint;  but, on examining
him, I found a very slight oozing at the corona, with a very slight
thickening of the corresponding portion of the lining of the pre-
puce ; and there  existed on some parts of his body slight cutaneous
desquamations of a suspicious character." 1  The lady miscarried
of a dead child, and the husband and wife were  placed under mer-
curial treatment and recovered.
  Balanitis is exceedingly liable  to return, without any  evident
cause, after it has been supposed to  be cured.  It breaks out again
and again, at uncertain intervals, showing the irritation  still to
exist which produced it in the first instance.   Sometimes the irri-
tation reappears in its  original form, sometimes it gives  rise to
herpes preputialis,  or to eczema of the glans, or to minute  and su-
perficial  ulcerations, which, after repeated returns, leavev behind
them some thickening, which may give rise to mild constitutional
symptoms, and is capable of producing disease in the female, as
the preceding remarks and cases fully show.  In such cases the pa-
tients must be put on general treatment, a mild mercurial  course,
the hydriodate of potass with sarsaparilla, and  the mercurial va-
pour-bath.  "
» Wallace, pp. 229-30. 
GONORRHOEA.
59
                         CHAPTER V.

                          OF GONORRHOEA.1

   Gonorrhcea, a disease of daily occurrence, is perhaps as much
or more  than  any other presented to the  surgeon, the  source of
annoyance to him, and anxiety and weariness to his patient.  This,
we apprehend, arises in a great measure from the want of a correct
knowledge of its modifications  and varieties,2 and consequently an
uncertainty in the  treatment more  especially  adapted  to its  dif-
ferent forms.    Gonorrhoea consists in inflammation, more  or less
acute, of the mucous membrane of the  urethra, or other parts of
the genito-urinary passages, accompanied by the secretion of a muco-
purulent fluid of a yellow or greenish appearance; pain, itching, or
irritation in voiding the urine, with, in the male, repeated and in-
voluntary erections of the penis.

  1 Urethritis, acute or chronic,—Desruelles.   Blennorrhagia,—Sicediaur. Veneroal
or syphilitic catarrh,— Wallace.
  2 Varieties of gonorrhoea.
First species—Gonorrhoea in thejemale:
                  C the vulva,   "^
                  J the vagina,  f may exist alone, or variously
  Varieties, seated in -< the uterus,  f         combined.
                  (^ the urethra, J
  Second species—Gonorrhoea in the male:
                  r the urethra,    -»
  „  .  ..      .  , . |   .,             may exist alone,  or
  Varieties, seated in -l on the prepuce,or l
                                  I  variously combined.
                   I. the glans penis,  J
  Hecker; 'Des difKrentes especes des Gonorrheas,' has described the following va-
rieties :
  1. Ordinary, specific, or virulent gonorrhoea.
  2. Consecutive gonorrhoea (gleet.)
  3. Gonorrhoea accompanying syphilis (probably depending on chancres of the ure-
thra.)
  4. Gonorrhoea accompanying scurvy.
  5. Gonorrhoea accompanying scrofula.
  6. Gonorrhoea dependent upon or kept up by rheumatism.
  7. By gout.— 
60
PRIMARY SYPHILIS.
  The  discharges from the male urethra which  are produced by
sexual intercourse may be reduced to three, and these I term, simple
gonorrhoea, ordinary or specific gonorrhoea, and gonorrhoea which
is the result of a venereal sore in the urethra.   These three kinds
are different  in the  causes which they recognise, their pathology,
mode of treatment, complications, and consequences.
  Simple gonorrhoea results from cohabitation with females during
the menstrual period, or when they are labouring under inflamma-
tory or diseased states of the vagina or os uteri; which furnish dis-
charges of a more or less acrid or irritating nature.   These gonor-
rhoeas are not capable  of  propagation in the same way that an or-
dinary  specific gonorrhoea generally is;  in fact, they are  not con-
tagious.  Many writers have endeavoured  to discover some distin-
guishing marks between gonorrhoea and other discharges from the
female  which we may call leucorrhceal, and which, under certain cir-
cumstances,  give rise  to  simple  gonorrhoea  in the male.   That
differences do exist  in  the nature of these discharges on  the  part
of the  female we are perfectly convinced; differences which the
speculum cannot distinguish, but which are evident in their effects
upon the male.   These various discharges  produce in the male, oc-
casionally, a  disease which may be termed simple  gonorrhoea, to-
tally different from a specific gonorrhoea in duration, intensity, and
consequences; and, still further, not to be cured by the same reme-
dies.1

  8.  Accompanying various local exanthemata.
  9.  Accompanying hemorrhoids.
  10. Produced by certain conditions of the urine.   The crystals of oxalate of lime
present in the urine—oxaluria.
  11. By masturbation, &c.
  12. By continence.
  13. By causes acting directly on the parts affected, as the introduction of instru-
ments into the bladder, for the relief of  stricture, or for lithotomy.  I have in two
instances seen a disease  precisely similar to gonorrhoea, with  a swelled testicle,
occur after the latter operation.
  14. By sympathy.
  15. Occurring in females after delivery.  s
  Most if not all of these varieties must be recognised by those familiar with dis-
eases of this character.   Many of them are dependent on specific or ordinary gonor-
rhoea occurring in certain constitutions; thus, the  ordinary specific gonorrhoeas,
in habits confirmedly rheumatic, gouty,  scorbutic, or scrofulous, form varieties of
the disease which require most important modifications in treatment.
  1 The  secretions from a healthy female will sometimes produce in certain indi-
viduals discharges closely resembling gonorrhoea.   Hence some authors have be-
lieved in the spontaneous origin of this disease. (Skey's Lectures on Venereal dis- 
                          gonorrh(ea.                       61

  The late  Mr. B. Bell was of opinion that discharges from the
male urethra, accompanied by heat and scalding on making water,
may succeed to connexions with women suffering from fluor albus.1
He merely  remarks, that such  discharges generally subside much
more quickly than an ordinary gonorrhoea.   He  mentions its con-
tinuance from this cause eight or ten days, and cautions young prac-
titioners against giving precipitate opinions on such cases.   I have
frequently been consulted by persons  labouring under discharges
of this character, which have been communicated by females with
whom they had been in the habit of cohabiting, and who had never
perceived any disease till they visited  their mistresses after dining
out and drinking freely; then a discharge, with scalding on mictu-
rition, has been set up, which has continued a few days, been ren-
dered worse by specific-remedies, and yielded to low diet, aperients,
and an injection.2
                            Case VIII.
   A gentleman  contracted a gonorrhoea in South America, which
disappeared  under treatment.   On  returning to this country he
perceived, the  day after intercourse, a profuse purulent discharge
from the urethra, which at first had many of the characters of go-
norrhoea, though unaccompanied by scalding or chordee: the dis-
ease disappeared in a few days.  The  same  discharge appeared
frequently after intercourse,  especially if the patient had been
drinking wine previously.  No disease was  communicated to  a
healthy female  by  this discharge, after repeated intercourse.   It
always disappeared with a few days' low diet and a mild aperient.
    This is the type  of a class of cases which are common, and which
generally yield to  the treatment  mentioned, to which  a weak as-
tringent injection may be added, should they prove obstinate.

eases, p. 174, &c.)  Mr. H. J. Johnston has recorded three very remarkable cases
of this  kind.  (On Gonorrhoea, and its Consequences, p. 32.)  I have examined fe-
males more than once, in whom I could  detect no disease whatever, who were  said
 to have communicated a gonorrhoea.
  ' See a remarkable case recorded  by him, vol. i. p. 425, of his Treatise on the
 Venereal Disease.
   ' "Both sexes are liable to complaints that very closely resemble the gonorrhoea.
This occurs to men who have an irritable stricture, or at least an irritable urethra,
who find on some excitement a sudden  appearance of copious discharge; and if it
appear after intercourse, it may be as soon as twelve hours, is at once of a puru-
lent character.  The symptoms of this spontaneous complaint usually remain a
short time without increasing, and then cease  without any apparent cause, or de-
 cided course of treatment."  (J. P. Vincent;  Observations on some points of Surgi-
 cal Practice, p. 328.) 
62
PRIMARY SYPHILIS.
   We believe, with the best  pathologists of the day, that gonor-
rhoea, though the result of impure cohabitation, and hence termed
a venereal disease, is an affeetion of a totally  different  character
to the primitive syphilitic ulcer.  We do not believe  the opinions
of the late Dr. Wallace and others to be true, that syphilis and go-
norrhoea are varieties  of  the same  disease;1  modern  testimony,
drawn from the results of inoculation, universally proving that the
pus of chancre has never produced gonorrhoea, and the reverse.2
   The causes of gonorrhoea  are various;  the most frequent, how-
ever, is  cohabitation with a female affected with the same  disease.
It is certain that inflammation with muco-purulent  discharge from
the urethra, may be the  result of intercourse  with  women  who
labour under various forms of disease,  such as inflammation  of the
vagina,  the lochial  or  menstrual  discharges, fluor albus,3 ulcera-
tions of various kinds not syphilitic, secondary syphilitic ulcers of
the os uteri, and other  morbid conditions, amongst which Cullerier
and Ratier specially mention the cancerous  ulcer.   It appears to
me evident that, in the  present  state  of  science, it is  impossible

  1 On the venereal Disease,  &c, p. 284, and elsewhere.
  1 See Ricord, and the authors quoted by him  in his work already referred to;
also Cullerier, in Luca3 Championniere's work, p. 384, &c.  &c.  The whole history
of the pathology,  consequences, terminations,  complications, and the effects of re-
medies in the treatment of gonorrhoea, mark it as a disease distinct from chancre.
This was the universal belief in this country, with few exceptions prior to the time
of Ricord, who only confirmed what British surgeons already believed and acted on,
yet, with all this,  there do occur from time to time  cases of secondary syphilis, in
no way to be distinguished from those which succeed to chancre, which own  as their
source and origin  discharges from the urethra only, which discharges apparently in
no way differ from common gonorrhoea, and on examination of the urethra after the
disappearance of  such  discharges, no vestiges of contraction or stricture, or any
condition  incompatible with  a healthy organization, can be detected; surely if a
concealed or urethral chancre (which is evident  enough in most cases where it ex-
ists) had been present in such instances, its healing must have left some mark be-
hind.   I do not deny the existence of urethral chancre, I  have seen it frequently,
but I say that in  all the class of cases I have alluded to, the existence of  chancie
has been presumed, not demonstrated.
  s "It sometimes becomes a question of considerable interest, and of no little im-
portance in married life, to determine whether leucorrhoeal  discharges in the female
are capable of producing the assemblage of symptoms in the male, constituting the
ordinary phenomena of gonorrhoea.  If questioned  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 myself witnessed several
incontrovertible instances of the  kind."  (Whitehead; On  Abortion and Sterility,
and morbid conditions of the Uterus, with reference to the  Leucorrhoeal Affections
&c. &c.) 
GONORRHOEA.
63
with certainty to ascertain what may be the true cause of that go-
norrhoea which succeeds to cohabitation, unless the female be sub-
mitted to examination with the speculum:  and hence little confi-
dence is to be placed upon any statements of this character, unless
the speculum have been employed as a means of confirming our di-
agnosis ; the condition of  the constitution also at the time of expo-
sure to infection must be ranked  as a predisposing cause.   Gonor-
rhoea is also due to other  causes apart from sexual  intercourse, as
masturbation, habitual costiveness,  inflammation of the  prostate
gland, certain morbid conditions of the bladder or ureters, particu-
larly the presence of calculi in these parts, piles, the excessive or
immoderate use of  wine or fermented liquors generally, and  the
warmer spices,  more particularly cayenne pepper.  In  children
this affection is  sometimes dependent  upon teething or intestinal
worms.  It also recognises for its cause a  gouty or  scorbutic  dia-
thesis, or succeeds to the suppression of habitual discharges, or the
cure of old-standing cutaneous eruptions.   In addition to  all these
causes, which are strictly internal, gonorrhoea is produced by ex-
ternal violence or injuries to the penis, and the  operation of a
second class of  causes of  various kinds which are external.
   Gonorrhoea consists in  an inflammation  more or less diffused of
the mucous membrane of  the urethra, &c.   Dr. Wallace considers
this inflammation, from its  diffused  or erratic character, to  be of
the erysipelatous kind; hence Desruelles  terms it  "inflammation
erythemateuse."  The inflammation does  not commonly affect the
 whole surface of the urethral mucous surface;  when it does so, it
 is generally accompanied with  violent symptomatic fever.   The
 points in which the inflammation remains most commonly fixed, or
 in which it is manifested with greatest intensity, are the fossa na-
 vicularis, and the vicinity of the bulb: this  arises from  the  ana-
 tomical disposition of the mucous membrane, which, in this situa-
 tion, is much more intimately adherent to the erectile tissue be-
 neath it.  Gonorrhoeal inflammation  may be diffused over a wide
 surface, and " may involve  at the same time the whole of the ure-
 thra, the bladder, the testicles, the glans and prepuce in the male;
 and in  the  female the nymphae, clitoris,  labiae, vagina, &c;  and
 thus commencing at the preputial  end of the penis, in  the fossa
 navicularis, it not  unfrequently  creeps slowly on to the  posterior
 parts of the urethra, to  the bladder, or to the testicles, while it
 decreases  or ceases entirely in the  parts first affected."1  It may
1 Wallace, pp. 237-8. 
64
PRIMARY SYPHILIS.
be confined to the mucous membrane itself, or extend to the tissues
beneath it; in the latter instance  the  irritation constantly deter-
mines a flow of blood into the cells of the erectile tissue of the cor-
pora cavernosa and corpus spongiosum, which occasions a continual
tension of  the penis.   Occasionally the inflammation becomes lo-
cated in some part of the canal, producing thickening, effusion into
the submucous cellular tissue, and in some cases ulceration; in
these forms the disease assumes more of a  local character, and is
not so much disposed to spread by continuity of tissue.
  The general symptoms of gonorrhoea are too  well  known to
need description, yet those which indicate  its localization in par-
ticular parts  of  the urethra  may  be detailed with  advantage.
When the disease is confined to the fossa navicularis, it is only in
this portion of the passage that uneasiness or pain is felt when the
patient voids his urine; the glans is more or less swollen, and its
lips tumefied  and red.   On pressing and rolling  the urethra be-
tween the thumb and finger, a distinct thickening is felt, as though
a portion of a sound had  been introduced into the urethra; the
pressure  is also painful  to  the patient.  The  greater and more
marked the thickening of the urethra in this situation the stronger
is the presumption that the disease is localized there, and does not
extend to other portions of the canal.  The discharge, under these
circumstances, is trifling, though very teazing to the patient;  it is
constantly presented at the orifice of the urethra.  When the in-
flammation predominates, or is fixed in the  straight portion of the
urethra, between the glans and the bulb, the patient has  no pain
in the perineum, but he experiences severe pain in  making water,
has frequent erections of short duration, and the discharge is more
copious than when the  disease is confined to the fossa navicularis.
  If the  disease be  located in the bulbous  portion of the urethra,
the patient has pain in the perineum increased  by pressure, a con-
stant desire to void his urine, with frequent erections of the penis.
The discharge is  abundant, accompanied with great pain, and the
stream of urine is diminished.  When the membranous portion of
the urethra is chiefly affected, the pain is severe in the perineum
and the neighbourhood of the anus; the desire to void the urine
is in  many cases constant.   The prostate and  testicles are  com-
monly enlarged  and painful, the  spermatic vessels congested, as
well as the vasa deferentia.   Consecutive diseases of the bladder
prostate, and testicles, are more frequently to be feared when the
gonorrhoea occupies principally the two last-mentioned seats. 
GONORRHOEA.
65
  During the course of a gonorrhoea the patient is not unfrequently
tormented with pains in  the groins, weight and dragging in the
testicles, irritation in the  rectum, tenesmus, with  retention or in-
continence of urine.   These depend chiefly upon the localization
of the primitive disease,  and are easily explained by the anatomi-
cal relations of the urethra. *Fever of an  inflammatory or inter-
mittent character is sometimes present, and affections of the joints,
which have been described by some authors under the title of go-
norrhoeal rheumatism.
  Gonorrhoea is not  always confined to the organs of generation,
or their dependencies: hence, varieties in its seat, owing either to
the sympathies  of other parts during the presence of an urethral
gonorrhoea, or from the direct application, from accident or care-
lessness, of the matter to a healthy mucous surface.  These vari-
eties in the seat of gonorrhoea have chiefly been observed in the
eye, the nose, and the rectum.1
  The more acute forms of gonorrhoea may terminate in resolu-
tion,  or chronic discharges simply, a mere supersecretion, without
ulceration or breach of surface.'  To ascertain this, however, when
a discharge continues indefinitely, without being materially influ-
enced by remedies, the canal of the urethra in the  male, or the
vagina in the female, should be  carefully examined.  The  other
more Ordinary  terminations of gonorrhoea  are  ulcerations of the
urethra, stricture, and diseased  conditions of the bladder, pros-
tate,  or testicles.
  Gonorrhoea can  hardly be confounded with any disease, except
a primary venereal sore  situated in the urethra.  From this it is
to  be distinguished  by the character of the discharge, which, in
the latter instance, is serous, sanious, or bloody, and less in quan-
tity than  in the former, and by the  presence of  a circumscribed
induration in some  part of  the urethra.  The  lips of the urethra
may be everted, and when a sore exists in this situation it can oc-
casionally be seen.  In many instances, however, the ulcer is fur-
ther down the passage, and  then the  latter mode of examination
fails.

  11 have seen three cases where protracted gonerrhoeal discharges have been suc-
ceeded by purulent  discharge from the gums.  The matter found round the sockets
of the teeth could be pressed up by the patient.  In one case, all the teeth were af-
fected, and the gums gradually receded from them, and  were red and spongy.  I am
not able to say on what this condition depended, whether from the accidental appli-
cation of gonorrhoeal matter or not.  This explanation seems most probable.
       5 
66                    PRIMARY SYPHILIS.
   In order to understand clearly the  principles  upon which  the
treatment of a specific  gonorrhoea  is to  be conducted, it will  be
necessary to premise that this disease admits of a  division into
four  stages, to each of  which a distinct  treatment  is applicable;
and it is owing perhaps to prescribing for the first stage what is
only  suited to the second, or to the second what should have been
employed in the first, that the disease is  so often and so  long pro-
tracted.1   The first stage of gonorrhoea is characterized by the ab-
sence of acute inflammation; there is slight pain or heat in mictu-
rition, pufliness and redness of the  lips  of the  meatus urinarius,
which are sometimes everted and sometimes stuck so fast together
by an  adhesive muco-pus  that we have some difficulty in sepa-
rating them; there is also  a slight muco-purulent discharge, and a
flattening in the stream of urine.   This is the first stage  of gonor-
rhoea; and when these symptoms occur wholly or in part  from four
to ten days after a suspicious  intercourse, we may be pretty sure a
gonorrhoea has been contracted, and, if not  cut short, will  run  on
quickly to the second  or  inflammatory  stage.   It  is to the first
stage  only that  the  abortive  treatment  about to be spoken of is
limited.
   The treatment calculated  to cut short a gonorrhoea in  its first
stage  should not, as a  general rule, be resorted to  after twenty-
four hours from the first invasion of the disease, and is then not in
all cases successful.  Yet when the  protracted character of dis-
charges of this kind is considered, their frequent, various, numerous,

  1 Gonorrhoea naturally divides into four forms or stages, which, although they do
not all follow each other with  perfect regularity, yet when a case is presented to us,
it must assume one of the following varieties:—
  1. The first stage is marked by slight puffiness and adhesion of the lips of the meatus,
with slight discharge of an adhesive muco-pus, variable in its duration  from two to
forty-eight hours.  To this stage the  abortive treatment is limited.
  2. The inflammatory stage,  characterized by more or less heat and pain in mictu-
rition, swelling and redness of the penis, with purulent discharge.  This state or-
dinarily continues from seven to twenty-one days; whilst it lasts, a strictly antiphlo-
gistic treatment is to be adopted, and neither injections nor specific remedies used,
although there are here one or two exceptions.
  3. The stage of discharge without inflammation, or marked complications, a pa-
thological condition of the urethra.   In this stage injections and specifics are  ge-
nerally safe and beneficial.
  4. In this last stage, known by the name of blennorrhoea or gleet, the general in-
flammatory symptoms have altogether subsided, and the discharge has diminished
to a drop or two in the day.   The treatment must be regulated by the pathological
conditions of the urethra, and the state of the general health or constitution of  the
patient. 
GONORRHOEA.
67
and even dangerous complications, and sometimes their disastrous
consequences, we cannot but do right to recommend this treatment
when the patient applies in proper  time, and there is nothing to
contra-indicate its employ.   An additional reason that this treat-
ment, under such circumstances, should be employed, is the consti-
tution of certain patients: the scrofulous, the rheumatic, the gouty,
and those troubled with chronic diseases of the skin always suffer
much from gonorrhoea; and if the disease once becomes established
in the system it is very difficult to cure.
  When a patient seeks advice before the inflammatory symptoms
of a gonorrhoea are set in, an attempt may be made to extinguish
the disease by  what has been called abortive treatment;  but if
there be decided marks of inflammation, or any pain in micturition,
or if  the disease have existed more than twenty-four hours, this
treatment will" be attended, to say the least, with risk, if not with
injury, and under the most favourable circumstances  it will not
always succeed.   This plan consists in the use of injections, and
the administration of smart purges, or large doses of fresh-ground
cubebs or copaiba.  When a patient consults me in a state favour-
able  for the  employ of the "abortive" treatment, I  recommend
rest and the lowest possible  diet for, the succeeding twenty-four
hours, with the use of a weak injection of the sulphate of zinc,1 or
diacetate of lead,2 or nitrate of silver,3  which is to be  used  every
hour.  With this, in the form of medicine, I prescribe  a large tea-
spoonful of freshly-ground cubebs every three or four hours.  This
plan  very commonly succeeds, if the patient is in a condition for
its adoption;  and it is perfectly safe, and does not aggravate the
succeeding stages, should  it not succeed.  Nor does  it lay the
foundation of organic mischief in the urethra.  Some surgeons re-
commend strong mercurial and saline aperients, others large doses
of copaiba.4   The cubebs are safer than large doses  of copaiba,
and  either of these remedies more certain, because their action is
more direct, than the treatment by aperients.   It is the practice
of many to employ one, or even more, injections of strong solution

              ! R.  Zinci sulph., gr. viij;
                   Aquae desk, ^viij.  M. ft. Injectio.
              * R.  Liq. plumbi, ^iij;
                   Aquae dest., ^viij.  M. ft. Injectio.
              * R. Argent, nit., gr. ij;
                   Aquae dest., j$viij.  M. ft. Injectio.
  * It is to this stage that the large doses of Copaiba, alluded to in the article on
that drug, are to be limited. 
68                   PRIMARY SYPHILIS.
 of nitrate of silver in this stage of gonorrhoea, varying in strength
 from five grains to a scruple, or even more, of the salt to an ounce
 of water.  I have seen the most disastrous consequences from this
 practice.  It certainly occasions severe pain, which is the least evil;
 very commonly lays the foundation of  organic stricture, or pains
 and discharges from the urethra, which harass the patient for years,
 or for ever.  It frequently fails, prolongs and renders more severe
 the subsequent  stages of the complaint; and its employ has been
 followed by death.

                           Case IX.
   A  student of medicine, previously in good health, contracted a
 gonorrhoea, for which he  used in the early stages,a strong solution
 of the nitrate  of  silver.  An  intense  urethritis succeeded, with
 pains in the groins and abdomen; and on the third day of the attack
 I was sent for to see him.  There was great tenderness over the
 lower part of the abdomen, and a large abscess forming in the right
 groin.  He died within the week  from peritonitis, and the abscess
 in the groin contained more than a pint of matter.1
   The first stage of gonorrhoea speedily passes into the second, in
which the inflammatory symptoms are more marked,  and  the dis-
charge  altered  in character.  The penis is red and swollen, the
urethra feeling like a cord when rolled between the fingers; mic-
turition is frequent, and attended with severe pain; and the patient
is  tormented with frequent and involuntary erections of the penis.
Under  some circumstances, if the inflammation run high, severe
 symptomatic fever may be present.  In the third and fourth stages
 all these symptoms  have subsided, and there only remains  slight
 discharge, with  varied pathological conditions of the urethra.
   It is of immense importance, from reasons already adduced, that
 gonorrhoea should be prevented, or cut short in its commencement,
 since its duration, in many instances, is almost indefinite, and its
 consequences so serious.  Patients, in a  state of alarm after a sus-
 pected connexion, frequently seek the advice of their surgeon with
  1 Mr. Henry James Johnson details another fatal case, and a third where the con-
 sequences were very disastrous.  "On the whole," says he, "this plan is open to
 grave objections, and I am neither disposed to practise nor to recommend it "  (Op.
 cit., p. 60.)
  Vidal (de Cassis) says that he tried nitrate of silver injections for a whole year,
 and succeeded but in one case.  He thinks, and with justice, that we are rarely con-
 sulted sufficiently early to attempt abortive treatment with  safety, or a probability
 of success.  (Op. cit., p. 27.) 
GONORRHOEA.
69
the following symptoms: slight irritation in the urethra, dragging
of the penis and testicles, uneasiness in voiding the urine, with red-
ness and tumefaction of the lips of the meatus, and a slight increase
in the natural secretion of the mucous membrane  of the urethra it-
self.  These symptoms do not indicate that a gonorrhoea has been
contracted, since an excessive excitement of the organs of generation,
without infection, might  produce them; but in the positive absence
of any means of a differential diagnosis between this and the com-
mencement of actual gonorrhoea, it behooves the patient to be care-
ful.  Some are of opinion that many gonorrhoeas might be avoided,
and the symptoms cut short on the onset, if the patients did not com-
mit errors or excesses in diet at this period, and continue to expose
themselves to all kinds of excitement.   This opinion is deserving
of the more attention, since we commonly see a discharge from
the urethra set up and continue for  some  days after a debauch, and
then of itself subside.   When the symptoms  we have indicated
make their appearance, the  patient should strictly adopt and ad-
here to'the lowest possible  diet, repose as much as possible in the
recumbent position, and  take smart aperients with diluent drinks.
The warm bath must be avoided;  this,  of itself, under such cir-
cumstances, has frequently  produced  the disease; the  cold bath,
in warm weather, may be used.
   A true gonorrhoea may be either acute in its commencement, or
ushered in with symptoms so mild,  and apparently so trivial, as to
be termed chronic.   The  disease  also  may assume a variety of
shades of intensity, varying  between these two extremes.  Against
the first form a pure antiphlogistic  treatment should be adopted.
Aperients, low  diet,  with  local bleeding,  by means  of  leeches,
from the perineum, with the warm bath, and complete repose of
the organs affected, constitute the  remedies especially applicable
to the stages of acute gonorrhoea.  Little  medicine is here  requi-
site beside small doses of the nitrate of  potash, administered in a
copious draught of barley-tea.1   The gonorrhoeal discharge may
be ushered in with symptoms less acute than those just described;
and under these circumstances  general bleeding  may be unneces-
sary, although, if the patient be  plethoric  and of full  habit, local

                ' R.  Sodae carbonat., gr. xx ;
                    Sodae potass-tart., j£j.  M.
                Bis terve die sumend.  ex aqua, tepida; or added to half a bot-
                   tle of soda water.—Carmichael.
  Mr. Milton (on Gonorrhoea, p. 38,) prefers the preparation of potass to those of 
70
PRIMARY SYPHILIS.
 depletion in the commencement will most materially facilitate our
 chance  of a  speedy cure.1  Again, in that form  of  gonorrhoea
 which is chronic from the  commencement, it will be well, at first
 to  examine  carefully the  urethra, and if we find a part which is
 indurated, hot, and painful on pressure, to apply a few leeches over
 it.2   It  is merely necessary to state that local bleeding, employed
 for these purposes, is not to be resorted to  for the removal of dis-
 charge  merely; nor without the symptoms of inflammation on some
 point of the  urethra  are evident.   If employed when  the  mem-
 brane is lax,  and no  inflammation is present, where the disease is
 merely  a gonorrhoea and  not  a urethritis, we  shall prolong the
 affection instead of cutting it short.
   An antiphlogistic treatment, although  calculated to facilitate
 the action of other  remedies in the cure of gonorrhoea, is not cal-
 culated  of itself, at  least  but  rarely,  to  accomplish this object.3

 soda, and  they are certainly very valuable in this stage of the complaint.  Mr. Milton's
 forms are the following: —
                   °                                           *
                         R. Potass, chlorat., gij ;
                             Potass, acetatis, ^ss;
                             Liquor, potassae, giij;
                             Pulv.  rhad, Qj—^ss;
                             Aquae dest., gviij.
                         M. §j ter. die.
  The distilled water is to be boiled, and poured  on the chlorate of potass, and the
 other ingredients subsequently added.          s
  Or,                    R. Potass, acetatis,  ^j;
                           Spirit,  aetheris nit., jjiij;
                           Mist, camphorae, §vj.
                         M.  gj ter. die.
  * "Ne"gliger de pratiquer la saigne"e dans  ce cas, c'est laisser €chapper l'une des
indications les plus pressantes."  (Desruelles, p.  421.)
  2 To illustrate by a case the use of topical bleeding  from a point of the urethra,
in that form of  gonorrhoea which is termed  chronic:—A gentleman consulted me,
who had been the subject of a slight discharge from the urethra for five months; he
had frequent desire to void his urine, with a constant and troublesome tenesmus; he
had tried  remedies of all kinds, and injections, during this period, with partial be-
nefit and occasional injury.   On examining his urethra, which had not been before
done, I discovered tenderness, with thickening of the urethra, in the perineum.  Four
leeches were applied with great benefit, and by  their repetition at intervals, three
or four times, he lost his pain, his tenesmus, and the discharge.
  a  Gonorrhoea  is sometimes more than a  urethritis.   Though  it would be, as a
principle,  unsafe to adopt any other than an antiphlogistic treatment  in the  earlier
stages of  this complaint, where the inflammatory symptoms run  high, yet  such a
treatment does not always succeed in subduing them.   I have known cases where
the patient has been confined to bed, lived on nothing but tea and gruel, taken ape-
rients, &c, for a fortnight together, and  yet the inflammatory symptoms have hardly 
GONORRHOEA.
71
 Hence another plan of treatment has been framed, which is termed
 " revulsive."  This consists in the employment of remedies which
 are supposed, by producing a specific action of their own on  the
 lining membrane of the urethra, to  supersede  that of gonorrhoea:
 these remedies are principally  copaiba, cubebs, turpentine,  the
 preparations of iron, iodine,  and  cantharides, with  injections.
 Every practitioner must  daily witness the  uncertainty of the  re-
 vulsive treatment of gonorrhoea  employed  alone, and the change
 from  remedy to remedy,  with  but partial  benefit to the patient.
 In this uncertainty many  authors have endeavoured to  lay down
 certain rules at what period the  revulsive  treatment may be  re-
 sorted to with the most certain hope of realizing its full and cura-
 tive  effects.1  "When the  acute  stage has ceased, although  the
 patient  may yet continue to be troubled with erections, and al-
 though the penis may be heavy and  uneasy, and the glans and lips
 of the meatus still  red and slightly swollen, I have recourse to
 those  remedies which are termed  ' par excellence' anti-gonorrhceal,
 which, however, I  abandon, to have recourse  again to  antiphlo-
 gistics, if their employment occasion the  least increase of inflam-
 mation."3   The use of specific remedies should be limited to the
 purulent stage of gonorrhoea, when  the more  acute  symptoms of
 inflammation have  been subdued.  "  When an impression has been
 made  on the inflammatory symptoms, and they cease to advance or
 remain stationary, the urethra should  be  injected every morning,
 and the  patient should be  placed  under the  combined influence of
 the balsam of copaiba and cubebs."
   We are not to conclude from what has been  said, that in all in-
 stances an antiphlogistic treatment is to be employed in gonorrhoea
 before we have recourse to those remedies that are more particu-
 larly termed specific.  Thus, in scrofulous  and weak subjects, or
 those previously troubled with nocturnal  emissions, the inflamma-
 tion may be of  so passive a character that it  will be proper  to
 have recourse at once to the revulsive treatment, with injections.
 In all  such cases, however, as I have before  said, a careful exami-
 nation of the state of the  urethra and the constitution of the pa-
 tient should  be  instituted.
yielded at all;  whilst under such circumstances, with the cautious use of specific
remedies and mild injections, the  symptoms have very quickly abated.  If the acute
symptoms of a gonorrhoea do not yield in ten or twelve days to antiphlogistic treat-
ment, the so-called specific remedies should be cautiously administered.
  ' They should rarely be employed before the  tenth day of  the disease.
  3 Ricord, pp. 725-6. 
72
PRIMARY SYPHILIS.
  The copaiba balsam is one of the most common remedies used
in the revulsive  treatment of gonorrhoea, and that upon which
most dependence is to be placed.  It may be employed early in the
disease, unless the inflammation of the urethra be very acute; it
is then only to be used when the symptoms are in some measure
mitigated  "by general or local  bleeding, &c.   If the  disease be
subacute, it may be  administered  during the  period  that local
bleeding from the perineum, &c. is practised.   In the  chronic
forms of the complaint  it may at once be employed.   Ricord re-
marks, that it is only  against the  urethral form of  gonorrhoea
that copaiba is efficacious;  he believes it possesses little or no in-
fluence over the vaginal  or uterine varieties, &c.  Both  this author
and Desruelles think it is  much more effectual given  alone than
in a state  of combination with other remedies,  and recommend
it to be given, as the most pleasant way and least  likely to disturb
the stomach, on the surface of a glass of white  wine  or lemonade.
I believe  its effects  are more marked  in a state of combination,
at least that the  combination is more beneficial than the balsam
taken singly.1  It may be given by way of enema when the stomach
will not bear it; but when so employed, the dose must be much larger
than when given by the mouth.  The copaiba has likewise been ad-
ministered with success  in large doses at the very onset of gonor-
rhoea, however acute, and without any preparatory treatment.  Mon-
teggia and Fuller administered from half an ounce to an ounce of the
balsam for a dose night and morning, at all periods of the disease.2 M.
Delpech succeeded in curing four hundred cases by administering
two drachms and upwards for a dose three times a day: if the in-
flammation was acute, general bleeding preceded its employ.3 Ros-
signol was successful in three hundred cases of gonorrh'oeas of all
kinds. He employed large doses of the  medicine uncombined, and
did not submit his patients to any preparatory treatment, or any
dietetic regimen.4  The average duration of treatment in these
cases was  eight days.  The method we  have just described must
be employed with caution;  and in most cases where the patient is

              1 R. Bals. copaibae, §ss;
                   Pulv. cubebae, gvj;
                   Liq. potassae, giij;
                   Pulv. acaciae, ^ss;
                   Aquae cinnamom., ^vij.  M.
  a Bulletin de la SochSte" MSdicale d'Emulation, 1822.
  3 Revue M6dicale, t. vii., p. 403.
  * Dictionnaire de Merat et Delens. 
GONORRHOEA.
73
plethoric it would be well to accompany or precede it with a ge-
neral bleeding.  We think it might be then employed with pretty
general success in cutting quickly short a gonorrhoea, when a pa-
tient applies immediately after  having contracted  it.  M. Lalle-
mand, in repeating the experiments of M. Ribes,1 concludes that,
although the large doses of copaiba  succeed sometimes in cutting
short an acute gonorrhoea, they sometimes augment  the  inflamma-
tory symptoms and the discharge.  1 have seen one or two patients
in which an incurable incontinence of urine has been brought  on
by large doses of copaiba.
   The balsam of copaiba may be administered alone in wine or le-
monade, as I have said, and this is the best way when it is used in
the  commencement of the disease.  It may also be given  in va-
rious forms of combination.
   The essential oil of copaiba, the resin of copaiba, the balsam en-
closed in capsules, the alkaline solution, and  a soluble extract,
have been employed  with the  vie,w of  getting  rid of the un-
pleasant smell and taste of the balsam fthese remedies, however,
are  none of them entitled to the same confidence as the latter re-
medy.2
   The  piper cubebae is employed  in  the revulsive treatment of
gonorrhoea, after the same manner as the copaiba.   It may be ad-
ministered in moderately large  doses on the onset of an acute af-

   ' Memoire sur l'emploi de  baume de copahu a haute dose dans la gonorrhe"e et l'en-
gorgement consecutif du testicule.   (Loc. cit., et Revue Me"dicale, t. ix.) M. Ribes
gives from two drachms to an ounce of the balsam for a dose, to  cut short a gonor-
rhoea in the commencement.
             1 Particular forms for the administration of Copaiba.
                        MIXTURES.
                R. Balsam, copaibae, t^j ;
                  Mucilaginis gummi acaciae, gij;
                  Vini  Xerici,  giv.  M.             (Val de Grace.)
               A fourth part twice a day or more frequently.
                R. Balsam, copaibae, gj ad §ij;
                  Aquae, giv;
                  Vitelli ovi, No. 1;
                  Liq. opii sedativ., ni x ad xx.       M.  (Cullerier.)
               The quarter part, or more, night and morning
                R* Balsam, copaibae,
                  Syrup, tolutanos,
                  Mucilaginis  gummi acaciae,  aa gj ;
                  Aquae rosae, giij.
                  Sp. aetheris nitric, giij.
               The quarter to the half, night and morning. 
74
PRIMARY  SYPHILIS.
 fection, with a view of at once cutting it short; when  employed,
 however, under these  circumstances, the same rules must  be  ob-
 served as those we  laid  down for the administration of copaiba.

                  R. Aquae menthae pip.,
                     Sp. vini rect.,
                     Balsam  copaibae,
                     Aquae aurantii,  aa ^ij;
                     Sp. aetheris nit., gj.  M.              (Chopart.)
                 Two large spoonfuls, three times a day.
                  R. Resinae copaibae,
                     Sp. vini rect.,
                     Syrup, bals. tolutan.,
                     Aquae menthae pip.,
                     Aquae aurantii,  aa ^ij;
                     Sp. aetheris nit., gij. M.              (Chopart.)
                 Three or four large spoonfuls, night and morning.
                            PILLS.
                  R. Sapo. Hispaniolae, ^ij;
                     Balsam, copaibae, ^j;
                     Pulv. glycyrrhizae, q. s. ft. pil. 120.
                 Dose.—From  15 to 40 a day, at intervals.
                  R. Ext. catechu, gss;
                     Bals. copaibae, giij;
                     Terebinthinae chiae, ^j;  *
                     Sanguinis draconis,  gss.  M.
  To be made into pills or boluses of ten grains, from ten to thirty of which are to
be taken daily, at intervals.
                 R.  Ext. catechu,
                     Bals. copaibae, aa giij;
                     Hyd. chlorid., J}j;
                     Pulv. glycyrrhizae, q. s. ft. pil. 150.
                 Dose.—Twelve a day, at intervals.
  When employed as an enema, the dose of the  balsam should be from half an ounce
to an  ounce, f
                        INJECTIONS.
                 R.  Bals. copaibae,
                     Vitelli ovi, aa gss;
                     Infus. rosae, §xv.   M.
                 R.  Bals. copaibae, gj;
                     Sacchar. alb., gj;
                     Sp. vini, gvj;
                     Aquae  destillat., gxiv;
                     Ext. opii, gr. vj.
  * I have substituted the  chia turpentine for the  colophane, or powdered yellow
resin, of the original prescription.
  f See Velpeau;  Recherches et Observations  sur  l'Emploi du Baume de Copahu,
et du Poivre Cubebe, administrSe par l'anus contre  la blennorrhagie.  Archives g6-
ne"rales de M^decine, t. xiii.,  p. 45. 
                              GONORRHOEA.                          75

 The cubebs may also be given in chronic gonorrhoea, and in gleet,
 separately, combined with copaiba, or  united with some prepara-
 tion of iron.   It may also be employed in form of enema.1
   Many other remedies may be resorted to in the protracted forms
 of chronic gonorrhoea: these are chiefly the preparations of  iron;
 chalybeate waters; iodine, particularly in its combination with iron,
 so successfully employed  by Ricord, Richard, and  Henry;3 lead,3

   Mix the balsam with the  sugar, then  add the  alcohol and the water gradually;
 pass the injection through a funnel with a view of extracting those portions of the
 balsam which may not be dissolved.  This injection is employed  at Val de Grace, in
 chronic gonorrhoea, complicated with cystitis.
   ' The piper cubebse soon loses all  its medicinal properties when ground.  In order
 to derive any benefit from it, it should be fresh ground, as it is wanted.
                   Particular Forms for the exhibition of Cubebs.
                      MIXTURE OF CUBEBS AND  COPAIBA.
                           R. Bals. copaibae, gss;
                              Pulv. pip.  cubebae, ^j;
                              Vini Xerici, giij;
                              Aquae rosae, aurantii, vel menthae, ^v;
                              Pulv. acaciae, q.  s.;  ft. mist.
   Employed with great success at Val de Grace, in acute or chronic urethritis.
                           ELECTUARY OF CUBEBS.
                           R. Pulv. pip.  cubebae,
                              Sanguinis draconis,
                              Pulv. ratanhiae,
                              Ext. catechu, aa ^ij;
                              Bals. copaibae, q. s.; ft. elect.
   Dose.—From two to four drachms every twenty-four hours, in chronic gonorrhoea,
 or gleet.
                           R.  Pulv. pip. cubebae, §ss;
                              Balsam, copaibae, gij;     Q
                              Ferri sulphatis, gj;
                              Resinae flavae, v. terebinthin. chiae, giij.  M.
   To be made into boluses of ten grains each. Dose.—From fifteen to thirty a day,
 at intervals.   In chronic gonorrhoea, or gleet, in lax constitutions.
                          R.  Pulv. pip. cubebae, gj ad gij;
                              Ferri carbonat, gss ad jjj.  M. ft. pulv.
  This mode of exhibiting cubebs combined with the carbonate of iron is much and
 successfully  employed after  the acute symptoms of a  gonorrhoea have  subsided.
 One powder should be taken three times a day.
                          2 R.  Ferri iodidi, gr. ij ad v, or more.
                               Pulv. opii, gr. \;
                               Mucilaginis, q.  s.; ft. pil.
                           Ter. die sumend.
                          3 R.  Plumbi acetatis, J}j;
                               Bals. copaibae, 3J;
                               Pulv. glycyrrhizae, q. s.; ft. pil. xxiv.
  Dose.—One pill to eight.   Employed with advantage by Desruelles in chronic
gonorrhoea, or gleet. 
\
 76                  PRIMARY SYPHILIS.

cantharides, and turpentine.1   In all instances, however, of chronic
discharges  from  the  urethra,  this  canal  should  be carefully
examined, to determine, if possible, the pathological  conditions
which keep up or are associated with the discharge; without  this
we must be at a loss for correct indications, we must prescribe at
hazard, and our patient's disease  may be prolonged indefinitely.
It is often of great service to employ small local bleedings from the
perineum at the time we are using astringent or tonic  injections,
or the remedies alluded to in the present chapter.
   I have hitherto said  nothing about the use of mercury in gonor-
rhoea, because I do not believe in the  specific effect of mercury
over purely gonorrhoeal diseases.2   Dr. Wallace employed it  con-
stantly in gonorrhoea till the system was brought slightly under its
influence, with the view " of  preventing bubo  and  secondary
symptoms."  I believe  this opinion to have originated, as I have
before stated, in a false notion of the pathology and nature of this
disease.   Whilst,  however, I  deprecate the  use of mercury as a
specific remedy in gonorrhoea, I think it a remedy  of great utility
in the latter stages of  this  affection, exhibited with a view of re.
moving those morbid changes in the urethra which long-continued
chronic inflammation has occasioned.  With this object it may be
advantageously employed in the manner laid down by Dr. Wallace.
" When," says this author, " gleet  or chronic gonorrhoea is  con-
nected with an indurated state of  the urethra, &c, it will be  pru-
dent to submit the patient to a short course of mercury, partly be-
cause the  indurated and narrowed state  of the  urethra often
depends on  the  specific effects of the venereal  poison, and partly
because, even  wlien this is  not  the case, an alterative course
of mercury frequently  offers the best remedy.  Indeed  I have, on
many occasions, experienced much  pleasure on observing not only
the gleety discharge, but also the  contracted  and  indurated state
of the urethra  to disappear, as soon as the patient's  constitution

                 1 R. Terebinthinae chiae,
                     Sanguinis draconis, aa gij;
                     01 ei terebinth., q. s.; ft. pil. xxx.
  Dose.—From three to six or more in the day.
                  R. Guaiaci resinae,  pulv.,
                     Terebinthinae chiae, aa £j.  M. ft. pil. xxiv.
                  Capt. iii v. iv bis terve die.   In gleet, or chronic gonorrhoea.
  2 Yet I have seen two cases, one where an  accidental salivation cured  an inveterate
class, and another case, of fourteen months' duration, where an eminent surgeon
prescribed mercury to salivation with  success. 
GONORRHEA.                        77
was brought under the specific influence of mercury."l  Dr. Wal-
lace recommends, as exceedingly efficacious, a combination of calo-
mel with antimony and opium.2
   Many surgeons object to the use of, injections in gonorrhoea, fear-
ing that they frequently occasion stricture, and other morbid condi-
tions of the urethra.  I am, however, of opinion, that a long-con-
tinued  irritation or inflammation  of the urethra is much  more
likely to give rise to these evils, and hence it is of consequence to
cure a gonorrhoea by the means which will accomplish this  object
most quickly, at the  same time that they do it safely.  It is true that
injections require great  caution in  their use, and their injudicious
employment is frequently followed by serious consequences, but, in
these instances, the  blame rests with the surgeon, and not with the
remedy.  Injections should  generally be used  from three to six
times in the day, and the fluid injected should  be made to remain
in the urethra a minute  or two before it is discharged.3
   In the  acute  forms of gonorrhoea, injections are  inadmissible;
they should be employed as  soon as this  stage is passed, and in
cases chronic  or indolent from the commencement, they may at
once be used.
   To cut short a gonorrhoea at once, when a patient  applies be-
fore the acute  stage has commenced, Ricord prefers injections of
tne  nitrate of silver, which  he employs of the strength of two

                      1 Op. cit., p. 285.
                      3 R. Hyd. chlorid., gr. j  ad iij;
                           Pulv. antimon., gr. iij ad v;
                           Pulv. opii, gr. ss.   M.
                           Conf. aromat. q. s.; ft. pil.
                     Nocte maneque sumend.
   If the disease occur in a gouty or rheumatic constitution, colchicum may be sub-
stituted  for the antimony in the above prescription.
'   a The manner of using injections is important, and the patient should be instructed
by his surgeon how to inject the urethra, if he do not perform this operation him-
self.  The whole  surface  supposed to be  diseased should be brought into contact
with the injection, and for this purpose syringes with a long point or nozzle should
be used, as introduced by Mr.  Milton, or again, a small catheter perforated at 'the
sides, may be introduced into the urethra, and the injection poured  through it: in
other chronic forms of the disease when the prostatic or membranous portions of the
urethra are implicated, a catheter should be passed into the bladder itself, and the
injection thrown through it into the bladder; the instrument must be then withdrawn,
and  the  injection  poured out  through the urethra, the whole urethral surface of
which is thus in contact with the injection, as it is forced out by the contraction of
the bladder.  In chronic cases, where the seat of the complaint is uncertain, this is
the most efficacious mode of using injections that I have ever practised. 
78
PRIMARY  SYPHILIS.
grains  to eight ounces  of distilled water,1  gradually increasing
the  strength  as long as  no irritation is produced.   When the
acute stage has passed, this surgeon generally employs the acetate
of lead2 for a few days, but has recourse  again  to the nitrate of
silver in stronger solution, if the lead  does  not quickly succeed.
Dr. Wallace employs  the nitrate ef silver as long as  any morbid
sensibility exists in the  urethra; when this has ceased, and the
discharge still' continues, recourse  may be had to  solutions of bi-
chloride of mercury, the acetate of zinc, or the sulphate of copper;
the  chloride of zinc  has also  been lately very successfully em-
ployed.3
  A vast variety of injections  are employed in the various forms
of chronic  gonorrhoea; those which I have already indicated are
most generally used and  successful.  When the disease has become
perfectly atonic, and  all morbid  sensibility has disappeared,  or
when the patient is merely teased with a drop or  two  of mucous
discharge oozing from the  urethra once or twice in the day, injec-
tions of wine are used extensively both by Ricord and Desruelles,
and  with much success, alone, or combined with tannin.4  The in-'

                  1 R. Argent, nit., gr. ij—gr. v.
                       Aquae destillatae, ^viij.  M.  ft. injectio.
                  2 R. Plumbi acetatis, Qij;
                       Aquae rosae, ^vj.  M.
  This strength is for the male urethra; if used as an injection in vaginal gonorrhoea,
&c, the quantity of the acetate of lead may be much increased.
                  R. Argent, nitratis, 9j ;
                      Aquae destillata;, Oj.   M.
                  As an injection in chronic urethritis.—
                   R.  Adipis, |j;
                       Argent, nitratis, gr. iv.   M.
  Of use in the same affection, smeared upon a bougie,  and  thus passed into the
urethra.
  Injections should  never be used sufficiently strong to  cause severe pain in the
urethra;  mucilage and camphor are advantageously added to prevent this.
                  3 R. Hydrarg. bichlorid., gr. j—ij;
                        Aquae dest., ^viij.
                     R. Zinci acetatis, gr. xij—7,] •
                        Aquae, §viij.  M.
                     R. Cupri sulphatis, gr. xij;
                        Aquae, ,^viij.  M.
                     R. Zinci chloridi, gr. viij;
                        Aquae, ^viij.  M.
                    The strength gradually increased.
                     ' R. Aquae rosae, ,^iv;
                         Vini rubri, ^ij.  M.— 
GONORRHOEA.
79
fusion of galls1 with alum is also useful, and lately M. Ricord has
employed  the iodide of iron.2   In weak solutions  the iodide of
iron has frequently arrested the gonorrhoeal discharge  in four or
five days;  in other instances it has brought on an acute attack of
urethritis; but in these instances, when the inflammation has sub-
sided, the patient has been cured of his gonorrhoea.   In these in-
stances, the average duration of the treatment has not been more
than seven or eight days; in a  third  series of cases the patients
have been  unable to bear  the irritation which injections of the
iodide of iron occasioned, and consequently its employ was given up.
  It will often be found of great service to vary the character of the
injection, when one appears, from  continued use, to have  lost its
effect:  we shall also find that some patients  bear one kind  of in-
jection better than others; hence I have found persons much bene-
fited  by port wine and tannin, who could not  bear the weakest
solution of the nitrate of silver.
  Ricord, Fricke of Hamburg, and Desruelles, agree in opinion,
that gonorrhoea is kept up occasionally from the contact of the two
sides of the urethra;  and hence it was  proposed  by Fricke to in-
troduce, by means of an elastic gum  catheter or bougie,  a fine
piece of lint into the urethra, and let it remain there, removing  it
only at each  period of  making water; the lint may be employed
dry, or soaked in any astringent injection.   The practice has been
followed by occasional success.3
  Sometimes all our remedies are unsuccessful in checking the dis-
charge; it then becomes  necessary to examine  carefully the ure-
thra, to discover upon what pathologic  condition the  continuance
of this depends.  In cases of morbid  sensibility of one  portion of

  The quantity of wine gradually increased, till at length it may be employed pure.
Desruelles adds a sixth or an eighth part of brandy.
                    R.  Vini rubri, gvj ;
                        Tannin, gr. xviij.  M.
  For the male urethra; for the vagina, the  quantity of tannin may be doubled,  or
still further increased.  I have found this injection very valuable.
                    ' R. Gallae, & ad ^ij ;
                         Aluminis sulph., v)ij;
                         Aquae ferventis, ^viij.   M. ft. injectio.
                    3 R. Ferri iodidi, gr. iij ;
                         Aquae dest., j§vj.   M.
  The quantity of the iodide may be gradually increased.  Its employ requires cau-
tion and watchfulness.
  1 See Ricord, op. cit, p. 745, and in the  Gazette des Hopitaux; also Desruelles,
op. cit., and Fricke, Lettres au Dr. Desruelles, &c. 
80
PRIMARY SYPHILIS.
the canal  only, the solid nitrate of silver may be directly applied
to it, by means of the "port caustic"  of  Lallemand, or any other
convenient instrument.   When most other means have failed, and
a running still continues, with uneasiness, or morbid sensibility in
the urethra generally, or in several parts, Ricord considers it ad-
vantageous to pass the solid nitrate of silver over  the whole af-
fected surface of the urethra.   Chronic urethral discharges which
have continued for a long  period  lose their local  character, and
become  constitutional diseases.  I have succeeded  frequently in
curing them  by general remedies, when all specific treatments
had failed.
   Gleet, or Blennorrhoea, are names applied  to a class of symp-
toms which commonly succeed to the more active forms of gonor-
rhoea.
   In true gleet the discharge is said to  be  transparent, and of a
mucous and not purulent character; but  it will  almost always be
found that if  the  discharge exist in sufficient  quantity to be  col-
lected on a glass slide, and submitted to  microscopic examination,
it contains pus globules.
   The symptoms of gleet are variable.  Sometimes the lips of the
meatus are merely glued together by an adhesive matter, and no
discharge can be perceived; at others a slight oozing of a transpa-
rent fluid occasionally takes_ place  dail^y, or  only once in  three or
four days: again a drop will appear the first thing in the morning
and at no other period;  and in a spot or two of discharge follow-
ing the flow of the last drops of urine.  There are cases where no
excitement, either sexual or dietetic, appears to influence these
discharges, and there are other cases in which excesses of this kind
increase the discharge and render it purulent, if it was not so be-
fore.
   At times these discharges can only be forced  out by squeezing
the urethra between the fingers. When they succeed to the  flow
of the last drops of urine, they are  either seminal, prostatic, or
vesical,  and are forced away by the  increased muscular  exertion
necessary to  its expulsion.  Gleet is sometimes associated with
stricture,  and to ascertain its nature the urethra should always be
carefully  examined before framing a plan of treatment for the pa-
tient.  At times no change  can  be detected in the  urethra, and a
bougie of full size passes freely and without  pain into the bladder;
at other  times there is a peculiar soreness or tenderness at one
point, generally in the  vicinity of the membranous or prostatic 
GONORRHOEA.
81
 portion of the urethra; the passage is occasionally irregular and
 uneven, and when stricture exists discharge always takes place on
 withdrawal of the bougie after it has passed through the stricture.
 In all gleety discharges of long continuance, the condition of the
 urethra behind the scrotum and that of the prostate should be as-
 certained, since some forms of gleet are frequently dependent on
 chronic mischief in the latter organ.
  In some forms of gleet, although of long continuance, little con-
 stitutional or sexual debility is produced, but this is not commonly
 the case;  a certain amount of sexual weakness almost always suc-
 ceeds to a long-continued gleet, in which  the viril  power is more
 or less weakened or even altogether impaired or destroyed.  This
 is especially the case if the gleet depend  on  causes situated in the
 prostatic  portion of the urethra, or be complicated with discharges
 of semen, or the " liquor prostaticus,,n which is sometimes the case.
 In lax and irritable systems, where a gonorrhoea becomes implanted
 on a constitution where the sexual powers have been weakened or
 rendered  irritable by excess, these complications are not uncommon,
 and in such cases the virility of the patient sustains a fearful shock.
  Gleet is  the  termination of a gonorrhoea,  and an inflammatory
 disease, and hence it may happen that the discharge results from
 chronic inflammatory mischief, localized in  some part of the urethra:
 should this be well marked, an abstinence from  stimulants, three
 or four leeches  to the perineum, and a blister, may be of service;
 unless however  the inflammatory action be well marked,  bleeding-
 must be used with great caution, as it frequently tends to prolong
 a gleet.   Blisters to the perineum in such  states,.dressed with mer-
 curial ointment  till they are healed, succeed better.
  If the discharge appear to come from a point of the urethra an-
 terior to the bulb, injections will in most cases be of service, they
 should be weak  and frequently rqpeated.  In addition to those al-
 ready mentioned, the bichloride of mercury is here perhaps one of
 the best.2  If injections are to succeed, the whole mucous surface
 must be brought into contact with the remedy, and this is perhaps
 the reason why injections often  fail.  If the disease be confined to

  ' The exact nature of these discharges is at once rendered evident, by submitting
them to microscopic examination.  In a complication,  such as I have just alluded to,
we find the peculiar  globules of the liquor prostaticus mixed commonly with a few
spermatozoa and ordinary pus globules.
  2 R.  Hydr. bichloridi,  gr. j;
       Aquae destillatae, ^xij.  M. ft. injectio.
       6 
82
PRIMARY  SYPHILIS.
one or more of the lacunae anterior to the bulb, an injection as com-
monly practised is useless, for it does not reach the seat of the dis-
ease:  should they be practised in the ordinary manner, for any com-
plication behind the bulb, they are still  more inefficacious.  They
are good remedies  if properly applied.  In order to inject the
whole urethral  surface anterior  to the  bulb, a small  electro-gilt
catheter, perforated at the sides in its whole length, and about six
inches long, should be passed into  the urethra; the point of a sy-
ringe, holding about four ounces, should then be applied to its ex-
tremity, and the injection gently pressed in through the catheter;
the injection  passes  through the  foramina, and  comes in contact
with all the mucous surface, and acting laterally injects the cavities
of the lacunee themselves; the injection runs out by the  sides of the
catheter, so that the action can be kept up as long as it may be re-
quired.
  I adopt a different plan in affections of  the deeper-seated  portions
of the urethra.  I pass a catheter into the bladder itself, and throw
the injection through it to the extent of four or  six ounces; then
withdraw the catheter, let the injection remain a  few minutes, and
desire the patient to force it out.  The bladder should be  emptied
before the  injection  is  used.  In  this  manner weak solutions of
creosote, bichloride of mercury, nitrate  of silver, the  tincture of
the sesquichloride of iron, and other remedies, may be used, with
perfect safety and a very great amount of success.
  Bougies  are valuable remedies in the  treatment of many forms
of gleet.   They may be used simple or smeared with various kinds
of ointments,1 and in many cases  succeed where injections  fail.
They are especially useful if this complaint be combined with stric-
ture, or that uneven condition of the urethra already alluded to,
which is  so common in many forms of gleety and spermatorrhceal
discharges. A bougie is useless if too small, injurious if too large:
it should moderately distend the urethra, but not unduly stretch it.
A bougie should be  suffered to remain in the urethra till some
amount of irritation is produced by its presence.   It is a good plan
to pass the bougie at night, desiring the  patient to retain it for an
hour or more.   In such instances it is well to retain the bougie by

                1 R.   Argent, nitratis jjj;
                     Unguent, cetacei, ^j;  M.
                 R.   Ung. hydrargyri fort, gj ;
                     Ext. belladonnae, gij. M.   (Vidal de Cassis.) 
GONORRHOEA.
83
a piece of tape;  should the patient fall asleep, it might slip down
the urethra.
  From the time of Benjamin Bell to Mr. Milton, blisters have
been applied to  the perineum  and penis  for the cure of gleet.   I
have used them often, at best with variable and uncertain success.
Blisters to the penis are a nuisance to the patient, and must neces-
sarily confine him, for a  short  period  at least.  They are useful
only when the disease is located in some spots anterior to the bulb.
One rarely cures, and we  can hardly persuade a patient to repeat
a remedy of this  kind time after time.  In the deeper-seated forms
of disease, blisters to the perineum may be advantageously com-
bined with the bougie and injections.
  Internal remedies alone are rarely successful in the cure of gleet.
It generally happens that, when the surgeon is consulted first, the
patient has been ringing the  changes on all kinds of specific reme-
dies.  In such cases it is well to abstain for a time from everything
of this kind, to regulate the diet  according to the constitution of
the patient and the peculiarities of the disease, and exhibit a smart
mercurial,  followed  by a saline  aperient, repeating  the remedy
once or twice.
  Specific remedies rarely succeed in curing a gleet.   Should they
be  indicated,  I  generally prescribe them in combination with
tonics.!   Tonic remedies  alone are frequently useful.2   Occasion-
ally, when there is a thickened and uneven condition of the urethra,
I have found much benefit from  alterative mercurial medicines.3

                1 R.  Bals. copaibae, ^ss;
                     Tinct. cantharidis, gss;
                     Tinct. ferri  sesquichlor. ^j.  M.
                 Capt. guttas xxx., ter. die.
                1 R.  Tinct. cantharidis, gj ;
                     Quinoe disulph., £ss;
                     Tinct. ferri  sesquichloridi, gij;
                     Acid, sulph. dil., n^ xxx;
                     Aquae destillat., §viij.
                 M. §j ter. die.           (Childs.)
                8 R.  Hydr. biniodidi, gr. iij ;
                    Potass, iodid., 33;
                    Spirit, vini rect., ^ss;
                    Syrup, aurantii, ^iss.  M.
                 Capt. guttas xxx., ter. die. 
84
PRIMARY SYPHILIS.
                       CHAPTER VI.

  OF DISEASES WHICH COMPLICATE OR SUCCEED TO GONORRHOEA IN
                          THE MALE.

  The diseases which complicate, and succeed to gonorrhoea in the
male, are exceedingly varied and numerous, and very frequently
of much more consequence than the original affection, to which,
however, they are in most instances strictly due.  The following
are those which I have most commonly observed and treated.
  Occasionally when a  patient has suffered from gonorrhoea, and
when the more prominent features of the disease have altogether
subsided, the patient, after micturition, finds that he has not com-
pletely emptied the urethra, although he fancied  that be had done
so; the water comes away in drops, orjn a stream, for some minutes
or even longer, wetting the linen, and rendering him extremely
uncomfortable.  This I attribute to an  alteration in  the natural
elasticity of the urethra, for on examination  no stricture is to be
found.   The proper remedy is the bougie; one of large size should
be introduced  three times a week, and suffered  to remain  in the
urethra for an hour, if  no irritation be produced.
  Strictures in the urethra are almost always the consequence of
protracted gonorrhoeal  inflammation, seated in one or  more points
of the urethra, which,  ultimately extending to the  subjacent  tis-
sues, occasions thickening, induration, or vegetation.   These are
the diseases which, in the expression of Desruelles, an imprudent
youth bequeaths  to adult age, and which, in  certain instances, at
more advanced periods, render the patient's life miserable.   In  the
advanced stages of chronic gonorrhoea, recourse should be always
had to the bougie, which should occasionally be passed, with  a view
of preventing contraction or thickening of the  passage, and pro-
moting the absorption of any submucous deposit, or effusion, that
may have taken place.
   When a gonorrhoea is seated in the deeper parts of the urethra,
in the membranous or  prostatic portions, the rectum is sometimes 
GONORRHOEA IN THE MALE.                85
sympathetically affected, and the patient very often suffers from
severe  pain in the  fundament, and a very troublesome tenesmus.
This sympathetic irritation is  carried  in some cases so far, parti-
cularly if the patient have used much exercise during the course of
his disease, that inflammation is set up in the subcutaneous cellular
tissue surrounding the anus, and abscesses form.  If circumscribed
swelling, with heat and tenderness in the vicinity of the anus, come
on during the course  of  gonorrhoea, the parts should be freely
leeched, and the  patient subjected to the  recumbent position, and
perfect quietude.   Supposing these means have little or no influ-
ence,over the circumscribed induration, and the presence of matter
be suspected, this should at once be discharged by a very free in-
cision: if a puncture instead of an incision be made, the matter in
all probability will  not get free vent, may burrow up by the side
of the rectum, and  a true  " fistula  in ano " may ultimately ensue.
I have seen two or three instances in which such a  result has taken
place.
   Although  gonorrhoea  is not generally  followed by secondary
symptoms, properly so called,1  it appears to  dispose the  economy,
either from sympathy, metastasis, or other  causes, to several dis-
eases of a very important nature.  One of these diseases is gonor-
rhoeal rheumatism, which makes  its appearance under two forms;
the first seated in the joints, and resembling very much synovitis
from other causes;  the  second confined more to the muscles and
aponeuroses, and  affecting the fleshy parts, such as the shoulders or
hips.  In some instances these diseases are owing to a sudden sup-

  1 Two classes of constitutional diseases or secondary symptoms, properly so called,
succeed to  discharges from the urethra, which resemble gonorrhoea: the first are
acute, and succeed to the quick suppression of a free  discharge; the second are
chronic, and resemble the ordinary forms of secondary syphilis generally.  The fol-
lowing case illustrates the first-mentioned affection:
                              Case X.
  A very healthy young man contracted gonorrhoea, which was  marked by profuse
discharge.  He consulted a druggist, who prescribed for him an injection, which he
used very freely, and dried up the discharge.  Soon after its suppression a bubo
formed in the right groin; and its appearance was succeeded by an eruption of red
blotches over the whole body, and superficial redness of the fauces.  . At this period
I was consulted; the skin disease was an acute syphilitic roseola; the redness died
away into a marked copper coloured mottling.
  Cazcnave says, " This is the form of skin disease (roseola syphilitica,) which gene-
rally appears  when a gonorrhoea has been suddenly suppressed, either by injections
or large doses of copaiba." In the above instance, no copaiba had been taken, al-
though this is commonly  called the "copaiba rash." 
86
PRIMARY SYPHILIS.
 pression of the gonorrhoeal discharge, whilst in others they bear a
 strict relation to the condition of the local disease, the rheumatic
 symptoms yielding as the discharge lessens, and returning with in-
 creased force, when, from any circumstances, the gonorrhoea becomes
 worse.   When these forms of rheumatism complicate gonorrhoea,
 or appear to  be produced by it, the gonorrhoea itself is generally
 very troublesome to cure.  The treatment will depend altogether
 upon the form under which the rheumatism is manifested.  If syno-
 vitis be present, it may be necessary to leech the affected joints,
 whilst the patient takes, in combination with the  ordinary specific
 remedies, colchicum, camphor, or opium.1  If the disease be owing
 to a sudden suppression of the discharge, it has been recommended
 to bring it back by introducing a bougie, smeared  with gonorrhoeal
 matter into the urethra.  The warm,  but more  particularly the
 vapour-bath, is an important adjunct to any internal treatment that
 may be  adopted.
  Pure  gonorrhoeal ophthalmia may arise—1st,  From  the direct
 application of gonorrhoeal matter  to the eye; 2dly, From  metas-
 tasis;  and,  3dly, It has been supposed to be due to sympathetic ir-
 ritation merely, without either the  direct  application of  gonor-
 rhoeal matter or from  metastasis.   Some writers have denied that
 the direct application of gonorrhoeal matter to the eye of the same
 individual has power to produce the first form of the disease, and
 this was the opinion of Dr. Vetch.  Numerous  cases, however,
 establishing the fact that gonorrhoeal  matter produces the most
 destructive form of inflammation of the  eye, have fallen under my
 own notice, and under that of all modern surgeons who have writ-
 ten on the disease.  In  the  second form of the disease the eye is
 supposed to suffer from metastasis, analogous to  those  successive
 attacks of different parts which are observed in  gout or rheuma-
tism.2   That  this form of ophthalmia is  not caused, like the  pre-
 ceding, by  the direct  contact  of matter from without  is  demon-
strated by the fact that  it has been observed to occur more than
once in the same individual, although every means had been most
carefully employed to protect the eyes from contamination.3

         R Ext. colchici acetic, gr. j ad gr. iij;
            Camphorae,  gr. iij;
            Pulv. opii, gr. ss;
            Ft. pil. ter die sumenda.
         3 Lawrence; on the Venereal Diseases of the Eye, p. 34.
         3 Wallace, op. cit. 
GONORRHOEA IN  THE MALE.
87
  Mr. Lawrence thinks "as much blood should be taken from the
arm as will flow from the vein, and that the evacuation should be
repeated as soon as the state of the circulation will allow us to
get more."  (p. 36.)  Blood must also be taken from the temples
by cupping, and by the free application of leeches round the part,
until the pain and vascular congestion  is relieved.  Mr. Wardrop
goes so far as to say that the only case of gonorrhoeal ophthalmia
he had seen, in which the eye  was saved, was that of a young wo-
man, in whom venesection was repeated as often as blood could be
got from the arm.  Bleeding alone, however, must not be depended
on; but  at the very commencement of the disease  local applica-
tions of an astringent character, hereafter  to be mentioned, must
be combined with it.  Notwithstanding these authorities, "it is
stated that the  gonorrhoeal discharge is suppressed, and that the
inflammation of the eye occurs in consequence of that suppression."
This view is supported  by Richter, Scarpa,  and Beer, and they
consider the restoration of the  discharge from  the urethra  as a
principal indication in the treatment.  I have never seen a well-
marked  case of this kind,  though there are  many  on  record.  I
have seen the most acute ophthalmia associated with profuse dis-
charge from the urethra.  Swediaur has collected a few cases, in
which the return of discharge from the urethra cured an ophthal-
mia which had arisen from its sudden suppression, and which had
resisted the usual modes  of treatment.  The third form of gonor-
rhoeal inflammation of the eye  is that which occurs  during  the
continuance of a clap, without the direct application of  the matter,
or without the  suppression of  the discharge.  "Since, then, gonor-
rhoeal ophthalmia may occur whilst the discharge from the urethra
continues, and since it does not take place when that discharge is
stopped, we cannot  admit that the affection of the eye owes its ori-
gin to the cessation of disease in the urethra."
  We are disposed to think that bleeding has been too  exclusively
relied upon  in this  disease, which is, in its commencement, purely
local;  and Mr. Lawrence himself is dissatisfied with the results of
the cases treated exclusively on this plan, although he attributes
its want of success to its not having been employed to a sufficient
extent.  However, he mentions a case (Case 5,) in which blood was
taken very largely, both locally  and generally, and other powerful
antiphlogistic means were resorted to, yet the eye was lost.  Mac-
kenzie  says, "bleeding alone must not be  depended on;" and
O'Halloran is of opinion that, if an inquiry were instituted amongst 
 88                   PRIMARY SYPHILIS.

army surgeons, it would  be found that those who had used the
greatest depletion were the least successful practitioners.
  Directly after the system has been depressed by loss of blood
we  must have recourse to local, astringent, or  specific remedies.
Amongst these may be mentioned, as entitled to most confidence,
the solution, or pomade of nitrate of silver.  The former may be
employed in  the proportion of ten grains to the  ounce of water,
dropped  into  the eye  at the very commencement of the disease.
O'Halloran "had become  dissatisfied  with the antiphlogistic treat-
ment, from having  found it frequently insufficient.   I  was hence
led to use astringents, not only in the  early stage of the disease,
but when the purulent discharge and chemosis were  fully esta-
blished.   He  employed the sulphate of copper in substance, rub-
bing with it the inner surface of the eyelids after everting them,
or he dropped into the eye the ten-grain solution of the nitrate of
silver."1   Mr. Lawrence mentions two cases where this treatment
was successful.  Most modern  authors  are agreed upon this plan
of treatment,  and use  as astringents a solution of the nitrate of
silver, of the sulphate of copper, or  a pomade of the first-named
salt.  I have seen one case in which a solution of the sulphate of
copper was completely successful, when the nitrate of silver in the
same form appeared to do little good.  In the intervals of the
dressings the eye is to be covered with a compress soaked in the
Liquor aluminis compositus diluted.  The  extract of belladonna
may be rubbed over the  temples, and round the orbit, during the
treatment, with a view of preventing any adhesions of the iris,
which commonly becomes affected, as well  as  the other deeper-
seated structures of the  eye.  If the chemosis be great, Ricord
recommends a portion of it to be removed with a pair of scissors,
a practice of which Dr. Mackenzie speaks also in very high terms.
  It is perfectly useless, not to say criminal, in such cases, to waste
the time, so precious to our patient, in administering the remedies
looked upon as specific in gonorrhoea, such as copaiba and cubebs,
recommended by Dr.Wallace.  "The  anti-gonorrhoeal remedies,
properly so called, have absolutely  no action  upon the disease,
whatever be their  mode of administration."   The  testimony of
modern experience  is against the use of mercury in the acute forms
of this disease; we lose  time, and compromise the vision of the
patient, by relying  upon  it in this stage; in the chronic forms it
may be employed with a  reasonable prospect of success.
                     1 Lawrence, p.  44. 
GONORRHOEA IN THE MALE.
89
  Those authors who support the view of gonorrhoeal ophthalmia
being produced by metastasis place great stress upon the restora-
tion of the  urethral discharge; it  is also recommended in cases
where this  ceases during  an attack of disease of this  character.
Swediaur, Richter, Beer, and Scarpa, recommend the introduction
of a bougie smeared with the discharge from the eye, or with go-
norrhoeal matter taken from another patient.   In spite  of the au-
thorities of these names, I think their advice rather the result of
preconceived theoretical notions than the  deductions from the re-
sults of treatment.  Mr. Lawrence supports the latter opinion, and
the modern writers of greatest experience agree with him.  " If,"
says Ricord, "the discharge from  the urethra is for a short time
diminished during an attack of gonorrhoeal ophthalmia, it is never
completely suppressed, and we can  affirm, in spite of contrary opi-
nions, that not the least benefit is to be expected from attempting
to increase or restore it," (p. 763.)   Swediaur appears to  have been
successful in some chronic cases of this character by the  restora-
tion of the urethral discharge;  but  I cannot find in any late writer,
neither have I ever seen a case supporting the efficacy of this treat-
ment.
  Many modern surgeons  admit a  true gonorrhoeal inflammation
of'the iris.  This generally occurs in scrofulous patients labouring
under gonorrhoea or gleet.  Sometimes it succeeds  to gonorrhoeal
inflammation of the conjunctiva or the sclerotic, or occurs with that
peculiar species of rheumatism which sometimes accompanies a go-
norrhoea.  It very commonly  alternates Avith  affections of  the
joints, and an acute attack of synovitis frequently  cures  or very
much relieves the inflammation of  the eyes.  The frequency with
which this species of disease succeeds to mild gonorrhoeal ophthal-
mia, and the facility with which adhesions of the iris take  place
renders it necessary that in the various forms of gonorrhoeal oph-
thalmia we should adopt the plan of keeping the pupil dilated by
the external application of belladonna.  " This affection  of the eye
is exactly the same as rheumatic inflammation of the sclerotic and
iris occurring independently of gonorrhoea.  Both this and the mild
purulent inflammation of  the  conjunctiva are to be regarded  as
rheumatic affections of the organ  excited by gonorrhoea; that is,
they take place in individuals in whom this constitutional disposi-
tion is shown by inflammation affecting either the synovial mem-
branes or the fibrous structures of several joints."1  Dr. Vetch has
1 Lawrence, p. 57. 
90
PRIMARY SYPHILIS.
given cases of this disease.   In one instance the gonorrhoea was
well-marked and violent, and was succeeded by a swelled testicle ;
rheumatic inflammation of the joints and of the external proper
tunic of the eye followed.   They terminated in an irregular and
contracted pupil,  some opacity of the capsule of the lens, adhe-
sions between it and  the  iris, and  a considerable loss of vision.
Generally, however, the prognosis  is favourable, and the disease
very much more under the control of art than the more acute forms'
of purulent ophthalmia.   "The gonorrhoeal  is  generally  more
rapid in its progress than any of the other varieties  of  iritis, and
is  one of  the most severe and formidable whilst it  lasts; but it
yields  more promptly to  decided  treatment than any of the rest,
and affords  examples of perfect recovery even when the aqueous
chambers are filled with lymph."1
   The treatment  must consist, in  the onset,  of  general  and local
bleeding,  suited to  the urgency of the  symptoms;  calomel and
opium, so  as rapidly to affect the system, and the application of the
extract of belladonna.   Our chief reliance is to be  placed upon
mercury united with opium and antimony;  and if there exist a
rheumatic state  of the system, colchicum and  turpentine will be
useful.  Sir B. Brodie places great reliance  on colchicum.   As
local applications,  warm decoctions of poppy are generally agreea-
ble to the patient's feelings on account of the  great pain that some-
times attends the disease.  " When the inflammation is checked,
blisters may be advantageously employed, and the  cure may be
completed by Plummer's pill, with mild aperients and  regulated
diet."
   Perhaps the most frequent disease which succeeds to gonorrhoea
is  an inflamed  testicle, known also by the name of epididymitis
(from the constant  pathological changes found in this part,) orchitis,
and hernia humoralis.   It  is not often that  an opportunity is af-
forded of seeing the changes which  take place in the testis, or its
envelopes, in consecutive gonorrhoeal inflammation;  nevertheless,
dissections of testes which have been the seat of such  diseases have
been recorded  by M. Gaussail,2 Mr. Curling,3 Sir B. Brodie,4 and
Sir A. Cooper.5  The epididymis, in such instances, is enlarged to
  1 Mackenzie, p. 476.
  - Me"moire sur l'Orchite blennorrhagique, 'Archives Ge'ne'rales de Medicine,' Jan.,
xxvii., p. 210.
  3 On Diseases of the  Testes, p. 254, &c.
  ' London Medical Gazette, vol. iii., p. 219.
  1 The Anatomy and Diseases of the Testes, p. 80. 
GONORRHOEA IN  THE  MALE.
91
twice or thrice its natural size, this enlargement being produced
by the effusion of a  brownish deposit between the convolutions
of the duct.  The indurations felt on handling tne epididymis are
generally the result of  adhesions only, and not due to an effusion
into the interior of the  duct.  This, I think, is proved by the fact,
that  the viril power is  not impaired  generally after ordinary at-
tacks of gonorrhoeal  orchitis.  The coats of the vas deferens are
thickened and injected,  and an albuminous deposit is found in the
cellular tissue around the tortuous part of the vas deferens and tail
of the epididymis. Marks of inflammation are  also found in the
tunica vaginalis, consisting of effusions of lymph and bloody serum,
loose  adhesions, and  general vascularity of the membrane.   It is
owing to the extension of inflammation to the tunica vaginalis that
is due the intense pain and tenderness which accompany consecutive
orchitis.  The  body or glandular structure of the testes is fre-
quently affected;  and in instances where testes, which  have  been
previously the  seat of consecutive  gonorrhoeal examination  have
been  examined, the tubular or proper secreting structure has  been
more  or  less disorganized; in the case dissected by Sir B. Brodie
and Sir A. Cooper, one-third of the tubules had become converted
into a white fibrous substance, and " were rather chords than tubes."
On handling testes which  have been  the  seat of  consecutive or-
chitis, although little change appears  in  the body of  the gland
itself, the epididymis is  always found enlarged to a greater or less
degree, and I believe this condition seldom entirely disappears.
   This disease hardly ever occurs during the first,1 or even in the
second week of a gonorrhoea, more commonly in the third.  The
disease has been supposed  to  originate in two ways, from the di-
rect propagation of inflammation from the ejaculatory ducts to the
vesicular seminales, and through the vas deferens to the epididy-
mis.   Cullerier believes that it is owing to the direct propagation
of disease along the seminal passages, and  not to metastasis.  The
longer the continuance  of a gonorrhoea, the more likely is it  to be
thus complicated;  the best way to prevent  it is to cure the disease
as quickly as possible.  Amongst other causes are exercise, consti-
pation, the  neglect of the suspender^ free living,  and the use of
stimuli during the course of a gonorrhoea.  Amongst the predis-
posing causes of this affection may be enumerated fatigue, violent
exercise, repeated sexual intercourse, and any circumstance pro-
' Not once in three hundred times.  (Ricord.) 
92
PRIMARY SYPHILIS.
ducing excitement of the organs of generation.  Various occupa-
tions  predispose to it, as  those  of weavers, turners, grooms, and
all trades where *the testes are exposed  to frequent friction.   "A
flaccid state of the scrotum is also to be ranked amongst the pre-
disposing causes: a strong cremaster and firm scrotum  are rarely
met with in individuals suffering from swelled testicle."
  It is generally believed that the discharge of a gonorrhoea is di-
minished, or disappears altogether, when the testicle becomes in-
flamed:  this, though most commonly the case, is by no means a
constant occurrence.  Hunter long ago remarked, that there were
cases  in which the discharge rather increased than diminished,
when  the  testicle became inflamed.   In the cases analyzed by M.
Gaussail, and M. d'Espine,1 the discharge was  generally lessened
when  orchitis supervened, although in many of the cases it under-
went no change, and in some was increased.   A patient is never
free from the risk  of a swelled testicle as long as gonorrhoeal dis-
charge remains.  I have known it occur where disease had existed
six months.
  A swelled testicle is not caused, in ordinary cases, by the use of
injections, or the  quick suppression of the  discharge, but by the
extension of the  inflammation in the manner already named.  The
tables of M. Gaussail show that swelled testicle is much more fre-
quent in  the fourth and  fifth weeks of the disease;  hence  the
quicker the primary affection is cured, the less chance there is of
consecutive inflammation of the  epididymis  and affections of the
testicles.
  The judicious use of injections  and specific remedies certainly
does not produce an inflamed testicle.  More risk of this is seen
by suffering the discharge to continue week after  week, than by
the employ of specific  remedies and injections, after the tenth or
twelfth  day.
  It is not improbable that in certain positions of the  testes, and
where an irreducible scrotal hernia is present, a swelled testicle
may be  mistaken for a strangulated hernia.   I attended a gentle-
man for gonorrhoea who had an irreducible scrotal  hernia of the
right  side.  In  the third week of  the disease, after a long walk,
he became affected with swelled testicle on the ruptured side; this
was accompanied by constipation, vomiting, tenderness of the ab-
domen,  and other symptoms common to strangulation of the bowel;

  1 Me"moire Analytique sur 1 'Orchite Blennorrhagique.—M6moires  de la Socie'te'
M6dicale d'Observation, torn, i.,  p. 494. 
GONORRHOEA  IN THE MALE.               93
for two days the case had a very formidable aspect.   Mr. Acton'
has recorded a curious and instructive case bearing upon  this sub-
ject.   " A young man, 24 years of age, was in the'habit of amusing
himself, when  a boy, by pushing his testicles  into the abdomen.
Two  months  previous to his  admission into the hospital he con-
tracted  a gonorrhoea which discharged profusely; he continued,
notwithstanding, his employment.   In about a fortnight  after, he
felt a painful sensation in the left groin; and this becoming worse,
he entered the hospital a month after the commencement of his
complaint, suffering under great pain in the inguinal region, which
was greatly inflamed, whilst pressure on  that part produced that
peculiar  feeling, but in a greater degree, which is excited  when
the testicle itself is compressed.   On examining this patient, no
testis was found on the left side of the scrotum, but, on passing the
finger into  the left inguinal canal, a rounded body was distinctly
felt, resembling the testis in shape, and the patient stated that he
experienced a similar pain to that felt when the testicle on the op-
posite side was squeezed."
   This case was recognised as one of ordinary swelled testicle,
notwithstanding the unnatural position of the organ.   It is not im-
probable that such  a case might be mistaken  for a  strangulated
inguinal hernia, more particularly when such symptoms as vomit-
ing,  constipation, and  tenderness of the  abdomen  are  present.
The history of the concomitant  affection, and the absence of the
testes in the scrotum, are the chief points which should decide the
surgeon. Should such a  case coexist with a strangulated hernia,
it would form a curious and puzzling  complication, and one which
would render the operation extremely embarrassing.2
   If gonorrhoeal  epididymitis occur with any degree of intensity,
the disease soon involves the neighbouring tissues of the  testicle;
and hence we observe speedily succeeding to it, or complicating it,
diseases of the tunica vaginalis, or testicle itself, and very com-
monly inflammatory hydrocele, oedema, erysipelas, or phlegmon of
the scrotum.
   This disease is prevented by the antiphlogistic treatment of go-
norrhoea, the  use  of the suspender, and the early employment of
   1 On Venereal Diseases, p. 95.
  a A. L—, aet. 32, was admitted into the Queen's Hospital with gonorrhoea ;  he had
a large  painful tumour in the inguinal canal, and only one testicle in the scrotum.
This was a case of orchitis, the testicle being fixed in the inguinal canal.
  A boy, aet. 14, was admitted into the Queen's Hospital, having a tumour in the
right inguinal canal, hard, tender, and inflamed; it was clearly an undescended tes-
ticle, there being but one gland in the scrotum. 
94
PRIMARY SYPHILIS.
 specific anti-gonorrhceal remedies, as copaiba, cubebs, &c.   When
once set up we must employ general bleeding, if circumstances re-
quire it, or local bleeding from the region of the spermatic chord,
or perineum; the patient must keep the testicle suspended, and re-
main in the  horizontal position.  To relieve the pain, which is
sometimes  very acute, frictions upon the  testicle with  oil,  opium,
or belladonna, &c, may  be employed.1   When the acute symptoms
have in some measure  subsided, the  most efficacious  practice  is
compression of the testicle by  strapping.   This practice generally
succeeds in curing most forms of epididymitis in five or six days,
and has the advantage of not confining the  patient.   I  have re-
peatedly employed it from the very commencement of the disease
with the most complete  success.2
  The plaster is to be cut into  thin straps, and applied in a circular
manner round the testicle, drawing this organ, as far as can be done
without pain, to the bottom of the scrotum, and taking care not to
pucker the skin in applying the plaster.3   The first strap is placed
                1 R.  Olei camphorati, ^j ;
                     Tinct. opii, ^j.  M. ft. liniment.      Or,
                 R.  Adipis, gj ;
                     Ext. opii, gij.  M.                 Or,
                 R.  Adipis,
                     Ext. belladonnas, aa §j.  M.
  * The emplastrum "de Vigo" is generally employed for this purpose in the French
Venereal Hospitals; it resembles much, though is in some points superior to, the
Emp. ammoniaci cum hydrargyro  of the London Pharmacopoeia.  The form is as
follows:
                 R.  Hydrargyri, 95 parts;
                     Styracis  liquidae, 48 parts.
These are to be rubbed together till the globules of  mercury disappear; then melt
together, in a separate metal pot,—
                     Emp. plumbi,      312 parts ;
                     Cerae flavae,         16 "■
                     Terebinthinae puree,   16 "
                     Picis Burgund.,      16  "
                     Gum ammoniaci,      10  "
                     Olibani,             5  "
                     Myrrhae,             5  "
                     Croci in pulv.,        3  "
  These ingredients are to be  well mixed, first among themselves, and then with the
mercury and styrax.   The plaster  thus made is to be spread  upon linen, calico, or
thin leather, and then cut into strips of convenient thickness.
  3  The  best  plaster for strapping the testis is  composed of soap, belladonna, and
adhesive plasters, in about equal proportions, carefully spread on thin, firm leather,
and then cut  into thin straps.   The mercurial plaster sometimes irritates the scro-
tum.  The one I have mentioned I now always employ. 
GONORRHOEA IN THE MALE.
95
circularly round the testicle at the insertion of the chord, compress-
ing the organ as much as the patient can bear; a succession of straps
are then applied till the organ  is covered: and a second series of
straps then placed over the circular ones from below upwards, and
over  these again a few  more circular ones  to keep the whole  in
place.  If the pressure of the plaster occasions pain or irritation,
the straps are to  be removed till the inflammation or sensibility is
more diminished; in many instances the patients experience relief
directly the testicle is supported  by the  plaster.   In spite of the
sneers of a modern writer, strapping the testis is a very valuable
remedy in consecutive gonorrhoeal orchitis.  I have  tried it in sy-
philitic sarcocele, and other chronic diseases of the testis, without
benefit.  As a general rule it should not be employed till the more
acute symptoms  have somewhat yielded.  The  size of the testis
rapidly diminishes  under it, so that the straps want reapplying at
the end of about the third day.
   During the local treatment of the disease, the patient is to per-
severe in the use of specific anti-gonorrhceal  remedies; the'copaiba
and cubebs; and  a mild  mercurial course may be recommended, to
remove  any thickening  or enlargement  which remains after the
more acute symptoms have subsided.1
   A chronic enlargement of the testis, sometimes occurring alone,
and sometimes complicated with hydrocele, occasionally remains
after the subsidence of the more acute symptoms accompanying a
swelled testicle.  For this affection compression is of little use.   I
believe the proper remedy to be the hydriodate of potass, with al-
terative doses of mercury, and the external application of the tinc-
ture of iodine, or the iodide of lead ointment.  Mercury pushed to
salivation is occasionally of great service in these consecutive dis-
eases of the testicle and its envelopes.
   In some constitutions gonorrhoea leaves behind it a general weak-
ness and irritability of the organs of generation, and an alteration
in the character of their secretions.  The semen is scanty and de-
void of its characteristic smell; it is thin and  watery, and ejected
languidly  during coition;  very quickly, and without sensation.

                1 R.  Hydrarg. chlorid., £)j ;
                     Pulv.  v. Ext. conii., J)ij;
                     Sapo.  dur., $ij. M. ft. pil.  xxiv.        Or,
                 R.  Pil. hydrarg., gr. v;
                     Camphorae, gr. iij;
                     Pulv.  v. ext. opii., gr. j.   M. ft. pil. q. o. n. d. 
96
PRIMARY SYPHILIS.
When the bowels are  evacuated there is occasionally forced from
the urethra a thin substance like gum, which has a soapy feeling
when rubbed between the fingers.   This is no doubt a vitiated
hyper-secretion which  hangs about the relaxed mucous membrane
of the urethra, the lacunae, and the  ejaculatory ducts, and which
is  forced  from the urethra by the action,of defection.1   At the
same time the penis and scrotum are  flaccid, and the reflex actions
of the erector and ejaculatory muscles are with difficulty excited.
With these  symptoms  there commonly exists weakness and trem-
bling of the legs, and  a general lassitude of the whole system.
  The balsams and turpentines, with  the preparations of steel, and
cantharides, are very useful in  such  states  as  general remedies.
Tonic and stimulating injections should also be practised with a
syringe perforated on the sides so as to inject the lacunse of the
urethra, which are commonly the principal seats of disease.   Fric-
tion of  the loins, scrotum, thighs, and penis, with warm spirituous
embrocations, should be practised at  the  same time.  Pain, heat,
and various forms of irritation sometimes  affect the penis after an
attack of  gonorrhoea.   Many of these symptoms are disordered
sensations merely.  They may or may not be associated with the
various  forms of  discharge already alluded  to, or they may again
be indicative of some  pathological change in the urethra, such as
stricture, upon the earlier stages of which they are occasionally de-
pendent.  In all cases, before forming a plan of treatment, the pas-
sage should be carefully examined by the bougie, which is, in such
cases, very  commonly the most  efficient remedy  in  their  cure.
Great caution, however, is necessary in the employment of bougies
in an irritable urethra.   I have been consulted by several unfor-
tunate patients who have suffered from these neuralgic conditions
of the urethra, who have wandered from surgeon to surgeon; and
where the too frequent, and perhaps injudicious use of instruments
has terminated in perineal abscess, in chronic orchitis, or irritable
testis.
  Many writers have alluded to gonorrhoea of the rectum, a disease
happily rare in this country at least.  I have seen but one well-
marked case, in which the cause and nature of the disease were

  1 This fluid, though chiefly composed of vesical or prostatic mucus, sometimes, but
not always, contains spermatozoa. I have examined  it in a great number of cases.
It is occasionally altogether composed of peculiar corpuscles, with which, at times,
a few spermatozoa are mixed.  The remedies are injections, practised  through  a
catheter passed down to the  prostatic portion of the urethra. 
GONORRHOEA IN THE MALE.
97
frankly admitted by the patient.   The first symptoms were those
of acute inflammation; the anus was swollen, red, exceedingly ten-
der and painful, and the seat of a profuse purulent discharge; the
symptoms were sufficiently severe to confine the patient to bed for
several weeks.   They were slowly subdued under rest, a low diet,
leeches, fomentations, and weak astringent injections.  I have seen
this patient at intervals, for seven years, and even now much  irri-
tation  remains, with occasional  discharges of pus;  the faeces also
occasionally being more or  less covered with purulent matter.  On
examination with the speculum the mucous membrane of the rectum
appeared  vividly and generally red, but no  ulceration was present.
In cases like the present an antiphlogistic treatment appears the
only one applicable, combined with injections of cold water or weak
solutions of the sulphate of zinc, the acetate of lead, or nitrate  of
silver; these  should be thrown up in large quantities by a common
enema syringe.  Specific remedies are useless; it is a singular fact
that it is  only  over the urethral form of gonorrhoea that the so-
called  specific remedies appear to exert any influence.
7 
98
PRIMARY  SYPHILIS.
                       CHAPTER VII.

                OF GONORRHOEA IN THE FEMALE.
  Gonorrhoea in the  female is for the most part a disease of very
different character to that in  the male; the anatomical structure
and functions of the organs implicated modifying the affection both
in its seat, its course,  its treatment, and its terminations.
  This  disease  recognises for its pathology, acute or chronic in-
flammation of the vulva, vagina,  uterus, or urethra; the inflamma-
tion  itself being of a specific  character, and capable of producing
gonorrhoea in the male.  Pathologists have as yet failed in estab-
lishing  any differential diagnosis between a specific and an  ordi-
nary inflammation of the parts mentioned.  " It is  a singular patho-
logical fact that although the  existence of a specific and contagious
form of vaginitis is -generally  admitted, yet it is difficult, if not im-
possible, to  point  out any decided characteristic  by which it may
be distinguished from ordinary vaginitis.  Like all those who have
preceded me, I  am unable  to  indicate satisfactorily any absolute
means of distinguishing between simple inflammation of the vagina
and  gonorrhoeal inflammation, though I believe the difference does
exist."1   Certainly there is a  gonorrhoeal virus, although it cannot
be demonstrated.   In the female, gonorrhoea is not confined to the
urethra; it is seated  in the mucous membrane reflected over the
neck and mouth of the  uterus, in the vulva, or the vagina and its
follicles, and  the vulva vaginal gland.2
  We have to consider:
  1st. Urethral gonorrhoea, the  type and model  of gonorrhoea or
blennorrhagia properly so called; eminently contagious.
  2d. Vaginal  discharges,  termed gonorrhoeal or blennorrhagic,
much more  common than the  preceding, particularly in females of
loose character, the precise nature of  which it is often very diffi-

  1 A Practical Treatise on Inflammation of the Uterus, its Cervix and Appendages,
&c,  by James Henry Bennet, M. D.,  3d edit., p. 218.
  1 Huguier; M6moires de l'Academie de Medicine, vol. xiv.—J. H. Bennet, op. cit,
p. 213. 
GONORRHOEA IN THE FEMALE.
99
cult to determine;  nevertheless the vagina may be  the seat of a
pure specific gonorrhoea, either alone or complicated with urethral
gonorrhoea.
  3d. Uterine gonorrhoea or blennorrhagia, capable  of producing
a similar disease in the  male.   The uterine discharge  continues
long after  the other forms have  been cured, and is contagious, al-
though it resembles mere leucorrhcea.
  The ordinary pathological changes found in females who are known
to have produced gonorrhoea in the male, are found in the labia, in
the vulva, the vagina, the meatus urinarius, and the lips and mouth
of the uterus.  The labia majora are generally more or less swollen;
on everting them, their internal or mucous surface is red and in-
flamed, uniformly, or in patches;  or again it has an aphthous, patchy
appearance, especially in old cases: the surface is sometimes stud-
ded with warts, and occasionally  the whole labia are converted into
a condylomatous mass, which runs backwards along the perineum
to the margin of the anus, which is surrounded by similar growths.
Sometimes a similar condition of the mons veneris exists, but this
is comparatively rare.  If the seat of the complaint affect the vulva,
the labia minora are also red and swollen, and the  entrance to the
vagina contracted, red, and intensely tender in acute cases; between
the folds of tlie labia, a white sticky secretion  is found, like  that
under the prepuce in balanitis in  the male.   The irritation, itching,
and pain, are intolerable in gonorrhoea, where  the vulva is espe-
cially affected, particularly in cases where a newly-married female,
previously  healthy,  has been diseased  by the  husband, who has
married  with an uncured blennorrhoea, a circumstance  not very
uncommon.
  When the  vagina is affected in gonorrhoea, it is contracted, red,
and painful, and  the ruga) red and elevated; the inflammation rarely
affects the  whole vaginal surface at once, that part under the arch
of the pubis  being  most  frequently the seat of disease.   In acute
gonorrhoeal inflammation of the vagina, the speculum should not be
used till the more acute symptoms have subsided.
  The labia and os  uteri are very greatly affected in gonorrhoea.
In seven out of nine cases examined by Mr. Whitehead, the disease
was confined  to the  uterus, in two the vagina was  affected, in one
the urethra.  The truth is  that the gonorrhoeal inflammation of
the vaginal surface of the uterus is very commonly combined with
affections of the vagina, and hence these forms have  commonly been
described as utero-vaginal.   In  some rare cases the  canal of the 
100                  PRIMARY SYPHILIS.

neck only is affected, without participation of the vaginal portion
of the uterus, and these are the cases in which some continental
practitioners have proposed injections into the uterine cavity itself.
When we consider the elaborate organization of the mucous mem-
brane lining the canal of the cervix, as revealed by  the dissections
and microscopical examinations of Dr. Tyler Smith,1 we must be
quite  aware that a local  treatment is  essential in this form of dis-
ease.
  The urethral form of gonorrhoea in the female is rarely met with
alone, it  sometimes complicates the other forms.  M. Ricord says,
in two thirds of the cases, in my own  practice, I have not found it
so frequent.
  In addition to the  pathological conditions just mentioned, ab-
scesses very commonly form in the vagina and perineum.
  In the more acute forms of the disease, a strictly antiphlogistic
treatment and regimen must be adopted: aperients, the warm bath,
emollient fomentations and poultices,  and injections or rather con-
tinual irrigations of the parts, by means of a self-acting syringe,
with sedative, demulcent, or slightly astringent fluids.
  In the earlier and more acute stages of the disease, it is not pru-
dent,  and sometimes not always safe, to have recourse to the spe-
culum to ascertain whether  the  gonorrhoea is complicated with
venereal ulcerations or not; our  first duty is to subdue the acute
inflammatory symptoms, and then if the chronic stage be protracted,
or do not yield to treatment, and there is reason  to suspect the
existence of deep-seated ulcers, the speculum may  with propriety
be used to clear up our diagnosis.
   The internal treatment of gonorrhoea in the female is very limited.
The remedies which are  considered  specific in  this disease in the
male, as  copaiba, cubebs, &c, are here almost inert.  Their action
upon  the vaginal forms of the disease is very feeble, a little more
energetic over the urethral varieties.  Aperients, with diluent and
demulcent drinks, constitute  nearly  the whole of  our  resources
under the  head of internal treatment.  Mercury appears  useless
in the uncomplicated forms of the disease, except  with  a view of
removing any chronic enlargement or thickening which may be the
result of long-continued chronic  inflammation.  The treatment is
then  to  be  the  same as that we  recommended, when speaking of
the use of mercury in gonorrhoea in the male.
) Medico-Chirurgical Transactions, vol. xxxv. 
GONORRHOEA  IN THE FEMALE.
101
  The local treatment of acute vaginitis or urethritis in the female
consists in the use of emollient and  narcotic fomentations and in-
jections.  This treatment, however,  should not be long continued,
if ineffectual; for we frequently find rest, emollient and narcotic
applications of little use, the patient still continuing to suffer from
severe pain, and an abundant puriform discharge, whilst the mucous
surfaces of the vagina, &c, continue red, and  turgid with blood.
The nitrate of silver may now be employed with the best effects,
either by passing solid nitrate over the diseased surface, or in form
of injection.1  When the  acute  stage has in some measure given
way, we may have early recourse to astringent  injections, with a
view of preventing the discharge assuming the chronic form, and
thus continuing for an indefinite period.  The preparations of lead1
or alum3 may be employed for this purpose.
   When the more acute stages of disease are passed, and the chronic
form continues but little influenced  by remedies, it will be well to
examine the  mucous surfaces of the vagina, &c, by means of the
speculum.  These may be found in several pathologic conditions;
simply red, turgid, and hypertrophied, or covered with red isolated
patches, aphthae, vesicles, pustules, or superficial ulcerations.  After
the  continuance of the disease for some time, the  os uteri is always
more or less affected; its lips are turgid, red, and everted, and
generally covered with  small  ulcerations,  granulations, or other
changes, the  result of chronic inflammation.
   In the chronic forms of the  disease, unattended  by change of
 structure, as  local applications or injections, we may employ solu-
 tions of tannin,4 kino,5 the infusion of roses with  bark,6  alum or

             ' R •  Argent, nit., gr. x .
                    Aquae, Jj. M. ft. injectio.
             - R.  Aquae, Oij;
                    Plumbi acet., giij ad ^ij.  M. ft. injectio.
             ' R.  Aquae, Oij ;
                    Aluminis sulph., ^iij ad ^ij.   M. ft. injectio.
              4 R.  Tannin, 9ij iid.^j;
                  Vini rubri, ^vj.  M.
              s R.  Gum. kino, £j ad £ij ;
                  Aluminis sulph., ^j ad ^ss;
                  Aquae ferveutis, Oij.   M.    (Swediaur.)
             6 R.  Infus. rosae comp., Oij;
                  Pulv. cinchonae, gy.   M.    (Hotel Dieu.) 
102
PRIMARY SYPHILIS.
 myrrh and  catechu,1 &c. &c.   The  solutions of the  chlorides  of
 soda or lime are chiefly of use when the discharges are offensive
 and accompanied by ulceration.2  When the gonorrhoeal discharge
 is secreted by the mucous surfaces of the vagina, these applications
 maybe thrown up with an ordinary female syringe; when, how-
 ever, the os uteri or its neighbourhood is the  seat of the disease,
 it becomes absolutely necessary to use a syringe, by which a con-
 tinual irrigation can be kept up; in this way a pint or several pints
 of injection may  be thrown slowly up, without removing the pipe
 or tube of the  syringe.
   When the chronic state of gonorrhoea in the female is accom-
 panied by any alterations of tissue, these changes demand our first
 attention, since it is useless to attempt to check the discharge as
 long as  these  conditions  remain upon which it depends.  Ulcera-
 tions or papulous granulations  should be cauterized with  the ni-
 trate of silver, or, what is better, with the acid nitrate of mercury.3
 This caustic is to be applied by means of a camel-hair pencil, or a
 small roll of lint,  to touch the diseased surfaces, these having been
 previously cleansed  by dry lint  or a soft sponge.   When ulcera-
 tions themselves have destroyed the  tissues more or less deeply,
 caustics must be employed with extreme caution.  In  these cases
 M. Ricord covers the surface of the ulcers with calomel, upon which
 he places some  dry soft lint, and afterwards passes into the vagina
 some lint soaked in one of the astringent or tonic injections pre-
 viously mentioned.  Where the  disease has extended more or less
 into the  canal of the cervix, and has assumed a form of disease
 termed uterine  gonorrhoea or catarrh, the solid nitrate should be
 introduced, and the mucous surface lining  the neck well  rubbed
 with it.
  A true vaginal gonorrhoea may be confounded with acute or

            1 R.  Pulv. catechu,
                  P. myrrhae, ail %j;
                  Liquor, calcis, giv.  M.
            a R.  Solut. sodae, chlorid., pt. 1;
                  Aquae, pts. 12 ad  16. M.
                                      (Hopital des Venenennes.)
  3 To 100 parts of mercury, add, in a retort, 200 parts of nitric acid; when the so-
lution has taken place, reduce to 225 parts by evaporation.  This, the acid nitrate
of mercury, is a solution of deutonitrate of mercury in an excess of acid, and con-
tains 71 per cent, of the deutonitrate.  This agent is a powerful caustic, giving rise
to a white eschar, which does not fall off for five or six days.  (Dr. J. H Bennet
op. cit., pp. 278-79.) 
GONORRHOEA  IN THE FEMALE.
103
chronic vaginitis arising from other causes; and hence arises a
question of great delicacy and importance, whether we are in pos-
session of any facts which will enable us to establish a correct dif-
ferential diagnosis between vaginitis as the result of impure sexual
intercourse and those  forms of disease  which  are  the  result of
other causes? " The diagnosis of leucorrhoea," says Dr. Churchill,1
"is, according to all authorities, extremely difficult."  Sir C. M.
Clarke  seems to think  it impossible.   I have already quoted Dr.
Bonnet's opinion on this point.
   In gonorrhoea the discharge is generally more frequent and the
inflammation more acute than  in leucorrhoea.  In  the former dis-
ease the glands of the groin  are more frequently enlarged, tender,
and painful, and in gonorrhoea the affection extends to the urethra
in about two-thirds of the cases.2
   Many causes  contribute to render the treatment of gonorrhoea
in the female tedious and  unsatisfactory, and a disease  more diffi-
cult to cure in this sex than  in the male.  The  recurrence of the
menstrual period is constantly interfering with the success of treat-
ment; and  a gonorrhoea that has been almost subdued  in the in-
terval,  is renewed with all its intensity at the  time of menstrua-
tion.
   I believe that gonorrhoeal diseases in the female are very rarely
completely cured.   This, in most cases, arises either from  neglect
on the part of the patient, or the want of a proper  knowledge of
the disease, careful  examination of the parts affected, and an  ap-
propriate topical medication on  the  part of the surgeon.  If Mr.
Whitehead's notion be correct, that the canal of the cervix is the
first part affected, and  the vaginal or urethral mucous surfaces are
only secondarily diseased, the disease is not likely to be cured with-
out topical applications to the primary seat of complaint.  M. Vidal
de Cassis3 and M. Mercier have described gonorrhoeal affections of
the uterus and of the ovaries, and  carrying out an anatomical  to
a pathological  analogy, have  described a gonorrhoeal ovaritis  in
the female as the analogue of a swelled testicle  in the male.
   In affections of the canal  of the cervix, or other portion of the
internal surface of the uterus, I have been deterred from employ-
ing injections into the cavity of this organ by the narration of some
fatal issues to such a proceeding; and, indeed, the accounts given

   1 Outlines of the Principal Diseases of Females, &c.; Dublin, 1838, pp. 23-4.
  2 See the paper of M. Ricord, " Me"moires de l'Acad6mie Royale de M6decine," 1833.
  ■ Op. cit., p. 127. 
104
PRIMARY SYPHILIS.
by Vidal de Cassis  himself, the modern originator of this plan, of
the effects produced by such a measure, would hardly tempt me to
follow it.1
  The douche or irrigation of the os uteri, by means of a proper
syringe, practised through a bivalve  speculum, afterwards placing
against the os a piece of lint or sponge soaked in a weak astrin-
gent solution, is an exceedingly efficacious  plan, and  prevents the
discharges from the uterus inoculating the  mucous surfaces of the
vagina.

  1 M. Vidal's favourite injection is a concentrated decoction of the walnut-tree leaf. 
ULCERS.
105
                      CHAPTER VIII.

  OF THE SECOND CLASS OF PRIMARY SYPHILITIC DISEASES—ULCERS,
              THEIR VARIETIES AND CONSEQUENCES.

  All primary venereal ulcers do not present the same aspect or
character, and in this respect differ very materially from each
other.   They  resolve  themselves naturally into  a  few principal
forms.   These are, 1st The simple primary ulcer, characterized by
negative rather than positive characters, i. e. by the absence of in-
duration, irritability,or inflammation; 2d. The irritable; 3d. Those
characterized  by an excess of inflammation; 4th. The indurated,
the induration being a primary feature of the sore, and not being
produced by the injudicious use of local stimulating dressings, by
which any primary sore may be made to assume an appearance of
induration;  5th. Those  spreading  by  rapid  ulceration, or  co-
vered by sloughs of varied colour and appearance; these varieties
being the ulcerative  and sloughing phagedena of authors.  The
difference in  the  appearance of primary syphilitic sores depends
also on  the anatomical organization of the parts on which they are
seated.   1st. The elevated chancre is most commonly seated  on
the internal surface of the prepuce.  2d. On  the angle  between
the glans and prepuce, a common seat of cjiancre, the bottom of
the ulcer has  always a honey-comb appearance.   3d.  On the side
of the fraenuin the ulcer is deep and burrowing; these last two va-
rieties depend for their peculiarities on the lax cellular  tissue of
the parts on which they are  seated; this ulcer frequently perfo-
rates the urethra.  4th. On the glans penis the sore is excavated
and hard, with ragged and thick edges, but never burrows, or has
that honey-combed appearance at the bottom I have just described;
it spreads generally by ulceration on the surface,  and  not by ulce-
ration in depth.   5th.  Chancre in the interior of the fossa navicu-
laris is  accompanied by great induration of the  glans penis, and
very commonly by phymosis: this ulcer also has a  tendency to per-
forate the urethra on its lower part. 
106                  PRIMARY  SYPHILIS.

  Little doubt can generally exist with regard to the nature of a
sexual ulcer; the history given by the patient, its situation, with its
aspect, are generally conclusive  on this point.  There may, how-
ever, occur cases which may puzzle the most experienced surgeon.
The test of inoculation is here very valuable, but unhappily it is
only of certain value when  positive.  If no characteristic pustule
be produced, we  may certainly assure  the patient that the ulcer
does  not yield any positive evidence of its being syphilitic,  and
that there is  great reason to believe that it is not so. Patients are
naturally anxious to know whether an ulcer, following a suspicious
intercourse, is a " chancre," i. e. a syphilitic sore, liable to be fol-
lowed by a constitutional taint; and it is most important that the
surgeon should be able to give a reasonable and positive opinion
on this point.  I have shown how far inoculation will aid him. The
microscope may also assist us as a means of diagnosis.  I  have seen
a chronic ulcer with induration on the lip and penis, of a syphilitic
character, very closely resemble  cancer.  If  the test of inocula-
tion failed in these  cases, the secretions may  be submitted  to mi-
croscopical examination, where we should at once distinguish  be-
tween the pus globule of the syphilitic ulcer and the cancer cell.
I have never been able to distinguish by the microscope any diffe-
rence between the pus of a primary syphilitic  sore and that of an
ordinary ulcer, and I have never  been able to detect the existence
of the animalcules, described by Donne as existing in the pus of a
chancre.
                               .*
  Primary syphilitic ulcers are commonly situated on the prepuce,
the glans, or  body of the penis, at  the orifice, or other parts cf
the urethra, on the mons veneris, or lower part of the abdomen; I
have seen them also on the tongue and on the finger, and they
have  been observed also "on  the chin, the  lips, the  scrotum,  the
anus, and the thigh."1   Ricord and Vidal have also seen them  in
the bladder.
  The whole probability of success, in what is termed  the  abor-
tive  treatment of a primary syphilitic  sore, turns upon  the ques-
tion whether  this be  at first a local disease merely, or a local  mani-
festation of a constitutional taint.  Observation has taught  me to
believe that  the  primary syphilitic  sore is, in  a great majority of
instances, a local disease; but there  are cases  occasionally occur-
ring which seem to favour the truth of the latter position. A pri-

           • M'Carthy; These inaugurale, p. 13, quoted by Vidal. 
ULCERS.
107
 mary sore generally appears  on the organs of generation, from
 four  to  eight days  after suspicious  intercourse;  I have known a
 month elapse in one case, and  three  months in another.  If, how-
 ever, a chancre be  inoculated the effects are immediate.  In  the
 one case, however, the  virus is introduced under the  epidermis by
 the lancet, and in the other it  only penetrates this membrane by
 a process of slow absorption.  This, I think, will explain what is
 termed the "incubation" of chancre, and this view is  supported by
 the experiments of Mr. Ceely, of Aylesbury, who tells us that he
 has frequently succeeded in producing the vaccine pustule by keep-
 ing lymph in contact with the  epidermis for a certain period of
 time, "without abrasion of the cuticle."
   In  cases where long periods have elapsed between intercourse
 and the manifestation  of disease, we must either admit that  the
 virus has lain in contact with the skin for a  long time, without
 producing any effect, or that the  local  disease  then  set up is  but
 the first indication of an already existing constitutional taint. The
 latter opinion has been maintained by Vidal and others, and brought
 forward as an argument against the abortive  treatment of chancre,
 which I  am  about to consider.   I must confess that I lean  to  the
 first opinion, viz., that the virus has remained  in contact with  the
 cuticle for a long period without producing its customary effects.
 We are  daily witnessing this period of incubation, extending  not
 only over months but even years, in the development of secondary
 or constitutional  diseases.  Again, if the local disease was the first
 manifestation of  a constitutional taint, why  is it, under such  cir-
 cumstances, always  developed  on the part exposed to infection?
 and why does such a sore precisely resemble an ordinary chancre
 occurring at  the  usual period after exposure?   Independent of
these  reasons, the test  of inoculation might add  additional cer-
tainty to the nature of the sore thus produced.
  The abortive treatment of  a  primary syphilitic  sore consists in
its early and immediate destruction by caustics, the object of which
is to eradicate the disease at the onset, and thus prevent all risk
of constitutional taint;  but in order to ensure this, according  to
M. Ricord, the chancre is to be  destroyed before the fifth day, and
this is not to be reckoned as the fifth day from the appearance of
the disease, but the fifth day  from  the "exposure  to contagion."1
If this is the only way, as M. Ricord assures us it is, that constitu-
' Ricord's Letters, by Stapleton, p. 39. 
108                 PRIMARY SYPHILIS.

tional disease can be prevented, I will venture to assert that we
shall not  be successful in one case in five hundred.  How often
does a chancre appear within the fifth day after intercourse?  and
how rarely again is the surgeon consulted on its immediate appear-
ance?   Nevertheless, the  destruction of  a chancre is to be at-
tempted, unless there are some special  contra-indications, as soon
as it is presented to our notice;  but we cannot say that such de-
struction will inevitably convert a specific ulcer into a  simple one,
or prevent the occurrence of constitutional symptoms; it, however,
may, and therefore the practice is a safe and a proper one: we gain
nothing by neglecting it.
   The venereal pustule, if presented to  us  sufficiently early, and
conveniently situated, should be removed  by the knife or scissors,
or should the fears of the  patient prevent this, it  is to be opened
with the  point of a lancet, and  the whole internal surface well
cauterized, and  afterwards treated  in the manner we shall  direct
for the management of the primary venereal ulcer.
   When we are called upon to treat the  simple  primary venereal
sore during its first stage,  or that of ulceration, our  first object is
to destroy the diseased surface and reduce it to the condition of a
simple  sore.  This is to be  accomplished  by  means of an appro-
priate  escharotic, with which the whole surface of the sore is to be
well cauterized, taking care to avoid any parts of the sore, if such
there be, where the process of granulation has already commenced.
   It is during  the ulcerating stage of primary syphilis, or when
the process of granulation has only partially commenced, that our
assistance  is for the most  part sought;  and when the disease is in
this stage there is no doubt of the propriety or practical utility of
immediately applying an escharotic in such a manner as to destroy
the diseased surface.  Should any  of the ulcerated surface have
entered on the stage of granulation, that portion is to  be avoided,
and the application of the caustic confined, as much  as possible, to
such parts of the sore as are still in the stage of ulceration.
   Whilst the  chancre continues in the state of ulceration, the ap-
plication must be repeated, waiting for the separation of the eschar
produced  by the caustic, to ascertain clearly the condition of the
sore before we reapply the caustic.   After the application, the ulcer
should be covered with a  piece of fine soft lint, spread with some
simple ointment,1 over which may be placed a bread  poultice, or

   * One of the best applications as an ointment at this period is the opiate cerate of
the French Codex:— 
ULCERS.
109
fine linen moistened in the liquor plumbi diacetatis dilutis, and
the whole covered with a piece of oiled silk or isinglass plaster.
   The local dressings to chancres, employed by M. Ricord at this
period, deserve particular notice.  They consist in the application
of aromatic wine,1 medicated either with tannin,2 with opium,3 or
with both.
   The sores are to be carefully washed with one or other of these
preparations, and afterwards covered with soft lint, moistened in
them.   Care must be taken, in renewing the dressings, to soften
the lint well before it is removed, so that no part of the surface or
surrounding skin may be torn away with the lint.
   These preparations possess the advantages of modifying the sur-
face of the sore, of promoting its rapid cicatrization, of diminishing
the secretion of pus from its surface, and, by their astringent pro-
perties acting upon the surrounding  tissues, of preventing the ex-
tension of the disease, or the formation of fresh chancres, a circum-
stance common in other modes of dressing.  The use of the aro-
matic  wine  with or without tannin  is contra-indicated  when the
surface of the sore  is dry, furnishing no secretion and remaining
indolent, or again where the edges being indurated these dressings
seem to increase the induration.
   Local applications to primary sores are of infinite importance.
During the  ulcerating stage aqueous solutions of opium, or weak
solutions of sulphate of zinc, copper, nitrate of silver, &c, are the
proper remedies.  Sometimes even all these disagree, and produce
pain, and dispose the ulcer to become sensible, and increase its se-
cretion.   At such periods frequent ablutions with cold water, and
a dressing of soft lint or charpel, will often suit  better than any

                 R.  Adipis, Jbj;
                    Vini opii, £j.  M-
A strong aqueous solution of opium may be used where ointments are objected to,
more particularly if the patient suffer much pain.
                 R.  Decoct, papaveris, v. conii, ^viij;
                    Ext. opii purificati, gr. viij.  M.
  1 The aromatic wine of the French Codex is composed of four ounces of aromatic
herbs, (rosemary, rue, sage, hyssop, lavender, absinthium, origanum, thyme, laurel
leaves, the flower of the red  rose, chamomile, mellilotum, and elder,) digested in
two pints of red wine for eight days.
               1 R. Vini aromatici, Jfviij;
                    Tannin, J}ij.  M.
               * R. Vini  aromatici, ^ viij ;
                    Tannin, ^ij;
                    Ext.  opii pur., Jss.   M. 
110
PRIMARY SYPHILIS.
thing else.  Topical mercurial applications, either in the shape of
black wash, yellow wash, or ointment, should  not, as a  general
principle, be used  till the sore has become indolent, or disposed
to heal.
  The state of the economy at large  demands much attention on
the first appearance of a venereal ulcer; and we must here bear in
mind the golden rule, that the varied appearances of primary vene-
real sores, and the characters they afterwards assume, depend very
much, if  not altogether, upon  the natural constitution  of  the  pa-
tient, and upon  the particular condition of  his health at  the
time he  imbibes the venereal poison.  Thus, in  many instances,
a primary venereal sore upon the penis produces  the most intense
local inflammation and fever.  Under these circumstances the pa-
tient must be treated upon general principles: he should be re-
stricted to the simplest diet, and kept quiet in bed, whilst emollient
fomentations or poultices are applied to the sore.  The local inflam-
mation and fever are first to be removed, in these  cases, before we
think of resorting to escharotics; and should the stage of ulceration
be arrested  by these means, and the  sore assume a disposition to
heal, it will not be necessary,  or even safe, to use them at all,  but
the  granulating ulcer must be  treated in the way we shall pre-
sently mention.
  Cullerier, in the treatment of the primary venereal sore, confines
his patients to bed  and keeps them upon low diet; if there be any
local inflammation or fever,  he bleeds them from the arm, and
covers the sore with a poultice, the opiate cerate, or a strong  aqueous
solution of opium.  All local inflammation and accompanying fever
are to be subdued before the use of  the caustic;  and, during  the
two or three days which are generally spent in its application, the
patient should live low, keep his bed if possible, and  take daily
aperients, unless specially contra-indicated.  This plan has the two-
fold object  of preventing or  mitigating  the  inflammation which
may be caused by the application of the caustic, and preparing the
patient for any subsequent general or local treatment  the nature
of the sore may require.1
  During the earlier periods of the local treatment of chancre, a

  ' During those two or three days which are generally spent in the application of
the caustic, the patient should be prepared by a purgative, and by regularity in his
mode of living, for subsequent constitutional treatment; the lotio plumbi subacetatis
may be applied without disturbing the dressing, by immersing the diseased part in
it two or three times a day, or by rolling the penis in lint kept wet with this lotion,
and covered with oiled silk.  (Wallace; op. cit., pp. 97-8.) 
ULCERS.
Ill
regimen suited to the constitution of the patient should be observed.
Under  this point of view no exact rules are to be laid down.  In
some cases a purely antiphlogistic treatment becomes necessary,
whilst in  others, tonics and a nourishing diet are required.   The
state of the general health requires particular attention, for it must
be  recollected that, from a bad constitution, or one enfeebled by
previously existing  disease, result those complications and severe
local affections, so frequently observed during the progress of pri-
mary venereal sores.
  The  more mildly primary ulcers are treated locally, the less
likely are they to be followed by those appalling complications which
sometimes accompany them, such as rapid ulceration, sloughing, or
disorganization of the penis and scrotum, which used to be so com-
mon under the old treatment of stimulating mercurial  applications
during the first days of chancres.  I dwell upon this .point because
I deem it of the first  importance, whilst we have the universal
testimony of modern writers on syphilis in its  favour.   To well
understand the principles on which the local as well as the  gene-
ral treatment  of primary sores  must be conducted, the surgeon
must constantly bear in  mind the two stages of chancre: in the first
we have to do with a specific sore, irritable, poisoned, and poison-
ous, liable to be irritated  by the least stimulus; whilst in the se-
cond, we have a simple ulcer destitute of all these characters.
  A chancre, when first presented to the notice of the surgeon, is
generally in one of two states, either in that of a small pustule with
its  contents yet undischarged, or a minute ulcer.   In whatever
state it may be, our  first duty is to endeavour, by the use  of escha-
rotics, to convert the specific sore into a simple one.  For this pur-
pose most authors recommend  either a strong solution of the ni-
trate of silver, or the application of this caustic in substance.
  When the nitrate  of silver is used, if the disease be pustular, it
will be necessary to  open the pustule with  the point of a lancet, to
discharge its contents, and rub the whole surface and edges of the
ulcer thus  produced with the nitrate of silver previously cut to a
sharp point; if the disease be'an open ulcer it is to be treated in
the same way.  The nitrate of silver thus  applied will sometimes
have the effect of producing a simple sore, but  it will more com-
monly  give rise to considerable irritation and inflammation, whilst
the specific character of the sore is not destroyed.   I have seen so
much evil, in this  respect, from the use  of. this escharotic, that I
have now abandoned its use under such circumstances, and  have
recourse to other caustics of a  more powerful character. 
112                 PRIMARY  SYPHILIS.
  The great evil  in  the use of the nitrate of silver in these cases
is, that it is powerful enough to irritate, but not sufficiently power-
ful to destroy.  We  want a remedy that will at once disorganize
the tissue to a depth co-equal* with that of the chancre.  For this
purpose I now employ several remedies: highly concentrated nitric
acid, the acid nitrate of mercury, the acid nitrate of silver, or the
potassa cum calce of the London Pharmacopoeia.   I  have already
given a form for the preparation of the second  of these remedies;
the third is made by dissolving a drachm of the nitrate of silver
in an ounce of nitric acid.  When it is determined to destroy a
primary venereal ulcer with any of the first three caustics, a camel-
hair pencil must be  dipped  in them, and the surface and edges of
the sore pencilled thickly over;  if the acid be sufficiently concen-
trated, the whole surfaces touched are at once destroyed, and con-
verted into a yellow eschar, which, on separating, generally leaves
a clean simple sore underneath.
  When the potassa cum calce is employed, which is the most cer-
tain of all  the remedies I have  mentioned, it must be made into a
paste of moderate consistency with spirits of wine, at the time it is
wanted for use, and  the sore and its edges covered with it.  When
it has been on a few seconds, a smart burning pain is felt, which
continues to increase as long as  the caustic is suffered to remain
on, which it should be from half a minute to a  minute, or even
longer, according to the effects produced.  After this the caustic
must be all removed by means of a fine bone spatula, and the black
eschar left may be covered with a poultice, a cold saturnine lotion,
or  fine, soft, dry lint.   The pain  soon subsides after the caustic
has been removed, and  in about half an hour the patient is gene-
rally pretty comfortable.  The aggregate amount of pain produced
by the application of this  remedy is not so  great as  that by the
nitrate of silver, whilst the effect of the potassa cum  calce is cer-
tain; all the parts touched by it are at once destroyed, and, on the
separation of the eschar, we have a clean  granulating sore left,
which commonly yields with great'rapidity, particularly if the ulcer
 be a recent one.
   Whenever, then, a primary venereal sore is presented to us, un-
 less there be some special contra-indication in its situation, &c, it
 should be immediately  destroyed  after the manner laid down.  If
 the sore be recent, i. e., of few days' standing, it is very probable
 we may eradicate the,disease at once; the constitution may not as
 yet have become infected.  In other instances it will become a 
ULCERS.
113
matter of consideration whether any constitutional treatment, and
what  kind, should be adopted during the healing of the sore pro-
duced by the caustic.  A poultice is the most convenient and best
application during the time the eschar is separating, if the patient
can rest, which should always be urged upon him as an essential
point, if it can possibly be managed.  The moment the eschar be-
gins to be detached, and a secreting surface is exposed, the poultice
must  be done away with and other remedies employed.   Of these,
weak lotions are the best.  I employ weak solutions of the nitrate
of silver, acetate or sulphate of copper, alum, or zinc, or tannin in
port wine, in the proportion of about two drachms of the former
to six ounces of the latter.
  There are certain  conditions of primary venereal  ulcers which
contra-indicate the use of the caustic in the first  instance.   If an
ulcer of this kind produce violent inflammation of the penis, this
must be reduced by  a proper general treatment before we have
recourse to these remedies, which  may bo used  after  the inflam-
mation has been subdued, if the sore be foul  and stationary, and
show no disposition to heal.  The situation of a primary venereal
sore frequently altogether prevents  the use of the remedies in ques-
tion ; for instance, chancre situated under the prepuce, and producing
complete or partial  phymosis.  In such cases there is generally
more or less inflammation or tumefaction of the penis, more or less
discharge from the preputial opening, and a  distinct hardness can
be felt, tender to the touch.  This hardness may be lesser or greater
according to the size  of the concealed sore; I have felt it extending
from the prepuce, under the skin of the penis, down nearly to the
pubes.   It is almost  useless, in such cases as these, to attempt the
reduction of the inflammation of the penis by the ordinary means,
which would succeed, were the surface of the sore exposed and not
so situated.  It must be borne in mind that the situation of the sore
produces and keeps up the inflammation, and the phymosis which is
dependent upon it.   If the inflammatory symptoms in  such  a case
run very high, general bleeding, aperients, rest, fomentations, and
low diet, may be employed as preliminary measures, and we may
 succeed in subduing the inflammation more or less completely by
 these means.   We must not, however, conceive that we have com-
 pletely succeeded, unless we can reduce the phymosis, and expose
 the sore to view, the grand object towards which  all our treatment
should be directed.
   These measures, then, in chancre, with inflammation of the penis
        8 
 114                 PRIMARY SYPHILIS.

and phymosis, may, and perhaps must be, resorted to in the first
instance; but if, after a reasonable time spent in their employ, the
inflammation and tumefaction of the penis do not give way, and we
cannot denude the glans, recourse must be had to the  operation
for the relief of the phymosis, and the surface of the sore then ex-
posed must be instantly pencilled over with one of the liquid caustics
before recommended.  By these means we shall prevent the inocu-
lation of the recently-cut surfaces.  The parts should then be co-
vered with pledgets of lint soaked in an appropriate lotion, and
the whole enveloped in a poultice.
  All primary venereal ulcers are  attended, in the commencement,
with more or less local  inflammation, sometimes of  so  violent  a
character as to produce pretty smart symptomatic  fever.   Indeed,
some of the most  appalling results we witness, under circumstances
of this kind, arise from  the excess of local inflammation and the
sloughing, rapid ulceration, or gangrene, which is  its  result.
  I am convinced, from a very extensive experience in the treat-
ment of syphilitic diseases, that many of the ill effects produced by
primary sores are attributable to the want of a proper regimen on
the part of the patient,  and, perhaps, also to a want of sufficient
directions on this point on the part of the surgeon.
  Whenever we  are consulted by a patient with a primary vene-
real ulcer, particularly if it is the first from which  he has ever suf-
fered, it will become necessary to point  out to him in  as strong
terms as possible, the  necessity of his adhering rigidly to  a very
abstemious diet till the ulcer assumes a granulating condition; it
is well, also, at this period, to administer repeatedly, for  some few
days, aperient medicine,  and to insist on a total  abstinence from
malt liquor, wine, or spirits.  If the patient, from circumstances,
cannot lie by and rest altogether, press upon him the advantage of
retiring early to bed, rest in bed being a most important  auxiliary
in the treatment of all forms of primary syphilis.   It is very easy
to regulate all these matters in the hospital; but in private practice,
to which I am now more  particularly referring, such means cannot
always be adopted; and I am afraid their extreme  importance and
advantage  are  not always stated  in  as strong a  manner as they
should be to the patient.
  Whether it be  the intention to submit the patient ultimately to
mercurial treatment or not, these preliminary cautions should never
be omitted.   Many of the evils attendant on mercurial causes are
to be attributed  to  not  preparing the patient by diet,  rest, and 
ULCERS.                         115
aperients, for the administration of this medicine.   I do not sub-
scribe entirely to the tenets of those  who treat syphilis systemati-
cally on what  is termed the rational or simple plan without mer-
cury;  but I must bear so far testimony in favour of this school to
say, that they have conferred an immense advantage upon society
by pointing out that diet, rest, simple dressings, and an antiphlo-
gistic regimen, have a vast influence over the ravages produced by
syphilis; and wherever mercury is exhibited for the cure of syphilis,
more particularly its primary forms, let the  concomitant measures
relative to diet and regimen  be those which the rational school
teaches, and I have just laid down.
   If mercury be given for the cure of a primary venereal ulcer, it
Bhould not be used till  the patient has been prepared to receive it by
adopting, for some days, the regimen  laid down, and till all inflam-
mation produced by the action of the escharotics has subsided; it
may then be employed with every hope of realizing its most bene-
ficial effects.   To throw it carelessly in without these precautions,
under a vague impression that  mercury is a specific for syphilis, is
worse than injudicious; it is criminal, and cannot be too much cen-
sured.
   Having arrested the progress of ulceration in the primary vene-
real ulcer, and brought it to the condition of a granulating sore, a
change in the plan of  treatment becomes necessary, both constitu-
tionally and locally.  If mercury be used, now is the time  to have
recourse to its employ with the hope of realizing its most benefi-
cial effects.1  I refer the reader to the section qn the "Mercurial
Treatment of Syphilitic Diseases," for rules to regulate him in the
exhibition of mercury, and to  the section on "Particular Prepara-
tions of Mercury," &c. for forms for its employment.

  1 The reader may consult, if he thinks proper, the works of Wallace, Ricord, Des-
ruelles, and Cullerier, on the points here in question.  He will find all admitting the
superior efficacy of mercury in hastening the cicatrization of a primary venereal
ulcer.   The  last three—partisans of the simple treatment—recommend mercury
when the sore is indolent, does not cicatrize under the simple plan, when its edges
are hard and elevated, or the sore leaves behind it, in healing, an indurated cicatrix.
  Mercury, although not a specific against syphilis, is the most powerful therapeutic
agent we can employ, in many cases, in its cure. (Ricord.)  I am far from rejecting
the internal use of mercury  in the treatment of the primary venereal ulcer.  I be-
lieve that in many cases it is necessary, and even indispensable.  (See Cullerier;
op. cit., p. 186; and the remarks of Desruelles; op. cit, pp. 313-15.)
  Lugol believes that the  simple or rational treatment of syphilis without mercury
favours the development of scrofula in a future generation. (See his work translated
by Dr. Ranking.) 
J16                 PRIMARY SYPHILIS.

  The local treatment of the sore must also be changed when the
granulating process has commenced; and as mercurial applications
are generally injurious during the ulcerating stage of chancre, so
are they beneficial during the stage of reparation.  Local applica-
tions during this stage may consist of calomel and lime-water, mer-
curial ointment, the ung. hydrargyri nitratis, or the bichloride in
lime-water; these applications  being enumerated in the order of
their stimulating properties.  The aromatic wine, with or without
tannin, will be useful, if the  sore secrete much pus; if the surface
of the sore  be dry and foul,  great benefit will be found  by alter-
nating the dressings with the wine, and some detergent ointment.1
  The local applications  must be varied to suit the actual condi-
tion and aspect of the sore: hence, should it be painful, opium
combined with the remedy we  apply is useful.2   Should the irrita-
bility of the ulcers be of the inflammatory  kind, it will  be neces-
sary to leave off all stimulating pressings, and  have recourse to
emollient fomentations, and  the simple  or  opiate cerate.  Culle-
rier employs as topical applications, when the inflammatory symp-
toms have  subsided, solutions of the nitrate of silver, sulphate of
copper, mercurial ointment, or pomades of  calomel and opium, or
mercurial ointment and opium.3  All these varied preparations may
be found useful in various conditions of the  surface of the primary
venereal ulcer.   The  condition of the latter is the only circum-
stance that can guide us in their proper mode of application.
  Dr. Wallace thinks topical mercurial preparations of great value
in the treatment of primary venereal sores, in  the  second stage,
and believes that, in some measure, they supersede  the  necessity
of an internal mercurial treatment.   " In dispensary practice, and
among the  lower ranks of society, the internal administration of
mercury, particularly at inclement seasons of the year, can seldom
with safety be recommended.   In such persons, and under  such
circumstances, topical applications are of infinite value.   In cases
of this kind I generally confine my treatment to them, in conjunc-

              1 R.  Resinae flavse,
                   Gum. elemi,
                   Cera? flavae, aa gj ;
                   01. olivae, gvj;
                   Olei terebinth., ^ij.  M. ft. unguent.
              2 R.  Cerat. opiat.,  gj;
                   Hyd. chlorid,, ^ij.  M.
              * R.  Cerat. opiat.,
                   Ung. hyd. fort., aa |j. M. 
ULCERS.
117
tion with  the internal use of nitrous acid, and, by these means,
succeed for  the most part in healing the disease with rapidity.
Cases treated in this way are also very rarely followed by secon-
dary symptoms.1
  The indurated primary ulcer demands a treatment, both local
and general, in some measure different from the ordinary forms of
disease.   Its destruction by caustic must not be attempted.  This
requires a mercurial course till the sore has  healed without indu-
ration of  the cicatrix.   It must be recollected  I limit the expres-
sion "indurated" to an ulcer that is so from the commencement of
the disease,  and do not apply it to those sores which have become
indurated from the repeated application of stimulating dressings.
Local treatment is not generally so efficacious in ameliorating  the
condition  of this as the other varieties of primary syphilis;  the
sore is not commonly much benefited except  through  the  medium
of the constitution. Dr. Wallace gives some good diagnostic marks
by  which  we are enabled  to distinguish between the induration
which is the natural attendant upon this species of ulcer, and that
which is produced in ordinary simple sores by  the injudicious ap-
plication of  remedies: " We may always distinguish by the history
of  the case  and by the  character of the areola, the indurated ul-
cerations  which are connected with irritation or inflammation.
Thus, if indurated primary syphilis be not attended by these mor*
bid states, it will not be surrounded by an inflamed, but by a  cal-
lous or livid white areola, with or without a whitish line at  the
very edge or margin of the ulcerated  surface; or else  the skin
surrounding the ulcer will present its  natural appearance."  (Pp.
310-11.)
  I never now adopt the ordinary mercurial  treatment in  the spe-
cific indurated ulcer. I rarely give blue pill, or calomel and opium,
or use frictions with mercurial ointment; the evils of these treat-
ments I have pointed out in the sections on  the " mercurial treat-
ment" of  syphilis.  I confine my patient  to a milk  or broth diet,
submit him  to  the action of the mercurial vapour-bath daily,  and
give him  the biniodide  or bichloride  of mercury in solution, in
doses not  exceeding from the 20th to the 12th  of a grain. I con-
tinue this plan till the gums are red, elevated, and spongy; the va;
pour may  then be administered every two or every three days till
the sore has healed and the induration gone.  Two or three days'
1 Wallace, p. 113. 
118
PRIMARY SYPHILIS.
treatment generally makes a marked  impression  on the disease,
even before the  constitutional effects of it are ascertainable.  I
will venture to affirm, that this is by far the most certain method
of preventing constitutional taint from an indurated primary sore,
and it has the vast  advantages of being free from the evils of a
mercurial course, as  commonly conducted.
  There is a symptom  succeeding  to primary ulcers which some-
times occasions considerable anxiety to the patient and annoyance
to his surgeon; this is, "induration of  the cicatrix."  After the
healing of a primary sore the cicatrix occasionally remains hard
and elevated, and is prone  to  ulcerate  on  the occurrence of the
slightest exciting causes. This local  condition denotes the per-
sistence of syphilitic action on the system, and is the " forerunner
of accidents to come."  A patient in this condition may daily look
for secondary local ulcerations  of a rapid and destructive charac-
ter, and constitutional symptoms of the most formidable kind.  It,
therefore, behooves  him to adopt speedy means for the removal of
the induration, which may be generally accomplished, and till that
period arrives he cannot be considered safe.
  I could detail a number of cases of induration of this character
which  I have entirely  succeeded  in removing by the following
treatment. The  patient should have  his diet regulated, and  be
prepared for  the use of the mercurial vapour-bath, which  should
be employed three times a week; at the same time, he should take
the biniodide of mercury in solution with  the hydriodate of potass,1
till the mouth becomes sore, which should be kept so till the indu-
ration  is gone.   Few recent indurations will resist a perseverance
in this plan of treatment. If perfectly chronic, and of long stand-
ing, the case may be more obstinate.

               1 R. Hyd. biniodidi, gr. iij;
                  Potass, iodidi, 31J;
                  Syr.  aurantii, ^ss;
                  Aquae cinnamomi, ^iss.  M.
               Cap.  guttas xv—xxx ter. die. 
CHANCRES OF  THE  URETHRA.           119
                       CHAPTER IX.

                 OF CHANCRES OF THE URETHRA.
  Cases of syphilitic ulcers in the urethra have been cursorily al-
luded to  by many surgical writers.  Hunter mentioned them, but
certainly had no clear idea of their true  character and effects;
they are also noticed by Mr. R. Carmichael in his clinical lectures
on Venereal  Diseases.  The late  Dr. Wallace spoke of some dis-
charges from the urethra of venereal origin, which were only cu-
rable by mercury, but it has been left to modern surgical patholo-.
gists to demonstrate that primary venereal sores, precisely resem-
bling in their nature and  consequences sores situated externally,
may exist in  the canal of  the urethra itself, at variable points be-
tween the meatus urinarius and the bladder.
  It is clear, both from the statement of English and French wri-
ters, that discharges from the urethra are due to more causes than
one;  and hence it is that we find Dr. Wallace saying, "that there
occur cases of these discharges, in which we find mercury to act in
the most salutary manner;  and others again, in which the discharge
will continue, and  be, after a time, followed by  induration  and
bubo, and, most probably, by secondary symptoms, unless this me-
dicine be given."1  When we consider the generally powerless ef-
fect of mercury over pure gonorrhoea, we cannot but suppose that
these remarks of Dr. Wallace must refer  to chancres or venereal
ulcerations of the urethra, which an  imperfect diagnosis has  con-
founded with gonorrhoea.
  These are heat, itching, or irritation in the urethra,  occurring
after a suspicious connexion, unaccompanied by discharge; pain or
tenderness in a particular part of the urethra when it is  rolled be-
tween the fingers; the presence of a distinct induration at the point
where the pain is complained of;  pain also increased during  mic-
turition, and referred to the same point.  Discharge from the ure-
thra occurs at various and at irregular periods after the setting in
1 Op. cit., pp. 248-9. 
120
PRIMARY SYPHILIS.
of the first symptoms already described.  It is very different from
the discharge of gonorrhoea;  it may be sanious, bloody, or of a
sloughy character, and commonly does not  flow unless the indu-
rated portion before described be pressed forcibly between the
fingers.
  A gentleman consulted me  for a disease in the urethra, which
had existed many months, and which he said consisted at first in a
small sore, visible when the lips of the meatus  were separated.
This  part had healed; but it was evident that the  ulcer  had ex-
tended its ravages down  the urethra, since, on pressing an indura-
tion which existed behind the glans between the fingers, there
escaped from the urethra a tenacious slough, precisely resembling
that covering an indurated or Hunterian chancre  in its first or ul-
cerating stage.
  The only disease for which  chancre of the urethra can be mis-
taken is gonorrhoea.  From this it is to be distinguished by the
history of the case, the  character and quantity of the discharge,
the presence of  a distinct circumscribed induration in some part
of the urethra, most commonly seated in or immediately behind
the glans penis.  This circumscribed  induration must not be mis-
taken for that general induration of the corpus spongiosum urethras
which accompanies acute gonorrhoea, and results from an effusion
of lymph, &c. into the cells of the spongy body.  This state in go-
norrhoea is generally accompanied  by chordee, a symptom absent
in chancre of the urethra.
  In cases where muco-purulent discharges from  the urethra con-
tinue to  resist the usual methods of treatment we may resort to
the means of differential diagnosis, of testing the character of the
disease by inoculation.   It1 has been established  that the inocula-
tion of the skin of the thigh, the prepuce, or elsewhere, with the
matter of pure gonorrhoea produces no result, or at best a nega-
tive one.   The same inoculation with matter from the urethra, se-
creted by a chancre in that part, gives a characteristic pustule, and
subsequently a chancre or sore of venereal aspect.  In eighty-five
cases of urethral discharges, thus tested by M. Mairion, at the mili-
tary hospital of Louvain, four were found of true  syphilitic  cha-
racter, and produced chancres by inoculation; the remaining eighty-
one gave no  result; they were cases of simple gonorrhoea.

  1 See the chapter  on "Inoculation," and the cases of "chancres larve's," in Ri-
cord's work, before referred to. 
CHANCRES OF  THE  URETHRA.
121
  In some rare cases I believe it possible that a primary venereal
sore in the urethra and gonorrhoea may be contracted by the same
connexion.  I will mention a case which seems to bear upon this
point.   A gentleman, fifty years of age, contracted from a suspi-
cious  connexion a discharge from the urethra, which had  all the
characters of ordinary gonorrhoea; he placed  himself under the
care of an eminent practitioner, and took for a month the ordinary
remedies, such as copaiba and cubebs: with this treatment the dis-
charge disappeared.  At this time a slight ulceration was percepti-
ble round the meatus, which seemed to come from within the urethra.
This spread rapidly, soon involving the whole under surface of the
glans, and the urethra for an inch and a half, which were entirely
destroyed by ulceration and sloughing.  I was consulted on this case,
which was succeeded by extensive nodes, and a pustular eruption;
and what is very remarkable, the nodes were the first constitutional
symptoms which occurred, an exception to the law which seems to
regulate the appearance of constitutional symptoms generally.
  I believe the poisons of gonorrhoea and syphilis to be perfectly
distinct, but  yet there are cases occasionally presented to  our no-
tice where both chancres and gonorrhoea exist at the same time.
  It is not uncommon to see patients with external sores and a true
gonorrhoeal discharge from the urethra at the same  time; neither,
in the female, is  it rare to see true primary venereal sores in the
vulva, vagina, or uterus, coexisting with  purulent discharge from
the os uteri or urethra.   In the male, however, more particularly,
these two primary forms of disease are not curable by the  same
remedies.  In the case I have just quoted, it appeared that the
two forms of primary venereal infection existed simultaneously in
the urethra at the commencement, since the symptoms of gonor-
rhoea disappeared under the use of the ordinary specific  remedies;
whilst the venereal ulcers continued to spread, and  ultimately
produced the most serious mutilation.  We have  no further proof
of the opinion I have hazarded than is to be drawn from the effect
of remedies, a fact to which I am disposed to attach very considera-
ble importance.
  Chancres in the urethra  may be met with  as a solitary form of
primary venereal infection, or they may coexist with sores situated
externally.   The case  of M'Knight, subsequently recorded,  is a
proof of this.  It very commonly happens, also, that the presence
of external sores, and the absence of  discharge from the urethra,
prevent any  examination of the latter.   In examining, however, 
122
PRIMARY SYPHILIS.
a patient who applies with a primary venereal affection, the canal
of the urethra should always be pressed  between the fingers, and
the lips of the meatus opened.
  A gentleman contracted several small sores situated on the glans
and prepuce; they were free from pain and  irritation, and healed
quickly under ordinary  treatment; the  glans, however, became
swollen, red,  and shining, and  yet there was no external symptom
to account for it.   In everting the lips of the meatus a small sore
was discovered, upon which the condition of the glans was evidently
dependent, since it  disappeared as soon as the sore in the urethra
healed.
  The prognosis of chancres in the urethra is not always favoura-
ble; Ricord and Vidal de Cassis have shown that by extension to
the bladder they may terminate fatally.   The prognosis is again
unfavourable as regards the integrity of the organs of generation,
since, however carefully  they may be watched, severe mutilations
are occasionally produced.  The chief evils I have seen arise from
chancres in the urethra have been the following:
   1st. Contraction of the orifice of the urethra by the  cicatrix of
the chancre.   I attended a gentleman who  had a chancre of the
orifice of  the urethra, which, in healing, so contracted the meatus
orifice, that it would  not admit the bulbous extremity of an ordi-
nary silver probe.
   2d.  Contraction of the urethra by the cicatrix of the chancre
where the sore has been  situated lower down.  To this species of
stricture the term traumatic has been applied.  It does not readily
yield to the bougie.
  3d. Perforations  of the urethra.  These are variable in extent
and situation, but are commonly situated  immediately behind the
glans.  I have said  that a very common seat  of chancre of the
urethra is  the fossa navicularis, and the glans is sometimes scooped
out as it were by the spreading  out of venereal ulceration in this
situation.   I have seen this passage behind the glans opened for an
extent of an inch and a half by the ravages of a urethral chancre.
  4th. The urethra itself may be completely destroyed to a greater
or less extent.  Of  this also I have seen one example, where the
passage was destroyed by ulceration for two inches, and the urethra
opened on the under surface of the body of the penis.
  I can conceive of nothing more horrible  to a young man than
mutilation of this character, which, in spite of all our care and at-
tention, will sometimes take place, if the disease assume a phage-
denic form, and spread  by rapid ulceration or sloughing.   They 
CHANCRES OF THE  URETHRA.
123
are not, however, so likely to happen if the disease has been at
once diagnosticated and properly treated from the commencement.
  Constitutional symptoms are just as likely to occur in consequence
of primary venereal diseases in the urethra, as when  such  sores
are situated externally.
 • The question next arises, how are primary venereal sores situated
within the urethra  to  be treated?   The situation of these  sores
precludes the adoption of the practice I have recommended  to be
employed in primary venereal sores situated elsewhere.
  The use of caustics is clearly impossible, unless the sore be situ-
ated immediately within the urethra, and even  then their applica-
tion will require great care and attention, and is not generally to
be recommended.
  From  the situation  of a primary venereal sore in the urethra
we  are prevented employing the local remedies commonly used in
the treatment of chancre; and an indiscriminate course  of mercury
is still more useless and injurious.
  The existence of chancre of the urethra being ascertained, the
inflammatory symptoms are to be first subdued  by a treatment ap-
propriate to the earlier stages of gonorrhoea; diet, rest, diluents,
and cathartic medicines, with emollient injections.  Afterwards we
may resort to injections with aromatic wine, or solutions of the ni-
trate  of silver, or the solid nitrate may be introduced, and the sur-
face of the  sores cauterized, if the inflammatory symptoms are too
acute, and the  chancre situated within reach.   It is useful  to in-
troduce a small plug of lint into the urethra, impregnated with the
injection we employ, with the view of keeping  the surface apart,
and preventing any extension of the disease.
  Mercury  may be employed, in chancres of the urethra, at  the
period, and in  the  manner before recommended in the treatment
of indurated primary venereal sores, attending  to the local aspect
of the sore during its administration.
  A man entered the venereal hospital, said to have suffered from
gonorrhoea for twelve  months, in the treatment of which copaiba,
cubebs, and various astringents had  been  vainly employed by a
variety of surgeons.   The discharge, from  the patient's account,
had never been very profuse; on pressing the urethra firmly  there
hardly issued  some drops of pus.   The glans  was considerably
swollen, and its summit the seat of an induration the size of a nut,
surrounding the meatus.   On separating the lips of the orifice a
large chancre was  discovered, which had  burrowed itself deeply 
124
PRIMARY SYPHILIS.
into the parietes of the canal.  This patient had been submitted to
several mercurial courses without benefit, because (says M. Cullerier)
the local treatment of the sore had been neglected.  All internal
treatment was now suspended;  a strict dietetic regimen and repose
were directed to be observed,  and leeches were applied from time
to time.  In the intervals, a piece of lint, covered with opiate cerate,
was kept in the urethra;  emollient fomentations were frequently
used, and the penis enveloped  in a poultice.  Under the influence
of these remedies the inflammation soon disappeared, the sore be-
came  clean, and a few applications of the  nitrate  of silver were
sufficient to effect a cure.

                          Case XI.
   Robert M'Knight, by trade a Scotch hawker,  aged  29, con-
tracted, from the same connexion, sores on the penis and a run-
ning from the urethra, seven years ago.  The ulcers on the penis
were  cured, very likely by  a  mercurial course, as M'Knight has
been repeatedly salivated. The treatment which cured the external
sores  had no  effect upon the discharge from the urethra;  this con-
tinued: it  has  been repeatedly treated, but  never cured.  Soon
after this, scaly blotches appeared on the forehead and other parts
of the body, which disappeared under medical treatment.  Disre-
garding the discharge from the urethra, which never disappeared,
and fancying himself  well, our patient  now married.   His first
child died a few  months after birth, covered with blotches:  a
second and a third child shared the same fate, and died under the
same circumstances.  The wife  also had sores and bloody discharge
from the vagina, and blotches on the body, the husband still having
no affection  except  the slight running from the  urethra, which
sometimes  attracted his attention, and at others was totally disre-
garded.
   During these periods M'Knight had, at several times, fresh con-
stitutional  symptoms, for which he underwent a variety of treat-
ment, but was never free from the running from the urethra.  In
November, 1843, between six and seven years after M'Knight con-
tracted his primary disease, he came  under my care as a patient of
the Queen's  hospital.  He was then in the following state:  The
head  and face were covered with foul blotches, which Consisted of
incrustations or scabs, concealing deep, irregular, and  ill-condi-
tioned ulcers; there was superficial  redness of the fauces, but no
ulceration  at this time; he  was feeble  and emaciated from long- 
CHANCRES OF THE URETHRA.
125
continued disease.  The skin disease was evidently pustular in its
commencement, as one or two fresh-formed pustules were  on the
face:  these pustules were situated on an inflamed base, and, when
they broke and  discharged, ran into ulcers, covered with  flat or
conical crusts, thus constituting a variety of disease to which the
term " pustulo-crustaceous " has been applied.
   He denied at first having any thing  the matter with the geni-
tals, but, on closer questioning, admitted that he had a running so
slight as  to be  hardly worthy of notice.   On  examination I per-
ceived a sanious oozing from the  urethra, very different from that
which characterizes chronic gonorrhoea or gleet.  About an inch
from the meatus, immediately behind the glans penis, existed a cir-
cumscribed induration, about the size of a hazel nut: this was pain-
ful when pressed between the fingers, and the pressure occasioned
some blood and portions of white tenacious sloughs to issue from
the urethra.  On separating  the lips of the meatus urinarius, by
means of a small speculum  made for the  purpose,  the commence-
ment of ulceration, which appeared to extend deep into the ure-
thra, could be perceived.
   This case is  remarkable under  many points of view.  In the
first place the disease itself (primary venereal sore  in the urethra)
is not of every day occurrence, although I have  seen  many in-
stances of it; again, the time which the sore has existed is remarka-
ble.   There is  no evidence that M'Knight had ever contracted a
 venereal disease subsequent to his marriage; the evidence of the
 wife and himself  is conclusive upon  this  point.  The sores which
 M'Knight contracted at the same time  he contracted  the running
 were cured previous to his marriage, the  running still remaining;
 some days he perceived none; yet having no other disease than that
 in the urethra, we observe the wife  becoming diseased, and three
 children dying, with unquestionable venereal affections.
    This case is one, then, of primary venereal sore in the urethra,
 contracted at  the same  time  with external primary sores. The
 primary sores were healed, but the urethral sore remained uncured,
 and, marrying in this state, his offspring all die diseased, and his
 wife also is affected.
    The patient has had repeated  attacks of constitutional disease
 in the most alarming forms, which have recurred as often  as they
 have been cured, and this I explain by the sore  in the  urethra
 being still open and poisoned, and thus forming, as it were, a well
 of poison, which was constantly tainting the system. 
126
PRIMARY SYPHILIS.
   It  is proved  by the  history of this case, then, which has  been
very  carefully watched and  examined, and the history very cor-
rectly taken, that primary venereal sores may exist within the ure-
thra for a long period of time.   M. Cullerier has recorded a case
of this nature, which had, when presented to his notice, continued
upwards of a year, and was then uncured, although the patient had
been  submitted to repeated treatments.  These sores may be seated
in any part of the urethra, and even in some rare cases extend to
the bladder itself.

                          Case XII.
Thickening and contraction of the urethra, from the cicatrices of venereal sores situ-
        ated in the fossa navicularis; chancre of the fossa navicularis.
  A middle-aged gentleman  came to consult  me respecting what
he termed an obstruction in his urethra; he gave the following
history  of his case:—About  eighteen months ago  (September,
1843,) shortly after a suspicious intercourse, he perceived a slight
discharge from the orifice of  the urethra, from which  there issued
some  drops of pus; on  separating the lips of the urethra  he  per-
ceived within  them a small sore.  He applied to a druggist, who
furnished him with an ointment which irritated the sore and made
it worse.  Some time after this, a surgeon was consulted, who re-
commended mercury; this was taken till salivation was produced.
The sore,  however,  did  not amend under its use; it was still to be
perceived when the urethra was examined, and the same discharge
of drops of pus continued.
  He consulted, some time after  this, a second surgeon, who cau-
terized  the  sore daily  with  the  nitrate of silver; this produced
hardness of  the  glans penis,  and discharge of sloughs and blood
from the urethra.  This state of things continuing, the patient be-
gan to lose confidence  in the mode of treatment, which he aban-
doned, and, three weeks after the last  application of the caustic,
he consulted me.  Copper-coloured spots  made  their appearance
on several parts of the body, the  arms, and trunk, at this time.
  When the patient pressed the urethra forcibly between the fin-
gers, he brought from it a thick  tenacious slough, exactly resem-
bling  that which covers  an indurated chancre in its first or ulce-
rating stage.   The  under surface of the glans penis was red and
inflamed, and,  when this part  was examined between the fingers, a
considerable induration  was perceived, which appeared to  exist in
the lower part of the fossa navicularis, just within  the urethra. 
CHANCRES OF  THE URETHRA.             127
When this induration was pressed, there issued from the urethra
pus, sometimes mixed with blood, and at times tenacious shreds or
portions of sloughs similar to those already spoken of. I examined
the interior of the urethra for an inch and a half or more, with a
small speculum made for the purpose.  A white smooth cicatrix
occupied the whole of  the fossa  navicularis on its upper part and
sides;  I could not obtain a clear view of the bottom of  the fossa,
where I believe ulceration still existed.  This I inferred from the
induration, the redness opposite  this part, and the character of the
discharge forced from the urethra when the induration was pressed
between the fingers.

   There were no constitutional symptoms in existence either in the
throat or vicinity of the anus, some copper-coloured blotches only
occupied the arms and legs.  In  primary venereal sores of the ure-
thra, the local treatment is a main point to be attended to.   I re-
commended the patient to inject the urethra three times a day with
tepid olive oil, and in the  intervals introduced into the passage a
thin shred of soft lint soaked in a solution of tannin and extract
of opium.1   The lint was kept  constantly in the urethra, merely
being removed when the patient wished to make water.  The pa-
tient was also directed to take one grain of the iodide of mercury
with three of the  extract of conium,  in a pill, every night, and
to be strictly regular in his mode of life.  With very slight modi-
fication in the mode of treatment at first laid down, this case was
brought in a few weeks to a successful  issue, the induration and
discharge disappeared from the urethra, and the copper-coloured
blotches from  the  body.   There remained merely some contrac-
tion of the urethra, produced by the first cicatrix, which was ma-
terially relieved by the  bougie. This constitutes what  has  been
termed by some writers "traumatic stricture," very commonly pro-
duced by the  cicatrices of primary venereal sores  thus  situated,
which, when they do not actually contract the urethra, partially
destroy its elasticity, and produce  many troublesome symptoms,
more particularly a dribbling away  of the urine for some minutes
after the patient has done making water.  This constitutes a species
of incontinence of urine whose  cause  is to be sought for, not in
the bladder but in the urethra.

               1 R. Tannin, gr. x;
                   Ext. opii pur.,  gr. ij ;
                   Aquae, gj.       M. ft. lotio. 
128
PRIMARY SYPHILIS.
                        CHAPTER X.

                        OF PHAGEDENA.

  Instead of following the  regular course, the primary ulcer as-
sumes a character of rapid ulceration or sloughing, to which the
term phagedena is applied.  Phagedenic ulcers assume various
forms; sometimes they are intensely painful, the  surface covered
with a tenacious yellow  slough, the edge  red and hard, and the
surrounding integuments little or not at all  affected.  This  spe-
cies of sore spreads rapidly by ulceration, and if not arrested fre-
quently occasions fearful mutilation.   Primary ulcers  frequently
assume this character at  the commencement, without any evident
cause, but it is again a secondary condition, produced by the habits
or constitution of the  patient, the injudicious exhibition of mer-
cury, or improper local treatment.  Primary ulcers assume a pha-
gedenic appearance from  an excess of local inflammation;  in such
cases the penis is  lividly  red, and much swollen, and the  sore it-
self covered by an adherent dark parti-coloured or black  slough.
With these local conditions the constitution of the patient sympa-
thizes more or less; there is, in some cases, smart symptomatic fever,
the pain prevents sleep, and there are profuse night perspirations.
  In many cases no positive cause can be assigned.  I have seen
phagedena in persons previously very healthy,  Desruelles, in the
true  spirit of Broussaism, attributes it  to  irritation  of the vis-
cera, a chronic gastritis, or gastro-enteritis.  Ricord believes, also,
that  there is commonly an  accompanying visceral irritation, but
believes, also, that a cold  damp atmosphere disposes primary sores
to become  phagedenic.  Mr. Mayo states that " what gives the
phagedenic character to  sores on  the  genitals after infection, is
some peculiarity of the general habit."  This is perhaps true, but
the difficulty is to know in what this peculiarity consists.
  I have seen primary  phagedena on the body of the penis,  on the
lower part of the abdomen, in three instances  in the male, and here
I am fully persuaded that they were produced by secondary sores 
PHAGEDENA.       ,               129
in the female.  This form of disease is particularly liable to occur
at the orifice of the urethra; it commences in the fossa navicularis,
the glans penis is red, shining, and  swollen, a sanious discharge
issues from the meatus, and a white ring soon surrounds it; the ul-
cerative process  soon extends over the whole glans.   Mutilation
can hardly be  prevented in such cases, for to  however a trifling
extent the substance of the glans may be destroyed by ulceration
it is never repaired, the ulcers may cicatrize and heal, but the loss
of substance  is not restored.  On everting the lips of the meatus in
such cases, a white slough may be seen covering the whole surface
brought into view.  I have seen five cases of this kind.
   The treatment of phagedena is local and constitutional.   I have
not much faith in the former.  The first  indication is clearly to
arrest the process of ulceration, whether this be done  by local or
constitutional measures, by escharotics of various kinds locally, or
by bleeding, tartar emetic, opium, or mercury, as constitutional
remedies.
   One of the most  apparently feasible means of arresting the ul-
cerative process is destruction of the whole surface of the sore by
strong nitric acid, or the acid nitrate of mercury, which is then to
be covered  with  a poultice or pledgets of lint soaked in warm
olive oil, or strong decoctions of poppy, or aqueous  solution of
opium.  Although this may be practised in some forms of phage-
dena,  there  are  others in  which it  is inadmissible  or positively
injurious.  In sores characterized by great irritability caustics are
hurtful, and in those marked by  great  inflammatory  action, this
must be subdued before the acid is used, but it may then be  em-
ployed,  if necessary.   In these  varieties of phagedena a purely
antiphlogistic  treatment, with anodyne fomentations or poultices.
is the safest  practice, leaving the application of caustics till the in-
flammatory action has been in some measure subdued.  As local ap-
plications to very irritable ulcers of  this kind  I have found  the
Unguent. Zinci with opium answer very well where all other ap-
plications have failed.1   Dr. Wallace recommends the  unguentum
hydrargyri with opium.2  As a detergent  for sloughy sores, or after
the acid has  been used, one of the best applications is composed of
equal parts of balsam of Peru and castor oil.

               1 R.  Unguent, zinci, ^jss;
                    Pulv. opii, gij.  M.
               1 R.  Unguent, hydr. fort., %j;
                    Extr. opii pur., £j.  M.
        9 
130
PRIMARY SYPHILIS.
  In those forms of primary phagedena attended by severe pain,
our chief reliance is to be placed upon opium combined with tartar-
emetic; conium, hyoscyamus, and other sedatives may be employed,
but the most certain remedy is the first; with this may be combined
sarsaparilla  in  conjunction with the iodide of potassium, or the
mineral acids, or the cold infusion of sarsa in lime water, which is
the best form.1   In the inflammatory forms, general bleeding may
be indicated, but, except in extreme cases, I do not approve of this
practice.   I prefer low diet  and  tartar emetic as a means of re-
ducing inflammation in such cases.   It must be remembered, also,
that we have to deal with a specific and not a common inflammation,
and as I have already remarked, when speaking of the inflamma-
tory forms of gonorrhoea, that the inflammatory symptoms do not
in all cases yield to antiphlogistic treatment, we debilitate the pa-
tient very often  by them, and do not ameliorate the disease.  In
such cases mercury is sometimes of great use.  There are  cases,
certainly, in which  the degree of inflammatory action accompanying
a primary syphilitic sore is not a positive contra-indication to the
use of mercury.   Dr. Wallace  had already remarked this, and
founds his opinion  on the value of mercury freely exhibited in sy-
philitic iritis, and  upon the  fact that mercurial fumigations, in
certain destructive  sores of the throat, are very frequently bene-
ficial, though attended by great inflammatory action.  No remark
can be more correct.  The  records of cases treated under my care
in the Queen's Hospital, afford abundant evidence  of this, and I
think the following rule laid down by Dr. Wattace of extreme value,
" that although that form of inflammation which  supervenes  when
a patient is under  a mercurial course, is sure to be aggravated by
persisting in the use of mercury, the remedy will powerfully assist
to subdue inflammation which commences under different circum-
stances."
  In those forms of phagedena which are characterized by a black
slough, the sloughing phagedena of British surgeons, the gangre-
nous  phagedenic chancre of  the French, mercury is wholly inad-
missible, the disease is to be treated on the principles which should
regulate us in the^management of similar diseases not syphilitic.
It must be recollected, however, when the sore has been brought to

              1 R. Rad. sarsae, ^iv;
                   Rad. glycorrhizae, gj;
                   Liquoris  calcis, Oij.
          Macera per horas xxiv.  Cap. poculum magnum ter die. 
PHAGEDENA.
131
heal by proper remedies, that  it has had a venereal origin, and
perhaps has succeeded to a regular primary sore, rendered gangre-
nous by irregularities and bad treatment, and therefore  that  it
may be followed by secondary  or constitutional symptoms.
  It will be evident  from what has been said, that mercury is not
to be generally employed in phagedena;  although there are cases
in which its use may be  beneficial, and these are chiefly where all
other ordinary means have failed in arresting the extension of ul-
ceration; when it  is indicated, the method par excellence is that
by  fumigation.  The other remedies consist of venesection, and
tartar emetic,1 the dilute nitric acid,  or the nitro-muriatic acid,  or
the hydriodate of  potass with  bark,  or sarsaparilla.  In the way
of local treatment in certain cases, no applications are better than
strong nitric acid, the  acid nitrate, or the per-nitrate of mercury,
" used freely to the sore, and repeated till a clean vascular surface
comes into view."   The first or second application is^not attended
with considerable pain, as  the disorganized surface tends to pro-
tect the more sensitive parts underneath; but as the slough becomes
detached, the pain is increased on each successive application.   If
the slough be reproduced, it may be dressed with equal parts  of
balsam of Peru and  castor oil.2
   Secondary venereal  ulcers sometimes assume a phagedenic cha-
racter.  Secondary phagedena, however, is chiefly met with in the
throat and fauces in bad constitutions, or constitutions broken
down by bad living, long-continued disease, or improper treatment.
To these we  shall return, when speaking of secondary syphilis.

                          Case XIII.
 Phagedena of the body of the penis, spreading by rapid ulceration; failure of ordi-
               nary treatment; cure by mercurial fumigation.
   A young gentleman,  of delicate constitution, aged 22, contracted
a sore on  the body of the penis.  It appeared first as a pimple, but

  * Carmichael's Antimonial Solution:
                 R. Antim. tart.,  gr. iv;
                    Tinct. opii, 33;
     k               Tinct. card, co., gss;
                    Syrup., ^ss;
            i        Aquae fontanae, gvij.  M.
  Administered in the  simple or compound decoction of sarsa, in  primary venereal
 ulcers, where much inflammation  is  present; also in the earlier stages of all sy-
philitic eruptions.
  a Egan; on Primary and Secondary Phagedena, " Dublin Journal," January, 1845. 
132
PRIMARY SYPHILIS.
rapidly ulcerated and spread.  I saw this patient seventeen days
after the  first appearance of the ulcer.   It was then as large as
half-a-crown, covered with  a  tenacious yellow slough, the  edges
hard, elevated, and red, but  no characteristic induration.  The
pain from the ulcer was most severe, its surface very sensitive; the
patient could not sleep, and was tormented with profuse perspira-
tions.   Various local remedies were tried without effect, the irri-
tability and sensitiveness of the sore were so great that I feared
to use caustic to avert the spread of the ulceration, which increased
daily.  The only local remedy which could be borne was the un-
guentum zinci with powdered opium.  For twelve or fourteen days
I kept this patient in bed, and gave him large doses of conium with
opium, sarsa with nitric acid, &c, with very little, or I may say no
good effect.  The ulceration continued to extend, and  threatened
to involve the whole integument of the penis.  I now resorted to
the moist mercurial fume.  I placed him in a strong bath, in which
he only remained ten minutes, the pain produced was so great, and
when he was removed he fainted.  On the next day the ulceration
had not spread; the bath was again used, with less pain; on  the
third day there was no pain, and one or two  healthy spots  made
their appearance in  the centre of the slough which covered  the
sore, and the edges were less hard.  After the fifth bath, the ulcer
was covered with healthy  granulations, and very shortly healed.
The gums were very slightly affected.

                          Case XIV.
Indurated phagedenic ulcer of the glans penis; failure of ordinary treatment; cure
                     by mercurial fumigation.
  A commercial gentleman, very healthy, 28 years of age, con-
tracted  a sore on the under surface of the glans penis, near the
fraenum.  I did not see it till the third week of its existence, during
which period the patient had pursued his usual avocations, and
used various local remedies.  When I first saw this case there was
a deep burrowing ulcer involving the whole under surface of the
glans, having destroyed the fraenum, and extended to the integu-
ment on the under surface of the penis;  this ulcer was covered
with a tenacious slough, black in some places, white in others.  The
glans penis itself was swollen and much  inflamed, and the whole
body of the penis was in a similar condition.  The patient was now
confined to bed, placed on  a  low diet, the parts enveloped in a
bread poultice, and aperients, with  nauseating doses of antimony 
PHAGEDENA.                     133
exhibited.   In two or three  days, the ulcer continuing to spread,
I destroyed the whole surface with  the acid nitrate of mercury,
and  after the  separation of the eschar, no improvement having
taken place, I  did this a second time.  The slough was again re-
produced, the ulcer still spreading, and threatening to open  the
urethra; a circumstance I have seen more  than once consequent
upon ulcers in  this situation.  It is to be remarked also that the
general inflammation in the glans and  penis were very little re-
duced by the rest, diet, and antiphlogistic treatment.  I now resorted
to the mercurial fume.  The patient was immersed daily for forty
minutes; there was no extension of disease  after the second bath.
At the end of  eighteen days the sore had healed without indura-
tion, leaving, however, an excavated cicatrix on the glans.  The
mouth was moderately sore.  Profuse night perspiration also ac-
companied the ulcerating and sloughing stages. 
134                 PRIMARY SYPHILIS.
                       CHAPTER XL

              OF VENEREAL ULCERS IN THE FEMALE.

  Primary venereal ulcers in the female are most commonly seated
in the external parts, as the labia majora, the nymphas, the folds of
mucous membrane surrounding the clitoris, at the orifice or other
parts of the vagina, or at the meatus urinarius.
  True chancres, i e., primary indurated sores,  yielding a charac-
teristic pustule by inoculation, are rare on the neck or at the orifice
of the womb, although ulcerations, unquestionably syphilitic, and
which  produce disease in the male, are exceedingly common in
this situation.   In reference to the first point, M. Ricord gives one
case  only (Case 13,) where, after inoculation,  the  characteristic
pustule succeeded.  Mr. Whitehead says (p. 367,) I have seen but
one case of this kind, it had the genuine chancrous appearance, but
yielded no result when inoculated.  Dr. Bennet quotes two cases
(on Inflammation of the Uterus, &c, pp. 441, 444,) which were
most probably primary venereal sores, but no account is given of
the results of inoculation, and  probably  they were not  tested.
Gibert (Traite des Maladies Veneriennes, chap, ii.) regarded many
of the ulcerations of the os uteri, which had been confounded with
syphilis, as purely inflammatory diseases, and this opinion has lately
been reproduced by Dr. Bennet.   Nevertheless, I am  persuaded
that many of the ulcerations which are found on the os and in the
cervix uteri, in females who  are suffering from secondary syphilis,
are of a syphilitic character, whether primary or secondary I am
not prepared to say.  If primary, they differ in their appearance
from chancres elsewhere, and I have never, in one single instance,
been able to produce a characteristic pustule by inoculation, although
a week has rarely passed without my  making  an  experiment of
this kind.
  These ulcers, however, produce disease in the male, although
not inoculable. 
VENEREAL ULCERS IN THE FEMALE.         135
                           Case XV.
 Secondary syphilis in the wife, suspicious ulcer of the os uteri; gonorrhoea, and su-
                     perficial sores in the husband.
   A. L----was admitted as an out-patient of the Queen's Hospital,
 with gonorrhoea, and several superficial  sores round  the corona
'glandis.  He said the disease had been communicated by his wife,
 who was suffering from secondary syphilis when he married her;
 and, soon after the disease under which he laboured broke out, he
 brought his wife with him for examination.   A well-defined inflam-
 matory patch surrounded the os uteri, on the lower lip of which
 existed a deep ulcer, the size of a sixpence, which appeared to run
 into the cervix.   The anterior lip was much thickened; I never
 saw any sore more closely resemble a chancre; but it produced no
 result when inoculated.  I must think with Mr. Whitehead, that
 the great majority of morbid conditions which  are found on the
 lips, and at the orifice of the uterus in females who are labouring
 under a confirmed venereal taint, are of syphilitic character, pro-
 bably they are secondary, or rather  constitutional.   It is rare to
 find the uterus free from disease where a confirmed constitutional
 taint exists; the os is either surrounded by a ring of inflammation,
 or the lips are everted and red, and more or less  thickened; again,
 superficial  ulcers  exist, either having a granular appearance, or,
 what is less common, the edges of the  ulcer well defined, and its
 edges elevated and hard.   M. Gibert says, we must admit that this
 granular condition, or this ulceration  of the  os uteri, is due  to
 syphilis, and belongs most commonly to secondary syphilis. 
136
PRIMARY SYPHILIS,
                       CHAPTER XII.

                           OF BUBO.1

  Bubo may be primary, secondary, or constitutional, sympathetic
or syphilitic, succeeding either to  chancre,  gonorrhoea, balanitis,
or making its  appearance without  any of these diseases  having
preceded it.  The true venereal bubo is most commonly preceded
by a primary disease, and is hence  secondary, but it may occur as
a primary syphilitic symptom.   Authors are divided as to the fre-
quency of its occurrence under the  latter form.   I believe it to be
very rare.   It  very commonly happens that the most formidable
buboes succeed to affections so trivial that they have escaped the
observation of  the patient; and hence we may frequently, when
called to treat  buboes which are said  not to have  been preceded
by any other syphilitic affection, discover, on  drawing back the
prepuce, a slight balanitis, or excoriation, or the fresh  cicatrix of
some trivial  ulcer.  The bubo, which has been  termed primitive,
or d'emblee, which arises after promiscuous intercourse,  and has
not been preceded by either a discharge  from the  urethra,  a sore,
excoriation, crack, or  fissure, on the  genital organs, may  be, but
commonly is not venereal.2  It is  very commonly due, in  young
persons especially, to  over-sexual  indulgence, or violent  exercise
during coition: of this I have seen many instances.  This is clearly
not a primitive virulent bubo, produced  by the absorption  of any
special virus, but an ordinary adenitis due to an evident cause.   I
have never seen a case of primitive bubo, which has  been tested
by inoculation, and thus  proved to be of a syphilitic character:
my experience  in this point is supported by Dr. Egan.3  Such cases

  1 Adenitis.
  a M. Ricord now  denies the existence of primitive bubo, (see Letters by Stapleton,
p. 42.) One is at a loss to understand this, when M. Ricord says, in his "Traite"
des Maladies veneriennes," p. 149, there are cases where it is impossible to discover
any suspicious antecedent, and  we must consequently be compelled to  admit the
"bubon dit d'emble'e."
  3 Syphilitic Diseases, &c, p. 24. 
BUBO.
137
have, however, been seen and verified  by some modern surgeons
of credit and experience, and, therefore, we can hardly doubt the
existence of such buboes, although they  must of necessity be rare.1
  The first difficulty met with in the treatment of bubo, is that of
ascertaining its new character, whether it is due to the absorption
of venereal matter or not, and this is a  point of very considerable
importance, since it has a direct bearing on the subsequent treat-
ment.  Should a bubo succeed an ulcer on the penis, a discharge
from the urethra, or come on after promiscuous sexual intercourse
without these antecedents, it may be syphilitic, but in a great ma-
jority of instances it is not.  When a bubo has  suppurated, the pus
which it has discharged, or that found at the bottom of the ulcer,
may be tested.  Should the characteristic pustule succeed, we have
settled  the question, the  bubo  is syphilitic.2  But, on the other
hand, should the inoculation not produce a characteristic pustule,
are we  to conclude that the  bubo is not due to absorption, and con-
sequently syphilitic?  I have already shown why buboes are much
more rarely successfully inoculated than chancres.  The virus is
modified or diluted in its passage through the absorbent  vessels
and glans by the contents or  secretions of these  parts, (see page
31.)  This is evidently the true explanation why inoculation is not
a certain test of the true nature of a bubo.  Even M. Ricord admits
that  inoculable pus is never met with  beyond the first glands in
connexion with chancres.  (Letters by Stapleton, p. 44.) " Whilst,
therefore, I admit that this  test, when applied  to the inguinal
glands, will in many instances serve to distinguish the nature of
bubo, I cannot concur in the conclusion at which M. Ricord arrives
when he states that inoculation  in bubonic  enlargements may be
relied on as forming an unexceptionable and pathognomonic sign."
(Egan,  op. cit., p. 22.)  Inoculation is of value here, as in chancre,
only when followed by positive results.3
   The  causes of bubo, or of adenitis, are various: besides syphilis
and  gonorrhoea, they frequently arise  from excessive indulgence
with a  healthy female, from fatigue, jumping, swimming, skating,
long'journeys on foot, sudden and violent exertion, or from ulcers

  1 Even before a bubo has discharged externally, its contents, when it has suppu-
rated, may be tested, by introducing a fine electro-gilt test needle, and withdrawing
some of the pus, which may thus be tested by inoculation.  The puncture thus made
should be touched with a crayon of nitrate of silver when the needle is withdrawn.
  - See Vidal (de Cassis,) Traite" des Maladies veneriennes, pp. 201-3.
  3 See also Fabre, Bibliotheque du M^decin Practicien, torn, vii., p. 224. 
138
PRIMARY SYPHILIS.
 situate  upon any part of the  lower extremities; also from piles,
 ulcers, or condylomata in the  vicinity of the anus.   Any stimulus
 acting for a longer or shorter period of time  upon  the inguinal
 glands, is liable to  be followed by simple bubo.  A strumous dia-
 thesis is a frequent  cause of bubo.   This  form of  bubo occurs
 where syphilis is complicated  with other diseases, such  as albumi-
 nuria, phthisis, or a general cachectic, strumous, or bad habit of
 body.  In such cases the  enlargement of the glans arises  slowly,
 the tumour is lobulated, puffy, and uneven, affecting the glans on
vboth  sides, in the femoral frequently, as well as the inguinal region;
 it remains long indolent, or suppurates imperfectly, discharging a
 badly formed pus, the abscesses  running frequently into trouble-
 some sinuous ulcers, surrounded by much induration.  The use of
 caustics, or irritating dressing to primary sores, is occasionally a
 cause of bubo, though this does not affect the general question of
 the utility of caustics under  such circumstances.   The cases are
 rare, but still this must be admitted as one of the occasional causes
 of bubo.
   It  is of  great importance to the patient that a bubo  should be
 dispersed, if possible, and not  suffered  to suppurate, the  latter pro-
 cess  leading to a  long  and troublesome affection, fraught  with
 endless inconvenience, pain, and even  danger.  An abortive treat-
 ment has been attempted here, as well as in gonorrhoea and chan-
 cre, but, as in these  diseases, with an uncertain success.  In the
 first  stage of bubo, if much inflammation, pain, or tenderness be
 present, rest, with local  bleeding, blisters, tartar emetic, and the
 application of ice or cold evaporating  lotions, are the appropriate
 remedies.  If the inflammatory symptoms are not marked, and the
 bubo be indolent, rest and compression alone may  be resorted to.
 It has been remarked that patients wearing trusses seldom have a
 bubo form on the side where the truss  presses; hence,  in the first
 stage of bubo, that of simple  enlargement,  without much  inflam-
 matory action or pain, a  well regulated pressure is frequently suc-
 cessful in dispersing the tumour.   It must be associated, however,
 with  rest and an antiphlogistic regimen.
   The same plan of treatment may be followed in the  treatment
 of the true syphilitic bubo, unattended by much pain or inflamma-
 tion.   In this stage, unless specially contra-indicated,  mercury may
 be employed to assist the resolution of the tumour in bubo.   The
 primary syphilitic bubo  may (says Dr. Wallace,) in its  first stage,
 be resolved,  in ninety-nine cases out of a  hundred, by mercury; 
BUBO.
139
if this medicine be used after the plan recommended for primary
syphilis, and if its operation be assisted by rest,  laxatives, absti-
nence, and  cooling lotions.1  It is well, in reference to  this opi-
nion, to remark, that a vast number of those buboes which succeed
to primary ulcers do not furnish or secrete a specific  pus.  Hence
it must be evident that the general employment of mercury is, to
say the least, unnecessary, except so far as it may be used with a
view of controlling inflammatory action.  Cullerier thinks that,
at this period, uncertain as we must be as to the true character of
the  bubo, that  it should  be treated as a pure and simple inflam-
mation.  When accompanied by chancre, it is of vast importance
to our success in the resolution of the bubo  to allay all pain or
irritation which may exist  in the sores themselves;  and for this
purpose the aqueous solution  of opium before recommended will
be found of great service.
   When the commencement of bubo is accompanied by much pain,
tenderness on pressure, or heat of parts, the local abstraction of
blood may be necessary, although I have not a high opinion of this
measure in the resolution of bubo generally.  It may even be ne-
cessary to bleed from the arm if the patient  be plethoric, and the
local disease associated with general excitement or much  symp-
tomatic fever.  In local bleedings thus employed, it will be found
advantageous to apply a small number of leeches, from four to
eight, or more, and wait till the  oozing of blood begins to  cease,
then, to apply another relay of leeches so as to keep up a constant
draining of blood from the part for twelve or more hours.   This
form of bleeding, termed "permanent," is found to reduce the in-
flammation more certainly and speedily than  the  application  of a
large  number of leeches  at once.  Two, three, or more relays of
leeches may be thus  employed, proportionate to the strength of
the patient and the intensity of the local disease.
   The method originally proposed by M. Malapert, a French army-
surgeon, is sometimes calculated to disperse the incipient bubo.
This method consists  in the application of blisters, and a solution
of the bichloride of mercury.2  The  bubo is to  be covered with a
blister about the size of half a crown, larger or smaller, accord-
ing to the size of the tumour; the following day, when the epider-

  1 Op. cit., p. 356.
  3 Archives generates de Medecine, Mars 1832.  Du traitement des maladies vene-
riennes par 1'application directe du deuto-chlorure de mercure en dissolution sur les
tissues affected primitivement ou conse"cutivement. 
140
PRIMARY  SYPHILIS.
mis is detached, a small portion of lint is to be moistened in a so-
lution of the bichloride of mercury,1 and laid upon the denuded
surface.  This is to be kept in its place for two hours by bandages,
or strips of adhesive plaster;  when it  is removed a dark brown
eschar will be found already formed.   The parts are now to be
covered with  a simple poultice, a cooling lotion, or a solution oi
opium, and  the  patient is to be  kept as quiet as possible till the^
eschar thus produced has separated; when this has taken  place,
the tumour is found materially  diminished,  or altogether gone.
If the tumour be of large size, or very  indolent, a second or even
third repetition of the process may become necessary.
  This plan of treatment is most certain in its effects if employed
in the first stage of bubo, when the inflammatory symptoms do not
run high; it may be resorted to in other forms of the  affection,
but not with  so well-grounded a hope  of its  success.  When the
tumour has involved to much extent the cellular tissue of the groin,
and the accompanying inflammation is great, it will be well to mi-
tigate at least the inflammation before the  blister, &c. is resorted
to.  Indeed, in the employment of this method, we are not to lose
sight of those other means of known efficacy which the established
practice of surgery indicates.
  Other caustics have been employed to form an eschar on the sur-
face denuded by the blister, such as the sulphate of copper, in the
proportion of two drachms to the ounce of water, the nitrate of
silver, the chloride of  zinc, or tincture of iodine.  These,  how-
ever, are not preferable to the bichloride of mercury.2
  When a bubo has suppurated, this method may be  still  occa-
sionally employed with success, if the skin covering the abscess is
thick; at this period it very commonly succeeds in dispersing the
bubo without having recourse to puncture, &c.  If the integuments
are thin,  and  the collection of  pus  on the point of discharging
itself, it ought not to be used.
  There are many objections to this plan.  The application of the
caustic is accompanied  by severe pain;  the eschar produced is  a
long time  separating, and I have seen a troublesome sore result
which has taken a long time to heal.  It does not always succeed,

               1 R.  Hydrargyri bichloridi, gr. xx;
                   Aquae destillatae, §j.
  3 Dr. Wallace resorts to a similar mode of practice in the treatment of indolent
buboes; this consists in  "the vesication of the  surface of the tumour with the
nitrate of silver, if there be not much increase of heat in the part." 
BUBO.
141
and I have more than once seen a bubo proceed to suppuration, un-
influenced by the treatment.  In hospital practice, I have recourse
to it occasionally, where  the patient  is confined to bed, and time
not an object.   In private practice, it is a plan fraught with incon-
venience, and I would rarely recommend or sanction  its  employ-
ment.1
   M. Ricord thinks that this method, however  certain  in  its ope:
ration, should be  used only in cases of bubo succeeding to  chancre,
and which may be presumed of a virulent character.  In ordinary
cases, pressure; discutient plasters or lotions;  compresses soaked
in solutions of the  acetate  of lead,  or  muriate of ammonia,2 or
plasters of belladonna, lead, iodine, or  mercury,  are to  be pre-
ferred!3  When much pain and tenderness exist, bleeding  becomes
necessary,  with the  application of  strong aqueous  solutions  of
opium.
   In the  treatment of indolent bubo, in  the  commencement, re-
course  may be had  to discutient plasters with compression and
friction with the  iodide of lead.   If this has not a marked  effect
upon the enlargement in  a few days, blisters with the bichloride of
mercury on Malapert's plan may be employed.  Frictions with
ointments composed of the  iodides of lead or mercury,4 or com-

  ' See the remarks  by  Cullerier,  on the employment of this method,  in Lucas
Championniere, " Therapeutique de la Syphilis," p.  356, et suivantes; also by M.
Ricord, pp. 582-4.
                a R.  Plumbi acetat., ^ij;
                     Aquae, gxvj.   M.    (Ricord.)
             This  is the "eau blanche" of the French hospitals.
                 R.  Ammon. muriat., ^ij ;
                     Acidi  acetic,
                     Sp. vini, aa gij;
                     Ext. belladonna?, gj;
                     Aquae rosae, ^xiv.  M.
  s For this purpose  maybe employed the "Emp. Ammoniac, c. Hydrargyro" of
the London Pharmacopoeia, the Emp. de Vigo, of which I have already given the
form.  Or,
                 R.  Emp.  belladonnoe, pts. viij;
                     Plumbi iodidi, pt. j.  M.
                 R.  Emp.  "de Vigo" c. mercurio, pts. iv;
                     Extract, belladonnae, pt. j.   M.    (Dupuytren.)
                 R.  Emp.  belladonme, giv;
                     Iodinii, 3J.  M.
                 R.  Emp.  hydrargyri, -iv;
                     Iodinii, ^j.  M.
                4 R.  Hydrargyri iodidi, ^j;
                     Adipis, |j.  M. ft. unguent. 
142                  PRIMARY SYPHILIS.
presses soaked in a dilute tincture of iodine,1 are also very useful
in the resolution of the chronic or indolent bubo.
   The disease may terminate  in two ways: the enlarged glands
may pass on slowly to suppuration, or assume a form of induration
of a scirrhous or scrofulous character.  In the latter form, the ap-
plication of the tincture of iodine, or the  emp. belladonnas with
tartar emetic, may be used as local applications. Small issues may
also be formed over the  indurations  by means of the  caustic pot-
ash.  The progress, complication, and termination of bubo will de-
pend very materially upon the constitution of the patient, and the
condition of his general health;  hence,  the latter demands  the
strictest attention on the part of the practitioner.   The organs of
digestion, and the  state of the viscera of  the chest and  abdomen,
should be carefully attended to; we must, to the utmost of our
power, take care that no  complication on the part of the latter or-
gans interfere with the local disease, and endeavour by  appropriate
treatment to combat any  general cachectic state that may be in ex-
istence, and which may not only prevent the resolution of the tumour
in the groin, but favour the extension of disease to other parts of
the glandular system.  For these purposes an antiphlogistic treat-
ment may be necessary on  the one hand, whilst, on the other, the
internal exhibition of mercury, iodine, or  sarsaparilla, may be use-
ful, either  simply  or  in  any of the forms of combination which
have been previously indicated.
  When fluctuation is evident, more particularly if the skin cover-
ing the tumour be  thin, it will generally be useless  to lose time in
attempting longer the resolution of the tumour.  It will, as a ge-
neral principle, be better to open it at once, either with the scalpel
or the knife.  Dr. Wallace believes that  buboes, in their stage of
suppuration may be resolved by mercury if it has not been  used
earlier in the disease;  and M. Reynaud has succeeded in dispersing
them by the blister with  caustics.  These remedies are, however,
to say the least, uncertain at this period, and we are more likely to
save time, and our patient's constitution, by opening the bubo at
once.
  The bubo may have suppurated freely, and  the collection of
matter be large, and the surrounding tissue little indurated, or there
may be much surrounding induration, and  the collection of matter
small and deep-seated.  In all cases, the best general rule of prac-
              1  R.  Tinct. iodinii Co., gj;
                   Aquae  destillat., ^ij.   M. ft. lotio. 
                             BUBO.                         143

 tice is to open the bubo as soon as  fluctuation is evident.1  " In
 fact, incision  into a bubo, when  in the state of incipient suppura.
 tion, will in general as effectually put  a stop to its progress as it
 will to that of anthrax when in an analogous state.  I would even
 say further, that we may, perhaps, uniformly stop the increase of
 bubo by a sufficiently free incision in its first, second, or third stage,
 i. e. before matter is formed."
   When the integuments covering a bubo are of a deep blue colour,
 more or less disorganized, or threatening gangrene, it is better to
 open the abscess with the potassa fusa, or some other caustic, than
 by simple incision.  Where it  is impossible to save, the integuments,
 from their  thinness and the degrees of disorganization which they
 have undergone, Desruelles  and Wallace prefer opening the ab-
 scess with  caustic;  the surface of the skin is  to be destroyed  by
 the potassa fusa, or other appropriate escharotic, to the  proposed
 extent, and the next  day a puncture made with the lancet in the
 centre of the slough thus formed.  Where, however, it is probable
 that the integuments  may be saved, the nitrate of silver is to be
 rubbed " on the surface of the bubo, and of the surrounding dis-
 eased skin, previously moistened with tepid water, until the cuticle
 is rendered of  a bluish colour to the extent of an inch beyond the
 diseased integuments  covering the tumour."  On the following
 day, a puncture is  to  be made in the thinnest part of the  integu-
 ments, and a compress and roller are  to be applied.   When th&sur-
i face of the cuticle has become dry after the first application of the
 caustic, it may be reapplied over the integuments as before.  This
 local treatment recommended by Dr. Wallace, almost universally
 succeeds in causing the sides of the abscess to agglutinate and the
 external wound to heal.2
   The open or ulcerated bubo may assume many morbid  conditions
 which  prevent  its cicatrization.   In  the first place, the inflamma-
 tion which sympathy, or the absorption  of the venereal poison, has
 occasioned in the glands of  the groin,  and which has terminated
 in suppuration, may continue to be violent after the pus has been
 evacuated; and hence, one obstacle to the cicatrization of the ulcer
 is a degree of inflammation in the part  itself.   This undue excite-
 ment results either from a continuance of the original inflammation,
 kept up by exercise of the diseased  part, by too nourishing a diet
 or other causes, or from the imprudent and too early local applica-
   1 See ,the principles inculcated by Ricord, p. 595, and by Dr. Wallace, pp. 360-1.
   a Wallace, pp. 377-8.
i 
144
PRIMARY SYPHILIS.
cation of stimulating  dressings.  In  this form of the disease, the
patient will derive benefit from repose, low diet, gentle aperients,
anodyne fomentations, and the application of compresses  soaked
in an aqueous solution of opium.   The  opiate, or simple cerates,
are the most appropriate dressings; and these may be assisted by
gentle pressure, by means of compresses and a roller methodically
applied.
  Again, the  surface of the open bubo is commonly covered with
a thick slough, the ulcer itself is indolent, or disposed to  spread,
and its edges are  red, angry, and elevated.   This is the most or-
dinary condition.of the true virulent bubo:  and all that has been
said on the ulcerating stage of chancres is applicable here.  It
becomes necessary, in these  states, to destroy the diseased  surface
of the sore by means of caustics;  and for this purpose the nitrate
of silver, the mineral acids, or the acid nitrate of mercury, may be
employed.  The  dressings well suited to this  form of bubo, are
Ricord's aromatic wine, with or without opium  or tannin;  this, as
in the case of chancre, may be alternated with some digestive oint-
ment,1 solutions of the sulphate of copper or zinc, or a weak solu-
tion of the chlorides of lime or soda.   Creasote is also very useful
as a local application, more or less diluted.
   In chronic open indolent  bubo, with a foul surface, where most
remedies have failed  in modifying the  condition  of  the sore, M.
Cullerier employs occasionally, as  a caustic, three, four,  or five
grains of the  bichloride of mercury dusted over the surface of the
sore, and suffered to  remain for some hours.  The application of
the remedy is followed by severe pain and inflammation, but gene-
rally succeeds in producing a healthy condition of the sore, speedily
followed by complete cicatrization.2  The indications of all local
applications are to be sought for in the condition of the sore; they
require constantly to be changed; what is useful to-day may be in-
jurious to-morrow.
   A formidable obstacle to the cicatrization of an open bubo is oc-
casionally presented by the edges of the sore itself.  The integu-
ments covering the cavity have lost part of their vitality; they are

  1 The reader will find the particular forms for the preparation of these remedies,
in the previous pages  of this work, under the article Primary Venereal Sores.
  2 This practice originated with Dr. Ordinaire.   He first employed it in  the treat-
ment of cancerous or  foul sores of the rectum, nose, and other parts.  The results
of the method were so favourable, that Cullerier tried it at the Hopital des Vene-
riennes in the treatment of foul indolent bubo. It has in many cases exceeded his
most sanguine expectations.
» 
                            BUBO.                         145

more or less discoloured, indolent, or indurated, and offer no dis-
position to adhere to the under surface of the sore, or to throw up
granulations by which the ulcer might be filled.   In this condition
they offer a permanent obstacle to cicatrization, and it becomes ne-
cessary to adopt means to bring about their union with the  sub-
jacent parts, or else to remove  them  altogether by the knife, scis-
sors, or caustic.  To accomplish the first intention, the under sur-
face of the integuments may be rubbed with the sulphate of copper,
the nitrate of silver, or some other caustic, the cavity of the ulcer
filled with soft lint, covered with some dressing suited to the  con-
dition of the sore, and a bandage and compress applied.
   When it becomes necessary to remove the floating portions of
integument, caustics or the knife may be used, but this  operation
must not be performed on a truly venereal bubo in a state of ulce-
ration, inflammation, or great irritability.  These conditions must
be subdued before  such an operation  is thought of.  The late  Dr.
Wallace thought that the removal of the diseased integuments
covering an open bubo might in most instances be prevented  " by
the vesication of the diseased integuments, and also of the sound
skin for a little way beyond them by means of the nitrate of silver."
The application of  the caustic is to be renewed  every four or five
days, or as often as  the surface of the integuments to which it might
have been applied becomes covered by a new cuticle.   It will  also
be useful to apply it occasionally to the whole ulcerating surface,
and to the orifices of any fistulous openings that may exist, not with
a  view of destroying  exuberant granulations, but to excite  the
granulating surface to more healthy actions.1
   Dr. Wallace  states that he has  known loose portions of integu-
ment of several inches in diameter, which  were so diseased in
their structure  that they lay on the surface of the ulcer like a dead
flap, saved  by this  process.   " I have also," continues this author,
"accomplished  the  cicatrization of other ulcerations, which  pre-
sented numerous fistulous openings or detached flaps, and in which
all the ordinary means,  such  as  injections, compresses, incisions,
&c, had all been employed in vain.   In  short, I  can  most confi-
dently recommend this treatment of indolent and atonic ulceration,
&c, as well as that  of abscesses of the same class, as a very great
improvement in the general practice of surgery.
   The internal  surface of the open bubo is rarely smooth, uniform,

                    1 See Wallace ; op. cit., p. 381.
       10 
146                  PRIMARY SYPHILIS.

or continuous; it is generally uneven and irregular, frequently di-
vided into compartments, or presenting numerous orifices which
are the openings to other glands which have suppurated, and thus
open by small orifices into  the chief or general cavity, which is
very commonly an abscess in the  cellular tissue surrounding the
gland or glands  which have been originally the seat of irritation.
It is this pathologic condition of open bubo which renders the treat-
ment so difficult and  tedious.
  Injections  may be employed  in  the treatment of these fistulous
openings with a  view of modifying the condition of their surfaces,
and disposing them to cicatrize.  Solutions of the sulphate of copper,
the nitrate of silver, the sulphate of zinc, or bichloride of mercury,1
may be thus  employed.
  If appropriate dressings and compression fail in the treatment
of these fistulas or sinuses, it may  be necessary to  lay them open
with the knife.  Sometimes the enlargement of the orifice is  suffi-
cient, or it may be necessary to divide them in their whole length,
or if the situation of the sinus permit, a counter-opening will ge-
nerally answer all the purposes of complete incision, a practice at-
tended with much terror and pain to the patient. Cullerier speaks
highly of counter-openings made with the  caustic  potash; the
caustic as well as the opening may contribute to the cure in these
cases.  The fistulas may likewise be cauterized internally by means
of solid nitrate of silver, or a  small  portion of the powdered bi-
chloride of mercury introduced  by means of a grooved director; this
practice is painful, but generally successful in its results.   Lastly,
the whole external skin, corresponding to the sinuses, may be ve-
sicated with  the nitrate of silver, in the manner recommended for
the treatment of loose portions of integument.
   The internal use of iodine alone or combined with potass or mer-
cury, is of great  service in the  treatment of chronic  ulcerated
bubo.   To the consideration of the employment of this remedy I
shall return  when treating of the  constitutional forms of syphilis.

               1 R. Cupri sulph.,  gr. vj;
                   Aquae dest., §j.  M.
                R. Argent, nit.,  gr. vj ;
                   Aquae, gj. M.
                R. Zinci sulph.,  gr. x;
                   Aquae, |j. M.
                R. Hyd. bichlorid., gr. jj
                   Aquae, gj. M. 
BUBO.
147
  Many causes will predispose a patient with a primary venereal
sore to the occurrence of bubo. Amongst these may be mentioned
a bad habit of body at the time of contracting the infection, a pre-
vious disposition to glandular enlargements, a scrofulous constitu-
tion or taint, full or high living, with errors or irregularities in
diet; such predisposing causes may be termed general. There are
others which .we  may denominate special; such are the  long con-
tinuance of the primary ulcer in an indolent or  ulcerating condi-
tion, the use of stimulating or irritating dressings, much exercise
either on horseback or foot, and  the absence of the suspensory
bandage.
   It is of vast importance to prevent the  suppuration of a bubo,
since matter once formed and evacuated  is often succeeded  by
sinuses and troublesome ulcers, which are exceedingly tedious and
difficult to cure.  In hospital practice we can commonly succeed in
dispersing a bubo,  because  we can  make  the  patient  do as we
choose;  but in private practice, where concealment is necessary, it
becomes a more serious matter.
   When, as a consequence of a primary venereal ulcer not yet
healed, or just healed,  we perceive  enlargement with tenderness
in the groin, producing stiffness when the  patient walks, we may
be sure that a  bubo is about to form.  I would not recommend the
old-fashioned practice of applying leeches;  it is a practice gene-
rally very unsatisfactory, rendering the cure long, uncertain, and
tedious; we must insist upon a strict regimen on the part of the
patient,  and absolute rest, if possible. The bubo may be frequently-
bathed with hot, not warm, water, and half-grain doses of the tar-
tar emetic exhibited, as recommended by Mr. Milton; or the part
may be smeared thickly over with mercurial ointment; over this a
linseed or a bread poultice, cold, and a piece of oiled silk to keep
it moist, confining all by a bandage.   Pressure  may also be made
by the emp. ammoniaci c. hydrarg., spread on thick wash leather,
the plaster to  be placed lengthways, parallel to the thigh, and not
 at right angles with it; this  prevents the plaster getting displaced
 when the patient walks.  The best means of  all, however, is to
paint over the enlarged gland night and morning with a strong so-
lution of iodine  and hydriodate of potash,1 should  the  inflamma-
tory symptoms not be too active.

               1 R.  Iodinii, £j;
                    Potass, hydriodatis, ^ij;
                    Aquae, ^j.  M. 
148
PRIMARY SYPHILIS.
  In the intervals of the dressings pressure should be made by a
pad and bandage.  If the patient has not used mercury for the
treatment of the primary sore, the dispersion of the bubo will be
hastened by now administering it, in combination with the tartrate
of antimony, so as gently to affect the system, always presupposing
that the patient is in a condition to bear mercury.
  Should these means not succeed (which in a majority of instances
they will,) and suppuration appears inevitable, it must be hastened
by warm poultices and fomentations.
  When matter is ready to be discharged, a question of very great
importance suggests itself, viz., how should  this be done?  Many
surgeons open the abscess freely with the bistoury or lancet, whilst
some prefer the potassa fusa for this purpose. I would not, under
ordinary .circumstances, recommend either of these methods.
  When a bubo is ready  to puncture, I would not advise a free in-
cision; for almost under every circumstance where this is practised,
there is a quantity of integument in the edges, which will not unite
with the granulating surface of the  sore thus produced.  By open-
ing an abscess in this way  the whole anterior wall of it is destroyed,
and the  cure  must be performed by the cicatrization of a granu-
lating surface which springs from the floor or posterior wall of the
abscess.  The great object is to evacuate the matter first, then to
diminish the disposition to  its re-formation, and lastly to  procure
union of the two sides of the cavity. This may  generally be done
in the way I have adopted in the treatment of chronic abscesses
in the Queen's Hospital, and which has been so successful in a great
many instances.  When a bubo is ready to be opened, we should
not suffer the skin to become too thin, but make  several very small
punctures over its thinnest part with a grooved needle, perhaps
six, eight, or ten; through  these  the matter will ooze  out till the
cavity  of the abscess is  empty.   Through  one  of the punctures
the point of a very small glass syringe may be introduced, and a
very weak solution of the sulphate of zinc injected, in the propor-
tions of two or three grains to the half pint of  water.  When the
abscess is quite empty, place over it a large  compress  of lint, and
use moderately tight pressure by means of a roller.  In many in-
stances, if we can keep the patient quiet for twenty-four hours, we
get either partial or total  adhesion of the sides of the bubo, and
a speedy cure will be the result;  in other instances this  may not
be the case, but by the daily use of the injection  through one of
the punctures, which should be kept open for that purpose, we sue- 
BUBO.
149
ceed in a few days, in almost every case, in effecting a cure.  If
the skin is thin, the  bubo may also  be opened with a fine seton
needle, containing five or six threads of silk;  the seton should be
passed in the axis of the bubo, and suffered to remain two, three,
or four days, according to circumstances; it may  then be with-
drawn, and injections practised, as already directed, through the
orifices left.
  I generally employ for an injection in these cases the weak  so-
lution  of sulphate of  zinc.  I have used also  a weak solution of
iodine  and hydriodate of potass.1
  The injections must be varied in strength to suit the feelings of
the patient; a gentle warmth and slight irritation should be expe-
rienced,  but violent pain on  no account produced.  Solutions of
the sulphate or acetate of copper, alum, port wine with  tannin,
may all be used; and if one does not succeed quickly, we  should
have recourse to another.
  This is the best way of treating a suppurating bubo with which
I am acquainted.
  After  the numerous  instances we have seen of foul, extensive,
burrowing sores, in the hospital, which have been produced solely
by laying buboes freely open, which sores have been for months in
existence, we must be quite aware that some  improvement is ne-
cessary in this branch of surgery.  Ulcers, the result of bubo, with
thick,  hard, cartilaginous edges, have been treated  in the hospital
by destroying the edges and the surface with the potassa cum calce.
Sinuses, resulting from  the same cause, have been  laid open and
their  edges destroyed in this way; and in many cases, I may say
in all,  for I do not know of a failure, the cure, although compara-
tively  tedious, has been satisfactory.

              1 R.  Iodinii, gr. iv{
                   Potass, hydriodate, gr. viij;
                   Aquae, ^viij.  M. ft. injectio. 
              PART II.

CONSTITUTIONAL OR SECONDARY SYPHILISl
                      CHAPTER XIIL

              OF CONSTITUTIONAL OR SECONDARY STFHJLIS.*

  Constitutional or secondary  syphilis consists of a class of mor-
bid actions, which make their appearance sooner or later after a
discharge from the  urethra, or  after the healing,, or during  the
course of a primary venereal sore on the genitals or elsewhere, or,
again, it is due to other causes hereafter to be mentioned.
  The phases of syphilis have been divided into the primary, the
secondary, and the tertiary, or, as Hunter has already laid down,
constitutional affections of the first and second order of parts.  The
primary  symptom is due to the  direct application of the venereal
poison by means of sexual intercourse, or inoculation.  It is capa-
ble of propagation, from one individual to another, by intercourse
or inoculation.  It is not capable of being transmitted by way off
hereditary taint;  a female having a chancre at the period of par-
turition  may produce, by inoculation, the same  disease in her in-
fant.   The primary symptoms may be followed by a series of symp-
toms which are successive or continuous, but not constitutional or
secondary; these  are new  chancres,  buboes, or abscesses, &c, of
various kinds, these being in their onset purely local, and not de-
pendent upon an affection of the constitution generally.
  Secondary symptoms are those  which make  their appearance
after the economy has become generally tainted by the  venereal

  1 Syphilis constitutionnelle; accidents secondairea et tertiaires. (Ricord.) Mala-
dies veneriennes conse"cutives. (Desruelles.) 
SECONDARY  SYPHILIS.                 151
poison, during which process the matter has  undergone modifi-
cations which, in some measure, change its character.  Secondary
syphilitic diseases  generally appear on the  skin, or mucous mem-
branes, in the eyes, or the testicles, &c.  Constitutional syphilis
rarely makes its appearance before the second week after primary
infection, more commonly later, towards the fourth or fifth weeks,
or at periods very much more remote.
  When syphilis has continued in the economy for an indefinite pe-
riod of time, we observe the symptoms which are termed secondary
to disappear, or to  lose the properties which at first characterized
them, whilst others of a different kind  succeed, to which  has been
applied the  term of  " tertiary.,'"   The tertiary symptoms appear
at an indefinite, and generally very long period, after the primary
diseases, and in the greater number of subjects, either after secon-
dary symptoms have disappeared, or whilst these are still manifest
in the constitution; thus it is exceedingly common to see scaly or
pustular diseases of the skin coexisting with diseases of the bones
or testes.  The diseases which have been termed tertiary are deep-
seated diseases of the skin, as tubercles, and affections of the glands
and bones, as periostosis, exostosis, caries, necrosis.  To these may
be  added various  internal affections, as yet neither well known
nor described.  M. Ricord has presented to the Royal Academy
of Medicine specimens of tubercles of the brain, which he believes
to be of syphilitic origin.   The tertiary symptoms are not heredi-
tary, under any specific form of venereal affection.   The children of
persons thus affected are very commonly  scrofulous, phthisical or
predisposed  to  cancerous  diseases.   Many of the constitutional
forms of disease are capable of propagation by contact or inocula-
tion; and in persons cohabiting as man and wife, a syphilitic symp-
tom existing in one  is very commonly produced  in the  other, in
precisely the same  form.
  It may be  naturally inquired here, whether any treatment of the
primary disease can certainly prevent the secondary.  This ques-
tion has also been agitated by Ricord.   This author states, that
he has  not been able  to meet with any recorded fact where a pri-
mary venereal sore healed in five days has  been  followed by se-

  1 The diseases which have been termed tertiary, such as affections of the bones,
&c, are not always the last to appear, neither are they in all instances preceded by
what are termed secondary diseases, such as affections of the throat and skin.  Pri-
mary diseases are sometimes immediately followed by affections of the periosteum
and bones: I have given several examples of this in the course of this work. 
152
SECONDARY SYPHILIS.
condary symptoms; neither  has he ever observed  such a circum-
stance in his own practice. The probability of secondary symptoms
is in direct proportion to the duration of the primary disease; the
longer this continues the greater is the chance that the constitution
may become affected; hence,  that treatment is the best prophylactic
under which the sore  most rapidly heals, without induration of its
cicatrix.   The early and complete destruction of the primary dis-
ease, by an escharotic  that will disorganize the tissues to the depth
of the ulcer before absorption has taken place, is the only certain
mode of preventing constitutional taint.   I have before stated that
the nitrate of silver is useless for this purpose; and the only caus-
tics that will char the tissues to the depth of the ulcer are the po-
tassa-fusa, the potassa  cum calce, or the acid nitrate of mercury: the
first two are certainly the most effective.  This  practice is useless
in a chancre already specifically indurated, the  induration itself
being an  indication that the constitution is  already affected, and
the local disease only  to  be cured by constitutional  remedies.
  Unhappily there are numerous reasons why the practice just re-
commended cannot always be adopted with a prospect of success.
In many instances the  surgeon is not consulted till many days after
the establishment of the disease, when,  in all probability, absorp-
tion has already taken place.  In other instances, the situation and
character of the ulcer are such  that we are prevented resorting to
the method recommended, though in all instances it should be done,
if at all practicable.
  All persons are not equally susceptible of a constitutional infec-
tion from a primary sore; hence some writers have spoken of the
syphilitic temperament, a vague expression, to which no  definite
meaning can be attached.   Those individuals are  most  likely to
suffer from constitutional syphilis whose general health is bad when
they contract a primary sore; hence, chronic affections of the skin,
stomach, or digestive organs, scrofula, general cachexy, or other
diseases, general or particular, under which the patient may labour
at the time of infection, are to be considered as predisposing causes.
Attention to the general health is of the first importance, and the
constitution of our patient must most  materially modify our treat-
ment.
  Secondary syphilis, like primary,  only becomes  formidable by
neglect and ill-treatment; it is a principle we should never lose
sight of, to commence  seriously the treatment  of constitutional
syphilis, the moment it becomes manifest in the economy.  There 
SECONDARY  SYPHILIS.
153
 is no contra-indication to the immediate  commencement of this
 treatment: should the constitution be bad, or the patient diseased,
 it must be modified to suit these circumstances: even the period of
 gestation is no  bar to the anti-syphilitic treatment.   M. Ricord
 states that he has  seen more females miscarry when their disease
 has been suffered to go on unchecked, than when they have been
 subjected to an anti-syphilitic treatment, framed with judgment to
 suit the circumstances of the case.  The same remarks  apply to
 the period of suckling.
   When constitutional syphilis is complicated, these complications
 should never be neglected: if they coexist with acute  or subacute
 affections of internal organs, the latter ought first to be attended
 to; these should be subdued before we commence the anti-syphilitic
 treatment.   When scrofula^ affections of the skin, or chronic dis-
 eases of internal organs, complicate constitutional syphilis, the anti-
 syphilitic treatment may be at once commenced, but it  must be
 framed and conducted with much care, that the accompanying af-
 fection, of whatever character  it may be, may  not be  aggravated
 by it.  An exclusive, or empirical treatment, cannot be too strongly
 condemned.   It is in these cases that the compounds of iodine and
 mercury, iodine  and iron, and iodine and potass, are commonly so
 useful, but, above all, the mercurial vapour bath.1
   Whenever any of the forms of constitutional syphilis are accom-
 panied by fever, or much inflammation, a strict antiphlogistic treat-
 ment and regimen are  absolutely necessary.  Without a rigorous
 observance of this rule we can  have no rational  hope of success.
 Whatever be the character of the constitutional symptoms, if they
 are accompanied by local  inflammation, or general excitement, a
 rigorous antiphlogistic regimen and treatment ought to be fol-
 lowed till the vascular excitement is subdued.  An antiphlogistic
 treatment is not to be adopted where these phenomena  are absent,
 and of course its employment as a general measure is to be severely
 condemned, for in many cachectic or scrofulous patients, or  those
 whose constitutions are already undermined by chronic disease, an
 opposite plan of  treatment becomes  necessary.   In the latter in-
 stances, a full, nutritious diet,  is essential to the success of the

  ' See the whole of the excellent remarks of M. Ricord, on Complicated Constitu-
 tional Syphilis, op. cit., pp. 615—18.
  "En un mot, l'accident le plus saillant, l'e'piplie'nomene, quel qu'il soit, est celui
qu'il faut d'abord combattre, sans negliger aucun des Clemens qui peuvent fournir
aux indications the"rapeutiques. 
154
SECONDARY SYPHILIS.
treatment.   Long experience has taught me that debilitated  and
scrofulous patients, who have been badly fed, quickly recover their
general health, and are cured of syphilis under a full diet; whilst
those whose circumstances have enabled them  to  live well, fre-
quently become  cachectic under a low diet; their syphilitic affec-
tions remain stationary, and they only recover  their health, and
lose  their disease, in  returning  to the  habits of living to which
they have been accustomed,
  That the internal treatment adopted against any particular form
of constitutional  syphilis may have every chance of success, it is
also  necessary that the stomach  and bowels be kept entirely free
from all irritation or disease* 
SECONDARY SYPHILIS.                155
                       CHAPTER XIV.

    OF THE CAUSES OF SECONDARY, OR CONSTITUTIONAL SYPHILIS.

   The chief causes of a constitutional venereal taint are:  1. The
 absorption into the system of the virus from a primary venereal
 disease, whether this be a sore, a discharge, or a bubo.  2. Inocu-
 lation or contagion, i. e., the direct communication of a secondary
 or constitutional affection, from  a diseased  to  a healthy person,
 without the  intervention of any primary disease.  3. Hereditary
 transmission.  4. The treatment of the primary disease, whether
 due to  the use or to the neglect of mercury.  5. A peculiarity of
 constitution.

 I.—PRIMARY ULCERS AND DISCHARGES CAUSES OF SECONDARY SYPHILIS.
   It is universally admitted that the  most frequent cause of a se-
 condary venereal disease is a primary venereal ulcer, and it is also
 as generally admitted that the ulcer  which is most commonly fol-
 lowed by such a condition  is one which presents a well-marked in^
 duration during its course, or is so where the  cicatrix  or site of
 the ulcer becomes indurated when the ulcer has closed*  Other
 ulcers,  however, which do not present this appearance of indu-
 ration,  are occasionally though not so frequently followed by se-
 condary symptoms.   Again, many forms of primary discharges
 from  the urethra are followed by secondary diseases:, it  is well
 known  that M. Ricord considers  sach discharges as symptomatic
 of primary venereal ulcers in the urethra.  Certain it is, however,
 that discharges from  the urethra, in which no ulcer can be disco-
 vered, and where no  circumscribed induration can be felt along
 the track of the urethra, and where, again, the matter discharged
 has not yielded any characteristic pustule by  iaoculatioa, when
tested, are occasionally, though not commonly, followed by consti-
tutional diseases. 
156
SECONDARY SYPHILIS.
                          Case XVI.
Primary disease, discharge from the urethra; never, at any period, any otber form
   of primary venereal disease; secondary disease six months after, in the testis
   and in the bones; cure by calomel and opium, and the iodide of potassium.
  M. B----, ast. 30, came under my care as an out-patient of the
Queen's Hospital, in July, 1849, suffering from enlargement of the
right testis, pains in the arms, bones of the head, and other parts,
with nodes on the head and clavicle, and general enlargement of
the right knee-joint.  One year and a half before his admission
he contracted a discharge from the urethra, for which he had never
been  treated, and for which he had never taken medicine; this
after a long period disappeared of  itself, and left no induration in
the urethra discoverable by examination, nor any impediment to the
passage of  an  instrument, or to the stream  of urine behind it.
Six months after, his right testicle enlarged without  pain; to this
succeeded general pains in the limbs and head, which incapacitated
him from work;  and large  nodes formed, two on the head, one of
which contained matter, and one on the clavicle, with general bony
enlargement of the knee.
  He was put on the use of calomel and opium at night, with  the
iodide of potassium and colchicum in the day;  and under this treat-
ment all the symptoms disappeared.  No change was made in  the
remedies employed.

  The cases recorded by M. Cazenave are well-marked  examples
of constitutional diseases which had never been preceded by any
primary disease, except a discharge from the urethra.1  Mr. Erasmus
Wilson,2 Dr. Egan,3 and others support this  doctrine.4   A  great
mass of the cases admitted under my care into the Queen's Hospi-
tal have  been carefully  recorded, and, although it is difficult  in all
cases, especially in hospital practice, to get correct histories, still
a great number have been collected, which carry conviction to my
mind that certain primary discharges from the urethra, of the na-
ture already alluded to, are followed by secondary diseases not dis-
tinguishable from those which succeed to ordinary chancre.
  What the nature of these primary urethral discharges may be,

          1 Cazenave;  Traite* des Syphilides.
          ' Syphilis, Constitutional and Hereditary, pp. 20, 21,  22.
          * Egan; op. cit., p. 18, &c.
          4 British and Foreign Med.-Chir. Review, No. xv., p.  88. 
CAUSES OF SECONDARY  SYPHILIS.          157
is another question.  If they result from an ulcer on the urethra,
the existence of the latter must  be a matter of conjecture, since
we are unable to demonstrate its existence.


                          Case XVII.
Discharge from the urethra as a primary symptom; scaly blotches on the skin, and
    a node on the forehead, as constitutional symptoms; cure by the mercurial va-
    pour-bath.
   A gentleman  consulted  me respecting a  lump on his  forehead,
which was  red, tender, and painful;  he had upon different parts
of  his body, and on the head more particularly, some dry, scaly
blotches;  his hair also  came off rapidly.  He  had never suffered
from  any primary venereal disease, except  a  discharge  from the
urethra.  When I saw him this no longer existed, the urethra  pre-
sented no induration in any  part, a bougie  passed easily, and he
made water in a good, free stream.
   1 recommended the use  of the mercurial vapour bath, which was
administered every other day. I prescribed no medicine internally.
In a month the cure was complete.

   I could bring forward many more cases which leave no doubt as
to  the fact that  discharges from the urethra, apparently in no  way
different from ordinary gonorrhoea, and which are not accompanied
or followed by any perceptible organic change in the urethra, are
the primary causes to which secondary syphilis is occasionally  due.

         II.—CONTAGION A CAUSE OF SECONDARY SYPHILIS.
   Constitutional syphilis may be communicated from a diseased to
a healthy person, without  the intervention of  primary disease.  I
do not mean to assert that constitutional syphilis is commonly ca-
pable of propagation by inoculation, and I  have never succeeded
in producing  any effect of this kind  by inoculations practised on
an individual, already diseased, by his own secretions; and I have
never attempted, and never shall,  to propagate secondary syphilis
from the  diseased  to the  healthy.  Waller1 and Vidal de Cassis3
have, however, succeeded  in  this.  The case of M. Boudeville (in-

  1  Du caractere corftagieux de la Syphilis secondaire, par le docteur Waller, in the
'Annales des Maladies de la Peau, et de la Syphilis,' torn, iii., p. 171.
  1 Traite des Maladies Veneriennes, pp. 240, 261, 353. 
158
SECONDARY SYPHILIS.
terne en  pharmacie) who voluntarily  submitted to inoculation
with the matter of the secondary syphilitic pustule, and in whom a
regular secondary pustular disease was produced, is conclusive on
this point, (Vidal de Cassis, p. 357.)   Although I have never seen
secondary syphilis propagated by inoculation from the diseased to
the healthy, I have seen it  communicated, by contagion, in this
way in a great number of instances; two I have already recorded.
The circumstances under which this takes place are generally from
the husband to the  wife,  where the primary disease  having been
cured for an indefinite period of time, a secondary attack takes place
after marriage, and by constant contact is thus communicated  to
the wife.
  In  a  number  of  instances,  secondary venereal diseases,  when
propagated by contagion, produce  their like.  Thus  skin diseases
are communicated under  the same specific form;  so are secondary
condylomata.  Some modern  authors (Waller, Erasmus Wilson,)
maintain the propagation of constitutional syphilis by means of the
secretions alone.  The ovum is constantly diseased  by the secre-
tions of the father; hence there is every reason to suppose that such
an origin of constitutional taint is exceedingly probable, especially
when we consider the condition of the blood (whence all the secre-
tions are derived) in secondary syphilis.

                             in.
  Hereditary transmission  as  a cause or origin of  constitutional
syphilis, is too well known, and too universally admitted, to require
me to dwell on it here.  Its physiological nature  is clearly a mode
of contagion through the medium of  the  secretions, and, in most
instances, the transmission takes place from the father to the ovum,
the mother never having been diseased, and never having exhibited
any symptom of disease.1  If the mother be suffering from secondary
syphilis, and give birth to  a diseased child, the  contagion  takes
place  through the medium of the blood itself.

                             IV.
  The general and  medical  management of the  primary disease
has, no  doubt, a most materialinfluence  over the prevention or
development of a constitutional taint.  There is no reason why a
grain of mercury should be exhibited for the cure of a primary ve-
nereal affection, which has, on the very first discovery of the dis-

  1 I have recorded in another part of this work several cases illustrating this point. 
CAUSES OF  SECONDARY SYPHILIS.          159
ease, been destroyed by a caustic sufficiently powerful.  Many con-
stitutions are inimical to mercury, and its exhibition so far disturbs
the system that it cannot be borne, and its use  must consequently
be given up.  There are other peculiarities of constitution,  or con-
ditions of constitution, in which, although mercury is borne, it ap-
pears to predispose  to the occurrence of certain diseases, which are
not known except the patient has had syphilis,  and taken mercury
for its cure.
  Mercury is certainly not the general  or common cause of secon-
dary or constitutional syphilis, although its  injudicious  exhibition
frequently produces very formidable constitutional  mischief.  Se-
condary  syphilis occurs where mercury has  never been  used, and
when administered  for other diseases, even when pushed to saliva-
tion, never gives rise to  diseases resembling secondary syphilis.
  In  143 cases of secondary syphilis detailed by M. Cazenave, 46
had taken mercury  for the primary disease, and 97 had taken none
at all.  These facts settle two points:  1st, that mercury does not
certainly prevent  secondary syphilis,  and  2d, that it does not
cause it.  Mercury, however, must be considered as a most power-
ful therapeutic agent in the treatment of secondary syphilis, and
it is in this class of syphilitic cases especially, that its judicious ex-
hibition produces the best effects, when combined with other treat-
ment, which I shall presently detail.
  There is a great deal in the management of the patient generally,
during  the time a primary sore  is under treatment, and as much
depends upon the patient as upon the  surgeon.   I  believe the or-
dinary methods adopted under these circumstances are not suffi-^
cient, and that the general  habits and diet of the patient  are not
sufficiently attended to; for a constitutional disease is  frequently
developed under the combined influence of an over-stimulating diet
and irregular habits, which, under different circumstances, would
never have appeared at  all.   If, as some have  supposed, and with
reason, the  primary forms of syphilis itself  are occasionally deve-
loped under the repeated influence of ordinary irritation, how much
greater is the reason for abstracting the patient from all sources of
irritation, when the primary symptoms  of disease are already pre-
sent in the system.   There is no question but that  the local treat-
ment of, and the constitutional treatment during the presence of a
primary syphilitic sore, has an immense influence over the  produc-
tion of secondary or  constitutional disease.  An over-stimulating
local  treatment unquestionably disposes to the  occurrence of bubo, 
160
SECONDARY SYPHILIS.
 in the same manner that the glands inflame, enlarge, and suppurate,
 in the vicinity of irritations in other parts of the body; and it has
 been shown by the tables of M. Cazenave, (on the Syphilida, p.
 511,) that secondary symptoms follow primary sores complicated
 with bubo, much more frequently than when the former  symptom
 had occurred  alone.
   Many of the  primary forms of syphilis are accompanied by a
 series of  symptoms, which  have been termed consecutive, and
 which are ordinary pathological phenomena, dependent upon irri-
 tation or inflammation, not of a specific character, but more likely
 to take place in  some constitutions than others.  If these are mis-
 taken by the unlearned for specific diseases, and treated specifically
 by mercury, constitutional symptoms are almost invariably pro-
 duced, when the simplest medication with unirritating local treat-
 ment and a regulated diet would in all probability have brought
 the primary disease to a safe and speedy issue, whilst the constitu-
 tional symptoms would never have appeared at all.
   Another frequent cause of the occurrence of constitutional sy-
 philis is, no doubt, the  administration of  mercury for  the cure of
 primary syphilis at  improper periods, whilst  the economy is not
 prepared to receive it.  A certain degree  of constitutional  distur-
 bance, irritability, or fever, almost invariably accompanies the first
 days of a primary venereal  sore, and during this period  mercury
 should  never  be given, nor till the patient is prepared for it by
 low diet, aperients, and the warm or vapour bath.   If mercury be
 administered  during a  condition of local or general irritability,
^constitutional  symptoms are very likely  to be developed.  It is
 from this  cause  that we  frequently see  constitutional symptoms
 arising during the second or third weeks of a primary sore, where
 the patient has been suffered to follow his ordinary diet and  habits.
 There are also certain conditions or forms of the primary sore, and
 different varieties of phagedasna, during which, if mercury be ex-
 hibited,  secondary  symptoms are very likely to follow.   I have
 dwelt thus long on the true causes of constitutional disease,
 because  of its immense importance;—no one knows, when once
 established, when it will be cured, or, in some constitutions, in what
 form it will return.
  Again, there  are  other forms  of constitutional disease, which
 must be considered as wholly independent of the treatment of the
 primary one, and which are  the result of absorption of the poison
 of syphilis, and its mixture with the blood. The earlier symptoms 
             CAUSES OF SECONDARY SYPHILIS.         161

of constitutional syphilis in good constitutions appear most  com-
monly under the form of diseases of the skin in the exanthematic
form, accompanied by some degree of fever; but this is invariably
of a more  chronic character than that accompanying the eruption
of exanthematic diseases, dependent on other causes.  There is
rarely anything specific in appearance in these diseases in the com-
mencement, and the pustular or squamous appearance is seldom de-
veloped till the eruption is perfectly matured or in the  decline.
The mucous membranes are the next parts affected, particularly
of the fauces and throat; deep redness, with superficial or  deep
ulceration,  accompanying most commonly the earlier symptoms of
skin disease.  It is not often, if the primary sore have not  been
improperly treated, and mercury not hastily or injudiciously given,
that the more formidable symptoms  of constitutional disease make
their appearance, before the healing of a primary sore, soon  after
it has closed, or whilst the cicatrix  is yet hard.  Neither do these
symptoms appear in ordinary cases, unless they have been preceded
by some affection of  the  skin or mucous membranes.  There are,
however, instances, and  I have witnessed several, where  diseases
of the bones and  periosteum  (which are  generally amongst the
latest constitutional  symptoms to appear,) have  been ushered in
almost before the primary sore has been healed.
  Perhaps one of  the most frequent causes of secondary diseases
succeeding primary,  and  tertiary succeeding secondary, is the re-
commendation by the surgeon, and the adoption by the patient, of
an incomplete treatment.  Thus all treatment is very commonly
given up by the patient as soon as a primary sore has healed, or
an eruption disappeared, and  the customary habits of life are at
once resumed, diet neglected, and medicine thrown aside.  In such
instances we have only succeeded in getting rid of a symptom, not
of eradicating a disease; and sooner or  later other  symptoms are
made manifest, and they are generally of a more formidable cha-
racter than those to which they gave place.  Endless examples
might be given, corroborating  this statement; a patient has a bet-
ter chance  in following no treatment at all than following an in-
complete one.
  Treatments are rendered incomplete from two causes: first,  from
the adoption of inefficient remedial agents; and, secondly,  from
discontinuing the remedies too  soon.   If a primary sore be treated,
the remedies should be continued for fourteen days at  least after
       11 
162                SECONDARY SYPHILIS.
it has healed, and hardness of the cicatrix disappeared; in the se-
condary forms of disease in the skin and mucous  membranes, the
patient should follow treatment for a month after the subsidence
of symptoms.  In the tertiary forms of tubercles, diseases of the
periosteum and bones, the remedies should be continued for two
or three  months after  the disappearance of the symptoms.  The
next common cause is, the inefficient or improper nature of the re-
medies used, or the irregularities of the patient during the time he
is using remedies.   If mercury be used, the proportions  and that
form of administration should be chosen which suit the  patient;
again, these preparations must be used at the times, and under the
circumstances already laid down.   With some patients all prepa-
rations of mercury taken internally disagree;  they pass off by the
bowels, or produce so much irritation that their use must be given
up. In these instances, frictions or fumigations may be substituted
for internal remedies; and these can very commonly  be borne, and
are useful when internal remedies are injurious.  Under this head
may be mentioned also the use of mercury for syphilitic symptoms
which do not require mercury for their cure.
  The neglect of  warm,  or  simple, or medicated  vapour-baths,
during treatment, more particularly of the constitutional forms of
disease, is, again, one of  the  most frequent causes  why  syphilis
becomes  protracted, and why it so frequently returns when it has
been supposed to be cured. I have for the last sixteen years paid
particular attention to this subject, and made numerous experiments
in reference to it.   I have treated many thousand cases, both in
hospital and private practice, with and without the  mercurial va-
pour-bath; and, as a general statement,.in almost every form of
constitutional disease, I believe I can truly say that  the treatment
is diminished from  one-half to one-third of the time;  the cures
are vastly more certain, and there is no risk to the constitution of
the patient, his health generally being improved by the treatment.
  Vapour-bathing and mercurial fumigations have for a long period
been employed in the  treatment of syphilitic diseases, more par-
ticularly of the constitutional forms, and with the best success.  I
have adopted, however, a method somewhat different to any I have
hitherto seen used;  it consists in the application of  mercurial  va-
pour in a moist state to the surface of the skin, combining, in fact,
the mercurial fume  with the ordinary vapour-bath.  I have made
a number of experiments on this combination, and found it succeed 
CAUSES OF SECONDARY  SYPHILIS.          163
in a variety of cases, where ordinary mercurial fumigation, or the
vapour-bath, employed separately, had failed.1
   These baths should be associated with an  appropriate  internal
treatment.  I have frequently seen them  succeed where  internal
treatment had failed, but in  most  instances they should  be asso-
ciated with it.   Such, however, is their efficacy as an auxiliary
measure, that in all instances  the internal treatment may be of the
mildest kind.  When mercury is indicated, the  assistance  afforded
cannot be too highly appreciated, since half the  quantity of the
remedy will suffice for the completion of the cure, which is accom-
plished without risk to the constitution of the patient; a circum-
stance so much to be feared under the old plans of mercurial treat-
ment.

  V.—PECULIARITY OF CONSTITUTION,  OR HABIT OF BODY, A CAUSE OF
                      SECONDARY SYPHILIS.
   A peculiarity of constitution, or  habit of body, is  again to be
looked upon as amongst the causes of secondary syphilis.  Authors
have imagined what  they have termed a syphilitic temperament,
but have failed to point  out  in what  this peculiar temperament
consists.  A strumous habit has been considered as predisposing to
the ravages of secondary syphilis.  However this may be, it will
be found that constitutional syphilis is often met with of the most
obstinate kind in persons who, otherwise, appear in the best health,
and in whom  there is no evidence of struma.  If the health be
bad when a primary sore is contracted, there is greater reason to
fear secondary disease than though the patient had been  in  good
health at such time.  " It is not sufficient," says M. Cazenave, " for
the development of secondary syphilis that the poison should exist
in the  blood; it requires, occasionally, other causes of a non-specific
or ordinary character to  develop it.   These causes are infinitely
variable; a strong moral emotion, a blow, a fall, a vapour-bath, ex-
cessive fatigue, a debauch, &c, are  amongst the occasional causes
which give rise to an outbreak of secondary syphilis."2   I have
traced attacks of constitutional syphilis very frequently to circum-

  1 Of all the auxiliary remedies employed in the treatment of venereal diseases of
the skin, the most valuable are, without exception, Baths; and at the head of these
must be placed the various forms of vapour-baths. (Cazenave, on the 'Syphilida,'
p. 214.)
  2 Cazenave; op. cit., p. 528.—See also Vidal de Cassis; op. cit.—Causes de'termi-
nantes, p. 264. 
164
SECONDARY SYPHILIS.
stances of this kind: atmospheric changes, and diet, are no doubt
important agents in the development of secondary disease. I have
seen one case where a well-marked venereal eruption occurred in
spring and autumn for nine years; and a second, where  an  erup-
tion occurred every spring for three; a third, where the best health
had been enjoyed for twenty years, where violent exercise, followed
by some fever, developed a most formidable attack of pustular sy-
philis, with sore throat and  iritis.  How often have I seen the
symptoms of secondary syphilis reappear after indulgence in wine;
and it very frequently happens that patients who  have once suf-
fered cannot indulge in the stimuli which, before disease, they used
with impunity, without syphilitic symptoms showing themselves.
An extreme cold sometimes retards the development of constitu-
tional syphilis.  I was consulted by an officer, in one of the Arctic
expeditions, who had symptoms of secondary syphilis before leav-
ing England, which entirely  disappeared  under the  cold of the
Arctic regions, but which  reappeared when he returned home.
These facts show that, independent of the  specific condition of the
blood, occasional causes have a great influence both on  the deve-
lopment and course of constitutional syphilis. 
    »
DIAGNOSIS OF SECONDARY SYPHILIS.        165
                       CHAPTER XV.

                DIAGNOSIS OF SECONDARY SYPHILIS.
   The diagnosis of secondary syphilis is not always certain, either
in its acute or chronic form.  When eruptions on the skin, or dis-
eases of the throat, make their appearance within a few months
after the existence of primary syphilitic diseases, and these symp-
toms have the well-known  peculiar appearances of secondary sy-
philitic diseases, little doubt can be generally entertained of their
nature; but in many instances, diseases which resemble syphilis are
not syphilitic, and symptoms are really due to syphilis, which some-
times have not the characteristic aspect of this disease.   Even M.
Cazenave, with the experience of St. Louis to aid him, sees great
reason for doubt on this point.   " I repeat," says this author, " that
it is of the first importance to distinguish a syphilitic eruption from
one which is not syphilitic;  but how are we to arrive  at such a re-
sult?" (op. cit., p. 549.)  It is  difficult, in some cases, doubtless.
I have already said that diseases of the throat and skin of peculiar
aspect,  occurring  shortly after  a  primary disease, are generally
syphilitic, especially if the patient have never before  been subject
to diseases of a like character.  Sometimes our difficulties are in-
creased by the patient stoutly denying the existence of any primary
disease.
   The symptoms  of  secondary syphilis, in its more acute forms,
are seldom  met with alone; secondary syphilitic diseases of the
skin, whether scaly, papular, pustular, or tubercular,  rarely occur
without other symptoms of syphilis being present  at the  same time,
and these concomitant symptoms are most  commonly found in the
throat in various forms of ulceration, of the soft palate, the tonsils,
or the fauces.  The sub-occipital lymphatic glands are  also  com-
monly enlarged in such cases, but they are also very frequently
not affected.
  Secondary and vesicular diseases of the skin, rare forms of dis-
ease, but of which I shall record  a few examples, may be confound-
ed with various forms of herpes, particularly herpes zoster. 
166                SECONDARY  SYPHILIS.

  Scaly diseases may be mistaken  for the ordinary forms of lepra
or psoriasis, or the reverse, and I  believe this is a  very common
error; I have seen numerous examples of it.   I have recently wit-
nessed a very formidable case of secondary pustular syphilis, which,
in the onset,  had been  mistaken  for smallpox.  The syphilitic
pustule  on the face may also  be confounded with acne.
  Whatever difficulties may  surround the diagnosis of the more
acute or earlier forms of secondary syphilis, these difficulties are
vastly increased where syphilitic  symptoms occur in an isolated
form, after many years of apparently good health, and occasionally
when the patient denies  ever having had a venereal symptom at
all.
                         Case XVIII.
Chronic disease in both testes, occurring as an isolated symptom of secondary sy-
   philis; the diagnosis of the disease made out from the history of the patient's
   children; the patient denying the pre-existence at any time of any form of sy-
   philitic taint.
  A. L—, aet.  46, was admitted into  the Queen's Hospital, for an
ulcer on the scrotum, and enlargement of both testes,  in November,
1850.  Both testes were  large, heavy, hard, and lobulated;  and
on the scrotum was a foul, dirty, deep ulcer, with thickened edges,
which had first commenced  as a pustule some weeks previously.
This man  had been married many  years,  and was the father of se-
veral children.  He denied firmly that he had ever had gonorrhoea
or syphilis at any period  of his life.  On stripping him, however,
there were, on various parts of the  body, cicatrices, which appeared
to me similar to those which are left by the  healing of  sores  con-
sequent on the venereal pustule, but having had smallpox it was
not easy to say to what they were  due.   On questioning him as to
the health of his children and wife, it appeared that the first three
children were alive and healthy; the fourth died at nine  months
old, and had sores on the genitals and on the nates;  the fifth died
at three months old with  similar sores; the sixth was born dead,
and had blotches on the  body; the seventh died of smallpox at
fifteen months old, but previous to this had sores similar to the
other children; the eighth child is now alive, but has had the same
sores, and is reported to be  sickly and wasting.  The wife is re-
ported  to be  healthy, but some months ago had an eruption of
blotches as large as half crowns.  The  patient was placed  upon
an appropriate anti-syphilitic treatment, and left the hospital with
the ulcer  healed, and the testes much reduced in size.   He  took 
DIAGNOSIS  OF  SECONDARY SYPHILIS.        167
 ten grains of the Pil. Hyd. Chlorid. co. every night, the Iodide of
 Potassium in five grain doses, twice in a day, and after the healing
 of the ulcer on  the  scrotum, was directed  to use friction on the
 testes with the Unguent. Plumbi Iodidi.
   It will be noticed that in this case the disease in the  testes oc-
 curred as an isolated symptom; there was no other concomitant to
 assist the diagnosis; but the condition of his children at once re-
 moved any doubt as  to the nature of the disease in the testes; sy-
 philitic sarcocele very commonly occurs as an isolated symptom of
 constitutional syphilis, when  no  symptoms of the existence of this
 malady have been present in the system for years.
   The ulcerated syphilitic  tubercle  on  the face is very likely to
 be confounded with lupus.   Cazenave  considers the  diagnosis,
 under many circumstances, as exceedingly difficult, but gives some
 rules which may guide us, which arc  not certain.  The  syphilitic
 tubercle is larger  and rounder, of a dusky copper  colour, and
 much less prone  to ulcerate  than that of lupus:  in the  ulcerated
 condition, the two forms of ulceration differ in some respects; the
 " syphilitic ulcer is  deep, its edges  swollen, of a dusky copper
 colour, and sharply cut; the ulcer produced by lupus is  of a  dull
 red colour, and looks as if confined to the surface of the skin."1

                          Case XIX.
 Ulcerating syphilitic tubercle of the  lip and nose; close resemblance to lupus; no
    other concomitant, or anterior symptom of secondary syphilis; cure by the mer-
    curial fume, &c.
   J.  L—, aet. 36, was admitted into the Queen's Hospital in March,
 1851, with  a foul ulceration  affecting the  upper lip,  and also of
 the nose.  The ulceration was not deep, nor were the edges thick-
 ened or sharp, but it was surrounded by a deep red areola; it had
 destroyed the central, and a portion of each lateral cartilage, and
 had burrowed deeply into the integument of the upper lip.   The
 disease had commenced in the upper lip, in form of  a red,  hard
 spot, or pustule, which  then broke  and  spread  by  ulceration;
 the ulcers  had destroyed the alas and central parts of  the nose,
 and were covered with thick  black crusts.   This patient had suf-
 fered from  several attacks of  primary  syphilis,  but  had never
 had any symptom of secondary syphilis, except the one  now pre-
sent.

 1 Manual of Diseases of the Skin, by  Cazenave and  Schedel, translated by Dr.
Burgess, p. 257. 
168
SECONDARY SYPHILIS.
  Many who saw this case considered it as lupus:  it was admitted
by the house-surgeon as a case of lupus. Without having any posi-
ti ve data to guide me, I believed it syphilitic, and consequently placed
the patient on an anti-syphilitic treatment.  The ulcer was poulticed
to remove the crusts, and the ulcers were then dressed with a weak,
black wash, and the fume of the iodide of mercury was used every
morning.  A change in the aspect of the sore was soon visible;
and the patient was discharged  under the month, with  the ulcer
quite healed by a good, firm, but red cicatrix.
  The symptoms of secondary syphilis assume many varied forms,
and sometimes  affect internal organs, producing symptoms which
closely simulate those  which are reputed to belong to other dis-
eases.  I bring  forward  a case which forcibly illustrates this pro-
position.

                          Case XX.
Hoarseness, with relaxed throat, and loss of voice for three years; no benefit from
  ordinary treatment; subsequently an attack of tubercular syphilis;  cure of the
  former symptoms by the treatment of the latter.
  A barrister placed himself under  my care to be treated for se-
condary syphilis.   The symptoms consisted  in  the presence of a
large  round tubercle,  covered by a  patch of inflammation, in the
substance of the left cheek.  On the nates, and  on the upper and
back parts of the thigh, there had been  also several of  these  tu-
bercles, which had  ulcerated, and become  deep, irregular, foul, dis-
charging ulcers, seated on an indurated  base.  He had suffered
from primary sores seven years previously; and, three years ago,
the  throat had become  painful on  swallowing, was relaxed but
never ulcerated, and  the voice hoarse  and feeble.  For these
symptoms he had consulted several physicians in London, and had
used counter-irritation, local applications, and had been submitted
to internal treatment of various kinds, with little or no benefit: as
he got thin and weak,  he began to fear threatenings of laryngeal
phthisis.  Seven months previous to  my seeing the patient, the tu-
bercles on the back and thigh  appeared,  which  slowly increased,
ulcerated, and ran into foul sores; the tubercle on the face had also
recently made  its appearance.   For these  symptoms,  doubtless
syphilitic, the patient placed himself under my care.
  He was placed on the use of the mercurial vapour-bath, a milk
diet, and the biniodide of mercury with the iodide of potassium.
The tubercle on the face had disappeared after the sixth  bath, and 
           DIAGNOSIS OF SECONDARY  SYPHILIS.        169

the ulcers, which were dressed with the Ung. Hyd. Nit. Oxyd., and
Unguent. Elemi, looked healthy, and were  healing rapidly.  In six
weeks all the symptoms had disappeared;  but what is remarkable,
the hoarseness, and uneasy feelings in the throat, were gone, and
they have never returned.

  The symptoms in the throat and windpipe in the preceding case
were doubtless syphilitic, which is evident from their disappear-
ing under the treatment which was directed against the syphilitic
tubercles; but from their occurring as isolated symptoms of secon-
dary syphilis, in a form not common, their nature and  origin were
overlooked; the mischief in the larynx would have terminated in
ulceration, had it not been checked in time.
  Whilst on the one hand, symptoms due to secondary syphilis are
constantly unsuspected as to their nature and origin; soon the
other, are diseases reputed syphilitic, which certainly have  no de-
pendence upon the latter disease.  This proposition is of immense
importance in  its  practical application; patients who have once
had any  syphilitic taint, are apt to attribute the whole diseases of
after life, of whatever nature  they may be, to a syphilitic  cause;
and this apprehension or conviction is carried in many cases to such
an extent that  it is difficult or even impossible to  combat  it.  A
gentleman, upwards of sixty years of  age, called on me one day,
and showed me his  hands  and arms, which were covered  with a
well-marked eruption of "psoriasis guttata."  I said to him, "You
are come to ask me if  this eruption is syphilitic, and I tell you at
once, without asking a  question, that it is not."  He replied, "I am
glad to hear you say so, and I feel persuaded that it is not, for the
opinion you have expressed  coincides with others that have been
given me by some  of the first  surgeons and  physicians, both in
London and on the  continent;" but, continued he, "I showed it to
one person, in whom I  really had no confidence, who said it possi-
bly might be syphilitic.  I must confess, that this  opinion  makes
me uneasy, and I cannot get rid of the idea that it is just possible
the disease may be venereal, for I had a sore before I was twenty,
and this eruption, which I have had forty years, came on about that
time, after  bathing whilst I was  very hot.  My chief object in
coming to you,  is to beg that you will test the nature of the erup-
tion  by some anti-syphilitic remedy, which will  set the matter at
rest, till when I shall never be easy in mind on the subject." This
is not an isolated case; these fears are widely spread in society, 
170                SECONDARY SYPHILIS.
and are sources of continual mental uneasiness, in some instances,
threatening the minds of the  patients,  and even determining to
acts of suicide.
   In attempting to form a diagnosis in  reference to the nature of
a symptom supposed to be due to secondary syphilis, several points
must be taken into consideration.
   1. The nature and appearance of the  symptom itself.
   2. Its  history, the date of its appearance; the  character, date,
and number of primary symptoms which preceded it.
   3. The constitution of the patient, what diseases he may have
been subject to, and whether any similar symptoms had ever been
present prior to the contraction of any syphilitic taint by the pa-
tient himself.
  4. If, apparent^, an isolated symptom be present, other symp-
toms should be looked for, which may be generally found on close
examination and inquiry.
   5. If the patient be married, the health of his wife and children
should be noted;  and, lastly, we may resort to the test of treat-
ment itself.  By attention to these circumstances, I think it will
generally be found, that we shall be able to make out, in most cases,
a correct diagnosis of many secondary syphilitic symptoms,  of
whose nature we might remain in doubt, after a more cursory,  or
careless examination. 
PROGNOSIS  OF CONSTITUTIONAL SYPHILIS.      171
                       CHAPTER XVI.

         OF THE PROGNOSIS OF CONSTITUTIONAL SYPHILIS.

  The prognosis of constitutional syphilis involves  many  grave
questions, besides  that of the effect of the disease  on the health
and life of the patient.  It is true that constitutional syphilis rarely
terminates fatally, considered in reference to the number who suf-
fer from such disease; but yet where the pustular, or tubercular, or
even other forms of disease occur in advanced years,  the patient's
life is not unfrequently shortened by the  exhaustion  produced by
repeated outbreaks of disease.   Where constitutional syphilis ter-
minates fatally,  organic changes are not  uncommonly met with in
the mucous membranes, especially in those of the  intestines and
larynx, where ulceration is found, and the patient sinks exhausted
by diarrhoea, or symptoms resembling laryngeal phthisis; cough,
with profuse expectoration, and night sweats.  At other times the
constitutional condition is one of profound cachexia,  in which the
changes most evident are rather in the humours than in the solid
parts of the body.  In addition to its direct influence, a syphilitic
taint frequently becomes the means of developing latent  mischief
in various organs, especially in  the lungs, and I have, in more than
one instance, seen  patients die, in  the Queen's Hospital, of ordi-
nary phthisis, whilst suffering from syphilitic diseases of  the skin
and bones.
  The ordinary  forms of constitutional syphilitic taint do not, how-
ever, terminate  fatally; neither do they, in a great number of in-
stances, appear to  affect the  general health of the patient;  but a
serious question, in reference to the prognosis of constitutional sy-
philis, is that which relates to its curability, and whether, and at
what  period, we are capable of pronouncing a patient cured after
the disappearance of all external signs of a constitutional syphilitic
taint.  Some modern writers have denied the curability of consti-
tutional syphilis altogether, and asserted  that the virus "once re-
ceived into the blood, remains there for years, and possibly, indeed 
172
SECONDARY SYPHILIS.
certainly, for the rest of existence."1  Though there may be some
foundation for such a statement, it is too sweeping to be received as
an axiom.  If secondary syphilis attack persons of good constitu-
tion, under  thirty-five years of age, and  be properly and perse-
veringly treated, I believe, in a great majority of instances, that
the disease is eradicated, and I found my opinion in the fact, that
many persons who have so suffered have never exhibited any fur-
ther evidence of syphilitic taint, and their children have also enjoyed
the best health.   If,  again, a constitutional taint make  its first ap-
pearance over forty, especially in the forms of pustular or tuber-
cular diseases of the  skin; although treatment may do much in re-
moving the symptoms of such diseases, it would, perhaps, be going
far, to say that they are ever perfectly cured;  and I am sure they
rarely are, except vapour-bathing  be associated with any treat-
ment that may be adopted.  This is our sheet anchor in the treat-
ment of all forms of constitutional syphilis.
   If, again, the  symptoms of a syphilitic  taint have disappeared
from the system for years, the taint may remain latent, and appear
in the  offspring of such patients, in the various forms of hereditary
or congenital syphilis.  I could relate many cases of  this nature,
where, although no external sign betrayed the existence of a taint,
still children have been born to such parents, who have exhibited
formidable symptoms of syphilis.

                         Case XXL
   A gentleman  married, having been free from the slightest  ap-
pearance of syphilis for some years prior to his marriage.  His
lady aborted of  her first infant, and also of the second; the third
child was  born alive, but at six weeks  old  was  attacked with
"snuffling," and condylomata round the anus; the eyes were also
affected; the lady aborted of the fourth child; the fifth  had  condy-
lomata and inflamed eyes, with snuffling; and the sixth exhibited the
same symptoms  soon after birth.   The lady had also an ulcerated
throat of suspicious appearance, but no other symptom.

   Such cases might be multiplied; I have seen many: Mr. E. Wilson
has also recorded some very remarkable ones.   In  the face of
such facts, who  can say when some patients are free from syphilitic
taint, or who can deny the mode of infection by means of the blood,
or the secretions.
1 Erasmus Wilson; on Syphilis, &c, p. 158. 
STATE OF THE BLOOD.
173
                      CHAPTER XVII.

     OF THE STATE OF THE BLOOD IN CONSTITUTIONAL SYPHILIS.

  If the blood taken from any part of the body of a patient in an
advanced stage of constitutional syphilis be examined microscopi-
cally, it will be found to differ widely from healthy blood.  The
single corpuscles  are small and pale, and their circumference often
irregular; they are disposed to coalesce and run into irregular and
confused masses, in which all  trace of the individual corpuscle is
lost.  They are also very small  in quantity, their number in pro-
portion to the other  elements  being less numerous than in healthy
blood.  The blood of patients in this state is  poor and thin;  the
corpuscles  small  or  irregular, and much  diminished in  quantity.
This has been termed "deglobulization" by some modern writers.
The diminution of the relative  quantity of  blood-corpuscles in
secondary  syphilis  is  strongly  contrasted with  the  condition
of the same fluid  in the acute  primary forms of the disease, where
the globules are  full and large,  and their number relatively in-
creased.
  M. G-rassi1 states that in the advanced stages of the disease the
globule is converted into albumen.  It is certain that many forms
of constitutional syphilis are accompanied by albuminuria.  I have
seen many cases,  and have at  the  present moment one  under my
care.  M. Waller  has succeeded in inoculating with the blood of a
patient labouring under constitutional syphilis.2   MM. Diday  and
Vidal de Cassis also  believe in the contagious properties of blood
thus affected.3
  Of course the conditions of the blood I have just alluded to will
present infinite varieties, dependent on the age and constitution of
the patient and the length of time the disease has been in the  sys-
tem.  My observations  have  been made at all ages; but the de-

               1 Gazette M6dicale, 1850, p. 200.
               z Op. cit.
               ' See Vidal de Cassis;  op. cit., p. 2G8, &c. 
174
SECONDARY SYPHILIS.
scriptions I have now given have been taken from  the  blood of
patients upwards of forty years of age, where the disease had ex-
isted some years.
  The blood-disc taken from patients debilitated and exhausted by
an old venereal taint does not long retain its characteristic  shape.
It is well known that the healthy blood-disc, dried  on a piece of
glass, retains its shape and character for a length of time, and may
be preserved in this way for the  purposes of demonstration; but
the blood-disc of constitutional syphilis, if examined a few days
after  being drawn from the patient, has completely disappeared,
and nothing but a red cloud is perceived, produced by the dissolu-
tion of the disc, and showing the profound  alteration the  blood
undergoes in advanced stages of the disease. 
SYPHILITIC EXANTHEMATA.
175
                    CHAPTER XVIII.

    OF THE PARTICULAR SYMPTOMS OF CONSTITUTIONAL SYPHILIS.
              OP SYPHILITIC DISEASES OF THE SKIN.

  Syphilitic diseases of the skin may be referred to nine princi-
pal groups:  1, Exanthemata; 2, Squamae; 3, Vesiculae; 4, Pustulae;
5, Papulae; 6, Tubercula; 7, Ulcers of various kinds and in various
situations; many the consequences or necessary result of many of
the preceding forms; 8, Vegetations, warts, condylomata, or mucous
tubercles; and 9, Maculae, or syphilitic stains of the skin.

               OF THE SYPHILITIC EXANTHEMATA.1
  The syphilitic exanthemata generally make their appearance
under the form o,f irregular patches, of a shining copper or bronze
colour, at the onset of the disease: if there be much accompanying
fever they are more inclined to redness, and the  bronze or copper
colour is not marked till the inflammation and fever have disap-
peared.  Occasionally this form of disease commences in red patches,
spread more or less extensively over the body: these patches vary
in dimensions from the size of a sixpence to that of a shilling; they
are not elevated and solid like  the papulae, and  have no apex or
centre containing either lymph or pus.  They are commonly accom-
panied by fever, and but for the coexistence or  immediate prece-
dence of primary sores might be mistaken for an eruption depen-
dent upon other causes.  They very commonly appear before the
primary symptoms have  disappeared.   When  they are dying the
top is commonly covered with a thin dry scurf or scale.  They are
sometimes accompanied by papulae and other forms of constitutional
syphilis, as superficial redness or ulceration of the fauces, and are
frequently succeeded by  the squamous or tuberculous forms of dis-
ease.   These eruptions  frequently accompany the primary forms
of syphilis.

 1 Synonyms and Varieties.—Roseola Syphilitica, and papulous erythema. (Cazenave;
on the Syphilida, p. 226.) 
176
SECONDARY SYPHILIS.
  They demand, in the.first instance, if there be much symptomatic
fever, an antiphlogistic treatment, and the warm bath; afterwards,
if they are rebellious, the iodide, biniodide, or  bichloride of mer-
cury, with sudorifics and the mercurial vapour bath.  This is the
form of skin disease which frequently accompanies an acute gonor-
rhoea, or comes on when it has been suddenly suppressed in its early
stages by injection.   The ordinary forms of roseola generally occur
early in the history of a venereal taint; but there are cases where
eruptions  which belong to the exanthematic form are chronic, and
appear at varied intervals after primary diseases.  I have seen cases
where  they occurred two  years after, and ten years after the pri-
mary disease.  In these instances, the affection of the skin consisted
of circular red patches, fading into a brown colour, and covered
with a thin, dry scurf, not a scale.    After  a long period, in some
of the spots, the scurf became a scale, and gradually thickened, so
as almost  to appear like lepra or psoriasis, diseases from which it
is, however, essentially different.
  These spots of chronic  roseola, at first red, gradually fade into
a pale, shining copper colour, and frequently,  at last, die away into
a yellow stain of the skin, which remains for a long period of time,
and sometimes cannot be removed at all.
  The treatment, which is almost always successful in these  cases,
consists of a milk diet, minute doses of the bichloride or biniodide
of mercury, not exceeding the twentieth of a  grain for a  dose, and
the  mercurial vapour-bath three times a week.

                   OF THE SYPHILITIC SQUAMAE.
  The squamae are  particles of thickened epidermis, become hard
dull, and  opake, and elevated  above the surrounding skin by a
morbid condition of the subjacent  dermis, or simply of the rete
inucosum.  This disease is essentially chronic, and does not  gene-
rally succeed  to any febrile condition of the economy.  The syphi-
litic squamae generally appear in the form of  patches, more or less
diffused, varying from the size of a sixpence to that of a half-crown;
the  centre of these  patches is frequently depressed; they are of a
red copper colour,  changing ultimately to  a dull brown, or even
black, which  is a long time in disappearing.  I apply  the term
squamous, or scaly syphilitic  disease  of the skin, to that form which
is scaly from the commencement: it is to  be distinguished from
other diseases, such as roseola, papules,  or pustules, which either
become covered with a dry dandriff, as roseola, a slight ulcer with a 
SYPHILITIC SQUAMJG.
177
scab, as papules on the decline, or a crust which covers a ruptured
pustule; these  are not  scaly diseases, properly so  called, and the
distinction should be well made, as the scaly disease is that which
has been called "true syphilis," although it is not more truly sy-
philitic than a pustule or a tubercle, and not half so formidable in
its consequences or results.
  The  scaly syphilitic  eruption consists of thick, dry scales, ad-
hering  firmly to the skin, and resting upon a red, elevated surface,
the scales  being continually renewed when shed: those portions
of the skin on  which the scales  are placed, present a well-marked
thickening, and are thicker as the disease has been longer in ex-
istence.
  The scaly disease appears under various forms; as a ring, a spot,
(guttata,) an irregular ring, like  the track of a snail, (gyrata,) some-
times the scales are black, at other times of a shiny  or pearl-like
whiteness, and sometimes, when affecting the  palms of the  hands,
as thick as horn in old cases.
  Scaly syphilitic eruptions may be  confounded with other scaly
diseases of the skin not syphilitic, as the ordinary forms of lepra,
or psoriasis; they may be confounded, again, with other syphilitic
eruptions, which assume an appearance of scaliness on their decline;
some forms of papules (lichen,) when the papules are  large, resem-
ble it very closely.  On the hands the disease may be mistaken for
grocers' or bakers' itch; and this is not unlikely, as  the horny or
scaly syphilis of the palms of the hands, and joints of the  fingers,
very  commonly occurs as an isolated symptom of constitutional
syphilis.
  Scaly diseases occur at various periods after  primary infection,
sometimes as early as three months, in other cases much later; there
is no rule on this  point.  They  sometimes succeed to other forms
of skin disease,  as papules, or vesicles, and frequently occur again
under the same form when they have been apparently cured, a fact
peculiar to the scaly disease, for papules, vesicles or pustules, rarely
occur twice; if another attack of skin disease succeeds it is gene-
rally, if not always, under another form.
  The syphilitic squamae have a tendency to excoriate, or ulcerate
slightly in the centre, which then becomes covered by a small, dry,
thick crust; occasionally, also, their surface is traversed by fissures,
when there does not exist any apparent ulceration.  After the cure
of the disease, the dermis remains depressed in the  parts corre-
sponding to the centre of the squamous patches.  The other symp-
       12 
178                SECONDARY SYPHILIS.
toms of constitutional syphilis, with which the squamae are com-
monly associated, are inflammations and  ulcerations of the fauces
and palate, and pains and diseases of the periosteum and bones.
  As the syphilitic squamae are not generally accompanied by vas-
cular excitement or fever, an antiphlogistic treatment  is rarely in-
dicated.   Sudorifics, as the decoction of sarsaparilla, or the prepa-
rations of Zittman or Feltz, with the carbonate of ammonia, and
the mercurial vapour-bath, are generally successful.  The bichlo-
ride or biniodide of  mercury, or  frictions, are the  best remedies
when mercurials are indicated.  The  preparations of arsenic are
useful in some forms of disease, particularly those which succeed
to primary diseases  which  have  been fully treated by mercury.
Biett relates a case of this character speedily cured by the  liquor
arsenicalis, and the arseniate of soda, after the  failure of other
measures.  Over true scaly diseases the iodides have very little
influence.

                 OF THE SYPHILITIC VESICUL^E.
  The vesiculse are the most rare of all the syphilida.   M. Biett
has only seen a few examples of it.  Cazenave says that he pub-
lished the first account in 1828.  The disease is characterized by
vesicles seated upon an inflamed  base, of a deep copper-coloured
red; they are indolent, and  remain stationary much longer than
eruptions of the same character, not having a venereal origin.
Some of them shrink up, and are transformed into gray squamous
crusts; others disappear and leave behind them on the skin where
they are situated, a brown mark. They  are accompanied by some
degree of fever, inflammation of the fauces and  palate,  and other
symptoms of secondary syphilis.   I have  seen several  examples of
this form of secondary venereal disease of the skin, which is not,
perhaps, so rare as might at first be imagined, as the vesicles soon
rupture, shrink, and  are transformed into  little  crusts or scabs,
which look like lichen or lepra.   An error in diagnosis might be
very easily committed, both as regards the form of syphilitic erup-
tion, and as to the nature of the eruption itself, whether syphilitic
or not,  especially if there  be no other  concomitant  symptom of
secondary syphilis.
  The syphilitic vesiculae are commonly preceded by  other forms
of skin  disease, which they replace.  I have seen the vesicle pre-
ceded by roseola, and replaced by a pure scaly disease; thus corro-
borating a former remark, that with the exception of scaly diseases,
the syphilida are seldom reproduced under  the same form. 
SYPHILITIC PUSTULE.               179
  Vesicles on the  penis, whether venereal or not, sometimes ac-
company primary  diseases.  I have seen one case in which, three
days after the appearance of a gonorrhoea, the  skin of the penis
was  covered with  a  crop of vesicles, from which the  patient had
never suffered before.   Cazenave (p. 266) believes these symptoms
to be syphilitic.  Vidal de Cassis states  that he has  succeeded in
inoculating the  syphilitic vesicle, by which inoculation a  similar
disease was produced, (p. 343.)

                  OF THE SYPHILITIC PUSTULE.
   Pustules  are  characterized by an elevation  of the epidermis,
raised by a collection of pus secreted by a circumscribed portion
of inflamed skin.  The syphilitic pustulae are frequently  compli-
cated with tubercles, and the pustules themselves commonly placed
upon a tuberculous base.   The pustules are again occasionally as-
sociated with papulae, but are rarely complicated either with squa-
mous  or  exanthematous affections.   The syphilitic  pustulae  fre-
quently ulcerate, and give place to a sore of characteristic appear-
ance, with hard and elevated edges, and a foul surface, secreting
a  sanious pus.   Unlike other pustular diseases of the skin, the sy-
philitic pustule follows no regular course; they are  developed
slowly, and remain stationary for a longer or shorter period, fre-
quently for many weeks,  or  till an appropriate treatment be
adopted.   They are situated upon  a hard, raised base, of a deep
brown or copper  red: this colour is better marked when they
have continued some time, than in the commencement of disease.
The syphilitic pustulae strictly belong to that  class  of affections
which'are termed secondary, but are sometimes observed to co-
exist with a primary venereal sore: they are, under these  circum-
stances, developed upon  the  skin  of the penis, the  scrotum, the
pubes, or the labia: they are placed upon a red, indurated base,
soon burst, and change into foul and spreading ulcers.
   Pustular syphilis is characterized by the eruption of pustules
of various  sizes, over a greater  or  less  extent of the whole  sur-
face of the body, rarely accompanied by any symptomatic fever.
It is sometimes confounded with other forms of skin disease, not
venereal.   On  the face I have  known it mistaken for acne, espe-
cially when the pustules are  small, and I have also in more than
one instance  seen it mistaken for smallpox.  Pustular secondary
syphilis assumes several forms; in one form the pustules are small
and numerous:  this  has been termed the lenticular or miliary pus-
tule ; in a second form the pustules are larger and not so numerous; 
180                SECONDARY SYPHILIS.
and in the  third form we  have large single  pustules, irregularly
disposed, but  not numerous:  the  patient may have  from ten to
twenty of these pustules, in different stages, on various parts of the
body.  The secondary syphilitic pustule is a very common form of
constitutional  syphilis.  It  generally  occurs from six to  twelve
months after the primary poisoning, but I have seen cases, one now
in the hospital, where a well-marked pustular eruption occurred
before the primary sore was  healed; and again, I have known well-
authenticated  cases, where  pustular syphilis  has occurred ten,
twelve, twenty-seven, and thirty years after  a primary infection.
It is difficult to explain these facts, which I state from my own ex-
perience, and in which I am borne out by M. Cazenave :x of their
truth there can be no doubt.
   The syphilitic pustule runs  a very marked and peculiar  course,
and I will take a medium-sized pustule for the purpose of illus-
trating the history of this  course, because the progress I am about
to mention is not so well marked either in a very small pustule, or
a very large one.  When the syphilitic pustule first appears on the
skin, it consists of a  portion of  epidermis raised by a small quantity
of pus; but the disease remains a very short time in this state, some-
times only a few hours, at  most not more than a few days;  the
pustule  becomes  ruptured, the pus exudes on the surface of the
pustule, which shrinks and dries up.
   In the first form, (the lenticular,) the pustules commence in small,
red, elevated  spots," spread  more or less over the face, trunk, and
extremities; these spots suppurate at the apex, and each spot con-
tains a drop of matter about the size  of a large pin's head;  the
pustule soon breaks, the pus exudes and dries on the surface of the
pustule, each of which is then  covered  with a small crust, slightly
depressed in the centre.   On the face these pustules very much
resemble "acne."
   In the second form the pustules are larger, about the size of a pea,
or the smallpox pustule; these soon break  and become covered
with a thin, flat, or conical crust:  if the pustules are few and  iso-
lated, the crusts are circular, but if near together the crusts run into
each other and assume an irregular form.  The disease, in this stage,
has  been denominated "pustulo-crustaceous."   We may see  the
pustule before it has broken, surrounded by a narrow, red, or livid
areola, or the circular crust where  the pustule has ruptured, and
1 Traite" des Syphilides. 
SYPHILITIC PUSTULE.                181
the pus dried up, or confluent and irregular where the pustules
have been near together.
  The crust covers an ulcer which, when the former is detached,
may be found in varied conditions, either healthy and disposed to
heal, deep and sloughy with indurated edges, or even phagedenic.
These  are secondary venereal ulcers, succeeding to the rupture of
the pustule.   The ulcer may heal under the crust of the pustule,
which  is a very common circumstance, but when it does so it leaves
behind it a red cicatrix always more or less depressed in the sub-
stance of the  skin.  If the pustule have been placed on the fore-
head, and have been large and long in existence, the  surface of
the  bone is always more or less absorbed, and a well-marked de-
pression exists in  it, long after the ulcer has healed, and the skin
has recovered its natural appearance.  Till a proper treatment has
been adopted, the venereal pustule keeps constantly forming  on
the skin for long periods, and thus we commonly see the pustule,
the crust, the  ulcer, and the depressed and red cicatrix all present
in the  skin at the  same time, giving the malady the appearance of
a compound skin disease.
   In pustular secondary syphilis, then, we have four distinct forms
of local  mischief—the pustule, the crust, the ulcer, and the de-
pressed and coloured cicatrix, and in the advanced stages of the dis-
ease it almost invariably happens that all these conditions are pre-
sent on the skin at the same time.  In many forms of pustular sy-
philis, particularly "the first two, the constitutional disturbance is not
so great as the extent of the local malady would lead us to expect;
thus in  many cases the general health is little disturbed.  But
there are other instances in which the constitutional disturbance
is so great as to put  the  life of the patient in imminent danger.
All  the  forms of pustular  constitutional syphilis are formidable
diseases, and indicate a profound and complete contamination of
the system by the syphilitic virus.   In the second and third  forms,
the general health suffers more or less, and a fatal termination may
ensue, in which a  general breaking up  of the  constitution takes
place,  preceded by diarrhoea and profuse night perspirations. Hap-
pily, however, under a proper treatment, this is not often the case.
   Pustular  syphilis is formidable again, from the  marks and  de-
pressions left on the skin, and on the surfaces of the flat bones by
the  cicatrices of the ulcers  to which  it gives rise, which may be
frequently avoided if the patient is  treated  early and  before the
rupture of the pustule: it is commonly the forerunner of, if it be not 
182
SECONDARY SYPHILIS.
accompanied by, tubercles and diseases of the bones.   Pains in the
bones, nodes, and  periostoses, commonly complicate  pustular sy-
philis, particularly where the pustules are simple and large.  It
must  be quite evident that the stages of pustular syphilis are so
numerous, its complications and pathology so varied, and the con-
ditions of the general health under which it is met with, so diffe-
rent, that no specific treatment can be in any way applicable  to pus-
tular  syphilis considered as a mere secondary venereal disease.  It
must  be quite clear that  the treatment of the miliary  or impetige-
nous  pustule in a patient in good health, must totally differ from
that we should  adopt in one suffering from ecthyma, where  the
habit is weak and the health bad, and yet they are both pustular
secondary syphilis.
  If a patient  be  presented for  treatment, suffering  from either
the first  or  second form of pustular syphilis, and the health be
good  and the  disease  recent, the following plan of treatment
should be followed:— He should  first  have a smart aperient exhi-
bited, and be placed, not upon a low diet exactly, but upon a diet
consisting of cocoa, milk, broth, and farinaceous matters generally;
no  beer, wine, spirits, or animal food; if the latter be permitted
it  should be taken very sparingly.  Much  difference of opinion
exists with regard to diet in secondary syphilis, but on this point
it appears to me that the diet, like the medical treatment, must be
varied to suit the circumstances of the case.   Of one thing I am
certain, that should a patient upwards  of forty  become tainted
with secondary syphilis, and such patient has been in  the habit of
constantly living well, a low diet must be adopted with great cau-
tion.  Age and  habit have a vast influence over secondary syphilis,
and modify the course and treatment of both very materially.
  Where the health is not  impaired, the disease  recent, and  the
patient not  more  than thirty or thirty-five  years of age, the  fol-
lowing is an outline of the  best plan of treatment:
  1st. An aperient.
  2d. The diet  already indicated.
  3d. Decoctions of the woods, with antimonials.
  4th. The ordinary vapour or hot-bath three times a  week.  The
vapour, however, is far  superior to the  water-bath.   This treat-
ment  to be pursued for a week.  At the end of that time  the plan
should be somewhat modified.
  The diet should  be the same, a little better, if the patient feels
the change in his habits  much.   A tenth or twelfth of a grain of 
SYPHILITIC  PUSTUL.E.
183
the biniodide of mercury given in solution  in  water, with from
three to five grains of the iodide of potassium.  The vapour is to
be changed for the  moist mercurial fume, on  the plan I  have sug-
gested.   This should  be used three times a week.  If  the mercu-
rial plan thus laid down be well and carefully regulated and  ar-
ranged, no salivation or ulceration of the mouth, or  any of  the
more common and  evil effects of  mercury, will be produced.   A
mere redness, with  slight swelling and elevation  of the gums, is
all we shall observe, and this is enough for our purpose.
   The biniodide of mercury, with the iodide of potass, may  be
discontinued for two days in every eight or  ten, and an aperient
again given.
   If this plan be carefully pursued, a beneficial change is soon ob-
served in the condition of our patient.   In the first place, after
two or three days'  treatment we perceive  that no more pustules
appear, that the disposition to their formation is for the time ar-
rested; again, the red or copper coloured ring round the pustules
that are covered with  crusts,  looks less livid,  and the eruption
looks more dead: after  a time the  crusts begin to drop off, and we
find that in many places, where they formed the covering to ulcers,
that these ulcers have healed, and  that there  is a red cicatrix only,
marking the site of the previously existing ulcer.  This cica#fe,
very commonly, is  depressed more or less in the skin, forming a
pit not unlike that left  by the pustules of smallpox.  The crust is
the best dressing to the ulcers underneath, under ordinary circum-
stances, and this is  proved by the crusts adhering till the ulcer has
healed, under a proper constitutional  treatment, and then falling
off.   If, however, the ulcers are unhealthy, and disposed to spread,
we find drops of pus exuding through the  crust, or the crust falls,
leaving the sore underneath in very various  conditions.  To these
sores various applications may be used.    I  generally poultice
them if foul,  for a  day  or two, then wash them with a little black
wash, and cover them  with collodion,  or the  solution of gutta-
percha in chloroform,  suggested  by Dr.  Graves, of  Dublin.  If
they secrete much, they may be dusted  with starch and calomel:
ointments are generally unsuited to these ulcers, and under or-
dinary conditions  the  collodion,  or gutta-percha dressing, to de-
fend them from friction and atmospheric  influence, answers very
well.
   This plan  should  be followed for a month or six weeks,  and at
the end  of that time we shall find that  the  symptoms ©f pustular 
184
SECONDARY SYPHILIS.
syphilis have disappeared, with the exception, probably, of the red
stains left on the site of the ulcers.   If they have been deep, it is
some  time-before this redness altogether subsides, perhaps two
months, or even three, or more, according to the severity of the
attack.  Treatment should not be given up, although it should be
modified, till all the redness left on the skin has disappeared.  If
the destruction of parts by the ulceration has been great, the skin
is far from presenting its original healthy appearance; it remains
puckered, and uneven in  places, resembling the appearance of the
cicatrices produced by a  burn.

                         CASE XXII.
  S. R. was admitted into the Queen's Hospital, on March 30,1849,
with twenty-eight or  thirty large pustules, in various stages, on
different parts of the body; constituting the disease known as sy-
philitic " ecthyma." In this patient the constitution had been nearly
destroyed by the irritation of the disease.  When admitted, he pre-
sented an illustration of  the last stage  of syphilitic cachexia. He
could not  stand, the extremities were oedematous, night perspira-
tions  profuse, and pain in the bones of the head and legs  very
severe.  There were seven or eight large secondary ulcers, of foul
character, on the head, arms, and legs, which had  resulted from
the rupture of the pustules, and in two places were pustules recently
formed, which offered a good illustration of their commencement.
The epidermis was raised by a purulent collection, of the size of a
shilling, the covering of which  was very  thin, the pustule itself
surrounded by a deep livid-coloured areola; the skin on which the
pustule rested was not indurated.  This patient took at first large
doses of opium, an admirable anti-syphilitic in such states.   I have
employed opium very largely in  the advanced stages of constitu-
tional syphilitic diseases.  Opium has, by a number of authorities,
been extolled as a remedy of great value in many forms of secondary
syphilis, and its administration by some surgeons has been carried
to the  extent of twenty or thirty grains a day.  Opium is indicated
where the health has been broken by mercury and syphilis, and its
administration  is almost always  followed  by satisfactory results.
It is of especial use where the nights are bad, and the patient ema-
ciated and feeble, where a general  irritability, the result of mer-
cury and disease, appears to  be wearing the patient out.   In such
cases opium, in large doses, acts almost magically.   In many in- 
SYPHILITIC PAPULJ3.
185
stances it may be advantageously combined with other remedies,
to suit the exigencies of any particular case.  I am in the habit of
prescribing  it combined with guaiacum, with very good  results.
   Opium, the warm-bath, appropriate dressings  to the secondary
ulcers produced  by the rupture of the pustules, with  beef-tea, and
decoctions of the woods, are  the first remedies to be employed in
such states as those to which I have just alluded.  As the patient
improves, the mercurial vapour-bath must be used, and the iodide
of iron given.   There may be many other syphilitic symptoms pre-
sent, with the pustular  disease of the skin  and its  consequences.
Pustules are commonly complicated with tubercles, tophi, and al-
most always in advanced forms, with pains or diseases in the bones.
Such states, of course, require modifications in the treatment suited
to the exigencies of each particular case.

                   OF THE SYPHILITIC PAPULA.
   The papulas are small, solid, hard elevations upon the skin, con-
taining  neither  lymph nor  pus, surrounded  by a small inflamed
areola, having frequently  ulcerations at  their apices, which then
become   covered with small, dry  incrustations. The syphilitic
papulae are more or less disseminated over the body, arranged  in
groups,  or disposed  to be confluent.  They are distinguished by
their deep red, or copper colour, their tendency to ulcerate, and
to form  hard incrustations  on their surfaces,  which, falling off
when the ulcer has healed, leave brown, copper-coloured, depressed
cicatrices in the skin.  The papulae are commonly associated with
pustules, tubercles, or squamae; and are almost always accompanied
by syphilitic iritis, ulcers of  the mouth and fauces, diseases of the
bones, or'periosteum, nocturnal pains, or other  symptoms of con-
firmed constitutional syphilis.  This affection of the  skin some-
times accompanies primary symptoms; when it does so, it assumes
a more or less acute form, and is attended with  some fever.
   This variety of disease  has been  termed venereal itch, " scabies
venerea," on account of the  irritation the papulas occasion when
they are  seated on certain parts of the body.  It  sometimes attacks
the labia, principally on their external surface,  the orifice of the
vagina,  and the clitoris, which parts, on examination, are found
covered with small papulae of a deep red colour,  causing an in-
tolerable itching, principally in the night: the eruption sometimes
extends to the arms and internal  parts of the thighs.  Mercurial
ointment generally allays the irritation. 
186                SECONDARY SYPHILIS.
   If the papulae assume an acute, or subacute form, they must be
treated, at first, on the antiphlogistic plan, and a regulated diet
must  be observed.  Should  they succeed  to primary symptoms,
which have not been treated by mercury, this remedy may be em-
ployed: fumigations have a marked effect in allaying the irritation
by which they are accompanied; weak solutions of  the bichloride
of mercury may likewise be used, to sponge the  surface of the skin
affected with syphilitic papulae. The mercurial vapour bath is also
of essential service.


                 OF THE SYPHILITIC TUBERCULA.

   Syphilitic tubercles  of the skin  are deep-seated, solid,  circum-
scribed elevations, containing neither lymph nor pus;  they  differ
from the papulae in their size, being much larger, more prominent,
and better defined. Syphilitic tubercles  are either  isolated or
grouped, of a shining red, livid, or  brown  colour, surrounded by
an areola of a dark red or coppery appearance.  These tubercles
are prone  to ulcerate,  and form excavated sores with thick and
elevated edges,  and a foul  surface,  secreting  an offensive pus,
which, drying up, is transformed into gray or dark coloured  scabs
or crusts.  The syphilitic tubercle forms the link of connexion be-
tween the secondary and tertiary symptoms of M. Ricord: it  is the
first of that class of syphilitic diseases, in which the virus appears
to have  penetrated more  deeply into the  economy, and to  have
produced a disorganization in tissues, which those forms hitherto
considered have  left untouched.
  The flat tubercle of  M. Cullerier, or the  tuberculous pustule of
Alibert, sometimes  occurs  as a primitive affection, but more com-
monly as a symptom of constitutional syphilis: in the former in-
stance it is observed on the scrotum, the labia, the vicinity of the
anus, or the mammas.  The surface of these tubercles is  smooth
and flat, or granulated, of a deep red or  copper colour, varying
from the size of  a sixpence to that of a shilling: they are not so
much disposed to ulcerate  as the other varieties.
  The more common forms of tubercle are  conical, or round ele-
vations, dispersed here and  there over the  skin, or  assembled in
groups or clusters, which  are also  irregularly  distributed.   The
size of these varies from that of a pea to that of a large hazel nut,
or filbert; they are more commonly situated on the anterior sur-
face of  the chest, or the  abdomen, on  the neck, the face, or the
internal part of  the arms. 
SYPHILITIC TUBERCULA.
187
  Another variety of tubercle is situated, more commonly, on the
alae  or  lobule of the nose, or on the  forehead;  frequently,  also,
upon the neck of the uterus, or upon the tongue, where they may
be mistaken for cancerous affections.   These tubercles  are  com-
monly assembled in circular  groups of variable size;  they are so
prone to ulcerate, that this termination appears to be  one of their
natural characters:  when in this condition, they are frequently de-
scribed under the name of syphilitic lupus.  The tubercular syphi-
lida are commonly complicated with a scrofulous, scorbutic, or her-
petic tendency, or diathesis:  their progress is slow, and generally
without pain; they gradually increase  in  size till they terminate
in softening or ulceration.  They are the most formidable of all the
forms of constitutional syphilis, producing  great  deformity in all
the parts invaded by ulceration.
  Whilst the tubercles are  in a state of  induration, and  as yet
neither ulcerated nor softened, their resolution maybe attempted.
For this purpose, the iodide of mercury, with the iodide  of potas-
sium, may be employed: it must  be remembered, however, before
any  plan of treatment is framed,  that due attention be paid to the
general health of the patient.
  If there be no contra-indication, the treatment may be commenced
by administering a pill  of the iodide of mercury  daily, contain-
ing one grain of the salt and a solution of the iodide of potassium,
at first administered in  doses of ten grains in  the day.   On the
fifth day, two pills are given, and the quantity of the iodide of po-
tassium is increased: it  is generally unnecessary to carry the  dose
of mercury to any  extent, or to  continue  its use very long;  the
treatment is to be completed by the iodide of potassium.   The in-
durated tubercle is commonly resolved  by  this  treatment, leaving
behind  it, in the skin, merely a depression of a brown or  copper
colour, more or less deep.
  The mercurial vapour bath is also exceedingly useful, whilst the
tubercles  are yet unsoftened, in procuring their resolution: it
may be  employed with the iodide of potassium and sarsaparilla.
  As syphilitic tubercles are accompanied  by a process of  inflam-
mation, under the increase  of which they soften and ulcerate, a
local treatment, whilst they are in a state of induration, is of  vast
service in assisting the internal treatment in their resolution.  For
this  purpose, cooling lotions may be employed,  or fomentations of
poppy, henbane, or aqueous solutions of opium.
  When the inflammation is subdued, and  the tubercles are indo- 
188                SECONDARY SYPHILIS.
lent, folds of linen soaked in a weak solution of the bichloride,1 or
frictions with mercurial honey,2 or the ointment of the iodide should
be used.  They may also be sponged with a lotion composed  of
the solution of chloride of lime, and  afterwards  rubbed with an
ointment made of calomel, or calomel and opium.  Ricord  gives
one golden rule here, which, in attempting to resolve the tubercu-
lar syphilide, we should bear constantly in mind: that, as long as
inflammation exists, a local antiphlogistic treatment should be pur-
sued, whatever, according to the constitution of the patient, the
internal treatment may be.  The local applications above indicated
are only to  be employed in  a perfectly indolent condition of the
disease.
  In the ulcerated forms of tubercles, all that has been said on the
treatment of primary venereal sores may  be referred to with ad-
vantage, since these secondary ulcerations  require nearly the same
local treatment—the use of the nitrate of silver, the aromatic wine,
with astringents, sedatives, narcotics, or digestive ointments, or a
local antiphlogistic treatment, according to the aspect of the sore.
When caustics are indicated,  the surface of the ulcers may be
touched with the acid nitrate  of mercury: this is a favourite remedy
at St. Louis, and the  ulcers cicatrize rapidly under its application:
the separation  of the crusts  or eschars may be  facilitated by the
warm or mercurial vapour bath.
  The iodide of potassium, with decoctions of the woods, are ex-
cellent remedies during the ulcerated stages of tubercle: mercurials
also may be used in certain states, particularly if the primary dis-
ease have not been treated by mercury: the iodide,  the biniodide,
and the bichloride, with sarsaparilla and cinchona, are the best re-
medies.  The decoctions of Feltz or Zittman, the liquor arsenicalis,
or the arseniate of  soda, are also remedies  which, in particular
cases, may be employed with advantage.  If the disease do not
appear to amend under the use of one remedy, another should be
resorted to,  and in this manner it will sometimes  be found neces-
sary to try several before one is discovered suited to the constitu-
tion of the patient.   Sometimes the preparations of arsenic succeed
when all the rest have failed; occasionally one form of mercurial

              1 R. Decocti altheos officinalis, Oj;
                  Hydrargyri bichlorid., gr. xviij.  M.  (Biett.)
                       ' MERCURIAL HONEY.
               R. Hydrargyri chlorid., gj;
                  Mellis opt., ^j.  M. 
CONSTITUTIONAL ULCERS.
189
when another has  been unsuccessful.  There  are cases, happily
rare ones, in which all medicines appear useless: it is better, under
these circumstances, to omit them altogether for a time, to remove
the patient to a fresh atmosphere, to watch his general health care-
fully, and then again to resume the treatment, after the lapse of a
longer or shorter period.


               OF SYPHILITIC STAINS OF THE SKIN.1
   The various forms of syphilitic diseases of the skin which I have
just described, are frequently followed  or accompanied by altera-
tions of its colour, without any other pathological change.  These
stains are generally circular in form, and  either distinct, single,
and round, or placed in groups, or  clusters; or, again, consisting
of a mere mottled appearance.  They vary in colour, from a deep
brown  to a bright, or a dirty yellow, and  in  places the skin ap-
pears as though it had  not been washed clean.   These spots some-
times appear on the site  of previously existing diseases of the
skin, or on parts which have never been  affected.   They do not
disappear under pressure with the finger, they give rise to no ir-
ritation, and never ulcerate, or terminate in vesicle, papule, or pus-
tule; they consist simply in an alteration of the colour of the pig-
ment.  They commonly last for years, or  through the whole  of
life.  I have succeeded in curing some forms by the mercurial va-
pour bath, but I have seen others which have resisted all modes of
 treatment.  The general health is rarely disturbed in the majority
 of cases.

        OF CONSTITUTIONAL OR SECONDARY VENEREAL ULCERS.
   Secondary venereal ulcers are most commonly a consequence of
 other diseases of the skin, which have immediately preceded them:
 thus, the ruptured  vesicle, or pustule, or the softened tubercle, na-
 turally produces an ulcer:  there are, however, some rare forms of
 secondary ulceration which are not preceded by any of the diseases
 I have mentioned,  or, in fact, by any apparent disease.  The sites
 of primary sores not  unfrequently  become the seat of secondary
 ulcers, which appear long after the  healing of the primary sores,
 and which are doubtless due to a constitutional taint.  M. Cazenave
 mentions some very curious examples of this nature, where an ac-
1 Synonyms.  Maculae syphilitica—Taches. 
190
SECONDARY SYPHILIS.
cident, a wound, the application of a blister, or a relay of leeches,
have been succeeded by constitutional syphilitic ulcers, and where
no other evidence of a constitutional taint could be discovered.  Mr.
Paget, ("Lectures on Surgical Pathology," vol. 1, p. 492,) mentions
a case where a gentleman who, for not less than five years after a
syphilitic affection  of the testicle, had no sign of syphilis, except
that of general feeble health; but he accidentally struck  his nose
severely, and at once a well-marked syphilitic disease of its bones
ensued.   In another case, syphilitic  disease of the skull followed
an injury of the head.
  I have already alluded to the operation of this law of proximate
causes, in the development of secondary syphilis, when speaking
of the syphilidae generally. 
SYPHILITIC TUMOURS  OF THE  SKIN.         191
                      CHAPTER XIX.

  OF SYPHILITIC TUMOURS OF THE SKIN, AND THE SUBCUTANEOUS CEL-
                        LULAR TISSUE.1

  Isolated, hard swellings, varying in size from a horse bean to a
swan's egg, form on different parts of the skin  in the advanced
stages of many forms of constitutional  syphilis.  These swellings
are at first moveable, and the skin covering  them not  altered in
appearance.  In the advanced stages the tumour becomes adherent
to the integument covering it, which inflames and ulcerates in one
or more places, giving vent to the contents of the tumour, which
softens, and suppurates, discharges an offensive sanies, or quanti-
ties of brown or black sloughs:  the ulceration spreads  till the
whole skin covering the tumour is destroyed: we have then a deep
foul ulcer, filled with a black slough, and sometimes  an inch  or
two deep, the skin surrounding which is of a livid red colour, and
the edges ragged, everted and hard.
  These tumours, unlike the ordinary syphilitic tubercle, which in
many respects they very much  resemble, appear  rather to spring
from the subcutaneous cellular tissue, than from the skin itself; for
it is not till the more advanced periods of the disease that  the skin
is involved: they generally appear on the extremities.  I have seen
these tumours on the fore-arm, the external condyle of the hume-
rus, on the inner  part of the  leg, on the external hamstring, and
other parts of the upper and  lower limbs; they are rarely placed
on the face, or the  trunk, though occasionally met with in these
situations.   They may be confounded with the ordinary syphilitic
tubercle, or when occurring as an isolated symptom, (which they
rarely do,) with tumours arising from other  causes, or  even with
common,phlegmon, or chronic abscesses, particularly  those  of a
strumous character; the diagnosis in such cases is important, as

                      1 Tumeurs gommeuses. 
192
SECONDARY SYPHILIS.
the syphilitic tumour, when softening, or in that  stage which  re-
sembles a common abscess, should never be opened or punctured.
   The syphilitic tumour occurs late in the history of a syphilitic
taint, and generally many years after its primary cause: it has  ge-
nerally been  preceded, at no  long  period, by other symptoms
which render its nature certain.   It is also frequently associated
with pains, or diseases of the  bones, pustules, tubercles, or secon-
dary  venereal ulcers, which have succeeded to the detachment of
the crusts of ruptured pustules or ulcerated tubercles. In its ear-
lier  stages, the resolution of this  tumour  should always be  at-
tempted, and  this  may generally  be accomplished by appropri-
ate treatment, if the process of softening have not proceeded too
far.   If the tumour be seen in its  earlier stages,  before the skin
has become implicated, local treatment is of essential service: the
most efficient remedies are blisters, frequently repeated, and dressed
with mercurial ointment, or the compound iodine  ointment; next
in efficiency is  pressure by means of discutient plasters, composed of
belladonna, iodine, or mercury.  The Emplast. de Vigo, with mer-
cury,  also answers very well.   Some  writers have recommended
extirpation with the knife,1 an absurdity too great  to require a  se-
rious  refutation.  The  internal treatment  should  consist of the
administration of the iodides  of mercury, potass,  or iron,  either
alone or in a state of combination:  the mercurial vapour bath also
assists powerfully in  the  resolution of the  tumour; it should  be
used twice  or three times in the week.
   If the skin  covering the tumour has  become thin, and is of a
deep red or livid colour, we shall hardly succeed in dispersing the
tumour: in this diseased integument one or two  small spots of  ul-
ceration soon appear,  which spread  rapidly till the whole covering
of the tumour is destroyed.  When this is  the  case, we  have  to
deal with a secondary syphilitic ulcer, frequently of very formida-
ble character, which  has penetrated  sometimes to a  very great
depth in the soft parts, having destroyed the fascia, and laid bare
the muscles if situated on  the soft  parts of the extremities, or if
over bones, having  produced caries, necrosis, or  absorption of the
bony tissue to  a greater or less  depth.   In such-cases, the consti-
tutional treatment is still our chief reliance; but the local aspect
of the sore will  require a  treatment  suited to its varied  aspects:
should it become phagedenic, which it sometimes does, it must  be

                    1 See Vidal de Cassis, p. 446. 
             SYPHILITIC  TUMOURS  OF THE SKIN.         193

treated on the  principles laid down in the chapter on  that  sub-
ject.   Generally, after the surface  has become clean, black wash,
weak lotions of dilute nitric acid, or of creasote, in the proportion
of twenty minims to  the half-pint, answer very well, and better
than ointments, although  the latter are sometimes serviceable:1
these ulcerations require, from time to time, superficial cauteriza-
tion with the nitrate of silver, or the acid nitrate of mercury.

               1 R.  Unguent, hydrarg. nitratis. ^ss;
                    Ung. zinci, §iss.        M.        Or,
                R.  Ung. hyd. nit. oxyd., ^ss;
                    Ung. elemi, giss.       M.
13 
194
SECONDARY SYPHILIS.
                      CHAPTER XX.

    ON SYPHILITIC AFFECTIONS OF THE APPENDAGES OF THE SKIN.

     ALOPECIA.—LOSS OF THE HAIR FROM SYPHILITIC CAUSES.

  It not unfrequently happens, that whilst other symptoms of con-
stitutional syphilis are present in the system, the hair of the head
becomes thin and falls off rapidly, and so slight is its  adhesion  to
the scalp, that it comes off in large quantities when  the  hand  is
merely passed through it: this loss of hair is not confined to the
head, it affects the whiskers, the beard, the eye-brows, eye-lashes,
and even the hair on other parts.  The loss of hair rarely occurs
as an isolated symptom of constitutional syphilis; it has generally
been preceded, or is even accompanied by superficial ulceration,
or redness of the  fauces, or  pharynx, or those forms of skin dis-
ease which  are  seated in the  epidermis or  superficial layers  of
the dermis: it rarely accompanies tubercular or pustular affections.
Even when the hair does not fall off, patients  suffering from a con-
stitutional venereal  taint are subject to a constant formation  of
scurf on the  scalp, which is  doubtless due to syphilitic  disease:
cracks, fissures, and loss of the nails, considered in the next sec-
tion, are almost always associated with loss of the hair.
  I believe that when the hair comes off from causes which are
due  to  syphilis  alone, that  it is almost  always  restored under
an appropriate treatment.  The constitutional treatment required
for syphilitic alopecia is that which is-indicated for the other
symptoms with which it  may be  associated.  Local treatment is
here very important.  The best remedy for restoring the  hair
quickly, and preventing  its  becoming weak, is,  no  doubt,  sha-
ving the head, and repeating this operation  two or three times,
rubbing well into the scalp, at the same time, one of the prepara-
tions about  to be mentioned.  Pomades, containing various  pre-
parations of mercury,  or lotions or liniments with  cantharides,
are the chief remedies to be relied on in  the  restoration of the
hair lost from syphilitic causes. 
         LOSS OF HAIR FROM SYPHILITIC  CAUSES.      195
                R.  Hydrargyri iodidi, 3J ;
                    Adipis prep., giij. M. ft. unguent.

  A small portion to be well rubbed into the hair every night, and
washed out in the morning, dressing the hair, after washing, with
the following preparation:

                R.  01. morrhuse,
                    Tinct. cantharidis, aa ^j.  M.

or an ointment composed of one part of the Unguent. Hyd. Nit.
Oxyd. and three of scented  pomatum, (E. Wilson,) or the following
lotion to wash the head  with night and  morning:

                R.  01. morrhuae, gj;
                    Liq. ammonise, ^ss;
                    Tinct. cantharidis, ^ss;
                    Aquse mellis, 31J;
                    Spiritus Rosmarini, ^iv. M.

  The  mercurial  soaps  recommended  by Sir W. Marsh, and Dr.
Moore, of Dublin, will be found very serviceable to wash  the head
with in cases of syphilitic alopecia: they are made by beating up
a drachm of the white precipitate or red precipitate  of  mercury
with  an ounce of  Windsor  soap, adding a few drops of spirit, and
a little scent.
  Dr. Burgess speaks highly of.the vapours of iodine, or sulphur,
as superior to all other remedies in cases of alopecia not syphilitic.1
I have elsewhere shown that the vapour of the bisulphuret,  or iodide
of mercury, arrests syphilitic alopecia, after one or two applications.8

          1 On Eruptions of the Face,  Head, and Hands,  &c, p. 205.
          * On Secondary Syphilis, p. 26. 
196
SECONDARY SYPHILIS.
                      CHAPTER XXI.

           ONYXIS—SYPHILITIC DISEASES OF THE NAILS.

  The matrix or root of the nail, is very commonly affected with
syphilitic inflammation, under the influence of which the skin sur-
rounding this part becomes thickened and red, and ultimately ulce-
rates ; the sores thus produced having all the characters of secondary
syphilitic ulcers.  Sometimes the skin surrounding  the nail  conti-
nues red and everted,  and does  not ulcerate, but an offensive pus
oozes out from between the nail and the skin.   In other cases, the
nail alone is affected; it cracks or breaks easily, becomes thick and
opake, and loses  its transparency in whole or in  part; at  other
times the nail falls off without any appreciable inflammation of the
skin, or apparent alteration in the structure of the nail itself.
  Syphilitic diseases of  the  nails occasionally occur as isolated
symptoms of constitutional syphilis, and then their nature may be
mistaken, unless a strict  inquiry be made into the  nature of the
diseases from which the patient has suffered: when they accompany
other symptoms which  are decidedly due to syphilis, these are ge-
nerally superficial redness, or ulceration of the throat, alopecia, or
diseases of the superficial structures of the skin.  The  treatment
of onyxis is that of constitutional syphilis generally, of which it is
always a symptom.  Except in the ulcerated forms, local  treatment
has little or no influence  over the disease. 
WARTS,  EXCRESCENCES, ETC.
197
                     CHAPTER XXII.

   OF SYPHILITIC WARTS, EXCRESCENCES, VEGETATIONS, CONDYLO-
                          MATA, ETC.

  Vegetations, excrescences, or warts of varied form and appear-
ance upon the skin or edges of the mucous membranes, constitute
the last variety of syphilitic diseases of the skin.  These excres-
cences appear on the skin or muco-cutaneous surfaces of  the male
and female organs of generation, both in the primary and  secon-
dary forms of syphilis.  They are variable in appearance and con-
sistency, sometimes  resembling common warts on other parts of
the integument,  and at  others, presenting a surface  so fibrous, or
granulated, that they have  been  supposed to resemble the root of
the leek or the surface of the  raspberry.   These fungi, excres-
cences, warts,  or vegetations,  by  all which  names they are indis-
criminately known,  grow from the surfaces  of the skin in the im-
mediate  vicinity of the  organs of generation, or from the under
surface of  the prepuce,  and from the glans penis in the male; and
in the female  from the labia majora, the nymphae, or the entrance
of the vagina itself, which  they sometimes entirely surround.
  These warts or excrescences arise from several  causes.  In the
first instance, they are commonly  produced by the irritation excited
by the gonorrhoeal discharge on the common integument in the vi-
cinity of the  organs of  generation, and they are commonly pro-
duced by the same discharge  on  what are termed the muco-cuta-
neous surfaces of these  organs (by the  muco-cutaneous surfaces I
mean those where the skin and mucous membranes insensibly blend
into each other.)  On the pure mucous surface itself the warts are
rare, though  they may be sometimes found at  the orifice of the
urethra, or the entrance to  the vagina, which is sometimes studded
with a number of small, hard elevations, which are doubtless warts
in their  incipient state.  Warts, then, are caused, in the first in-
stance, by the irritation produced on the common integument, or
the muco-cutaneous surfaces of the organs  of generation, by the 
198
secondary syphilis.
irritation of  pure gonorrhoeal discharges.   They  are caused, se-
condly, by superficial forms of irritation, excoriation,  or ulcera-
tion of a venereal character, seated on the surfaces to which I have
just alluded.  These are most common in the male, and are situated
on the glans penis itself, more commonly round the corona glandis,
or on the under surface of the prepuce, these being properly muco-
cutaneous surfaces.
  In the third instance, they arise from the surfaces or primary
venereal sores themselves, from chancres or ulcers during the period
of cicatrization; and most  commonly this takes place when vene-
real ulcers are  treated on  the simple or non-mercurial  plan.  In
such cases, more particularly when the  patient is  suffered to fol-
low his customary avocations during the treatment of the primary
syphilitic sore,  the latter  heals slowly and with  difficulty, occa-
sionally remaining stationary for many days together, and show-
ing neither disposition to heal or spread, although its surface may
be covered with healthy granulations. In such cases, when the sore
does not close, instead of skinning over or cicatrizing in the usual
manner of an ordinary ulcer, the surface assumes a hardened cha-
racter, and begins to grow or throw up this hardened substance,
which ultimately assumes the aspect of a wart or vegetation.  In
this way is the third variety of venereal  excrescences  produced.
  All the varieties of warts that I have as yet described belong to
the different forms of  primary syphilis.  Vegetations  or warts,
however, are commonly met with  as symptoms of constitutional
syphilis, and  they are then termed  condylomata.  The  secondary
forms of syphilis, on some occasions, strongly resemble the primary
forms; and hence it is, that, although  the varieties of  which  we
have just spoken  are produced, like all the other forms of primary
syphilis, by  the  direct application of the venereal poison, they
present a striking resemblance to certain excrescences, or fungous
growths, commonly denominated  condylomata, which result from
the contamination of the system.   "However, with proper atten-
tion, primary condylomata  can easily be distinguished from secon-
dary condylomata; for  the latter are uniformly  accompanied or
preceded by other symptoms which point out constitutional dis-
ease, and particularly by a  very slight scaly or rubeoloid eruption,
either with or without a superficial affection of the mucous mem-
brane of the mouth and fauces."1
1 Wallace; pp. 388-9. 
                WARTS, EXCRESCENCES, ETC.             199

  The secondary condylomata are not always accompanied by af-
fections of the skin or throat, but " they appear as a distinct symp-
tom of constitutional syphilis in advanced periods of the disease."
It is of the first importance  to distinguish between these two va-
rieties:—viz. the primary and  constitutional,  since the treatment
suited to the one is not admissible in the other.  The first varieties
are generally purely local, and may be cured  by local means: the
second are constitutional, and require a general treatment for their
eradication.  In forming our judgment as to  their true character,
we must be guided by the history of the case, the preceding and ac-
companying symptoms, and the appearances of the disease itself.
" They are not so hard as primary warts;  they are more of a fleshy
nature, more tender, and more apt to  bleed.  They have a  more
uniform surface; and instead of being formed of a number of smaller
warts connected together, they are composed  of one uniform mass.
They do not approach so near the verge of the anus as  primary
watery excrescences generally do, being for the most part of the
greatest extent, and most elevated near the tuberosity of the ischium.
In some cases they become ulcerated, and discharge a great deal of
very offensive matter; for the most part, the ulceration which takes
place being superficial, and not reaching below the surface.  Like
the other symptoms of constitutional syphilis, these  excrescences
either continue in the same state, or become gradually worse, as
no remedy is employed constitutionally for the cure of the disease."1
  Venereal warts, excrescences, or condylomata, arise on  cutane-
ous, muco-cutaneous, or mucous surfaces, though more rarely on the
latter—
  1st. From the  irritation there produced by purely gonorrhoeal
discharges.
  2d.  From superficial ulceration or excoriation of a purely vene-
real character.
  3d. From the cicatrices of excavated ulcers.
  4th. As a symptom of constitutional or  secondary syphilis; the
first three kinds belonging to the different forms of primary sy-
philis.
  " Whatever  tends to  excite the flow of an  unusual quantity of
blood to the  penis, seems to create a disposition  in these  parts  to
the formation of warts.   Irritation produced on the prepuce and

  1 B. Bell; on Gonorrhoea Virulenta and Lues Venerea,  vol. ii., pp. 125—7.  The
secondary forms of condylomata are termed by the French writers mucous tubercles,
mucous papulae; they differ in nothing from the description I have already given,
except in the name. 
200
SECONDARY SYPHILIS.
 glans, as we have seen, by a variety of causes, disposes  the  small
 blood vessels of the part to  sprout or  pullulate, by which  these
 warty excrescences appear to be formed." (Bell, vol. i. p. 414.)
   "We have mentioned irritation as a cause of these excrescences,
 but it is only the slighter kinds of  it that seem to produce  them.
 They often succeed to a slight degree of inflammation, but  never
 form on parts highly inflamed: on the contrary, much inflammation
 destroys the tendency  in these parts to the formation of warts,
 insomuch that our most effectual  remedies in the cure of warts,
 and for preventing a return of them, are such as always excite a
 good deal of pain and inflammation." (Ibid., pp. 416, 417.)
   The  surface of these fungi or vegetations frequently  secretes a
 puriform discharge, and this discharge has a power of propagating
 a disease similar to that which produced it."
   In proof of this  assertion, I  shall bring forward a case which
 Sir A.  Cooper used to  relate in his lectures.  " A gentleman in
, Sussex was called to attend a lady in labour; he felt something in
 the vagina  which appeared  unintelligible,  and  on examination,
 found it to be a crop of warts.  He delivered her, but did not say
 anything about the warts to the lady.   In conversation with the
 husband, he told  him that his lady had a number of warts.  The
 gentleman stated, that  at the time he was married he had a wart
 on the  penis, and he had  no doubt that he had communicated them
 to his wife." (Cooper's Lectures, p. 497.)  This  case  shows that
 warts occasionally, though the circumstance is rare, spring from a
 purely  mucous surface; it proves also, beyond a doubt, their con-
 tagious character.
   It is asserted by some authors, though denied by others, that all
 the varieties of syphilis are infectious; and Dr. Wallace more par-
 ticularly asserts  that each has a  disposition to produce its like.
 "We have a remarkable proof of this assertion in the effects oc-
 casionally resulting from the application of matter secreted by
 these fungi;  for although they may have  been caused by poison de-
 rived from an excavated ulcer, their secretions, as we have seen,
 will most generally produce vegetations of their own kind." There
 can be  no question about the contagious character of the secretions
 from secondary condylomata, the mucous pustule  of the French
 writers; independent of daily observation, the experiments of Wal-
 lace, Vidal (de Cassis,)  Waller, and  many others, place the matter
 beyond a doubt.
   These warts, or primary excrescences, grow in many instances
 from the epidermis, their  attachment being so slight, that on being 
WARTS, EXCRESCENCES, ETC.            201
removed the cutis vera is left entire.  In other cases they proceed
from the skin itself; they have not been observed to go deeper than
this.  Hunter seemed to  entertain the idea, that generally they
are produced from the surface of the cutis vera.  This corresponds
pretty much with the opinion of Dr. Wallace, who  believes that
these vegetations have sometimes their origin in the papillary body
covering the cutis vera, and sometimes in the rete mucosum itself.
   We now come to speak of the treatment of vegetations; and here
it will be necessary to  recollect what has  been  said with  regard
to the divisions of these affections into the  primary and secondary
forms.  The primary forms, being generally purely local diseases,
are in most instances to be removed  by a  treatment purely local;
the secondary, resulting from a poisoned or infected constitution,
as generally require a constitutional or general treatment for their
cure.
   The primary forms of warty venereal excrescences are generally
to be cured without great difficulty by local applications or means,
either by the knife  or  the application  of  escharotic or irritating
remedies.  Hunter says, " They are so little of the true animal, and
so much of the disease,  that many trifling circumstances will make
them decay: an inflammation in the natural and  sound parts round
the wart will give it a disposition to decay; many stimuli applied
to the surface will often make them die.  Electricity will produce
action in them which they are unable to support; an inflammation
is excited round them, and they drop off."  These are the principles
which are to guide us in the treatment of  these forms of disease;
the application of remedies which, producing irritation and inflam-
mation  in the surrounding integument, dispose the wart, in which
the vital actions are very feeble, to drop off. The knife or ligature
may be resorted to where the  apex of  the wart is  large, and the
base  pedunculated or narrow.   Where the base is broad, and its
attachments to the skin extensive, it is better to  trust to the reme-
dies  already mentioned, which we shall presently pass in review
more particularly*  Hunter mentions as escharotic remedies the
nitrate of silver and the sulphate of copper;  as stimulants, a mixture
of equal parts of  the acetate of copper and the powder of savine
leaves.   When the  knife or ligature is used,  it  is always  advisa-
ble to touch the cut surface with some caustic.
   In the more ordinary cases these excrescences may generally be
removed by bathing them and the contiguous parts, several times a
day, with a strong solution of the muriate of ammonia or the bichlo- 
202
SECONDARY SYPHILIS.
ride of mercury.1 With these applications the warts may be sponged
freely several times a day, till as much irritation and inflammation
are excited in the surrounding parts as the patient can reasonably
bear.  In mild and recent cases these remedies will generally ac-
complish a cure.  When the surfaces of the warts are hard, if they
are of long  standing, or do not yield to the remedies already men-
tioned, it becomes necessary to employ escharotics and irritants of
a more powerful character.  When such are used, the parts " should
be merely moistened with a pencil dipped in them, nor should this
be repeated above once in two or three days."  Amongst  these
stronger preparations are the acid nitrate of mercury, the tincture
of cantharides, and  the liquor potassa? arsenitis.  Arsenie was a
favourite remedy with Sir A. Cooper in the destruction of warts.
He employed an ointment composed of one drachm of the oxide of
arsenic (arsenious acid) to one ounce of spermaceti ointment or lard,
the surface  of the warts to be smeared  with it frequently, accord-
ing to circumstances.  Powders which, when dusted over the warts
and  integument in their neighbourhood, irritate and inflame the
latter, are  generally more efficacious than  solutions  of  the  same
substances.   Amongst these may be mentioned equal parts of the
savine powder and chloride of mercury, savine leaves powdered,
and corrosive sublimate, and the hydrargyri nitrico-oxydum.*   We
may also use for this purpose  equal parts of the dried or burnt
alum, and the nitric oxide of mercury.   "After  these warts  have
been removed, by local irritants or by the knife, it will be necessary
to use some  astringent lotion, to  restore tone  to the capillaries of
the diseased surfaces, and to remove any excoriation or catarrh
which may have coexisted with the fungous growths."  (Wallace,
p. 337.)  Strong acetic acid, or the undiluted  Liquor Plumbi, are
both excellent applications to many of the primary forms of warts,
especially those  which form round the  orifice of the vagina, as a
consequence of protracted gonorrhoeal  discharges.   I have  seen
large masses of these warts disappear in  two or three weeks by the

               1 R.  Ammoniae hydrochlor.,
                     Aceti destill.,
                     Aquae, aa !|ij.  M.
                 R.  Hydrarg. bichloridi, Jss;
                     Sp. Vini, l);
                     Aquae, ^iij.  M.
               2 R.  Pulv. sabinae,
                     Hyd.  bichloridi,
                     Hyd. nit. oxydi, aa gj.  M. 
               WARTS, EXCRESCENCES, ETC.            203

use of the latter remedy, which is exceedingly convenient, as it
occasions  little or no pain; the skin  generally remains for some
time of a  deep red in the places where  these warts have been si-
tuated.
  We may now inquire whether these vegetations, which  are the
consequence, as we have  seen, of some forms of purely syphilitic
diseases, require mercury for their cure, or for the prevention of
their return, since in many instances they are very liable to do so.
Mercury is unquestionably not required for the removal of  the first
form of venereal warts which are  produced by the  irritation of
gonorrhoeal discharges.   Nor do we conceive it can  ever be re-
quired for the cure and prevention of the second variety, which we
have stated to be the result of venereal excoriations.  In the treat-
ment of the third variety it is possible that mercury may be occa-
sionally required.  The  last form of vegetation, which  springs
from the  surface of the excavated ulcer, rarely occurs where mer-
cury has in  the first instance  been judiciously used for the cure of
the  primary ulcer. We must bear in mind, then, that a primary
venereal  ulcer for which  mercury is judiciously employed, is less
likely "to heal into a wart"  than when such  remedy has not been
employed.
   In ordinary and long-standing cases of vegetations which  are
the result of venereal sores, mercury will not be required, and we
must,  in  most instances, trust to local remedies  only.   Hunter
and Bell  express themselves  strongly on this point.   " These ex-
crescences (says the former) are considered by many not as simply
a consequence of the venereal poison, but as possessed of its spe-
cific  disposition,  and, therefore, they have  recourse to^ mercury
for the cure of them; and it  is asserted that  such treatment often
removes them.  Such an effect of mercury 1 have never seen, al-
though given  in such quantities as to cure in the same person re-
cent chancres."
   The latter  says, "The warts which  succeed to chancres com-
monly remain equally firm and obstinate  after mercury has been
given as  they were before, and are to be removed by the same
means as  if the constitution had  never  been diseased.  This is a
point  which, in  a particular manner, merits attention, for whilst
the opinion is retained of warts on these parts being, in most in-
stances, connected with a constitutional syphilis, much mischief is
apt to be  done by a great deal of mercury being given where  no
advantage can ever ensue from it.  In the  treatment of warts I 
204
SECONDARY SYPHILIS.
 have known the constitution almost ruined  by one course of mer-
 cury after another, without any effect upon the excrescences, which
 were afterwards easily and  speedily removed by remedies applied
 directly to the parts themselves."
   In the very recent state, where they spring from the surface of
 an ulcer which has been treated  without  mercury, they may, in
 some cases, be removed by  the administration of this medicine in
 the usual way in which it is employed for the cure of chancres ge-
 nerally; but this, unquestionably, should not be done till local re-
 medies have been fully tried, and found to fail.  In the very re-
 cent state, then,  of fungi springing from  the  surface of ulcers
 treated without mercury, this remedy may and should be employed
 if local  means fail.  If,  again, warts have  been removed by the
 knife, a plan certainly not generally to be recommended, and the
 cut surface  run into a  foul intractable sore, mercury may be  em-
 ployed for the treatment of such sore, which is, in all probability,
 specific.  In all other instances of primary warts mercury must be
 abstained from, since not the least probable benefit is to be ex-
 pected from its employ.
   The treatment of the secondary forms of  venereal excrescences
 is to be conducted on principles totally different from those which
 guided us in the management of the primary forms.   Here local
 treatment is comparatively of little use, and constitutional or ge-
 neral treatment is most to be depended on.   When, then, we  are
 fully satisfied, from the history of the patient, the appearance of
 the disease itself, and the preceding or accompanying symptoms,
 that we are  called to treat a case of this nature, if  there exist  no
 special contra-indications in the constitution or state of the patient
 at the time he is presented  to us, we should lose no time in sub-
mitting him to a mercurial course under the rules which ought ge-
 nerally to guide us in the administration of  this drug.  The mer-
curial vapour-bath may be  employed with great benefit, and the
condylomata touched with Plenck's solution.1

               1 R. Alcoholis,
                    Acidi acetici, aa ^ss;
                    Hyd. bichloridi,
                    Aluminis,
                    Camphorw,
                    Plumbi carbonatis, aa £ss.
  M.  Verrucce aut condylomata penieillo hoc liquore madido semel vel bis de die
       tangantur. 
ULCERATIONS  OF MUCOUS MEMBRANES.      205
                      CHAPTER XXIIL

    CONSTITUTIONAL OR SECONDARY SYPHILITIC ULCERATIONS OF
                      MUCOUS MEMBRANES.

  Secondary or constitutional  syphilitic ulcerations of mucous
membranes are extremely common.  They may be seated in all
parts of the mouth, upon the tonsils, on the posterior part of the
pharynx, in all parts of the nasal fossae, at the orifice of the glottis,
and even in the larynx itself.
  The  mouth  is frequently the  seat of  superficial ulcerations,
sometimes  placed upon the tongue, the pillars of the fauces, the
inner surface of the lips, or other parts.  Occasionally these ul-
cerations resemble ordinary aphthae;  again there is a distinct loss
of substance surrounded  by an inflamed margin, and, at other
times, it appears as though a pencil dipped in a strong  solution
of nitrate of silver had been drawn over the tongue.  These ul-
cerations  generally, if not always, occur  in  persons  who  have
taken mercury  for the cure of some venereal symptom.  They
are not  under the control of  any specific treatment, but generally
improve under a regulated diet, general treatment, and frequent
gargles, more particularly those in which tannin forms an ingre-
dient. l  In most instances they are extremely difficult to cure; and
are very frequently rendered worse by mercury.  These aphthous,
or superficial  ulcerations  in the mouths of patients who have suf-
fered long under a venereal taint, and have irritable mucous mem-
branes,  are generally due  to mercury and not to syphilis.   It is
remarkable that such patients suffer much also from dyspepsia.  It
almost  invariably happens that mercurial  medicines  given  inter-

                ' R.  Tannin, 7)j ;
                     Spiritus vini Gallici, gij ;
                     Aqua rosa, ^vj.  M. ft. gargarisma.
                 R.  Tincturae myrrh, ^j ;
                     Mellis cuprati, gss.  M.
        The ulcers to be touched with this liniment night and morning. 
206
SECONDARY SYPHILIS.
nally aggravate these conditions of the mouth, whilst they subside
under the use of mild astringents and tonic gargles,1 the adminis-
tration of small doses of conium and opium, and the cold infusion
of sarsaparilla  in  lime wrater.2  Where  such conditions of  the
mouth are associated with  other symptoms of constitutional sy-
philis, they may still have a mercurial origin: should the general
means we have mentioned fail  in  benefiting them, the  mercurial
fume applied locally, or the  mercurial vapour-bath, may be used.
  The syphilitic ulcers of the throat, pharynx, and fauces appear
under several forms.
  1st. The deep excavated  ulcer of the  tonsil, covered with an
ash-coloured slough, and surrounded by a deep, livid, red condi-
tion of  the  mucous membrane.   This  ulcer, though  generally
seated between the pillars of the fauces, is sometimes seen on the
uvula.  This is the true venereal  sore throat of Hunter, and En-
glish surgeons generally; and, unless the remedy be specially con-
tra-indicated, requires a mercurial course  for its cure. It  may oc-
cur with other  symptoms of constitutional syphilis, and very fre-
quently is  found to be associated with persistent induration of the
cicatrix of a recently-healed chancre.3
  2d. Creeping superficial ulcers, found on the uvula, fauces, and
pharynx.
  3d. Sloughing ulcers extending rapidly down the fauces, covered
with white tenacious sloughs.   These may extend over  the whole
of the«pharynx; they resemble precisely phagedena in other parts.
  4th. Deep, livid redness of the arch of the palate, fauces, and
throat, occurring with various forms of the syphilida, or  soon after
the healing of a primary sore.   These ulcers, &c. may occur with
or without different forms of cutaneous eruption, pains in the head
and limbs, loss of hair,  and other forms of constitutional infection:
also with the most varied conditions of the general  health.  One
kind of  ulcer of the soft palate is generally situated immediately

                1 R. Acid, hydrochloric, TTj^ xl.—gj;
                     Tinct. cinchonae, ^j;
                     Aquse fontanse, ^vij.  M. ft. garg.
                3 R. Rad. Sarsae, |iv;
                     Rad. glycirrhizae, ^j;
                     Liq. calcis,  Oij.  M.
        Macera per horas xxiv. deinde capeat cochlear, iv. larg. bis die.
  3  This ulcer, which has been termed "amygdaline chancre," has been inoculated
with success.  The details of the case may be found  in the 'Annales des Maladies
de la Peau, et de la Syphilis;' it is also quoted by'Vidal de Cassis, p. 404. 
           ULCERATIONS OF  MUCOUS MEMBRANES.      207

 under the posterior nares: by passing the finger into  the  mouth,
 it will be perceived at once where the hard palate terminates and
 where the velum commences; the length of the latter, which is va-
 riable, will also be at once ascertained:  it is this part of the throat
 which is most commonly perforated  by secondary venereal ulcers,
 which are commonly due to disease concealed in the  passages of
 the nose: there is redness in this place some days before perfora-
 tion takes place, and this, being unaccompanied  by that dryness
 which accompanies ordinary syphilitic inflammation of the fauces,
 is not under ordinary circumstances noticed by the patient.
   Patients who  have  suffered from constitutional  syphilis, fre-
 quently complain of  pains in the throat, increased  by deglutition,
 and referred to various points about the larynx and pharynx: the
 parts which  are the seats of these pains have previously been af-
 fected by ulceus, or inflammation^ but although the  ulcers had
 healed, the pains remained. I have' frequently been unable to de-
 tect any lesion in parts thus affected, and have been led to regard
 many of these cases as pure syphilitic " neuroses."
   The treatment of the venereal ulcers of the throat resolves itself
 into local and constitutional.   To the first variety local treatment
 is hardly beneficial, and against it, unless specially contra-indicated,
 as I have already said, a mercurial course  should  be directed, the
 best mode being by inunction, employing at the same time the mer-
 curial vapour-bath.
   Local treatment of all the other forms is very important.   The
 ulcers should from time to time be touched  with one of the caustics
 already recommended in the treatment of the primary ulcer;  such
 as the nitrate of silver, the acid nitrate of mercury,  the muriatic,
 or nitric  acid.1   In the intervals of these  applications gargles of
 various kinds are very useful.   I»have found the oxymel  seruginis
 one of the best of these!3 With  this local treatment should be
 associated whatever constitutional treatment the nature of the case
 may point out, and here so various are  the conditions that  it  is
 impossible to lay down any fixed rules.   Should mercury be used,

  1  Liquid caustics, such as the nitric acid, or acid nitrate of mercury, should be
employed with great caution in  extensive ulcerations of the fauces, soft palate, or
pharynx.  When used, the material should never be so wet as to risk a drop of fluid
falling into the  oesophagus, or pharynx; the fumes should also be suffered to pass
off before the remedy is applied.
  ' R.  Oxymel aeruginis, 25ij;
       Aquae  fontanse, ^vj.  M. ft. gargarisma. 
208                SECONDARY SYPHILIS.
and how?  This will depend upon the nature of the primary sore;
upon the state of  the cicatrix; the form of the cutaneous eruption,
if any be present;  condition of the general health; and the pre-
vious treatment.  Should there  be  a scaly eruption, an indurated
cicatrix, and tolerably good health, mercury may be fully employed
with a reasonable hope of success, according *to the general prin-
ciples inculcated in this work.  It may also  be employed as an al-
terative, under the form of the iodide, or biniodide, should its full
employ be contra-indicated, and other treatments fail.
   I would mention  as remedies likely to be of service;—the mer-
curial vapour-bath, the cold infusion of sarsaparilla in lime water,
and full doses of  opium; with the mineral acids, guaiacum, or the
hydriodate of potass. 
SYPHILITIC  DISEASES  OF THE NOSTRILS.      209
                     CHAPTER XXIV.

    OF SYPHILITIC DISEASES OF THE NOSTRILS AND NASAL FOSS.E.

  Primary venereal sores may unquestionably be produced in the
nostrils  by the direct application of the virus: these instances are,
however, rare, and must be the result of accidental inoculation by
means of the instruments, sponges, or linen used to cleanse sores
on  other parts.  Secondary ulcerations are frequent.  They are
seated sometimes on the septum nasi; and frequently perforate the
cartilage,  but most commonly these secondary ulcerations affect
the mucous membrane of the superior, or aethmoidal spongy bones.
Constitutional or secondary syphilitic affections of the nostrils are
by no means uncommon.  They generally appear under one of the
following forms.  In the first they are characterized by chronic
inflammation of  the pituitary membrane, with an alteration in the
character of its  secretions, the latter being offensive, profuse, and
commonly tinged with blood.  In the second form, we find ulcera-
tions of varied  character and appearance; and again, discharges
of vast  quantities of hard, discoloured, and offensive crusts, seem-
ingly of dried mucus, without any alteration in the appearance of
the mucous membrane of the nostrils, at least so far as this can be
seen, though these discharges may probably depend on chronic in-
flammation of the membrane  lining the upper meati of the nose.
In the latter form there is also a marked alteration in the charac-
ter of the voice.
  These diseases often commence with  the symptoms of ordinary
cold;  the  nose is dry and  uncomfortable, and  the voice slightly
hoarse:  the symptoms, however, do  not yield  to ordinary treat-
ment, and to this dryness ultimately succeeds  discharge of fetid
muco-pus,  and blood, and hard crusts of inspissated mucus, some-
times mixed with small  portions of bone.  An ordinary syphilitic
ostitis, or  periostitis, affects the  ossa-nasi, by which  they are fre-
quently thickened to a considerable extent.   I  have seen one or
two cases of this character.   The secondary syphilitic  diseases
      14 
210                SECONDARY SYPHILIS.
which affect the nose are, however, most frequent in its interior,
and affect the lateral  or central cartilages, the spongy bones, or
the membrane covering these parts.
  These diseases of the nasal fossae very commonly occur  as iso-
lated symptoms of secondary syphilis, and under  such circum-
stances, without a correct history of the case, their  nature  might
be mistaken.
  Their treatment is constitutional and local.   The former is that
of secondary syphilis generally, and in these affections the iodides
of mercury are singularly serviceable.  The local treatment con-
sists of  the vapour of the iodide, or bisulphuret of mercury,  di-
rected by a very simple process  into the nasal fossae, for a few mi-
nutes daily;  injections of calomel and lime water; the bichloride
and lime water, or weak solutions of creasote.
  The nasa-lacrymal canal is frequently obliterated by secondary
syphilitic diseases of the nasal fossae. 
SYPHILITIC AFFECTIONS OF THE  TONGUE.      211
                      CHAPTER XXV.

      OF SECONDARY SYPHILITIC AFFECTIONS OF THE TONGUE.

  The diseases which affect the tongue, during the presence of a
venereal taint in the system, are due to three causes:
  1. The use of the iodide of potassium;
  2. The exhibition of mercury; and
  3. To syphilis itself.
  The general symptoms of these affections of  the tongue are in-
creased vascularity and redness, tenderness; ulceration, superficial
or deep; enlargement, a nodulated or uneven condition of its  sur-
face, fissures, cracks, and vegetations.
  There is no doubt but that, in certain cases, iodine does produce
a disease in the tongue, characterized by many of the symptoms I
have  mentioned.   I have elsewhere recorded some  cases of  this
nature.1  A surgeon consulted me for a skin disease of suspicious
character, for which he had attempted to take the iodide of potass;
"but," said  he, "whenever"I use this medicine for two or three
days, solid lumps, like venereal tubercles, make their appearance
on  the skin and on the tongue, and the latter organ  becomes so
large and painful, that I am obliged to give the remedy up."  Such
is an acute condition produced by iodine, which  subsides when the
drug  is discontinued; but, in the more chronic forms, where the
mischief has been slowly produced, the disease in the tongue re-
mains even when the  medicine is used no longer.
  Mercurial and  venereal  diseases  of the tongue are frequently
confounded with each other, and great discrimination and experi-
ence, with the most accurate history of the case, and of the effects
of remedies, are necessary to enable  us to determine the exact na-
ture of these affections.  A gentleman who  had suffered  from va-
rious forms of constitutional syphilis for five years, was sent to me
for my opinion as to the nature of a disease in  his tongue, which
had been in existence for two years, and had resisted the ordinary
1 Provincial Medical and Surgical Journal, No. 3, 1852. 
212
SECONDARY SYPHILIS.
means of cure.  The organ was large, and could not be retained with-
in the teeth.   The saliva was continually running over the chin;
it was exceedingly tender to  the touch, crumbs of bread  and the
mastication of solid food occasioning severe pain.  The centre of
the tongue was hard and nodulated, and there existed also in the
centre, a deep, foul ulcer, extending through a great part of the
substance of the tongue.  On  either side of the tongue were small
fungoid growths,  resembling  small ripe  strawberries.  In other
respects the health was good, and there was no symptom of secon-
dary syphilis present, except  some coppery macular stains  on the
shoulder and abdomen.  This patient had taken large quantities of
the iodide of potassium for three years, so much, said he,  that my
perspiration stained my linen  brown: he had also used mercury by
the mouth: the latter remedy  always increased the mischief in the
tongue.  In this case,  it required some care to determine  whether
the disease were due  to mercury, syphilis, or iodine; and in such
cases it is exceedingly difficult to form a  correct opinion, particu-
larly where mercury internally disagrees with the patient.
  The disease was syphilitic,  and was ultimately completely cured
by the moist mercurial fume, used daily till the gums were sore.
  Aphthous spots and superficial ulcerations on the tongues of pa-
tients who have taken mercury internally, and who are still suffer-
ing from venereal taint, are due in many instances to mercury, and
not to syphilis.   It is remarkable, that such patients suffer much
from  dyspepsia.   It  almost  invariably  happens,  that mercurial
medicines in any form, given internally, aggravate these conditions
of the tongue, while they subside under the use of mild astringent
gargles, and the administration of small doses of the extracts of co-
nium or opium.  When they coincide with a well-marked  venereal
disease, they may still be due to  mercury, and mercury  given in
any form internally is, in such states, contra-indicated.  A patient
under  my care for syphilitic lepra, for which he was using the
mercurial vapour, and taking three grains of blue pill every night,
began  to complain of his tongue, although  the gums were  hardly
affected.  The organ  became large, tender, and covered with aph-
thous patches.  A large induration appeared on  the back  of the
tongue, which ulcerated, and ended in a deep, foul ulcer, with sur-
rounding  induration.   These symptoms increased, while the scaly
disease of the skin disappeared.   This had  happened twice before
when the patient had taken mercury.
   The mercurial tongue may be confounded with the syphilitic one, 
         SYPHILITIC  AFFECTIONS OF THE TONGUE.      213

if the history of particular symptoms and the effects of remedies
upon them be not carefully noted and watched.  Thus, we see, that
the remedy which cured  the  lepra  produced the disease in the
tongue.  Mercury, in some cases, fixes on the tongue, while it but
slightly affects the gums.   Acute mercurial glossitis is hardly to
be mistaken, as it directly succeeds to the use of  the remedy, and
subsides, though slowly, when this is discontinued: in such  cases
the tongue is large and patchy; red in some places, white in others,
very much resembling the appearance of the glans penis in  acute
balanitis.   The chronic forms of mercurial disease in  the tongue
are much more difficult to distinguish.
  Where chronic mercurial glossitis occurs in patients who have
long laboured under a venereal taint, it becomes a matter of some
difficulty to determine whether the mischief in the tongue  is due
to mercury or syphilis; and sometimes the effects of treatment only
will set us right on  this point.   I have  been consulted in several
cases by patients who have laboured under such conditions of tongue
for more than twenty years:—"A surgeon, aged 47, consulted me
for an  old venereal complaint of twenty-four years' standing, of
which the more prominent features  at the time  of his visit were
patches of psoriasis on the hands and other  parts, sarcocele of the
right testis, and tubercles, with fissures in the tongue. He had been
salivated several times, and taken large doses of the iodide for long
periods; but the ultimate effects of treatment showed that the con-
dition of the tongue was venereal."
   The symptoms which are most characteristic of the true venereal
tongue are vegetations, deep fissures or cracks, ulcers, and tubercles.
The vegetations of a syphilitic nature which occur on the tongue,
occupy its sides or its surface, are vividly red, and resemble a very
small ripe  strawberry.  I believe these never occur but from sy-
philis: they are met with  alone, or in conjunction with fissures, tu-
bercles, or ulcers; they come on early after the  disappearance of
other symptoms of  syphilis, or are associated with them, whether
mercury or iodine have been employed or not.
   The deep fissure, or  crack in the  tongue, is also commonly due
to syphilis: the tongue sometimes appears as though it had been cut
with a knife: the venereal ulcer of the  tongue is most frequently
long and sinuous: we  are obliged to unfold the organ, as it were,
to see the bottom of it; and its sides, unlike the common fissure, are
more or less indurated.  The venereal  tubercle appearing in the
tongue, is a hard, solid body, occurring alone, or  with some of the 
214                SECONDARY SYPHILIS.
other symptoms I have  mentioned:  it generally comes on late in
the history of a venereal taint, and sometimes long after the disap-
pearance of every other venereal symptom: it resembles very much
the state of tongue produced by the iodide of potassium, and may
certainly be confounded with incipient scirrhus of the tongue.
  Some discrimination is necessary to enable us to determine the
nature of the disease correctly, and consequently, to frame  an  ap-
propriate plan of treatment.  To enable us to do this, attention to
the following points is important:
  1. The condition of the general health.
  2. The nature of any concomitant disease, whether venereal or
not; and whether the patient has at any and  at what time suffered
from constitutional syphilis; under what forms, and how it has been
treated.
  3. Whether mercury  or iodine have been taken for the disease
in the tongue, and with what effect upon it.
  4. The condition of the submaxillary lymphatic glands.
  5. Whether the patient have worked at any occupation in which
the fumes of mercury are employed.
  A careful  inquiry, based on these  suggestions, will most fre-
quently enable us to ascertain the actual nature of the  disease, and
thus to treat it properly.
  If an affection of  the tongue, of the  nature of which we  are
doubtful, be aggravated by mercury internally administered, it is
generally benefited by opium, conium, sarsaparilla and lime-water,
with gargles of tannic acid, brandy and water, or the oxymel aaru-
ginis: should these fail,  the mercurial  fume,  used  locally or gene-
rally, is commonly successful. 
SYPHILITIC ULCERATION OF  THE  LARYNX.     215
                     CHAPTER XXVI.

           OF SYPHILITIC ULCERATION OF THE LARYNX.

  One of the most  formidable varieties of constitutional syphilis
is ulceration of the mucous  membrane of the  glottis, and larynx.
Of  this form of disease I have unhappily seen several examples;
and modern writers on venereal diseases,  more particularly Mr.
Carmichael  and M. Cazenave, have  reported  others.  Syphilitic
ulceration of the  larynx generally follows or  accompanies other
similar diseases of  the nasal fossae, throat,  or pharynx, or various
forms of the syphilida:  it does not commonly occur as a solitary
symptom of constitutional syphilis, and  consequently we are the
less likely to be deceived as to its true character.
  The symptoms are an alteration in the character of the voice:
it becomes hoarse, husky, or totally lost;  the patient expectorates
a fetid pus, and portions of slough mixed with blood; the thyroid
cartilage is sometimes enlarged, and there is considerable tender-
ness when the larynx is examined with the fingers.  In this  con-
dition the patient is generally much emaciated, and night perspira-
tions are present.  These  symptoms closely resemble  those of la-
ryngeal phthisis, and even ordinary phthisis pulmonalis:  from the
former disease syphilitic ulceration of  the  larynx  is to be distin-
guished by  the  precedence of primary, or other constitutional
symptoms of syphilis, or by the  co-existence of the  latter.   The
stethoscope will hardly suffer us to mistake this disease for  ordi*
nary pulmonary consumption: indeed  the almost invariable  exis-
tence of other, forms of constitutional  syphilis with  ulceration of
the larynx,  will, in most instances, clear up any doubt as to the
true nature of the latter.                •

                         Case XXII.
  j. M'K— was  admitted  under my care first as a home,  and
afterwards as an in-patient, of the  Queen's Hospital.   He  had
been suffering for two  years from a chronic  pustulo-crustaceous 
216
SECONDARY SYPHILIS.
disease of the skin, and a large ulcer in a sloughy condition occu-
pied the whole of the pharynx.  He was much emaciated, had
constant cough, expectorated an offensive bloody muco-pus, and
could not speak above a whisper.  Auscultation  detected  no dis-
ease of the lungs.  The constitutional symptoms of syphilis had
been preceded by chancres of the glans penis and  urethra, the
latter of which were not healed.  He underwent a variety of treat-
ment with little benefit, and ultimately died of extreme exhaustion.
The inner surface of the larynx was destroyed for a great extent
by an ulcer, precisely resembling that which occupied the pharynx,
and a series of creeping ulcers  extended down the urethra nearly
to the neck of the bladder.

  M. Cazenave has recorded some cases of syphilitic ulceration of
the larynx cured by the iodide of mercury: in all the  cases that I
have seen I  have found the disease difficult to manage, and  very
frequently fatal.  Mr.  Carmichael has experienced the same diffi-
culty, and has proposed to lessen it by performing tracheotomy.
" If the ulcer is in the larynx, there can be little hope of inducing
it to heal, on account of the constant current of  air through this
passage, and  the frequent motion  to which it is  subjected, as the
chief organ of voice.   I have, however, in many  instances, passed
into it with  decided  advantage, a long  bent probe, or metallic
bougie,  covered with lint, moistened in a solution of nitrate of sil-
ver, of from six to ten  grains to  the  ounce of  distilled water.  In
the act of passing the bougie, thus armed, into the larynx,  the pa-
tient should be desired to project the tongue as far as possible  from
the mouth, which prevents the epiglottis from closing the aperture
of the larynx; but in  the great majority  of cases, I must  confess
that nothing  more  than mere temporary alleviation was obtained
by this or any other measure I have seen tried, with the exception
of tracheotomy.  The  other measures to which I allude, are  mer-
curial fumigations, mercury internally exhibited, and blisters, moxa,
tartar-emetic ointment, caustic issues, and setons to the  integuments
covering the larynx."1

  1 Carmichael's Clinical Lectures on Venereal Diseases, pp. 141—2; Dublin, 1842 
SYPHILITIC  TESTICLE.                217
                     CHAPTER XXVII.

                  ON THE SYPHILITIC TESTICLE.

  The syphilitic testicle is a totally different disease to that which
I have already described under  the name of "consecutive gonor-
rhoeal orchitis."  The diseases are different in  their nature, their
symptoms, their pathology; and  they require also different reme-
dies for their cure.  This affection  is commonly called syphilitic
sarcocele, and also the syphilitic or venereal testicle.
  Symptoms.  Diagnosis.—When a gradual enlargement of the
testicle comes on without pain  in individuals who  have suffered
from a well-marked constitutional syphilitic taint,  however long
such symptoms may have  disappeared,  and whether any other
symptom of secondary syphilis be present or not, there is  reason
to suspect that the disease in the testis may be of a  syphilitic cha-
racter.  This enlargement takes place gradually, without pain in
the part, and without pain in the  back or loins.  When it is handled
there is little or no tenderness present, unless the organ be firmly
pressed.   The tumour is smooth and heavy, occasionally, however,
lobulated or uneven on its surface, and in its more advanced stages
no trace of the epididymis can be felt, and the spermatic chord ap-
pears quite  free from disease.   There are many other diseases of
the testis with which the  syphilitic testicle may be confounded, and
from these it is of the first importance to distinguish it, since in a
majority of  cases this disease  is very amenable to treatment, and
the records of surgery show that many testicles have been removed
under  the suspicion of their being cancerous, which were, in fact,
nothing more than ordinary syphilitic sarcocele, occurring as an
isolated symptom of secondary syphilis long after any other mani-
festation of this disease.   The diseases with which  syphilitic sar-
cocele  may be confounded, are: 1.  Chronic inflammation  and  en-
largement of the testes from causes which are  not  syphilitic.   2.
Scrofulous enlargement of the testes.  3. Scirrhus  of the  testes;
and chronic consecutive gonorrhoeal orchitis.   I think it is hardly 
218
SECONDARY syphilis.
 possible to confound this disease with either hydrocele or haemato-
 cele.
   Whenever gradual enlargement of the testes takes place with-
 out any evident cause, and  under the  circumstances already men-
 tioned, and the patient has previously suffered from symptoms of
 constitutional syphilis, there is great reason to believe the disease
 syphilitic, and such a supposition should always be  acted upon be-
 fore any more active measures be resorted to, particularly those
 which have relation to any operative procedure.   In  the  more
 acute forms of consecutive gonorrhoeal orchitis, the testicle is red,
 shining, and intensely tender and painful; in the syphilitic sarco-
 cele, the tumour is indolent from the commencement, is  not  pain-
 ful, and  is not tender  even when hardly pressed.   In  the  more
 chronic forms of consecutive gonorrhoeal orchitis, there may be no
 tenderness or pain, but the tumour is not heavy or smooth, like
 syphilitic sarcocele, and the epididymis, to which the enlargement
 in the former  case is chiefly confined,  may be distinguished  sepa-
 rately from the body of the testis itself.
   With the scrofulous  testis, and simple chronic enlargement of
 the testis, syphilitic sarcocele  may be confounded, without great
 care in the analysis of the history of the case.   The  effects of
 treatment, however, will frequently clear up doubts when any exist
 on this point.
  "Though a  late symptom." says Mr.Hamilton,1 "yet between it
 and the primary affection there is generally a chain of connexion
 by some  well-marked secondary affection,  (not always.) When the
 sarcocele is unaccompanied by  these, their previous existence and
 history help to 'distinguish  it  from  simple chronic enlargement,
 from which there  is otherwise  no  local difference or mark of dis-
 tinction."
  This disease very often  occurs  as an isolated  symptom  of con-
 stitutional syphilis, when the patient has  been supposed well for
 years; and these are just the cases, where the health is otherwise
 good, that constitute the difficulty in diagnosis.  At  other times
 the disease is associated with the sloughing ulcer of the  pharynx,
 with various forms of skin disease, or pains in,  or diseases of, the
 periosteum and bones.
  The syphilitic sarcocele, although easily distinguished from sim-
ple hydrocele of the  tunica vaginalis, is  sometimes  complicated

  1 Essays on Syphilis—Syphilitic Sarcocele.  By John Hamilton, Surgeon to the
Richmond Hospital, Dublin. 
SYPHILITIC TESTICLE.                219
with a small effusion of fluid into this part, and then the disease is
named hydro-sarcocele.  This form of hydrocele does not require
operation:  if  a trocar be pushed into it, the body of the testis is
sure to be wounded: the fluid  is generally absorbed as the testicle
approaches the healthy condition.  Should  it not do so, the fluid
is easily  evacuated by  puncturing the scrotum with a fine needle.
  In syphilitic hydro-sarcocele the  testis is  large, the fluid small;
in ordinary hydrocele, the size of the testis is not  increased, and
the collectidh  of fluid  large;  a precisely opposite condition to the
former.
  The syphilitic  testicle may certainly be mistaken for certain
forms of scirrhus  of this gland.  Dupuytren, Ricord,1 and M.'He-
lot,2 believe that numbers of  testicles which were syphilitic  have
been amputated under  the suspicion of their  being cancerous.  The
condition of the inguinal glands will  sometimes, but not always,
assist us in forming a diagnosis on this point, as the absorbents of
the testes open into the lumbar, and not into the inguinal glands.
  Pathology.—The best account we have of the pathology of  the
syphilitic testicle, has been given  by Mr. Hamilton, of the  Rich-
mond  Hospital, Dublin.  In  one form  of  disease  the  effects of
chronic  inflammation only are detected,  and this has been termed
by Mr. Hamilton,  "simple syphilitic sarcocele."  It consists in  the
" deposition of firm lymph of a pale yellow colour, into the  inter-
stitial cellular tissue external to the tubuli testes, as well, probably,
as into the tubuli  themselves." (On Syphilitic Sarcocele, p. 21.)
  "A  much more common  pathological appearance of syphilitic
disease of the testicle, is the presence of one or more tubercles in
the epididymis  or body of the testes.   These  tubercles are of a
yelloW colour, of a consistence rather less firm  than that of coagu-
lated lymph.  Very small at  first, they gradually enlarge, and ac-
cording to their duration, may vary from that of a  hemp-seed  or
split-pea, to that of a chesnut, or even larger.   They have a well-
marked cyst, which can, by careful dissection, be separated from
the yellow inorganic  substance contained  in them, and from  the
glandular substance of  the testes in which they  are imbedded.
The yellow substance within the cyst has sometimes a laminated ar-
rangement.   In some  preparations the yellow tubercle has gradu-
ally so increased  as to  have caused absorption of the  glandular
structure of the testicle, and,  finally, to have taken its place."
                1  Gazette des  Hopitaux, Aug. 25,  1845.
                3  Gazette Medicale, Oct. 18, 1845. 
220
SECONDARY SYPHILIS.
   " When the progress of the yellow tubercle is  not stayed by
treatment after having attained a certain size, it begins to soften
in  the centre, or at the side nearest the surface of the testicle,
where it causes an inequality;  adhesion  takes place between  the
tunica vaginalis and scrotum, and at last, these structures, with
the tunica albuginea, give  way, and the surface of the  tubercle
becomes adherent to the skin  of  the  scrotum.   Suppuration of a
slow, indolent character ensues, the abscess bursts, and  discharges
very little matter, and very thin, and terminates in fistula or lipo-
ma, and total disorganization of the testicle; the same disorgani-
zation may occur without any suppuration.   The tubercles are  ab-
sorbed, but, at the same time, the glandular structure of the testes
disappears;  nothing remains in the place  of the atrophied testicle,
but a hard, irregular, fibro-cartilaginous, contracted mass, in which
ossific matter is sometimes deposited.1
   Virility.—The virile power is not affected in the early stages of
syphilitic  sarcocele, unless the disease  extend to both  testicles,
which is not commonly  the case; but in the advanced stages, or in
protracted cases, especially  where  suppuration has taken place,
and a spermatic fistula formed, the virile  power is always more or
less weakened.  The desire for intercourse is not lost, neither is
the former erection much weakened, but the ejection of semen does
not take place, simply from the fact that  the glandular secreting
structure of the testes is destroyed.  I believe that when this is
the case the secreting power of the testes is never  recovered.  I
have wratched several cases of this  kind for some  years, and no
improvement in virility has taken place.  I have repeatedly  ex-
amined the  discharge from  spermatic fistulae in these "and similar
cases, but never in one  single case have I been able to  detect any
spermatozoa.
   Treatment.—In the earlier stages of what has been described as
simple syphilitic sarcocele,  local depletion by  means  of a small
number of leeches, may be employed if much tenderness be present.
The patient should at once be placed upon a mild mercurial course
suited to his age and constitution.   For this purpose the iodides of
mercury are most efficacious.  The iodide of potassium may also be
employed  in  conjunction with the  mercurial vapour-bath.  Alone,
the iodide of potassium  will frequently disappoint us, and will  not
cure the disease.   As local applications, frictions, with mercurial

                   1 Hamilton; op. cit., pp. 23-25. 
SYPHILITIC TESTICLE.
221
ointment and the extract of belladonna, the compound iodine oint-
ment, or the ointment of the iodide of lead, are useful: the two
former irritate the scrotum; the last does not, and, therefore, I prefer
it.   Compression, as recommended in consecutive gonorrhoeal or-
chitis, is comparatively useless.   In some obstinate cases I have
blistered the testes with great benefit.   Where sarcocele occurs as
a complication, and other and perhaps more important syphilitic
symptoms are present,  the treatment passed in review may require
modifications to suit the particular circumstances of the case, more
especially where the disease of the testes is complicated with the
sloughing ulcer of the  pharynx or fauces. 
222               SECONDARY  SYPHILIS.
                    CHAPTER XXVIII.

  ON CONSTITUTIONAL SYPHILITIC DISEASES SEATED IN THE MUSCLES.

                        CASE XXIII.

             Syphilitic tumour in the muscles of the fore-arm.
  M. V----,  was admitted, under my care, into the Queen's Hos-
pital, in April, 1853.  She had had primary sores five years pre-
viously, and since that  time had suffered from various forms of
skin disease,  ulceration  of the throat, and alopecia.  She was ad-
mitted for a large circumscribed tumour, which appeared imbedded
in the flexor muscles of the right fore-arm: the tumour was as large
as an orange, not very tender to the touch, the skin covering it not
altered in appearance.   I considered it of venereal origin, in fact,
a muscular node: it coincided with severe nocturnal pains in the
bones of the  head and  legs.   The  tumour  disappeared after six
weeks' treatment by the iodide of potassium and the biniodide of
mercury, with occasional blisters, pressure by means of iodine and
mercurial plasters, and frictions with the ointment of the iodide of
lead.
  I have described, in another part of this work, other tumours of
syphilitic origin, which are seated frequently on the tendons near
their insertions: M. Lisfranc has described such diseases under the
name of " white nodosities of the tendons."   M. Bouisson, who has
written a very good monograph1 on syphilitic diseases of the mus-
cles, mentions a case where the tumour was seated  in the substance
of the tendo-achillis, and was cured by the iodide  of potassium.  I
have seen another tumour of this kind in the substance of the gas-
trocnemius, and  they have been observed by M. Bouisson in many
other muscles.   M. Bouisson thinks they are peculiarly liable to
occur in  the tongue and  lips.   These tumours occur late in the his-
tory of a constitutional syphilitic taint, and have, in most cases, been
preceded by  other and  more common symptoms of secondary sy-
i Gazette Me"dicale, July 11-18, 1846. 
     SYPHILITIC  DISEASES SEATED IN  THE  MUSCLES.  .223

philis, which renders their nature  probable if not certain.  The
general remedies best suited to such cases are the iodides of mer-
cury, potassium, sodium, and iron, with the mercurial vapour bath;
locally, blisters and frictions with pressure: should any attempt
at extirpation be made, under a mistaken idea as to their true na-
ture, it is all but certain that the wound thus produced would as-
sume all the characters of a syphilitic ulcer. 
224
SECONDARY SYPHILIS.
                     CHAPTER XXIX.

       SYPHILITIC DISEASES OF THE PERIOSTEUM AND BONES.

       (OSTITIS, PERIOSTITIS, CARIES, NOCTURNAL PAINS, ETC.)

  Affections of the periosteum and bones constitute a most im-
portant class  of secondary syphilitic diseases, varying in their
nature from pain in the bone simply, without apparent alteration
in its structure, to complete destruction and disorganization.
  Pains in the bones.1—These pains are seated in various parts of
the osseous system, principally in the bones of the  head and ex-
tremities: they are generally worse when the patient is warm in
bed, but  at times they are present in the day also.   The parts
which are the seat of such pains are sometimes tender to the touch,
occasionally hot, or slightly enlarged; in other instances such symp-
toms are not present, and the disease seems to  consist in a lesion
of sensibility merely.  I do  not  think, however,  that this is the
case, or if it should be, the instances are very rare.  In the shafts
of the long bones, it is exceedingly  probable, if not certain, that
these pains are due to syphilitic inflammation of the medullary
membranes of these bones.  I have elsewhere shown this to be
the case.2
  These pains have been supposed by many to  be due to the mer-
cury which has been given  for the  cure of antecedent constitu-
tional syphilitic symptoms: to this it may be replied, that mercury
given for the cure of other diseases, not venereal, does not produce
such pains; that workers in the fumes of mercury are not so affect-
ed; that such pains occur where  mercury  has  never  been given
for the cure of syphilis, and, again, such pains are frequently cured
by  mercury.
  The treatment best suited to these pains consists in the adminis-

  1  Douleurs  Osteoscopes.
  3  On the Nature and  Treatment of some Painful Affections  of  Bone: Churchill,
1853. 
THE PERIOSTEUM AND BONES.            225
tration of the iodide or bromide of potassium, in full doses, which
may be advantageously combined with colchicum and  aconite in
some cases; also decoctions of the woods, especially the guaiacum,
with conium, and opium; if the parts be tender, or the pains fixed
and not fugitive, blisters are exceedingly useful: should these all
fail, mercury may be tried.  This treatment should  be associated
with simple vapour-bathing, or the mercurial vapour-bath twice or
thrice a week.   I have treated two cases with complete success,
with full doses of the iodide of potassium and colchicum, with tKe
mercurial vapour-bath, where the pains had never been absent for
one night in one case for seven, and the  other for thirteen years.
I  think division of the periosteum an  uncertain  remedy, unless
there be  well-marked  fixed tenderness, and then it disposes to
necrosis, or caries of the superficial  laminae of the bone.  Where
the pain appears to be seated in the medullary canal of the shaft
of a long bone, as the tibia, the canal may be opened with safety
and success (after the failure of the other remedies,) on the plan
alreadj' recommended and practised by me.1

                        Case XXIV.
   E. C. entered the Queen's hospital, under my care, in August,
1851, with  various secondary syphilitic symptoms.  Her chief
complaint was of severe nocturnal pains  in the  tibia of the right
leg, which was somewhat enlarged, and  tender  to the touch; the
pain in the bone was so severe  as  to prevent rest altogether:, she
took the iodide of potassium, and the biniodide of mercury, with
little or no benefit: blisters afforded,  at first, a temporary  allevia-
tion from pain  for a few days, but at length ceased to afford even
a slight relief.   The patient suffered so much that she  repeatedly
begged of me to amputate her leg.   The case was one of secon-
dary syphilitic  inflammation, affecting the medullary  membrane of
the shaft of the tibia, which, in a minor degree of intensity, is in
my opinion a very frequent  cause of pains in the long  bones.  I
determined to trephine the bone, to open the medullary canal, and
let the blood flow from the  divided vessels of the bone and medul-
lary membrane.  This was done, whilst the patient was under the
influence of chloroform, on Sept. 21.  I opened the medullary ca-
vity with  a long crowned trephine.  On removing  the bone, the
medullary membrane, turgid with  black blood, which ran  from it

              1 Op. cit., On some painful Diseases of Bone.
       15 
 226                secondary syphilis.

 in a stream, protruded through the opening; the perforation was
 filled with  a  piece of soft  lint dipped  in  oil.   No medicine was
 given.
   On  the 24th, pain was no longer felt; the opening  closing ra-
 pidly with  new bone.
   On Nov.  7, I removed a second piece of  bone with the trephine,
 which was carious;  and in doing  so, I penetrated the medullary
 carial a second time.   Not the slightest constitutional  disturbance
 followed  either operation.   The patient left the hospital well on
 Oct. 10th.

   Those  enlargements of the bones, termed nodes, appertain  to
 the natural history of the progress of syphilis, if suffered to go on
 unchecked by remedies.  Nodes arise as a consequence of primary
 venereal  ulcers, when the disease  has become  constitutional  from
 the absorption of the poison, and the poison has penetrated  very
 deeply into the system.  The bones are amongst the last organs to
 be  affected by the venereal poison; hence, Hunter places  them
 amongst the second order of parts affected  in constitutional syphi-
 lis, and Ricord ranks them amongst his tertiary symptoms, in which,
 says he, the syphilitic virus is completely transformed.  " It might
 be  said (says M. Ricord) that in the  secondary forms  of constitu-
 tional syphilis, the virulent cause—i. e. the poison, still exists un-
 changed ; but in the tertiary symptoms, amongst which we place
 the 'venereal node,' it is completely transformed."  We may natu-
 rally here inquire whether  mercury has any thing to do with the
 production  of nodes.  I confess that I am  disposed to  think  that
 a great deal of mischief is due occasionally to a mercurial course.
 " It  is a fact," says  Mr. Carmichael  (Clinical Lectures on Syphi-
 lis, p. 10,) " that in those cases of syphilis treated without mercury,
 the secondary symptoms are particularly mild,  and the bones are
 seldom or never affected."  Yet Mr. Carmichael admits the occur-
rence of diseases of the bones as proper to the natural history  of
constitutional syphilis, succeeding  to three out of the four kinds
into which he divides primary venereal sores.1

  1 Exposure to cold, whilst suffering from other forms of syphilis, or when using,
or after having used, mercury, are considered by many writers as the chief causes
of these forms  of diseases of the bones.  These diseases are  also much less frequent
in hot countries than cold, and in those places where a systematic simple treatment
without mercury is followed. They are said to be rare in Sweden, Denmark,  Ham-
burgh, and Vienna, where such treatment is adopted.  On the other hand, such dis-
eases of the bones are unknown,  except syphilis have existed in the constitution, 
THE PERIOSTEUM AND BONES.            227
  On the other hand, M. Ricord thinks that peculiarity of constitu-
tion, particularly the lymphatic temperament, a system depressed
by dissipation, poverty, insufficient clothing, exposure to damp, &c.
predispose to the occurrence of such forms of disease.
  The treatment of the primary and secondary symptoms certainly
has an influence over the occurrence or non-occurrence of the ter-
tiary:  "hence (says Ricord—Acton on Venereal Diseases, p. 390,)
daily experience proves that if secondary symptoms be treated with-
out mercury, tertiary  symptoms  will  frequently follow,  and that
even when mercury is  employed at the early period of the occur-
rence of secondary symptoms, the appearance of tertiary symptoms
cannot be prevented: in such cases,'however, provided the mercury
has been used judiciously, they will be slight."  (Acton, 390-1.)
It does not follow that secondary symptoms  should always precede
the occurrence of tertiary, though in most cases they do.  In many
instances the disease passes on from the first order of parts affected
to the third, without the intervention  of any disease belonging to
the secondary order.  Thus I have seen sores on the genitals, and
bubo (the first order of parts,) followed by nodes on the forehead,
and on the shafts of the long bones (third order;) but no disease of
the  second order of parts, no secondary symptoms, properly so
called.
   "The rarest cases that we meet with are those which succeed
to primary sores treated by mercury, when, after exposure to cold,
from disease, or  some  exciting cause, tertiary symptoms declare
themselves at first under a slight form, but successively increasing
in severity."  (Acton, 391.) In  such  cases we have a disease to
contend with wrhich, in the language of John Hunter, is compounded
of syphilis, mercury, and the  constitution.  It must at once be
evident that the treatment in  such a  case cannot  in any way be
specific.
  Nodes, as they are commonly termed, result from an effusion or
deposit between  the periosteum and bone, the result of inflamma-
tion affecting one or both  of these parts.  Very commonly they
are dependent  upon a superficial inflammation of the bone  itself.
These effusions between the periosteum and bone  may consist of
serum, pus, or lymph.   Again,  nodes are  produced by an effusion
of a proper osseous matter, similar to  the provisional callus  fir§t

though they are more frequent, perhaps, when mercury has been given for its cure
if the patient be of bad habit of body, and exposed to cold during its administration.
The same remarks will hold good with regard to  syphilitic iritis. 
228
SECONDARY SYPHILIS.
thrown out in cases of recent fracture.   Some nodes, very likely,
are thus formed, since they present the feeling of a true enlarge-
ment of the bone itself.   This is, most probably, the  first effect of
the inflammation of the surface of the bone, and the effusion of pus
and serum are subsequent, supposing  the inflammation  to proceed
unchecked by remedies.
   Nodes may terminate in a great variety of ways.   First  by
resolution, i.e., by the subsidence of the inflammation of the bone
and periosteum which produced them, and the absorption of the
fluids or matter  effused.   In other instances, after the  node has
disappeared, the surface of the bone remains uneven, depressions
exist in it, as though a portion of the bone had been eaten away,
which is the case.   This either arises from the pressure exercised
by the effusion of the fluid between the periosteum and bone having
produced absorption, or from the bone having become softened and
carious  from  inflammation of the bony tissue  itself.   This mode
of termination I have often seen exemplified where, after the dis-
appearance of nodes,  the surface of the bone  has been  found de-
stroyed to some considerable extent: this is, no doubt, the mode
in which the appearances witnessed  frequently in diseased bones
are produced.   If the node has suppurated, and has either burst of
itself or been punctured by a lancet, and the surface of the  bone
has been  exposed, caries  commonly follows to some extent, and
the soft parts  run into ulcers exceedingly difficult and  sometimes
impossible to heal.  Ulcers of this kind, to which every variety of
application has been used, at  times get nearly well, and them sud-
denly begin to ulcerate again, having thickened edges,  not unlike
a primary venereal sore on other parts.  In some instances, where
osseous matter has been thrown out between the periosteum and
bones, such effusion remains  permanent;  the inflammation accom-
panying, or dependent upon such state, subsides under proper treat-
ment, but  the deposit  of osseous matter remains permanent, and
produces one form  of exostosis.
  It is possible that venereal diseases of the bones and periosteum,
but more particularly inflammation  of the latter, causing effusion
between it and the bone, may be mistaken for or confounded with
periostitis arising from other  causes, and more  particularly where
these are of rheumatic origin and character.
  In drawing a differential diagnosis between  cases of  rheumatic
periostitis and venereal periostitis, we should be guided  by the his-
tory of  the case, and  the  preceding occurrence of some of those 
THE PERIOSTEUM AND BONES.
229
forms of constitutional syphilis which  belong to secondary symp-
toms.
  I am not aware either that periostitis, arising from  causes not
venereal, is complicated  or succeeded by those diseases of the
bojjes  ending in caries, which we so commonly notice  in the dis-
ease when it has a venereal origin.' I do not think that the symp-
toms immediately preceding the development of nodes  would ena-
ble us to form a very certain diagnosis of the  nature of the affec-
tion : they are both preceded, for some time before the appearance
of nodes, by nocturnal pains.  The seat of the pains may in some
measure guide us.   In the rheumatic  forms of disease the  pains
are situated in the joints or fleshy parts, as the shoulders; in those
of venereal origin the pains are more in the shafts of the long
bones, particularly of the radius, ulna, tibia, fibula, and in the
bones of the head;  in the  rheumatic  forms  they  sometimes, but
rarely, affect the parts I  have mentioned.  Venereal  nodes are,
again, to be carefully distinguished from that uneven and irregular
enlargement and softening of the surface of the bones, which  is
dependent upon rickets: 'the experienced Portal has shown that
some forms of constitutional syphilis are  marked  by softening of
the  bones, without caries or exostosis.  The  first series of cases
narrated in his " Treatise on Rickets," refers to venereal rickets, or  •
rickets traceable to a venereal taint.   He states that this species
of disease may produce softening of the bones without caries;  at
other times it produces a  peculiar brittleness.
  The prognosis in venereal diseases of the bones and  periosteum
is not always favourable.  If the health of the patient be unbroken
by  previous  courses of  mercury incautiously  administered,  we
may hold out hope of recovery with  some  degree of certainty;
but if the constitution has been impaired by poverty, debauchery,
bad  living, mercury, and syphilis, all contributing their part to the
destruction  of the patient, we  have  a disease to contend with
which  will sometimes baffle all our treatment, however skilfully it
may be framed, and  however unweariedly it may be followed out
both by practitioner and patient.  At  any rate no rash promises
must be made as to certain and speedy amendment, since relapses
after partial restoration are so frequent.
  The treatment naturally divides itself into constitutional and
local.  By the former we  endeavour to correct the poisoned condi-
tion  of the  system from which  the local disease  had its origin,
and upon which it depends.  By the latter we endeavour to remove 
230
SECONDARY SYPHILIS.
the local effects which such a condition of the system generally has
produced.
  Most of the  earlier modern writers on syphilis, from  Hunter
downwards, recommend full mercurial courses for the cure of sy-
philitic diseases of the bones and periosteum, such as those I have
described.   Amongst the more prominent of  these writers, I  may
mention Hunter, Bell, and Swediaur.  The latter says, " All sy-
philitic complaints  of the bones  require a complete mercurial
course, continued longer than for  the affections of the  soft parts;
for it is sometimes  necessary to continue the use of mercury for
three or four months, in order to obtain a radical  cure."   Bell
says (p. 239, vol. ii.)  "In every affection of the periosteum and
bones, arising from  the syphilitic virus, mercury should be given
immediately, for it is upon this remedy that  we chiefly depend."
The same opinions will be found reiterated by all modern writers,
from Hunter downwards, till the therapeutic effects of the hydrio-
date of potass attracted attention in certain forms of constitutional
syphilis.  We  find  Sir A. Cooper inculcating the same line of
practice.
  Venereal  diseases of the  bones  and periosteum we  have  now
learnt may, in many instances, be treated by iodine and the hydrio-
date of potass,  as successfully as by mercury; at least it  becomes
our  duty, generally speaking, in these affections, not to have re-
course to mercury till we  have tried these medicines and proved
their inutility.  Venereal nodes, too, will often return after  they
have been treated  by mercury, and it then becomes certainly a
much more prudent course to try  the effect of the preparation of
iodine than to  submit the patient  again to mercurial  treatment.
We may, perhaps, be enabled to judge from the history of a case
which remedy is the most likely to benefit the patient: I believe it
possible to point out the kind of case in which each might find its
suitable application.   If a patient present himself with a true vene-
real disease of the bones and periosteum, if the health be tolerably
good, and if the primary or secondary antecedent venereal disease
of such patient  have been  treated on the simple plan without, mer-
cury, I would recommend  at once a mercurial course.   He may, it
is true, be cured by the hydriodate of potass, but we shall be longer
about it; he will not be cured as well; and it will be at much greater
expense of pain to the patient.   If,  again,  in such a case, the inflam-
matory action  accompanying the disease  be very acute, the parts
very hot and tender to the touch, and the integument covering the 
THE PERIOSTEUM AND  BONES.            231
bones itself inflamed, mercury is still more strongly indicated; the
patient should be got as quickly as possible under its influence,
not, perhaps, so much with the view of specifically curing his sy-
philis, as with the intention of controlling inflammation by the aid
of mercury.  We know how efficacious mercury is in the treatment
of' many forms of acute disease, and more particularly when acute
inflammation of this  character  is the  result of a venereal taint.
The circumstances  which  are to  lead  us  to select mercury as  a
remedy in venereal diseases of the bones and  periosteum are, an
unimpaired constitution on the part of the patient, and his previous
syphilitic diseases having been treated  on the simple plan without
mercury.   Where diseases of the bones and periosteum occur in pa-
tients  whose health is either naturally delicate, or which has been
rendered so by protracted venereal diseases and repeated courses
of mercury, I would not advise mercury.  We may, possibly, by
having recourse to it under such circumstances, benefit the patient
for a short time, but the disease is very liable to  return, and the
constitution will be very probably utterly destroyed.  In a case of
this kind, we may, with every prospect of advantage to the patient,
commence the constitutional treatment of the disease by the hydrio-
date of potass in three or five grain doses, three times a day, in an
ounce of cinnamon or peppermint  water, the compound infusion of
gentian, or the compound  decoction of  sarsaparilla.   There com-
monly exists a preternatural irritability in the bowels of  patients
who have frequently had recourse  to mercurial courses; and hence
it becomes very necessary to guard against any ill effects (such as
pain or purging) which the hydriodate of potass may produce: for
this purpose a few minims of the tincture of capsicum, with  or with-
out laudanum, may be  added, according to circumstances, to the
vehicle in which the potass is given.  The dose of the hydriodate
must be gradually increased from  three to five  grains every three
or four days, till the disease give way, or some circumstance occur
which  will prevent us either continuing its employ, or requiring a
diminution in the dose.
  Almost all the varieties of venereal nodes arc, on their  first ap-
pearance, tender to the touch: the first  effect of the hydriodate is
a diminution of this tenderness, then diminution of the node itself,
which, in  many cases,  gradually and entirely disappears under the
use of  this salt.   If, after the continued  use either of this medicine
or mercury for a reasonable  length of time, the node have dimi-
nished to a certain  point, and there remains hard and stationary, 
232
SECONDARY SYPHILIS.
without tenderness, we  are  to look upon this as effused osseous
matter, constituting a true exostosis, which is hardly likely to be
removed by a further continuance of medicine.
  The local treatment of venereal diseases of the bones and pe-
riosteum is also of great importance. As many of them are ushered
in with symptoms of inflammation more or less acute, an antiphlo-
gistic local treatment, suited to  the  degree of inflammation  pre-
sent, should be adopted; several relays of leeches should be placed
over the node till all tenderness shall have disappeared : these are
to be succeeded by blisters, which  should  be dressed with the
stronger mercurial  ointment.  The continued  application of blis-
ters, even after all constitutional treatment appears to have  lost
its effect, will often succeed  in reducing very considerably the size
of a venereal node.  Many other remedies may be used, with the
view of  dispersing  a node when perfectly chronic, i. e. when all
symptoms of inflammation have disappeared: amongst  these may
be' mentioned frictions with  mercurial  ointment and camphor, the
hydriodate of potass ointment, the application of the tincture of
iodine, or the solution of iodine in the hydriodate of potass, so ge-
nerally used, and with such signal success; pressure and strapping
with the emp. ammoniaci cum hydrargyro, which I have so usefully
employed in the same way in affections of the testes which succeed
to gonorrhoea.  A question of great practical importance remains
to be here considered, in reference to the treatment of  collections
of fluid which succeed to or accompany venereal ostitis and perios-
titis.   If fluctuation be evident in a tumour of this kind, and no
redness or thinness of the integument  have taken  place, I do not
think any author imprudent  enough to recommend the puncture of
such a tumour, with a view of discharging its contents: should we
do so, we are very likely to produce  caries and exfoliation of the
bone beneath, the extent and consequence of which it is impossible
to foresee.  Sir A. Cooper mentions the case of a person who  died
in consequence of exfoliation produced  by the opening of nodes
on both his tibiae.  In these cases, Ave are  on no account to lay open
these collections of fluid, but by a perseverance  in  the constitu-
tional method of treatment, and the repeated application of blis-
ters, to endeavour to procure absorption of the fluid effused.  Where
the existence of pus is rendered still more certain by the redness
and shining appearance and thinning of  the integument covering
the tumour, I cannot follow  the advice  of Sir A. Cooper, "to make
an incision down to the bone."  I would rather press  the impor- 
THE PERIOSTEUM AND BONES.            233
tance of the advice given by Mr. Colles in reference to this point.
" Some," says Mr. Colles, " have proposed the early opening of the
tumour, and the evacuation of all the contained fluid.  To this pro-
posal I  would object, that in some cases this particular practice is
followed by painful, suppuration, and  by very copious discharges,
and not unfrequently by caries and tedious exfoliation of the bone.
It seems preferable in all cases to try the local and constitutional
effects of mercury and iodine, and by  means of these to endeavour
to avert suppuration and ulceration.   This rule should be  most
strictly adhered to in the case of nodes on the forehead, or on any
exposed part of  the body;  for when a  node has been  of  long
standing we often find that a sort of  chronic suppuration is estab-
lished, the integuments become  thin and  sometimes red; at other
times they are reduced to the utmost degree of thinness, and yet
may retain their natural colour, so that the surgeon is  actually
tempted to give vent to the fluid by the puncture of a lancet.  Yet
if he will but resist the temptation which the very thin state of the
skin offers to him to open it, and will still apply repeated blisters,
he will have no reason to lament his forbearance; for as soon as
the mercury or hydriodate of potass comes to  act favourably on
the system, he will perceive that the  fluid begins to be absorbed,
and that this process will finally be terminated by the adhesion of
the skin to the surface of the bone.  From the depressed position
of the skin, after adhesion has taken place, and the sunken unequal
surface which the bone presents  to the touch, we are convinced that
an absorption of  the bone has gone on to some depth."1
   In such cases, then, it might be wrell, if much distention be present,
not to  lay the abscess open with a lancet, but to puncture with a
 very fine trocar!  This mode of practice will relieve the disten-
tion, and give time for other treatment to be brought to bear; at
the same time the puncture will be so small that no air can possi-
 bly be  admitted, the surface of  the bone  will not be exposed, and
 the risk of caries and exfoliation will certainly not be increased.
' Colles, p. 187. 
234
SECONDARY SYPHILIS.
                       CHAPTER XXX.

  ON SYPHILITIC DISEASES OF THE LUNGS.—SYPHILITIC PHTHISIS.—
                     CHLOROSIS.—CACHEXIA.

  There can be no doubt but that a profound alteration in all the
humours and solids of the body, takes place in many constitutions
in the latter stages of constitutional syphilis: at such periods the
body wastes, the appetite is lost, the patients assume a white cada-
verous appearance, the strength diminishes, and night sweats, diar-
rhoea, and cough set in.  If this state continue, uninfluenced by
treatment, a fatal termination may take place, of which  I have
seen some instances.
  To this array of symptoms, the  term "Syphilitic Phthisis" has
been given.  The  name also  of "Syphilitic Chlorosis" has been
applied to similar constitutional states due to the same cause.  The
older writers,  particularly Portal,  Bell,  Lagneau, and  others, be-
lieved in  the existence of a true venereal phthisis.  That patients
may die of wasting of the body, with cough, and night sweats, and
even spitting of blood, as a consequence of prolonged  syphilis, is
quite certain; but whether a true "tuberculosis" is  ever produced,
or even developed by syphilis is a matter of great doubt.  Hunter
says, "This disease seldom or ever  interferes with other disorders,
or runs into or terminates in any other, although ft has been very
much accused of doing so." The cases recorded by authors of the
cure of syphilitic phthisis by courses of mercury, and other modes
of anti-venereal treatment, were  clearly not cases of " tubercu-
losis;" for the treatment which is said to have been successful in
such states, is clearly the last which would be applicable or bene-
ficial in tuberculosis.1   No one would think of prescribing mercu-

  1 The syphilitic virus is probably never converted into tubercle. Mr. Ancel ("On
Tuberculosis," p. 391,) says, "The only point of view in which the doctrine can be
held is the absolute transmutation of the syphilitic poison into the tuberculous ele-
ment of disease."
  "There is no fact or experiment which conclusively proves  that a  single case of
tuberculosis was ever produced by syphilis alone......At the same time,
syphilis, by its deleterious effects on  the constitution of the parent, may probably
weaken the reproductive faculty, and lead to the conception of children, who, from 
           SYPHILITIC DISEASES OF THE LUNGS.        235

rial inunctions, &c. in the latter disease, or expect such a treatment
to be successful.
   The assemblage of symptoms I have mentioned as constituting
what has been  termed " syphilitic phthisis," are  due to the exist-
ence of a syphilitic taint in the system, more particularly affecting
the blood  and humours of the body, and are not commonly met
with apart from some other local'and unequivocal symptoms (either
present or immediately preceding) of syphilis, such as old secondary
ulcers, diseases of the bones, throat, or larynx.  It frequently hap-
pens that the local disease, or  previous history of the  patient, is
not sufficient to account for the profound cachexia under which the
patient labours.  Manifestations of constitutional syphilis are fre-
quently met with of a very formidable character, and of long stand-
ing, where the general health or constitution of the patient has suf-
fered very little: in other instances, this chlorotic condition is very
quickly induced, and appears to arise  from a more direct action of
the syphilitic poison upon the blood itself: hence the pallid counte-
nance, the thin, wreak, frequent pulse, and the muscular weakness.
   It will be  seen that this state of constitution sometimes comes
on very quickly, and therefore is not, in all instances, due to the
time a syphilitic taint has been in existence, but to a more im-
mediate action of the poison on the blood, instead of on the  skin,
bones, or other parts?
   If  cough or diarrhoea be  present,  the  condition of the patient
resembles very much one  of phthisis;  but auscultation  must soon
clear up any doubt as  to the condition of the lungs themselves.
   If such a state of constitution  be due to the poison of syphilis
alone, it is quite clear  that those remedies  which will neutralize
or eradicate  the poison, are the only ones from which the patient
is likely to derive  permanent  benefit, to whatever state  of weak-
ness he may  be  reduced;  and experience bears out the fact of the
failure of all remedies except those I have mentioned.   I have fre-
quently known patients put on courses of cod-liver oil, and removed
to the sea-side, and to other climates, without the slightest benefit;
when they have recovered completely and rapidly on  being sub-
mitted to a methodical  and properly framed anti-syphilitic treat-
ment, more particularly one by the moist mercurial vapour.
  There are, however, some forms of constitutional syphilis which
resemble very closely consumptive diseases from other causes; and
these are syphilitic ulcerations of the windpipe.
poverty of blood and debility of organization, are predisposed to tuberculosis." (Op.
cit, pp. 391-92.) 
236                SECONDARY SYPHILIS.
                         Case XXV.
  A middle aged female was admitted into the Queen's Hospital,
under my care, in June, 1848.  She had  three years before been
treated, as  an out-patient, for primary venereal  sores, and in the
interval had had ulceration of the throat, and some pustules upon
the skin, which I did not see.  When admitted she was much ema-
ciated, had  profuse night perspirations: expectorated large quanti-
ties of purulent matter streaked with blood, had completely lost
her voice, and the  larynx was enlarged, tender, and painful.  I
drew the tongue forwards, and passed into the larynx a bent piece
of whalebone armed with  sponge, which was  soaked in a solution
of nitrate of silver, and directed the vapour of one grain of the
iodide and  a scruple of the bisulphuret of mercury to be directed
into the throat every morning.   The gums were made very sore
after the fourth application, and the remedy was used less frequent-
ly.  No  alteration was made in the treatment, and at the  end of
six weeks she was discharged in tolerable health, having recovered
her voice, though it remained hoarse, and having lost entirely the
night-sweats, the  cough, and the expectoration.
   There could be no doubt as to the  nature of this case; it was
one of syphilitic ulceration of the larynx; but if the previous his-
tory of the patient had been unknown  or  misstated, there must
have been great difficulty  in discriminating between such a disease
and one of ordinary laryngeal phthisis.
  Drs. Stokes, Graves, and  Munk, have  spoken of  syphilitic dis-
eases of  the lungs, but I have seen no facts recorded which prove
the production of a true  tuberculosis by syphilis.  I  have seen
no case of the syphilitic tubercle developed  and softened  in  the
lungs, and cannot suppose that  such cases  can be frequent, since
amongst  the great number of syphilitic patients daily treated at the
Queen's Hospital, where every case in my practice is carefully re-
corded, none  have  been  met with.   Should such  cases occur, I
know of nothing  that would enable us to distinguish them from
cases of ordinary tuberculosis, except the previous history, and
concomitant state of the patient; since, apart from such considera-
tions, both  the rational and physical symptoms of tuberculosis and
syphilitic tubercle would  most closely resemble  each other.
   The remedies best suited to the forms of disease 1 am consider-
ing, are  the  iodide of potassium, iron, the extract of opium, the
cold infusion of  sarsaparilla in lime water, sarsaparilla broth, the
moist mercurial  fume, residence in a fresh, pure,- dry atmosphere,
and the baths of Kreuznach. 
SYPHILIS IN PREGNANT WOMEN,  ETC.        237
                      CHAPTER XXXI.

ON THE  TREATMENT OF SYPHILIS IN PREGNANT WOMEN, NURSES, AND
                           INFANTS.

  Syphilis may be communicated from the mother or father to the
ovum, foetus in utero, or the infant, in the following ways:
  1st.  The Virus may be transmitted with  the  semen  by coha-
bitation,1  the father having  suffered from  syphilis, the mother
never;  or the father maybe healthy and the mother diseased;  the
foetus is then contaminated by the blood of the mother, the father
being healthy; or, again, both these causes may be combined.
  2d. The infant may contract disease during labour, by coming
in contact with parts of the  uterus, vagina, labia, &c, which  are
the seat of various forms of venereal taint.
  3d. The infant may become diseased  after birth through  the
medium of the milk, &c, the mother or nurse being affected;  the
breast being the seat of local symptoms  or not.2
  The  disease may also be  propagated  by a diseased child to a
healthy nurse; and the latter may again give it to a healthy infant,
"without," according to Bertin, " the nurse appearing to  be infect-
ed."
  Cullerier, in a memoir published in 1815, has endeavoured to
lay down  some rules to guide us in reference to this subject.
  1st.  If  the breast of the nurse and the mouth of the infant are
only, and  at the same  time, diseased, the question is one of  doubt
in which the disease originated.   2d.  If the breasts alone are  dis-
eased,  and if the infant has symptoms in other parts besides  the
mouth, it is very probable that the latter has been the first infect-
ed.   3d.  If  the infant has  the mouth  alone diseased, and  the

  • See Bertin (Physician "en chef" of the Venereal Hospital, Paris) Traite" de la
Maladie venenenne chez Enfants Nouveau-n^s, les Femmes encientes, et les Nourri-
ces; Paris, 1810.
  2 Contamination by means of the milk after birth is denied by Dr. Egan, though
admitted by Mr. Whitehead, Mr. Erasmus Wilson, and many foreign writers. How
can diseased blood produce healthy secretions ? 
238                SECONDARY SYPHILIS.
 nurse has other symptoms besides those of the breast, it is most
 probable the  infant has been diseased by the nurse. 4th.  If the
 nurse has  general constitutional  symptoms, and  the infant only
 local symptoms, the disease probably originates  with the  nurse.
 5th. If the infant has general constitutional symptoms the disease
 is most likely hereditary.
   This point is not always  easy to solve, but the rules given will
 be found, in most instances, correct, and are very useful in guiding
 us in the formation of a correct diagnosis.
   I should remark, that it is generally supposed a diseased infant
 cannot affect its own mother: the case recorded below, from my own
 practice, amongst many others, favours this view.  This remark
 was originally made by the late Dr. Colles of Dublin,1 and is strongly
 supported  by Dr. Egan.  I  have seen no case to disprove this.

                         Case XXVI.
   A patient, whose, case is already referred to, was admitted under
 my care at the Queen's Hospital, suffering from a pustulo-crustaceous
 syphilitic disease of the skin of very formidable character.  He was
 there treated  and cured.   His wife brought her infant to me co-
 vered with scaly blotches, whilst the husband was in the hospital:
 the child was  plump, and apparently healthy when born, but a few
 weeks afterwards these patches broke out, and the  health  began to
 decline.   The mother  presented  no evidence of disease, and the
 breasts, as  well as the infant's mouth, were free from ulceration.
 She was  extremely anxious  to be examined, fearing she might be
 labouring under some affection of the parts themselves.   1 instituted
 the most careful examination with the speculum, not only  once, but
 four or five times, and could never discover the least local disease,
 either in the  vagina, uterus, labia, nymphae, or the folds  of  muco-
 cutaneous membrane surrounding the clitoris, &c, &c.   The child,
 in this instance, was alone  treated, and  cured.   I purposely ab-
 stained from treating the  mother, whom I had watched for nearly
 two  years.   She has never  suffered from a syphilitic  symptom  in
 any form.

  This appears to have  been a case of syphilis in the infant,  trans-
mitted by the father to the ovum or foetus in utero;  the mother
never having suffered from disease, and never having been treated
under the suspicion that she was diseased.  I purposely abstained
      1 On the Venereal Disease, and on the Use of Mercury, 1837,  p. 304. 
           SYPHILIS IN PREGNANT  WOMEN, ETC.        239

from treating her to see whether syphilis would, sooner or later,
develope itself.   Up to the present moment, two years from the
birth of her child, she has remained perfectly healthy.  Mr. Acton
introduced to the Medical and Chirurgical Society, May 13th, 1845,
a case of similar character.

                        Case XXVII.
   M. II----, nine weeks old, was placed under Mr.  Acton's care,
on account of an  eruption, chiefly papular, over the whole body.
The voice was hoarse, and there was slight discharge from the nose;
the palms of the hands presented a scaly copper-coloured eruption.
The mother stated she married four years ago, became soon after-
wards pregnant, and at the full time gave birth to a dead child.
During the following year she miscarried.'  On the occurrence of
the third pregnancy, the child, the present patient, was born at the
full time, perfectly healthy. About the third week, spots were ob-
served on the genital organs.   No symptom, either of primary or
secondary disease, could be discovered in the mother.   The father,
about four  years ago, contracted chancres, was salivated, and se-
condary symptoms followed.  He again took mercury, and, fancying
himself well, married, and denies having had any primary symptoms
since, although  he has occasionally seen wiiite spots  on  his mouth
and tongue.

   This is a second example of  one mode in which syphilis may be
produced in the infant; by a constitutional taint in the father, and
no evident  disease in the  mother.   Many of the gentlemen who
took part in the debate on this case, Dr. King, Dr. Merriman, Mr.
Arnott, Mr. Wade, and others, alluded to similar cases.  The one
I  have brought forward from my own experience was watched for
so long a period and examined so" carefully and  so repeatedly, that
I  believe there can be no doubt of this occasional and perhaps fre-
quent origin of hereditary disease.1
   If a female not constitutionally affected at the  time  of her de-
livery be labouring under a primary venereal disease, either in the
shape of ulcers or  discharge, it is not improbable that such  dis-
ease may be communicated to the infant during its birth, and thus
a  primary, disease be produced in the offspring.   These cases are,
however, rare, and persons of the greatest experience, amongst

    /            i See the Lancet,  Jan. 7, 1845, No. 1136. 
240               SECONDARY SYPHILIS.
   whom may be mentioned M. Gibert, have hesitated to determine
   whether  the  ulcers or discharges with which some new-born in-
   fants born of parents labouring under primary venereal  diseases
   are affected, are due to a primary infection, or to a constitutional
   taint contracted " in  utero."  Bertin, to whom we have  already
   alluded,  has, however, recorded  many cases of children  born of
   women labouring under primary symptoms, and not evidently con*
   stitutionally diseased, who  have presented, shortly after birth, ul-
   cers, bubos, or discharges which had all the characters of  primary
   venereal diseases, and were, in all probability, due  to infection
   during the progress of labour.
     Two forms of syphilis, however, in the infant, are decidedly pri-
   mary, due to  direct contact or infection, and not  dependent upon
   a constitutional disease.  These are purulent ophthalmia, and ulcers
   in the mouth of an infant who has taken the breast of an  infected
   nurse, whose nipples present marks of ulceration.   The former of
   these is due to contamination during parturition,  the  second to an
   infection contracted after  birth.  It  must  not be supposed that
   the purulent ophthalmia of infants is invariably a syphilitic disease.
   It is not so.  It occurs where the female has never had primary sores
   or vaginal discharges of any kind.  It is, again, due to leucor-
   rhoeal or irritating secretions not of a venereal character,  at least,
   children born of parents so diseased have occasionally been affect-
   ed with purulent ophthalmia; and it happens  under a third form
   where the mother has decided  gonorrhoea, ulcers, or glandular
   erosions of the os uteri.  In the latter case it must be looked upon
   as a primary  venereal  symptom, at least  caused by the  circum-
   stances on the part of the  mother which we have  mentioned.   " I
   do not pretend  to deny,"  says Gibert, " that purulent ophthalmia
   may not recognise as its cause a local venereal disease on  the part
V  of the mother, but I say, that in the  actual state of science, this
   phenomenon  alone is insufficient to characterize syphilis."  When
   it occurs in infants born of parents infected with syphilis in the
   way I have mentioned, it is difficult to assign to it any other cause.
      Primary venereal diseases in the infant produced by disease in
   the passages of the mother are, at least, rare diseases.  Drs. Maun-
   sell and Evanson state (Diseases of Children, p. 351, ed. 4,)  that
   they do  not  remember a  case of this nature. Their experience
   corresponds with mine.  I have now  under my care an  infant of
   fourteen weeks  old, where neither father nor mother have had any
   trace of disease for five years:  the father was diseased six years 
           SYPHILIS IN  PREGNANT  WOMEN, ETC        241

ago, the mother never.   She has had three dead children prema-
turely born, since her marriage, and this, her first living child, ex-
hibited  symptoms of syphilis at five weeks old, commencing with
snuffling, discharge of pus and blood from the nose, subsequently
a pustulo-papular eruption, soon  becoming scaly.
  The symptoms are, as we have  shown, of twx> kinds, primary, and
secondary or constitutional; the former rare, the second more com-
mon.  The former consist in purulent ophthalmia, and ulcers of the
mouth, to which some have added chancres or ulcers in the parts of
generation or elsewhere, discharges from the vagina or urethra,
and even bubos.  The constitutional forms of disease consist chiefly
in affections of the skin, which are the most frequent, and belong to
the various forms of  the  " Syphilida " already described.  Affec-
tions of the  bones are very uncommon, although Bertin has-given
a case of  disease of the bones and periosteum in an  infant thirty-
five days old.
   A characteristic snuffling is one of the most marked symptoms of
infantile syphilis.  " The puckered mouth, the position of the very
characteristic eruption round the lips and anus, in addition to the
peculiar and fissured appearance of the  surface from which the
scales have faded, will seldom, if ever, fail to convert a suspicion
of the disease into positive certainty. Condylomatous excrescences
from the margin of the anus have  never, in any of the cases, ac-
companied the earliest development of the syphilitic affection, but
were always secondary,  being  observed in those children  only
whose primary affection was neglected  or incompletely eradicated.
When the eruption occurring on the nates and face, in the first few
weeks of life, had been promptly treated, no condylomata appeared
on  the anal margin, at least so long as the children were kept  in
sight.   But, on the contrary, when the eruptions were neglected,
condylomata were the almost certain results."1
   Occasionally infants at the  moment  of  birth present the symp-
toms of syphilis, and in addition to such symptoms, are shrivelled
and emaciated, the skin hangiirg in folds  in different parts of the
body.  It more frequently happens  that  these symptoms are not
manifested till many days, weeks, or even months after birth.  More
commonly disease shows itself from the third to the sixth week; it
may be however earlier, more frequently later.  "In the majority
of  infants confided to my care, the disease  has  not appeared till

          1 Dr. Golding Bird; Guy's Hospital Reports, April, 1845.
       16 
242                 SECONDARY SYPHILIS.
 the first, second,  or third month, and  frequently much  later."1
 "The two physicians who had preceded  me/' continues this writer,
 "have, with me, observed  that infants  born of infected  parents,
 have  not presented  the symptoms  of syphilis till many months
 after birth, and sometimes not till they were weaned,  and that up
 to this period they had appeared in the best health."  The records
of the Venereal Hospitals," du Midi" and " Vaugirard," have shown
 that some infants born of diseased parents have never had symp-
 toms of syphilis.   In some  instances  these were  the  offspring of
 parents who had undergone treatment during pregnancy; or they
 were  recently affected.   In a second class, much smaller, the pa-
 rents  have never been treated, and yet the infants, watched for
iiupwards of a year, had never shown any  symptoms  of  venereal
itaint.
  Many interesting questions propose  themselves for our conside-
ration  in reference to the treatment of pregnant women, nurses,
and infants.2   We will consider, first, whether a pregnant female
 presenting the symptoms of primary or constitutional syphilis is to
 foe treated, and how she is to  be treated.  Some have supposed that
 a mercurial course predisposed a pregnant female  to miscarriage.
 This, "however, is incorrect.  Bertin has stated (Op. cit. p. 169,) that
 pregnant females with constitutional syphilis much less frequently
 miscarry when they are  submitted to an appropriate treatment,
 than  they do if the  treatment be postponed till after delivery.
 The disease is here  more to be dreaded than the treatment.   If
 the treatment be adopted and conducted cautiously, there is very
little to dread, either on the part of the female, or the  foetus.  The

  1 Bertin, op. cit, p. 97.
  2  Infants conceived and developed in the womb of a female suffering from consti-
 tutional syphilis seldom live beyond the period of the first dentition;  if they survive
 this period, their health is  generally delicate and precarious, in spite  of the most ra-
 tional  treatment to which they may be submitted.  See "Lagneau,"  Ex-Chirurgien
 de l'Hopital Veneriennes, Syphilis de la Femme enciente; Paris, 1812, p. 283.—See
 also Professor Paul Dubois' paper on the subject in the "Annales de la Syphilis,"
Jan. 3, p. 78.  Syphilis considered as one of the possible causes of the death of the
foetus.—Also the same paper, in the "Gazette M6dicale," Aofit, 1850. The learned
professor comes to the following conclusions:   1. That the presence of pus either
diffused or circumscribed in the thymus gland of new-born infants,  who have died
 with other symptoms of a syphilitic taint, is not  to be considered as a coincidence;
but as a pathognomonic symptom of syphilis.  2.  That such a pathological condition,
in the absence of any other evidence of the cause of the death of the foetus, fully
warrants a specific treatment of the parents, as the only means of averting a repeti-
 tion of the same results. 
           SYPHILIS IN  PREGNANT  WOMEN,  ETC        243

mother is very likely to be cured, and a healthy child born.  If it
be neglected, premature labour, with death or formidable  disease
in the child, are almost certain.  For confirmed constitutional sy-
philis, or well-marked primary sores occurring in pregnant women,
a modified treatment, the effects  of which  are  to  be carefully
watched, is to  be adopted, and persevered in till the symptoms
have yielded.   If mercury be  used, the remedies best suited  to
these forms are frictions of small quantities of mercurial ointment,
either upon the thighs, or in the axilla, with the mercurial vapour
bath. These remedies are safer than internal mercuriaL remedies,
which, if used,  should be of the  mildest character.  In  the ad-
vanced  periods of pregnancy, great caution must  be  observed,
and we would then limit  the general  treatment to frictions only.
The remedies must be suited to the form  and variety of the dis-
ease with which we have to contend, according to the  rules already
laid down.  A plan of treatment must  be framed to suit the parti-
cular circumstances of the case,  whether the disease  be in the
throat, bones, or skin, and the nature of the eruption, whether pus-
tular, tubercular or scaly.
   It is certainly the correct practice to submit a pregnant woman
affected with syphilis to an immediate and direct specific treatment.
All experienced modern writers  are agreed on this point.  Mr.
Vidal says, "When I directed the department of the nurses at the
'Lourcine' Hospital, I treated  syphilitic pregnant women, in the
same way as those which  are not diseased:" the same view is sup-
ported by Dr. Egan.
   Is the father to be treated for syphilis in the absence of all
symptoms, if his  wife, also  apparently healthy,  miscarries, fre-
quently, or gives birth to children decidedly syphilitic?  Certainly,
if the father have ever had syphilis.  I have already alluded to a
case of this kind; I mention another.

                         Case XXVIII.
   A gentleman married, after having been free from all symptoms
of syphilis for  some years.  His lady aborted  of her first  child,
and of her second; the cause was not suspected.  The third was
born alive, but at six weeks old, had snuffling, iritis, and condylo-
mata about the anus. It was cured by mercurial frictions. The lady
aborted of her fourth child; the fifth and sixth both  had syphilitic
symptoms.  The mother had never any symptoms of syphilis.  She
was carefully and repeatedly examined. 
244
SECONDARY SYPHILIS.
  There can be no question about the propriety of submitting both
parents to specific treatment in all such cases.
  "Observation has taught me," says Bertin, "that diseased preg-
nant women more frequently miscarry when they have not been
submitted to any treatment, than when  they  have been treated
during pregnancy, and that when this event happens during the
course of treatment, it depends commonly either upon the disease
itself, badly treated, or treated too late, upon the state of cachexia
or weakness to  which the patient has been reduced by her disease,
or upon the excesses she has  committed during her pregnancy."
  The result of modern  experience  shows that a pregnant female
constitutionally diseased may be treated  with safety, and with a
strong probability of cure both to herself, and the eradication and
prevention of disease in  the foetus in utero.
  It is not prudent to commence the full  treatment  of a pregnant
female during the ninth  month of her pregnancy.  At this period
a palliative  treatment only should be adopted: if a mercurial one,
it should consist in frictions with small quantities of mercurial oint-
ment every two  or  three  days, leaving  the full  treatment to be
commenced  a month after delivery.
  If^a female contract primary sores during pregnancy, two things
are to be feared: constitutional infection both in herself and infant,
and the contamination of the infant during  parturition, a circum-
stance, though  rare, sometimes happening.  If the primary disease
occur during the earlier months or middle  of pregnancy, the fe-
male  is to be  fully treated, observing the cautions already laid
down in reference to treatments during pregnancy, whether mer-
curial or not.  Mercurial inunction is here also the best mode we
can adopt if mercury be indicated.1
  When a female is affected with' primary ulcers on the genitals
near the time of  parturition, they must be destroyed by  some ap-
propriate caustic, to protect  the infant  from infection on the one
hand, and the  accoucheur or midwife on the other.   I have seen
three or four instances of constitutions irreparably broken in me-
dical men by syphilis, contracted from attending a female, during
parturition,  with syphilitic affections  of  the vagina Or  os uteri.
  The best plan of treating  infantile syphilis is  that  by frictions

  1 "Je pense, comme quelques practiciens, que le traitement par les frictions mer-
curielies est.celui  qu'il convient le plus ge"ne"ralement d'employer dans la syphilis
primitive des femmes grosses."  (Baumes; Precis th6orique et pratique sur les Ma-
ladies veneriennes; Lyon, 1840.) 
           SYPHILIS IN PREGNANT WOMEN, ETC       245

with mercurial  ointment,  in the  way recommended  by Sir B.
Brodie.1   " I have  provided a flannel roller, on one end of which
I have  spread some mercurial  ointment, say a drachm or more;
and I have the roller thus prepared, applied, not very tight, round
the  knee, repeating the application daily.   The motions of the
child produce  the  necessary friction, and the cuticle being thin,
the mercury enters the  system.   This causes  neither griping nor
purging;  in a child it does not even, in general, cause  soreness of
the gums; but it cures the disease.   Very few children ultimately
recover, to whom  mercury has been given internally;  but I have
not seen a single case in which this other method of treatment has
failed."

  ' On the Administration of Mercury in cases of Syphilis, " Lectures on Pathology
and Surgery/' p. 248.
V 
246                SECONDARY SYPHILIS.
                     CHAPTER XXXII.

OP THE EMPLOYMENT OP PARTICULAR REMEDIES IN THE TREATMENT OP
                  CONSTITUTIONAL SYPHILIS.

                 THE MERCURIAL VAPOUR BATH.
  The patient is placed on a chair, and covered with an oil-cloth,
lined with flannel, which  is supported by a proper frame work.
Under the chair are placed a copper bath, containing water, and a
metal plate, on which  is put from one to three drachms of the bi-
sulphuret of mercury, or the same quantity of the gray oxide, or
the binoxide.  Under each of these a spirit-lamp.   The patient is
thus exposed to the influence of three agents, heated air, common
steam, and the vapour 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 gene-
rally commences, and  by the end of twenty or thirty minutes, be-
yond which I do not  prolong the bath, it is  generally excessive.
The lamps" are now  removed, and the temperature gradually al-
lowed to sink; when the patient has become  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 or sarsaparilla.
  The apparatus  requires some modification and management to
particular cases.   Where  it is wanted to induce a quick and  de-
cided action, the whole power of the bath should be brought into
operation, and the largest quantity of mercury should be employed.
In  rapidly-spreading  ulcers this is  required.  Again, in chronic
skin or throat diseases, where  a powerful action would rather op-
press the patient than  cure his disease, the power of the bath should
be modified, and not so great a heat or so much mercury employed.
This is accomplished  by using smaller spirit-lamps, or, when per-
spiration  has once been  induced, by the removal of one  lamp}
leaving the patient thus exposed for a time to the mercurial vapour 
MERCURIAL VAPOUR BATH.
247
alone.   This should be done where the patient has been broken
down by long-continued disease, in bad or weak subjects, or wbeie
a more prolonged  action is required to eradicate  the more  deep-
seated effects of"the venereal poison, as in diseases of the bones, or
indurations on the penis.  Each particular case would require  a
greater or less modification of this  kind.  The form of mercurial
employed is also of consequence.  In skin diseases the bisulphuret
is to be preferred, in diseases of the throat or nose the gray oxide,
or binoxide is  better, because the patient can bear the head im-
mersed without sneezing or coughing, which he cannot do when
the bisulphuret is  used.
   I am in the habit of using four mercurial preparations for the
baths; the bisulphuret of mercury, the  binoxide of mercury, the
gray or black oxide, and the iodide. These may be used singly or
combined in different ways, to suit the peculiarities or emergen-
cies of each particular case.   The first three preparations are
milder than the last, and from half a drachm to four drachms may
be used for a bath with perfect safety.  In one case half an  ounce
was used for each bath, and two  applications were sufficient to
bring  the system  fully under the influence of the remedy.  The
iodide must be used in smaller quantities: nearly the whole of
this preparation is rapidly converted into vapour, and, unlike all
the other preparations, leaves scarcely any  ash  behind  it.   From
five grains to  half a drachm of the iodide  is  sufficient, and it  is
better to use it in small quantities, mixed  with a larger quantity
of either of the other preparations.  In affections of the  testes
(sarcocele) and of the  bones (the various forms of ostitis,  or peri-
ostitis) a combination of a scruple of the iodide, and one or two
drachms of the bisulphuret or  binoxide would be a proper form.
For local application to  the cavities of the nose or mouth, a few
grains only should be employed, as the  vapour of  the iodide of
mercury is more irritating and more powerful  than that of either
of the other preparations I have mentioned.
   A short preparatory treatment should be adopted before using
the baths.  The bowels should be kept free, and the use of wine,
spirits, &c, prohibited.  The patient should  be free  from  fever,
the tongue clean, and the freedom from  organic diseases, such as
those  of the heart and lungs,  more particularly, should be as-
certained.  Should such, or other complications be present, they
might require  modifications of treatment, but would not  prevent 
248
SECONDARY SYPHILIS.
its employ, as this is not only the most certain, but the safest wray
of curing all forms of constitutional syphilis.
  This plan of  treatment does not commonly require that the  pa-
tient  should forego his ordinary occupations of business, or that
he should be confined to the house during its use.  It must be  ad-
mitted that its effects would be accelerated by confinement to bed,
or to a couch in a moderately warm room; but this is by no means
imperative, and I have very rarely advised it, except in such cases
where exposure or exercise would be positively mischievous, as in
cases of sloughing,  or rapidly spreading ulcers  in  the  throat or
elsewhere.
  The diet should  be light, nutritious, and unstimulating; milk,
chocolate  or  cocoa, night and morning; animal food for dinner,
with weak wine and water. Where the patient  has been reduced
by mercury given internally, or by a combination of syphilis and
mercury, the diet may be  more nutritious; but stimulants  should
be avoided. Smoking must be prohibited, particularly in diseases
of the throat and nose.
  In  a  great majority of cases the moist mercurial vapour, em-
ployed as  I have directed, is capable of curing the disease without
the assistance of internal medicine; but the cure is generally  ex-
pedited and rendered  more certain by the administration of  the
latter in small  quantities.   The treatment is  always assisted by
the decoction of sarsaparilla or guaiacum, drank warm  night and
morning, and immediately after leaving the bath.  I prefer  the
latter, the  compound decoction, made according to  the formula of
the Edinburgh Pharmacopoeia.   Where other medicines are  re-
quired to  assist the  treatment, and I allude particularly to  the va-
rious preparations of  mercury, it  is  surprising  how small a quan-
tity is required when the patient  is using the vapour.   I have
known several instances where diseases which have been rebellious
to large quantities  of mercury, given for long periods, yield  im-
mediately the baths were employed. The effects of mercury upon
the system become very quickly manifest under the influence of the
baths, when the  system had previously resisted   this influence.
When I employ mercury internally, during the  use of the  baths,
it is either under the  form of the  biniodide, or bichloride given in
solution in small quantities, not exceeding the twentieth of  a grain
for a dose.  The use of this medicine in drachm doses of the ointment
in form of friction,  in five  grains of blue-pill or calomel,  two or
three times a day, under the old plan of treating venereal diseases 
MERCURIAL VAPOUR BATH.             249
by mercury, can never be required, except it is wished to break up
the health and constitution of the patient.  How many have never
recovered  from internal  mercurial  treatments  of  this kiud.  I
never saw the most delicate patient, either  male or female, whose
health was injured for one hour under the plan I recommend, and
I have very rarely seen a disease that has  not  been cured.   The
experience derived from the treatment  of many thousand cases
warrants me in speaking thus positively on  the subject.
  The time occupied in the cure of venereal  diseases by the mer-
curial vapour-bath is vastly less than that consumed  by any other
kind of treatment: its effects are commonly immediate, one full
bath very frequently making at once an impression on the disease.
Where  the hair has been falling  rapidly,  one  bath has arrested
this: ulcers which  have been  rapidly spreading have been  ren-
dered  stationary by one bath.  After two or three baths, the im-
provement is in most instances marked; and the cure is effected in
one fourth, or even one sixth of the time required for the success of
ordinary treatments.  The nature of the cases determines the time
occupied in the cure.   In superficial skin  diseases, or superficial
ulcers of the nose and throat, the cure is  very rapid.  I have con-
stantly known affections of this kind entirely  cured  in a fortnight
or three weeks, with pleasure  rather than inconvenience to the
patients.  In enlargements of the bones and testes, indurations of
the penis, persistent induration of the cicatrix of a primary sore,
the cure is necessarily more tedious; the  change of structure pro-
duced in such diseases must have time for removal: nevertheless,
in these cases, which require months of treatment, under common
circumstances, and which are not unfrequently considered or given
up as incurable, the moist mercurial vapour will do more in a month
than any other treatment in six.   I have known cases of indura-
tion of the penis, removed in three or four  weeks, which have not
shown the slightest disposition  to amendment after months of or-
dinary internal treatment.
  All authors and all surgeons conversant with  the  treatment of
syphilitic diseases, admit the frequency of relapses under ordinary
treatments; hence constitutional  diseases are to be feared as the
result of primary ulcers; and when one form of constitutional taint
has been apparently cured, it is commonly, after a time, succeeded
by another.  Thus venereal diseases run through those phases or
grades which have been termed primary, secondary, or tertiary;
and it has been a primary object in all plans of  treatment to have 
250
SECONDARY SYPHILIS.
recourse to those which, whilst they cure the disease then present
in the best manner, and w'ith the least risk, shall prevent the oc-
currence of future diseases under another form.  Relapses will
occasionally occur under all forms of treatment, but I will under-
take positively to state, that they are by far less frequent and im-
portant under this plan of treatment  than any other;  and when
they do occur,  are trivial, and yield with great certainty to a se-
cond application of the vapour.
  The effects of the mercurial vapour-bath upon the patient vary
under different circumstances.   If the general health of the patient
be apparently good, and we have to control a single isolated symp-
tom of disease,  such as a primary sore, an enlarged testis, or an in-
durated cicatrix, and the baths be used too frequently, the patient
would become a little languid, and  probably a little thinner; this
would be avoided by properly timing the intervals between  the
baths.   Should the patient be labouring under general constitu-
tional taint, and exhibit as local symptoms loss of hair, sore throat,
ulcers of the nose, or skin diseases, he almost invariably gets fat
under the treatment.  The mouth is commonly affected, after using
four or six baths, more quickly if the head be immersed, which is
better: some patients can bear the head in the bath for five, ten, or
even twenty minutes without inconvenience: patients vary in this
particular; and it depends very much on the form of mercurial  em-
ployed.  The gums, when affected, are red, elevated, and tender,
but the baths never produce salivation, or ulceration of the mouth,
  Some forms  of constitutional syphilitic  diseases more readily
yield to the use of the vapour than others.  Some are cured with
an extraordinary degree of rapidity, and are perfectly cured, which
is proved by their not having relapsed, or presented a fresh vene-
real  symptom after many years.  These forms are  superficial  dis-
eases of the skin, loss of hair, superficial ulcerations  of the nose
and throat.
  Some varieties require  a longer treatment, as diseases of the
deeper-seated parts of the skin, some forms of ulceration, diseases
of the testicles and of the bones.
   To all  forms of constitutional syphilitic disease, the  treatment
by vapour is applicable, and beyond all doubt the  most speedy,
certain, and safe remedy that can be employed; yet there are some
forms of disease which yield with  greater rapidity than  others.
That which gives way with the greatest difficulty is the induration
which succeeds to the healing  of a primary sore.  I do  not mean 
MERCURIAL VAPOUR BATH.
251
that soft fulness which is sometimes found in such situations, but
that cartilaginous hardness which is met with under the  skin, and
which is sure, sooner or later, to end in local or constitutional mis-
chief.   I have seen cases which have resisted all  modes of treat-
ment but the baths; to these they yield but slowly, but they do
yield, and with certainty, after other plans of treatment have been
followed for months without  success, or with but partial amend-
ment.
  One or two objections have been raised  to this plan of treat-
ment by the reviewers of the last edition  of this work.  These
are easily answered, and would never have  been made had those
gentlemen been familiar with its practical  working.   The  chief
objection which has been raised, is that it is unmanageable, and the
quantity of mercury introduced into the system cannot be regulated,
and that rapid and severe salivation might occur.   For nearly
twenty  years I  have administered, or superintended the adminis-
tration  of this bath, from four to six times  every day, and I have
never seen one  case where  such an effect has been produced.
  The  analogy has been  made  with  the dry fume, which  some-
times has produced such an effect: the mixture and dilution of the
vapours of mercury with common steam, and the sweating induced
by  the bath, entirely removes any fear of this kind, and I would
stake my reputation that with proper management  it cannot oc-
cur.
  I must not be understood to say that I consider or  recommend
the mercurial vapour bath  as a specific remedy in all forms of con-
stitutional syphilis, but I repeat that it is the most powerful thera-
peutic agent in the removal of  disease, and the least  harmful to
the constitution of the patient of any  remedy with which I am ac-
quainted; neither am I so prejudiced in favour  of this remedy as
to reject the assistance of all others, which, as we shall presently
see, when associated with it, under certain circumstances, produce
the best effects, but which  effects, I am bound  to say, would not,
under many circumstances,  occur without the assistance of the va-
pour,  since in numerous instances these remedies have  failed in
curing the disease when used alone.  The profuse sweating induced
by the bath, prevents the accumulation of either iodine or mercury
in the system, and  thus contributes materially to the preservation
of the constitution of the patient. 
252
SECONDARY SYPHILIS.
                  THE CHLORIDE OF MERCURY.
  Calomel  may  be administered internally,  as  an antisyphilitic,
united to opium, or conicum and soap; it is, however, an uncertain and
unsatisfactory remedy, and one which, under such  circumstances,
except as an  aperient, I should  never employ internally.  Apart
from its internal exhibition, however, it has various uses in the
treatment of  syphilis.  Mixed with lime water in various propor-
tions, it forms a wash or lotion, exceedingly useful in dressing many
primary and  secondary venereal ulcers.  Formerly, mixed  with
honey, it was used by way of frictions on the tongue and gums,
according to the  methods of Clare and M. Brachet, of Lyons.   The
only way in which I use calomel, under ordinary circumstances, in
the treatment of syphilis, is in ulcerations of the nasal fossae, where,
mixed with powdered acacia, a  small quantity is blown into the
nares two or  three times a day.   I have  used this in the  Queen's
Hospital and in  private practice frequently.   After the failure of
other means M.  Biett has  used it in this way, with complete and
prompt success.
                    R.  Hyd. chloridi, gr. ij—v;
                       Pulv. acaciae, gr. v.
                    M. ft. pulvis ter die utend.

  M. Biett has carried the insufflation of calomel to the extent of
fifteen or  twenty grains a day.  Some very  remarkable and good
cures were  obtained in this way.  All modes of administering calo-
mel are, however, open to the objection of producing a troublesome
salivation.

                 THE BICHLORIDE OF  MERCURY.
  The bichloride of mercury is a valuable  remedy in the treat-
ment of many forms of constitutional syphilis, particularly of those
varieties which  are  complicated with ulcerations of the mucous
surfaces. According to Dzondi, whose method of treating syphilis
is extensively followed in Germany, and at the  La Charite Hospi-
tal of Berlin, the bichloride of  mercury is the chief preparation
of this remedy on which reliance should be  placed in the treat-
ment of constitutional syphilis.  This was a favourite remedy of
Dupuytren's,  who gave it in small doses in the form of pills.

                    R.  Hydr. bichloridi, gr. ij;
                       Pulv. opii, gr. viij;
                       Pulv. guaiaci, gr. xxxii.
                    M. ft. Pil. xvj; j ter die. 
THE IODIDE OP MERCURY.
253
  Dzondi's pills each contain one twentieth of a grain of the bi-
chloride, united with a small quantity of opium.  He administered,
in the commencement, four a day, half an hour after  the dinner
meal.  Twelve grains of the  bichloride  are made with an inert
powder, as liquorice, into 238  pills.  Four of these pills are given
the first day; the day but one after, six; increasing the dose two
pills every day, and leaving one day's interval between each dose,
so that on the thirtieth  day from the commencement, the patient
takes thirty pills, or one grain and a half of the salt.
   The bichloride of mercury  is much better administered in solu-
tion; it is a favourite remedy with  me.   I exhibit it  in solution,
with some decoction of  the woods, either of guaiacum, or sarsapa-
rilla. From twenty drops to a drachm or more of the Liquor Hy-
drargyri Bichloridi may be given in a tumblerful of one of these
decoctions, twice or thrice a day with the best effect.  United with
bark and hydrochloric acid, it is also exceedingly useful in the ad-
vanced stages of constitutional syphilis in debilitated habits.
   Mixed with lime water, in the proportions of from four to eight
grains to the half pint, it forms a useful application  to many se-
condary venereal ulcers.  I exclude from consideration the method
of Cirillo, which consists in using the bichloride  mixed with lard,
by way of friction, on the soles of the feet.

                    THE IODIDE OF MERCURY.
   The iodide and biniodide of mercury were first introduced into
the therapeutics of syphilis by Biett of St. Louis, and since largely
employed in that hospital by his successor, M. Cazenave.  They are
most valuable remedies in the treatment of many forms of consti-
tutional  syphilis, and I have for years employed them both, but
more especially the biniodide, with almost uniform success.  Many
surgeons who have employed it associate it with opium, but Biett
and Cazenave state that its combination with opium destroys  its
curative properties, although its efficacy is increased by treating
the patient with daily doses of opium for a few days before the use
of the iodide is commenced; it  is useful also  to omit  the remedy
for a day, every three, and give a full dose of opium.  The iodide
of mercury must be administered in the form of pill combined with
lactucarium, in doses of from one to three grains.
R.  Hydr. iodidi, gr. x.;
    Lactucarii, J)ij.  M.  ft. pil. xx. 
254
SECONDARY SYPHILIS.
 From one to four pills a day (Cazenave.)  A very good way of ad-
 ministering the iodide has been suggested by Dr. Neligan, to sub-
 stitute it for the calomel in Plummer's pill.
   The iodide of mercury is indicated in pustular, and tubercular
 diseases of the skin, in diseases of the bones and testes; in secon-
 dary venereal ulcerations, where the constitution has long suffered
 protracted and varied treatments, and  still the disease remains.
 It frequently cures after the failure of other remedies: its employ
 should  be associated with a nourishing,  but not stimulating diet,
 decoctions of the woods, and the mercurial vapour-bath.

                  THE BINIODIDE OF  MERCURY.
   I prefer the biniodide of mercury  to the iodide:  I find it agree
 well with the gastric constitution of the  patient, which the iodide
 frequently does not.  It is more manageable, and can be given in
 solution, a great advantage.  I employ  it always in solution with
 the iodide of potassium, a combination which I  have  been in the
 habit of prescribing in the Queen's Hospital for years.

                   R.  Hydr. biniodidi,  gr. iij;
                       Potass, iodidi, 3J —-3iij ;   /
                       Sp. vini, 3J;
                       Syrup, zinaib., ^iij;
                       Aquae dest., ^iss. M.

 Twenty or thirty drops three times a day in half a tumbler of some
 decoction of the woods.   M. Puch, of the  Hopital du  Midi, employs
 a form  somewhat similar.   This remedy is indicated  in the same
cases as the iodide.  Used in small doses with the mercurial vapour-
 bath, it produces excellent and permanent cures.

                  THE BICYANIDE OF  MERCURY.
  The bicyanide of mercury is frequently employed in secondary
syphilis, and for the following reasons.  It is soluble,  and not liable
to decomposition, acts  quickly, and does  not occasion  those pains
in the stomach and bowels  that so frequently accompany the pro-
longed  administration of some other preparations.   According to
the researches of M. Parent-du-Chatelet,1 the bicyanide of mercury
is not decomposed by either acids or alkalies, nor by decoctions con-
taining azotized principles  or gallic acid.
  The bicyanide of mercury may be administered  internally  in
1 Revue M£dicale, Aout, 1832. 
THE IODIDE  OF POTASSIUM.             255
 pills, or in solution, and used externally in form  of pomade or
 ointment.   Externally it is an extremely useful application to va-
 rious forms of herpes, particularly that form  termed  by Alibert,
 "herpes squamosus," the violent itching and irritation of which it
 allays.  It may be employed externally also as a dressing to indo-
 lent syphilitic ulcers, and scirrhous  tubercles, or  as a gargle in
 ulcerations of the throat.  The dose of the bicyanide is from x\ of
 a grain to a grain.

                 GARGLE OF THE  BICYANIDE OP MERCURY.
                  R.  Hydrargyri bicyanidi, gr. x;
                      Infus. lini comp. fl)j.  M.
                 SOLUTION OP THE BICYANIDE OF MERCURY.
                R.  Hydrargyri  bicyanidi, gr. vj ad gr. x.
                    Aquae, Ibj.   M.

 Half an ounce for a dose, administered in a mucilaginous vehicle
 or with the addition of sugar in form of syrup.

                  PILLS OF THE BICYANIDE OF MERCURY.
                  R.  Hydrargyri bicyanidi, gr. xxiv;
                      Ammonias muriatis, ^hj;
                      Guaiaci gummi, J iij;
                      Ext. aooniti, giij;
                      01. anisi,  TIJ xxiv.
                  M. mucilaginis, q. s. ft. pil. 400.

   One  or two twice or three  times a day, the  dose  gradually in-
 creased.  Each pill contains about T'8 of a grain of the bicyanide.
 These pills are a substitute for the bichloride of mercury in many
 forms of secondary syphilis.

                   THE IODIDE OF POTASSIUM.
   Iodine and its preparations, more particularly the iodide of po-
 tassium, are employed largely in the treatment of all forms of sy*
 philis.  Desruelles has recorded  several cases  of the cure of pri-
 mary sores with the iodide.  Hanck and  Kluge have, on the con-
 trary, given the results of  four hundred cases of primary syphilis
 in which the iodide of potassium had little or no effect.  M. Payan
 has related  some cases of indurated chancre, and  primary sorea
 with bubo, which yielded to treatment by the iodide.  My own ex-
 perience is  against the use of  the iodide in primary syphilis, ex-
 cept in some cases of phagedena, in bad  habits of  body, where  I
have seen it useful.  M.  Payan  lays it down as a  principle, that 
256
SECONDARY SYPHILIS.
the efficacy of the  iodide of potassium is in  direct ratio with the
long-standing of disease, and hence M. Ricord and others have been
led to regard this remedy as almost specific in what M. Ricord terms
tertiary symptoms, such as nodes, tubercles, affection of the testes,
pains in the  bones, caries, and  certain forms  of secondary ulcera-
tions.  M. Ricord regards the  iodide of potassium  as a  prophy-
lactic against tertiary symptoms when  secondary symptoms have
disappeared under the use of mercury.
   It is certainly in the class of cases just alluded to that the iodide
of potassium is most useful, and under many circumstances works
remarkable cures.  The iodide of potassium, as I have  already
said, is not to be depended on in the  treatment of primary sores;
neither is it generally indicated in the earlier stages of secondary
eruptions in healthy subjects, nor in the confirmed or chronic stages
of scaly or papular diseases of the skin.  In such complaints, an-
timonials, or the bichloride or biniodide of mercury in small doses,
in decoctions of  the  woods, are infinitely more certain and  effec-
tual.
   In  pustular and  tubercular  skin  disease, or in the secondary
forms of ulceration which succeed to these, more especially if mer-
cury have failed in their treatment, or the patient be weak and de-
bilitated,  or over forty years of age, the iodide of potassium is a
most valuable therapeutic agent.
   There are, however,  many  cases  of this nature  in which  the
iodide rather suspends than cures disease; and its prolonged  use
disposes  to  wasting  of the body,  and under some  circumstances
utterly destroys  the digestive powers.  I have known cases where
it has been taken respectively for  three, five, nine, and ten years;
and in these cases the  symptoms have returned when the iodide
has been discontinued.  A case will be found  in the next Chapter,
of a surgeon who took  three daily  doses for ten years, and yet his
disease remained.   Whilst he took the iodide the symptoms  were
kept under, but when he omitted it they always returned.  Pains
in the bones are very apt to return directly the iodide is given up.
Such cases are not singular; they  are exceedingly frequent.   Dr.
Neligan says, "Iodine and its preparations should not be trusted
to alone with the intention of producing  a specific  action in  the
treatment of the secondary eruptions; their combination with mer-
curials is of especial service, but, unless thus prescribed, they usu-
ally disappoint.  In scrofulous habits their administration should
never be omitted, but still a mercurial must be given with them. 
THE IODIDE OF POTASSIUM.
257
The administration of the iodide of potassium is attended with
the best results, as soon as the preparation of mercury which has
been given, evidences its action on the system by the mouth being
affected."1
  The iodide of potassium cannot be taken by some patients; in
many it produces swelling of the tongue, and salivation; in others,
puffing andswelling of the face, and a stiffness of the  muscles of
mastication.  I do not think it produces wasting of the glandular
organs, such as the testes and mammas.  1 have elsewhere ("Pro-
vincial Medical  and Surgical Journal,") recorded several cases of
the prolonged  use  of the iodide where the testes, &c, were un-
affected.
  The iodide of potassium may be administered in doses of three
to twenty grains three times a day, in distilled water, or some su-
dorific decoction, as sarsaparilla, saponaria, &c.  By some surgeons
its use has been carried much farther, and several cases have been
recorded wdiere the iodide of potassium has succeededin large doses
where it has failed  in smaller ones.  M. Vidal mentions a case of
ulceration of the tongue, where  the iodide had been taken for six
months to the extent  of twelve grains a day without benefit, which
healed in thirty days where the patient took for the first few days
thirty-six grains a day, and  afterwards seventy-two grains a day.
In  small  doses  the iodide is tonic, and as such may be employed
as a prophylactic of a further outbreak;  when  given after a mer-
curial course which has  been employed for the cure of secondary
symptoms, and  which have  disappeared' under  such  treatment.
The iodide should then be given in small doses, five or eight grains
three times a day, in  some sudorific decoction, for some time.
   When, again, secondary symptoms do  not  yield to mercury or
only partially yield, or where the remedy appears to benefit for a
time, and then loses its effect, its use should be given up, and the
iodine taken for some weeks in small doses; the mercurial  course
should then  be resumed, with another form of mercurial remedy,.
and it will  be commonly found  that the symptoms very quickly
yield.
   It is in large doses, rarely less than from ten grains to a scruple,.
that the iodide of potassium acts as a direct anti-syphilitic.

              *      * On Diseases of the Skin, p. 398.
       17 
258
SECONDARY SYPHILIS.
                         IODIDE OF SODIUM.
   The iodide of sodium has lately been recommended as a substi-
 tute for the iodide of potassium, by Dr. Gamberini, of the Hospital
 of Saint Orsola, Bologna.1   The following are the-conclusions made
 by Dr.  Gamberini:
   1. The  taste of  the iodide of sodium is much less disagreeable
 than the iodide of potassium.
   2. It is much less likely to occasion iodism.
   3. It is better borne than the iodide of potassium, and in conse-
 quence of this its  dose can be almost daily increased, and it thus
 becomes a more efficient remedy.
   4. It has succeeded where the iodide of potassium has failed.
   5. We may commence with doses of a scruple a day; two drachms
 a day have been taken without the slightest inconvenience.
   6. The  iodide of sodium is admirably suited  to cases in which
 the  corresponding  salt of potassium is indicated.
   7. The  iodide of potassium is the  best substitute  for mercury.2

                           IODIDE  OF IRON.
   The iodide of iron  may be employed with or without the iodide
 of potassium, in many of the advanced stages of constitutional sy-
 philis.   The cases best suited to its exhibition are those of syphilitic
 cachexia,  or chlorosis, complicated with old ulcers, or diseases of
 the bones, in a strumous habit of body.   It is advantageously pre-
 scribed in one  of the  decoctions of the  woods, hereafter spoken of.

  1 See Dublin Quarterly Journal, No. 28, Nov.,  1852.
  2 I have used the iodide of sodium  largely in the Queen's Hospital, prepared by
-an eminent and experienced manufacturing chemist of this town, Mr. Philip Harris.
 It has been successful in those cases where the iodide of potassium might also have
 been beneficial, such as nocturnal pains, diseases of the bones, and the ulcerating
 forms of tubercle.   In one  case of sj'philitic tubercle of the tongue, its effects were
 very speedy and marked.  It may advantageously replace the iodide of potassium in
 many cases where the latter cannot be borne, as it does not produce swelling of the
 tongue, discharge from  the nose or eyes, pains in the muscles of the face, or any
 pustular eruption, so common under the use of the iodide of potassium.  It is well
 known that some patients cannot take the iodide of potassium where it is strongly
 indicated, and here the  iodide of sodium will  prove useful: it is also exceedingly
 probable that it may cure where the iodide of potassium has failed.  On the whole,
 my experience in the use of this salt has been such, as to warrant my recommending
 it as a very valuable addition to the remedies at present employe^ in the treatment
 of constitutional syphilis, and it is exceedingly probable that many cases will occur,
 where it may find its special application.
  I have employed the  iodide of sodium, as an anti-syphilitic, in  doses of fifteen
 grains three  times a day, 
                     SUDORIFICS, ETC.                   259

       SUDORIFICS, VEGETABLE DECOCTIONS, AND INFUSIONS.
  The various vegetable decoctions and infusions have been long,
and are still, employed in the  treatment of secondary and consti-
tutional syphilis.   To some of these a specific action has been at-
tributed, whereas others must be looked upon as auxiliary remedies
merely, whose action is  comparatively feeble.   Of themselves, it
may I think be said, that they never cure alone;  occasionally some
symptoms disappear under their use, but generally return when this
remedy is omitted.   In many forms of skin disease these decoctions
of the woods are useful; as auxiliaries, they  certainly assist  the
action of other remedies, and I always prescribe  them with  this
view, during the time a patient is using the mercurial vapour-bath.
  The remedies which are chiefly useful in this  way, are sarsapa-
rilla, guaiacum, burdock, water-dock, saponaria, sassafras, dulcama-
ra, mezereon, and elm-bark. I generally recommend the compound
decoction of sarsaparilla, made according to the form of the London
Pharmacopoeia, or what I think better, the compound  decoction of
guaiacum of the Dublin  and Edinburgh Colleges, to be taken with
the bichloride or biniodide of mercury, or the iodide of potassium.
The  saponaria is a favourite  remedy with many Continental  sur-
geons, who seem to  place much faith in it as an  auxiliary remedy.
Mr. Whitehead speaks highly of the Rumex hydrolapathum (Water-
dock) in the secondary, or  rather  the  tertiary  forms  of syphilis.
Mr. Whitehead says its virtues as an anti-syphilitic cannot be too
highly extolled.  The only part recommended for use is the root.
Most of these remedies may be employed in  form of decoction, in
the  proportions of about an ounce to a pint.   All these decoctions
should be prepared  fresh every two or three days.
   In Germany especially, an empirical treatment by the decoction
of Zittman is said to be  very frequently successful; it is associated
with aperients, rest  in bed, and a most rigid diet.  It is, as Mr. E.
Wilson truly says, a compound of sweating, starving, and purging.
1 have seen several German patients, who  have been treated by
this plan, and their diseases not cured.  It reduces the patients to
an  extreme degree of weakness, and requires confinement to  bed
during the course.
                        ZITTMAN'S DECOCTION.
                    R.   Rad. sarsaparillae, ^xij;                ,
                        Aquae, ft xxiv.
                    Boil for two hours, and add— 
260
SECONDARY SYPHILIS.
                       Aluminis sulph., §iss;
                       Hydrarg. chlorid., gss;
                       Antimonii sulphuret., gj.
                   Boil down to two thirds, and add—
                       Fol. semne, t|iij;
                       Rad. glycirrhizae, ^iss;
                       Sem. anisi, ^ss.
                   Infuse for an hour, and strain.

This is  termed the stronger decoction.  The weaker one is to be
prepared by taking the residue which remains  after  straining the
stronger, and adding

                   R.  Bad. sarsaparillae, ^ij;
                       Aquae fontanse, lb xxiv.
                   Boil for two hours, and add—
                       Corticis canellse,  ")
                       Corticis limonum, s. aa giij.
                       Semin. cardamomi, J
                   Infuse for an hour, and strain.

The patient is directed to take  half a pint of the stronger decoc-
tion the first thing in  the morning, warm, and to remain in bed
some time after taking  it.  During the day, he should take at in-
tervals a pint of the weaker decoction, and  in the evening a second
half pint of the stronger.  The  last two doses are to be taken cold.
Every fifth  day the decoctions are to be omitted, and an aperient
taken.
  In some anomalous forms of scaly venereal diseases of the skin,
arsenic has been recommended:  alone, it is rarely if ever successful
in pure syphilis: with the iodide of potass, or mercury, it is some-
times useful.   In Donovan's solution, the,arsenic is combined with
both remedies.1  I have  found this  remedy uncertain, sometimes
inert, at others too active.

                             OPIUM.
   Opium has, by a number of authorities, both ancient and modern,
been extolled as a remedy  of great value  in the  treatment  of
many forms of syphilis, and by many surgeons the dose has been
carried to  the extent  of twenty or  even thirty grains in the day.
The cases in which opium is indicated, and in which I have em-
ployed  it with success,  are those  of constitutional syphilis where
the  health  has been broken by protracted disease and  the use of
1 Liquor Arsenici et Hydrargyri hydriodatis, Ph. D. 
OPIUM.
261
mercury;  when the nights are bad, and the patient emaciated and
feeble;  where a general irritability,  the result of disease and
mercury, prevails,  and appears to be wearing the patient out.
  In exostoses, periostoses, local pains, and secondary ulcerations,
occurring in constitutions and in persons thus circumstanced, opium
in large doses sometimes acts magically.   I have, employed it also
with marked success in secondary ulcerations of the throat which
have  remained after mercury had been a long time used,  and the
ulcers still remained rebellious to every plan of treatment.  In
protracted ptyalism, resisting local treatment, it is also very effi-
cacious.   In all these instances opium appears to subdue a certain
constitutional irritability which keeps up the disease  and upon
which the disease appears to depend more than upon any specific
cause.  It is surprising what large doses of the drug patients in this
state  will sometimes bear without producing constipation or head-
ache.  I have rarely given more  than four or five  grains a day,
but I have no doubt the dose, as recorded experience has already
proved,'might be  carried much  further without any risk, should
the circumstances  of the case require it.  In summing up the his-
tory of the remedies employed in constitutional syphilis, Cazenave
says,  "We have yet another mode of treatment to recommend, by
whose agency we  have seen the most formidable symptoms yield,
the most inveterate ulcerations healed, and the most durable cures
produced, when all other remedies have failed.  We speak of the
aqueous extract of opium, a precious remedy, even in the most pro-
found cachexia."1
1 Traite" des Syphilides, &c; Paris, 1843. 
262
SECONDARY SYPHILIS.
                     CHAPTER XXXIII.

CLINICAL OBSERVATIONS ON  THE TREATMENT OF SECONDARY  CONSTI-
  TUTIONAL AND CONFIRMED SYPHILIS, BY THE MERCURIAL VAPOUR-
  BATH, AND OTHER REMEDIES.

                         Case XXIX.
Various forms of constitutional syphilis for five years; failure of various remedies;
                   rapid cure by mercurial vapour.
  A physician contracted, in the year 1845, a sore at the orifice
of the urethra, which was followed by two buboes, which did not
suppurate freely: the patient's health was very much impaired by
this disease, and his constitution  had been previously debilitated
by hard work, and  an attack of typhus fever.  In August, 1849,
he had ulceration of the throat; in three weeks the palate  was
destroyed  to a considerable  extent.  After the ulceration  had
healed an artificial palate was applied: shortly after this the ulce-
ration again appeared, and has not again healed,  In November,
1850, this gentleman placed  himself under my care, and at that
period he was in the following state:
  A sloughy, foul, phagedenic ulcer occupied the left tonsil, the
whole of the pharynx, and the back part of the roof of the mouth.
In addition, there was a general faint copper-coloured mottling of
the skin  generally, a large scaly blotch on the chest, and a large
pustulo-cutaneous spot on the  back; on the  legs the cicatrices of
what appeared to have  been secondary ulcers, succeeding to pus-
tules or tubercles.  The health wras much impaired, the weakness
great, nights bad, severe pain in the throat, and a fetid discharge
from the nose.
  The patient used the mercurial vapour-bath every other day;
was directed to take the cold infusion of sarsaparilla with lime
water, with half a grain of the hydrochlorate of morphiae at bed-
time, and to wash out the throat  frequently with a weak creasote
gargle.   The diet to consist of wine and water, fresh animal food,
cocoa, and milk. 
cases.                        263
   The seventh bath was  administered on  November 20th.  The
copper-coloured mottling of the skin was all gone, the pustulo-
crustaceous spot on the back shrivelled up  into a hard crust, with-
out an ulcer underneath.  All the ulcers in  the throat and pharynx
rapidly healing, the general health, appetite, and strength much
improved, nights good, gums sore, no salivation.  This gentleman
could never take mercury internally under any form; when perse-
vered in  for a few days in this manner, it always produced dis-
tressing tenesmus, and great bodily and mental depression.
   Up to  December 2d, the  baths were administered every third
day: on that date all  the ulceration had healed; a very small
granulating healthy sac only remained in the centre of the site of
the old disease.   Gums sore, appetite good, no salivation.  All the
skin disease  had disappeared.  This patient was under my treat-
ment three weeks,  during which time he took fourteen baths.
He pursued the  treatment after he left me  for some time;  but the
cure appeared perfect.
   On writing to me a few weeks afterwards, he says, "My medical
friends  are quite  astonished at the  rapid  progress I have made
under the use of the vapour, both in regard to my throat  and my
general health."

                         CASE  XXX.
Constitutional syphilis under various forms for three years; failure of various reme-
   dies, especially the iodide of potassium; cure by the mercurial vapour-bath.
   A young gentleman, apparently healthy, contracted a primary
sore in 1849, which was four months healing, and left behind it an
induration which lasted two months longer.   The throat was  at-
tacked with secondary syphilitic ulceration before the chancre had
healed.   In 1850, he had an attack of skin disease, which was
succeeded by nocturnal pains in the  head  and legs: these pains,
being partially benefited by medicine, recurred with so  much vio-
lence in January, 1851, that he was confined to bed till  March.
The pains were  always mitigated, and  sometimes removed for a
short period, by the iodide of potassium;  but when this  remedy
was laid aside they invariably returned, a circumstance which very
frequently attends the  treatment of syphilis by the iodide, which
the history of the next case illustrates in a very marked degree.
   In August, 1851, this patient placed himself under my care. 1 did
not see him in any of the previous attacks which I have mentioned.
He had, at the present date, constant severe pains of the arms, legs, 
264
SECONDARY SYPHILIS.
and bones, which were worse on damp days, and when in bed.
There were also pustulo-crustaceous spots on the head, and a dry
red throat. All the symptoms disappeared under one month's treat-
ment by the vapour, and the use of the decoction of guaiacum.  In
twelve months afterwards no pain was felt.  Early in 1852, there
wras a very slight return, which was removed by the treatment first
adopted, which was again followed for a very short time: since that
period  there  has  been no fresh symptom,  and the  patient has ap-
peared perfectly well.

                         Case XXXI.
Constitutional syphilis for twenty-four years; repeated salivation; prolonged use of
   the iodide of potassium; failure of these remedies; great reUef and cure of many
   of the symptoms by the mercurial vapour-bath, &c.
  A surgeon, Eet. 47, consulted me in May, 1850, for various symp-
toms of constitutional syphilis, from which he had suffered for twen-
ty-four years.  He had, at the time when he consulted me, syphi-
litic sarcocele of the right testis, complicated with a small hydrocele;
a well-marked syphilitic psoriasis of the hands, which were like a
fish's skin, so  thick and hard were many of the scales: at times the
hands became painful and inflamed: he had also general thickening,
with enlargement of the tongue, which was covered with  hard
lumps, between which were deep fissures, extending nearly through
the whole substance of the tongue.
  This patient had taken ten grains of iodide of potass three times
a day for ten years: his appetite was bad, and he looked dry and
shrivelled. When the iodide was omitted, the hands always became
painful and inflamed, but no farther progress towards a cure was
made by the use of this remedy: when discontinued  for a few days,
all the  symptoms returned as badly as ever.
  I recommended the use of the mercurial vapour-bath three times
a week, ten grains of the extract of conium at bed-time, with the
cold  infusion of  sarsaparilla in lime water.  I must confess I felt
very uncertain about the  issue of this case.  In November, i. e.
about six months after I had first seen this  gentleman, he called
again on me:  I did not know him:  he had regained his flesh and
appetite, and  the  hands were well; the tongue most materially im-
proved, and the  sarcocele  much reduced.   He  was under an en-
gagement to marry; and stated that his  health had never been so
good as now,  since the  first outbreak of disease, twenty-four years
ago. 
CASES.
265
                        Case XXXII.
Pustular syphilitic disease of the skin (ecthyma,) with other symptoms of constitu-
    tional syphilis for two years; various treatments without effect; rapid disap-
    pearance of the symptoms by the use of the mercurial vapour-bath.
  A gentleman,  set. 34, of delicate health,fwas sent to me, on June
24, 1850, labouring under a most formidable attack of secondary
syphilis.  He had had primary sores two years before, and various
forms of eruption on the skin, from that time to the present.  This
patient's disease was  what I have described  as " pustulo-crusta-
ceous."  There were large distinct pustules on the face, head, body,
and limbs, to the number of about thirty-five.   In two places, the
pustules were smaller and placed in groups:  this happened on the
forehead, and on the  chest.   The pustules soon became covered
with dark-coloured, laminated, or conical  crusts, closely adherent
to the parts underneath, and surrounded for a short distance by a
deep red, or livid margin.   The crusts when  detached, were found
to have covered  ulcers more or less  deep, which, if healed when
the crust fell off, left behind  it a deep and vividly red cicatrix
slightly depressed: if the crust were detached before the ulcers they
covered were healed, the ulcers were superficial, but foul, unhealthy,
and disposed to  spread: the crusts situated over bones, or on the
forehead, ulna,  and ribs, when detached, always  left  a deeper
depression than  on the skin, and the surface of the bone over which
they were placed was always absorbed to a slight extent.  In ad-
dition to this formidable local mischief, the patient was weak, ema-
ciated, had night sweats and diarrhoea.
   The  mercurial vapour-bath was used for  a few minutes each
day, opiates  were administered at night, and the cold infusion of
sarsaparilla  in  lime  water was given.  The diet was good, wine
and ale being freely given.
   On July 5th, a great part of the crusts had fallen, and had left
the skin sound  underneath: many of the sores looked healthy,
others not so;  the general health much  better; appetite good;
bowels were settled; strength daily improving; patient bears the
baths for a longer periodJ|ith comfort; mouth sore; no salivation.
   In six weeks, the time I personally treated this patient, twenty
baths were taken; and at the end of this period all the  crusts had
fallen,and all the sores had healed; the bowels were regular, and
the health and appetite  good.   The  red colour of the cicatrices
remained for some weeks, gradually dying away:  this  is always 
266
SECONDARY SYPHILIS.
a work of time.  The patient has continued in good health since;
and there has been no recurrence of any fresh syphilitic symptom.

                        Case XXXIII.
Constitutional syphilis for seven years; failure of various remedies, amongst others,
   the iodide of potassium, and mercury pushed to salivation; complete cure by
   the mercurial vapour-bath, and very small doses of the biniodide of mercury.
  A married lady, set.  30, was brought to me by  her husband,
from Paris, to be treated by the mercurial vapour-bath.   She had
suffered from constitutional syphilis for seven years, but had never
had any primary affection; neither  on careful  and minute exami-
nation could I detect any disease of the sexual organs themselves.
Her disease consisted in dusky red patches spread over the whole
body, covered with a  dry dandriff or scurf, not to be  called  a
scale: in places the disease assumed the form of irregular patches,
in others circles or rings;  they were  uniformly spread over the
back, arms, chest,  &c.   On the knee was a ring  of rupial crusts,
resting on an inflamed base.   The patient had suffered from ulcers
of the throat,  and had entirely lost her hair.
  For seven years this  disease had remained uninfluenced by re-
medies.  A leading surgical authority did me the honour to recom-
mend my plan of treatment to be tried in this case, as  mercury
under the usual forms,  iodides, decoctions of  the woods, &c. had
all failed.
  The treatment by the mercurial vapour-bath  was commenced on
the 16th of July, 1851.   The  baths were used three times a week,
sometimes more frequently, and one twelfth of  the biniodide of
mercury was given in solution three times  a day in water.   On the
12th of August the skin was clear, all the coppery red stains, in
circles and patches, had disappeared; the skin  clean and soft; the
rupial ring on  the knee, or rather the dark stain it had left, was
fast disappearing.   At this period, the  patient left me.   The baths
were resumed again, after the lapse of a week, for a month;  since
which period the  cure  has appeared perfect, the health has been
good, and no other symptom of syphilis has appeared.   The gums
w^ere sore and spongy from the baths,^8ut no salivation was  pro-
duced. 
CASES.
267
                        Case XXXIV.
Constitutional syphilis, with bad health for seven years; failure of iodine, and mer-
   curial treatments, as commonly conducted;  disappearance of all the symptoms
   after a treatment by the mercurial vapour-bath, with the biniodide of mercury,
   and the iodide of potassium.
  A barrister, aet. 30, placed  himself under my care in August,
1850.  He had suffered from constitutional syphilis for seven years,
for which he had undergone a variety of treatment, under the com-
bined  influence of which, and his disease,  his health had become
completely broken.   When he first visited  me,  he suffered from
the following syphilitic symptoms: the face, arms, and body, were
covered with large pustulo-crustaceous patches; these patches con-
sisted  of a red base, upon which was placed dark flat crusts; some
of these crusts were large, others  small; they did not cover ulcers.
In other places there were large lividly red blotches elevated above
the skin: after a time these suppurated slightly in the centre, and
became covered with' a thick, black, flat crust.  On the cheek, just
below the orbit, on the left side, was a large solid tumour, lividly
red  on its surface, but presenting no  fluctuation (syphilitic tuber-
cle.)   Under and around each blotch, the skin was thickened and
indurated;  this thickening evidently implicating the whole thick-
ness of the  skin.  Both legs were painful, and  the shin  bones were
uneven and tender to the touch.   The patient was weak, tormented
with night perspirations  and pains, the digestion  bad,  and the
bowels disposed to relaxation.
   The treatment was commenced  on August 20th, and consisted of
the following plan: The mercurial vapour-bath four times a week,
with the twelfth of a grain of the biniodide of mercury in solution,
with three grains of the iodide of potassium twice a day: at night,
the patient  took ten  grains of the extract of conium, and drank
half a pint  of the warm  decoction of guaiacum; the  diet to  be
good,  but not stimulating.  This gentleman was treated personally
by me for eighteen days: he took fifteen baths:  at the  end of that
time the skin was soft and healthy, with  the exception of some
slight red stains, where the ulcers and tubercles had been situated.
All  the induration and thickening were gone.   The pains in the
limbs, and the night perspirations had also left.   The  gums were
puffy, swollen and sore; no salivation.
   He  was directed to continue the use  of  the vapour  three times
a week,  and to drink the cold  infusion of sarsaparilla in  lime
 water. 
268
SECONDARY syphilis.
  Writing to me  in October, this patient says: "I have already
commenced the beginning of the end of the treatment: I am won-
derfully improved in my general health, and  every appearance of
disease has entirely disappeared.   I am  enjoying  an  elasticity of
body and mind I have been a stranger to for many years.  I shall
think it my duty to humanity to become the propagandist of your
system of  treatment."

                         Case XXXV.
Constitutional syphilis for two years; failure of various remedies; cure by the mer-
               curial vapour, without any other remedy.
  A gentleman, set. 23,  placed himself under my care in January,
1849, suffering from  the  following symptoms:  sarcocele of  the
right testis;  severe nocturnal pains in the head,  arms, and legs,
their severity preventing rest at night altogether; a general cop-
per-coloured  mottling of the face, chest, and abdomen; three well-
marked large syphilitic tubercles on the cheek: he had suffered
from various  forms of secondary syphilis for two years, had  taken
so much medicine that  he declared it was impossible for him to
take any more, let the consequence  be what it might.
  I placed him on a milk diet, and commenced the use of the mer-
curial vapour, on January 17th; the head was placed  in the bath:
on February  4th every symptom had disappeared.  On June  1st,
a few scaly spots reappeared on the hands: four baths were taken,
the symptoms disappeared: the patient, whom I frequently see, has
enjoyed the  best health since  that  period.  No medicines were
taken.

                        Case XXXVI.
Ulceration and pains in the throat; thick scaly blotches, with burning and heat of
            the hands and feet; cure by the mercurial vapour.
  A gentleman aged 24, had suffered from many  forms of secon-
dary syphilis for eighteen months, many of which had disappeared
under treatment; but there remained an ulceration of the throat,
accompanied  by occasional severe pains in that part; but the chief
symptoms of annoyance were the hands, each of which was co-
vered for  three parts of its surface with a thick  scaly red patch,
occupying the whole of each palm, and part of the thumb and fin-
gers. The hands were always hot, and a painful burning sensation
was seated in the extremities of the fingers: the feet  were  also
hot and hard, but had no scale or patch upon them.  Medicines of
many kinds had utterly failed in relieving these symptoms. 
CASES.
269
  The vapour treatment was commenced on June 30th, and on
August the 22d  the hands appeared healthy, all the scales were
gone, the skin soft, pliable, and  healthy.  Some heat remained at
times, and occasionally the parts were red and mottled: the hands
were smeared with a little zinc ointment, and  the  patient slept
with them in compresses soaked in a lotion composed of camphor
mixture, spirits of wine, and glycerine.  In three months this cure
was perfect.

                       Case XXXVII.
Superficial primary sores; inability to take mercury; healing of the sores under or-
   dinary treatment; secondary disease in the skin, throat, and nose; cure of all
   the symptoms by the mercurial vapour-bath.
  A gentleman  consulted me respecting certain symptoms, which
he considered, and which  doubtless were, due to constitutional sy-
philis.  He had primary ulcers eight months previously, for which
he could not take mercury; the smallest quantity produced diarrhoea,
and  it even affected him  so, when used by friction.  The ulcers
had  healed under a simple  treatment, but soon afterwards, the
skin became covered with  small scaly blotches: there was a deep
redness of the throat and nasal fossse, and the hair and eyebrows
came off rapidly.  He  had taken iodine and sarsaparilla, under
various forms, without  success:  occasionally  there was a partial
amendment, but he constantly relapsed when medicine was discon-
tinued.
  The baths were  used twelve  times, the gums rendered uneasy
and  swollen, but nothing  more; not a bad symptom accompanied
the treatment, and the patient has had no fresh symptom for fifteen
months.  He took no internal medicines whilst under my care.
The  third bath checked the falling off of the hair and  eyebrows,
which  began rapidly to reappear before the termination of the
treatment.

                       Case XXXVIII.
Phagedena of the throat immediately arrested by the use of the mercurial vapour-bath.
  A  lady, aged  34, had a superficial ulceration of the throat, her
husband at the same time  suffering from the same disease.  She
had also large pustular scabs on the legs, and her health was bad.
She  took the bichloride  of  mercury with sarsaparilla, for some
time, and apparently recovered.   For six years she remained ap-
parently well.   In May, 1846, she began to suffer from cough, and 
270
SECONDARY SYPHILIS.
emaciated a good deal, yet there was no physical sign of disease of
the lungs.  At this period she complained of sore throat, and on in-
spection the soft palate had a swollen, thickened appearance.  In
this state she went into Wales, from whence she  returned in a fort-
night, her  throat having got rapidly worse.  There was  now a
small hole in the soft palate, with a white margin, and the whole
of the throat was intensely red: there was also  an ill-conditioned
ulcer, with a  white  slough, in the left nostril,  which threatened
speedily to perforate the cartilage of the nose.
  The danger was imminent, and the state of the  parts such as to
lead me to fear a very serious and extensive mutilation, as the ul-
cers in the throat and  nose  had only been present two days, and
already the soft  palate was  eaten  through in one  place, and two
other small ulcers threatened to perforate it in others.
  What was to  be done in such a case?  There was no ordinary
mode of treatment that could have been brought to bear upon
such a state of things in less than three or four  days, and by that
time the mutilations would have been fearful, as disease was spread-
ing with great rapidity.
  I determined to submit my patient at once to the action of the mer-
curial vapour-bath,in which she was placed, with the head immersed,
for half an hour:  this was repeated on the  next  and succeeding
days, when the gums became tender and swollen.   The first bath
arrested the whole of the ulcerative  process: on the third day the
sloughs  had fallen, and the ulcers looked healthy.  Six more baths,
at longer  intervals, completed the cure, there not remaining, at
the end of eighteen days, any apparent disease, except the perfora-
tion in the soft palate, which was  small, and occasioned but little
inconvenience.
  I directed this lady, who was of a weak habit of body, to take
afterwards for some  time the iodide of iron, with a decoction of
sarsaparilla.   She  has had no new symptom.  The cure has been
permanent hitheriip.

                        Case XXXIX.
Discharge from the urethra as a primary symptom; scaly blotches on the skin and
    a node on the forehead, as constitutional symptoms; perfect cure by the mercu-
    rial vapour-bath.
  A gentleman  consulted me respecting a lump  on his forehead,
which was red, tender and painful: he had upon different parts of
the body, and on the head more particularly, some  dry,  scaly 
CASES.
271
blotches: his hair also came off rapidly.  He had no primary vene-
real disease, except a discharge from the urethra, concerning the
nature of which there  had been some difference of opinion.  It
clearly had not been gonorrhoea, and had resisted the usual reme-
dies employed  in that disease.  The discharge no longer existed
when I first  saw the  patient, and I could not find in the urethra,
on examination, any trace of the previous existence of an ulcer.
  I  recommended the use of the  baths, which were given every
other day.  I  prescribed no  internal medicines.   At the end of
three weeks all the symptoms had disappeared, and the hair was
coming on rapidly.
  About a year afterwards this gentleman called on me, when pass-
ing  through Birmingham, and told me he had not had any return
of complaint.

  Loss of the hair is one of the commonest symptoms of constitu-
tional syphilis, and one  which generally follows  superficial sores:
its nature is frequently  deceptive, since, if it occur at that period
when the hair is lost from natural causes, it is very apt to be over-
looked altogether. I  have seen several instances  of  this.  On
carefully examining a patient, where this appears the only symp-
tom, we  shall  commonly find others  to  strengthen our diagnosis,
if the loss of hair arise from venereal taint.   One of the most com-
mon is an inordinately red condition  of the mucous  membrane of
the nostrils, with or without any increased or altered condition of
the  secretions from these parts.
  I consider the baths in such cases all  but specific.  I have never
seen them fail.   In almost all instances one or two baths has ar-
rested the fall of the hair, and before half a dozen have been taken
the hair  almost  invariably begins  to grow and  thicken.  I have
seen the eyebrows and whiskers, lost under these circumstances,
quickly restored by the use of the baths.
  Where it is important to  produce a marked and immediate im-
pression  on the system,  &c, to arrest the progress of rapid ulcera-
tion, as in the various forms of phagedena, this plan of  treatment
cannot be estimated too highly.  I  have  seen  phagedena in  the
nose, throat, and on the penis, stopped at once by immersion in the
baths for half or three parts of an hour.  No other remedy can be
brought  to bear thus speedily upon diseases of this nature, and  the
mutiFations and losses of substance which occur in such states take
place whilst we are waiting for the action of remedies. 
272
SECONDARY SYPHILIS.
                           Case XL.
  Phagedena of the urethra and glans penis arrested immediately by the baths.
  A gentleman contracted, from a suspicious connexion, a dis-
charge from his urethra, which in the commencement was supposed
to be gonorrhoea, and for which he was treated.   The discharge
did not yield to the remedies  employed, and about ten days after-
wards there appeared round the orifice of the urethra a white ring
of ulceration, which spread rapidly.  His surgeon became alarmed,
and sent him to Birmingham, to  be placed under my care.  When
I first saw this  case there was  an ulcer the size of a shilling sur-
rounding the meatus, covered writh a white  slough, and the whole
of the glans penis was intensely  red, swollen, and shining.  On se-
parating the lips  of the urethra the ulcer was seen to extend some
distance down the passage.
  I placed this patient immediately in the bath, and kept him there
nearly an hour: he was directed afterwards to take a full dose of
opium, to apply some decoction of poppies to the part, and to con-
fine himself strictly to bed.  On the next day the bath was repeated,
and the same practice followed.  On the third day the  bath was
again taken, by which time the sloughs were separating, and a
healthy granular surface appeared underneath.
  There had been no  extension  of ulceration since the first bath.
Nine baths completed this patient's cure in less than three weeks,
and the medicines employed, as well as the local applications, were
of the simplest  character.  The  mutilation was very trivial.   The
under  surface  of the urethra and glans penis was destroyed to a
small extent, but from this the  patient suffered very little incon-
venience.
  This was a case of phagedenic ulceration, commencing,  as it fre-
quently does, in or at the orifice  of the urethra, with the nature of
which I was unhappily too familiar, having seen frightful mutilation
from sores of this nature under ordinary plans of treatment.
  The first case of secondary phagedena of  the throat, in which I
had employed the mercurial vapour-bath, had been so successful,
that I felt confident of success here, and the  result justified my ex-
pectations.   I reflected that rules of practice in cases of phagedena
were quite unsettled, mercury being frequently employed as a last
resource after  the  failure of  other  remedies.   It  is during this
period, of bringing remedies to bear upon the  disease, and the un-
certainty of what to use, that the mutilations so commonly witnessed 
CASES.
273
in such diseases occur.   The remedies which I advocate are with-
out risk, and may be employed from the very first appearance of
phagedena, with every hope of success even in the  wrorst cases.

                          Case XLI.
Chronic enlargement of the testis; the primary affection consisting in enlargement of
    the glands in the groin, with superficial ulceration of the glans penis and pre-
    puce ; successful treatment by the mercurial vapour-bath.
   A gentleman, set.  26, contracted from  a  suspicious connexion
superficial sores which were situated on the glans and prepuce;
he had succeeding to  these, enlargement of  the glands in the left
groin, which were painful and tender, but after a time subsided
without suppuration.  Some time afterwards this gentleman mar-
ried, and soon  afterwards the right testis began to feel heavy and
uneasy, and gradually increased in size.
   When I was first consulted on this case, the testis was as large as
a turkey's egg, hard, but not painful or tender.   I considered it of
venereal  origin; the patient was not of strumous habit or family,
and, on examining him carefully, I found that his hair came off,
and  that the niucous membrane of the nostrils was intensely red,
and  there were one or two spots of superficial ulceration.
   I  recommended this patient to use the  baths every other day.
After the fifth bath the gums were a little uneasy, and,  generally
red and elevated.  The patient took five more baths  at  longer in-
tervals.   The cure was complete in six weeks, the patient pursuing
his customary avocations during the whole time of treatment.
   There can be no question as to the venereal  origin of this dis-
ease of the testis.  The history and concomitant constitutional
symptoms place the matter beyond doubt.  I consider the  condi-
tion  of the mucous membrane of the nostrils one of the  best tests
of the nature of many constitutional forms of disease, about the true
character of which there might otherwise be some degree of uncer-
tainty.  If this disease of the testis had occurred without  any other
symptom, there might have been a doubt  as to its true nature;  but,
coexisting with loss of the  hair in a young man, and with  an in-
flamed and ulcerated condition of the nostrils,  we cannot hesitate
to pronounce it syphilitic.
   The ordinary treatment of such a disease would have been either
a long uncertain treatment by iodine, or a more certain mercurial
course, which must have confined the patient to the house,  and
most likely  to his  bed, for an uncertain  period.  The baths were
       18 
274                SECONDARY SYPHILIS.
perfectly successful in a short time, without one  hour's  confine-
ment, or hinderance from business, and with benefit rather  than
injury to the general health, a risk that must be always run under
the ordinary forms of mercurial treatment, and yet  the patient is
not safe, and can rarely be cured without it.

                         Case XLII.
Regular primary sore, with induration; succeeded by pustular disease of the skin
    and impaired general health; rapid cure by the mercurial vapour-bath.
  A young gentleman contracted  a chancre,  the knowledge of
which, from certain family reasons and fears, he, for some time,
kept  to himself.  Several weeks afterwards I first  saw him, and
he had then undergone no treatment.   There  was a considerable
induration between the  glans and prepuce,  on  the  summit of
which was the primary sore not yet healed.   The skin was covered
with a well-marked  pustular eruption.   The pustules were in va-
rious  stages, some  recent, others broken and covered with eschars,
and others again had degenerated into  open sores.  He wa^ pale
and  emaciated,  and  his  general health much impaired  by his
disease, which had now existed  fourteen or fifteen weeks.   His
state of health was such as entirely to preclude  a mercurial course,
either by  the mouth or by friction.
  I recommended  the use of the baths, and directed him  to take
half a grain of the extract of opium, three times a day, and some
warm decoction of  sarsaparilla  night  and morning.   The open
ulcers were dressed with a wreak black-wrash, covered with oiled
silk, and  bandaged.  This patient  took fourteen baths..   At the
end of a month he  wras well, had recovered his health and strength,
and his disease was cured.   He has had no fresh  venereal symp-
toms for some years.
  In  this  case there was both a primary and  secondary disease to
combat; a primary indurated venereal sore yet open, when the
constitutional or secondary symptoms appeared, and these occurring
in a constitution originally delicate, and still  more impaired by
syphilis.  It is, in  such a class of cases, exceedingly  common, that
the application of the moist mercurial vapour is invaluable, per-
fectly harmless in  its application, and all but positively certain in
its effects. 
CASES.
275
                         CaseXLHI.
Pustular disease of the skin; ulcers of the throat; severe nocturnal pains in the hips,
   legs, and head;  impaired general health; rapid cure by the mercurial vapour-
   bath.
  A young man, set. 24, was sent to me, suffering from a formida-
ble skin disease of venereal origin.   He  had had twelve  months
previously what appeared to be a regular primary sore, for which
he had takeh mercury to salivation.   Under this treatment the
ulcer closed; but before it was quite well he became covered with
a well-marked eruption of venereal pustules.  The disease  had
run  the regular course of all pustular venereal  eruptions.  The
pustules were, in some places, recent, in others covered with dark
brown crusts; the crusts had fallen off in other situations, and left
foul, dirty, irregular sores underneath; in one or two  places the
ulcers had healed, and left deep, red depressions  in the skin.  In
addition to the skin disease there was an ulcer  on each tonsil.
This patient was pallid, weak, and emaciated, and  so crippled with
pains in the hips and shin-bortes that he could not walk without a
crutch and a stick, and got up stairs with the greatest pain  and
difficulty.   He had undergone a variety of  treatment without suc-
cess.
  This patient was directed to take the baths every other  day.  I
prescribed for him small doses of opium and camphor, and the de-
coction of guaiacum to be drank wrarm morning and evening.
  The ulcers were  dressed  as  in the  last case.   After the third
bath this  patient walked up stairs without assistance, and his pains
were all but gone.   In less than six weeks he was quite cured, he
had gained flesh considerably, and his appetite and  health were
good.  He had not been confined an hour by his treatment, and he
has never relapsed, a circumstance so common after ordinary mer-
curial treatments.   He had tried  the  common vapour-bath when
away from me with very little benefit
  The mercurial vapour-bath is very efficacious, if not  specific, in
removing those  pains, compounded of syphilis and mercury, which
have been produced by or succeeded to internal mercurial courses,
prescribed for  the cure  of  either primary or constitutional  sy-
philis.  The detail of the last case illustrates this position. I can
bring forward another in  support of it 
276
SECONDARY SYPHILIS.
                          Case XLIV.
 Severe pains in the limbs, succeeding to a primary and secondary venereal disease,
    treated by large quantities of mercury internally; radical and quick cure by the
    baths.
   A young gentleman contracted syphilis in a seaport abroad, and
 was treated by large quantities of mercury by the surgeon of his
 vessel.
   His primary disease was cured,  but a pustular eruption subse-
 quently made its appearance, and the glands of the groin on both
 sides  became enlarged and tender.  Before he returned to Eng-
 land the skin disease had nearly disappeared, but there remained
 copper-coloured depressions in the skin, marking  the  situations
 where the pustules had been, and these places were  at times much
 inflamed and threatened to ulcerate again.   The worst  symptoms
 under which this patient laboured,  were pains in the limbs, groins
 and different parts of the  body, due either to exposure during his
 mercurial  course,  or to a combination of the remedy and  disease
 yet remaining in the system.   The pains harassed him severely,
 and the apprehension of a further outbreak of disease rendered
 his life wretched.
   I directed the baths to be used every other day, gave him small
 doses  of opium, and recommended him to drink some warm decoc-
 tion of guaiacum night and morning.   He got rapidly well; in a
 few weeks the depressions were no longer discoloured,  the pains
 had left him, and  the  glands  in the groin were reduced in size.
 This patient was radically cured; he has never relapsed.

   It  sometimes happens, I may say frequently, that patients who
.had passed  through the whole  ordinary routine of treatment for
 the cure of syphilis, and have been subjected to mercurial courses
 in different ways,  three  or four times, apply for  relief for  symp-
 toms that still remain uncured, or wdiich have appeared after they
 had believed themselves perfectly safe.  These symptoms are very
 commonly confined to the epidermis and its appendages, and make
 their appearance  in  the form  of dry scales on  the  palms of the
 hands, from which the  epidermis ultimately peels off;  sometimes
 the nails crack and break,  or dry shining  scales  appear about the
 matrix of the nails themselves.  Sometimes there are  dry white
 patches on different parts of the skin, and with these appearances
 there is  commonly a dryness of the throat and nostrils, and the
 hair and whiskers almost  invariably get  thin.   There  are some- 
CASES.
211
 times, co-existing with these symptoms, pains of various kinds both
 in the bones and soft parts.  In such states after almost all varieties
 of internal remedies have been used, and yet disease remains, the
 baths become of the greatest utility, and rarely fail at working a
 speedy and permanent cure.  I bring forward one or two cases in
 illustration.

                          Case XLV.
 Regular primary sore; treatment by frictions; skin and throat disease as secondary
    affections; subsequently peeling of the epidermis from the palms of the hands.
   A gentleman contracted wrhat appeared to have been a regular
 primary venereal ulcer, for which he took  mercury by the mouth,
 and also used it  by friction.  He was salivated by this treatment.
 The ulcer was some time in healing, and before it was quite closed
 he became covered with red shining patches, and had a sore throat.
 For these symptoms he underwent a further mercurial treatment
 For some time he fancied himself well, though occasionally would
 break out a scaly blotch on various parts of the body.  To these
 he paid little attention.   At a later period the palms of the hands,
 in places, appeared as though they had been blistered, the epider-
 mis was raised, as by a  blister, and then peeled off, spreading in
 circles exactly like fairy rings.   Both hands were affected.
  He was directed  to  use the mercurial vapour-bath every other
 day for half an hour, and to drink some warm decoction of guaiacum.
 There was no complaint remaining  at  the  end of six weeks, and
 there  has been  no  relapse.  He has remained without any fresh
 symptom for nearly four years.

                          Case XLV I.
 Superficial primary ulcers in the commencement; as constitutional symptoms: scaly
    blotches on the skin, superficial inflammation and ulceration of the throat,
   peeling of the epidermis from the palms of the hands, scaly condition of the
   nails, loss of the  hair, eyebrows, and whiskers; cure by the baths.
  A gentleman consulted me for superficial ulceration of the throat,
 which he considered was venereal, and which doubtless was so, for
 it was accompanied by other symptoms which could not be mistaken.
 The membrane of the nostrils was intensely red; there were a few
 scaly spots  on  the  body;  the epidermis peeled off  in white, dry
patches from the  palms of the hands; and the same scurvy condi-
tion existed round the roots of the nails.  The eyebrows and whis-
kers fell from the least touch.  This patient had taken mercury in 
278
SECONDARY SYPHILIS.
various ways; his  disease from  time to time abated, but he con-
stantly relapsed, and  the  symptoms I have detailed had been in
existence nine months. The primary disease had consisted of three
or four superficial sores, which he had been assured were not ve-
nereal.
  As this  affection was perfectly chronic, and not making any
rapid advances, I directed the baths to be used only twice a week.
and during their use,  a teacupful of warm decoction of guaiacum,
night and morning.  In six weeks this patient got well, and after
many months had not bad any fresh symptom.
  I have to speak now of one or two cases of  a different kind to
any previously detailed, namely, the ulcerations  which are left
after, or  succeed to, the healing of primary venereal ulcers, and
in which I have seen the "moist mercurial Vapour" succeed after
the failure  of  other modes of treatment pursued for long periods
without success.

                         Case XLVII.
Superficial primary sores; secondary disease of the skin under the form of shining,
    red, copper-coloured patches; subsequently a large induration as hard as carti-
    lage, occupying the site of the original ulcers.
  A gentleman contracted some  superficial sores upon the penis,
wdiich he was assured were not venereal, and would not be fol-
lowed by constitutional symptoms.  They healed, and the patient
went abroad.   On getting up one morning he perceived his skin
covered with red shining patches; being alarmed, he immediately
set  off for  London, where he was told the eruption was venereal,
particularly as there  accompanied it an ulcer on each tonsil.   He
was put  upon  a mercurial course,  and  the eruption, after a time,
got well.   About this time an induration made its appearance in
the situation of the original ulcers,  and  kept increasing till it was
as large as a small walnut.  Notwithstanding  the  continuance of
the mercury by the mouth, the  induration remained stationary,
and at this period the patient placed himself under my care.  There
was a large induration, having the appearance and feeling of car-
tilage, occupying the place of the original sore.  It did  not seem
a general thickening of parts, but like a piece of cartilage in and
under the skin. . Mercury under two or three forms had failed to
remove this.
  I placed  my parent under the  use of the vapour-bath, which was
applied three times a week for a month, half an hour each  time. 
CASES.
279
He drank a'little warm  decoction of guaiacum twice a day, and
occasionally took an aperient.  A month's treatment was sufficient
to remove the induration, and no other symptom of syphilis re-
mained when  the  employment  of the  baths  was discontinued.
There has been no  relapse, a very common circumstance with in-
durations of this character, which I have  known frequently return
after the discontinuance of mercurial treatment by the mouth.
   The indurations  which remain after  the healing of ulcers of
suspicious character, or which come on after they have healed, as
they often do, are among the most obstinate symptoms with which
surgeons have to contend.  In themselves they are a sure indication
of constitutional taint, and are either, if left to themselves, followed
by secondary diseases of a formidable character, or ulcerating from
slight causes of irritation give place to rapidly-spreading and de-
structive sores; they are exceedingly rebellious, and sometimes re-
main after the pursuance  of  various forms of constitutional treat-
ment for long periods.  Local treatment by frictions soon  renders
them painful, and disposes  them to open.  In these forms of dis-
ease the mercurial vapour is very valuable, though it does not act
with the rapidity it generally does in affections  of the skin, throat,
or nose.

                         Case XLVIII.
Regular primary sore on the fraenum, mercurial treatment; copper-coloured scaly
    eruption on the back, superficial ulceration of the tonsils, ulceration of the mu-
    cous membrane of the nose, discharge of pus, blood, and thic'k crusts, pains in
    the hip and shin-bones; second mercurial treatment; failure of success; speedy
    cure by the baths.
   A  gentleman contracted a sore on the  frsenum, which healed
under a prolonged mercurial course, during which he took a hun-
dred five-grain mercurial  pills.   He fancied himself well.   Three
months afterwards, a copper-coloured scaly eruption appeared on
the  back, the tonsils became enlarged,  and their surface  was ul-
cerated; he had a discharge of quantities of hard mucus from the
back of the throat, which  appeared to come from the nose,  and  the
nostrils, also, gave passage to substances of the same character,
mixed with matter and blood.  His nights became bad, and he was
tormented with severe pains in the hips and legs, which prevented
him from sleeping.  For these symptoms a second surgeon was con-
sulted, who recommended a blue  pill three times a day, and some
other medicines.  The mouth was kept sore for three months, during 
280
SECONDARY SYPHILIS.
which period  the patient took one hundred and forty more pills.
Under this treatment the eruption  on the  back disappeared, but
the other symptoms  in the nose  and throat were wrorse, and the
pains in the hips and legs increased in intensity.
  This patient now came to me from a distance, and  placed him-
self under my care.  At this  period the  tonsils were large, and
on each side covered with ash-coloured superficial ulcerations; the
mucous membrane of the  nostrils was  intensely red, and covered
also with ash-coloured spots.   There  no doubt existed  mischief
higher up in the nose, as  the voice was thick, and  the breathing-
through  the nose obstructed.  The patient had now suffered from
disease and remedy for seven months.  He was pale and emaciated,
and much depressed in spirits.
  I placed him under the use of the baths, gave him small doses of
the extract of opium, and recommended him to drink half a pint of
warm decoction of guaiacum, night and morning.   The nose and
throat were better after the first bath; and at the end of five weeks
the baths having been taken every other day, this gentleman had
no symptom of disease remaining, had lost his pains, and recovered
his strength and spirits.
   This  case is one  of the many  that might  be recorded as an
instance of the  failure  of mercury, given by  the mouth  in the
ordinary way, to cure venereal diseases.  The failure is perhaps
not so much in the remedy itself,  as in the mode in which it is ad-
ministered.  The quantity given  is generally too  large, and the
patient is not placed in  circumstances whilst taking it which are
favourable to its action; and a peculiar class of diseases are, by
such treatment, created, which are  compounded of mercury and
syphilis, and which are very difficult to cure.   These diseases are
generally produced  by  the  indiscriminate  use of mercury in the
treatment of  the primary sore.  If mercury be required for the
treatment of  the primary sore, it  must be used according  to the
plan already laid down.   Primary ulcers so treated are never fol-
lowed by induration; salivation  or ulceration of the mouth  are
never produced; and secondary symptoms would not occur in one
case in five hundred.

                         Case XLIX.
Superficial ulceration of the throat and nose; alteration of the voice; relapses under
     internal mercurial treatment for four months; speedy cure by the baths.
   A gentleman  contracted several superficial sores on the penis,
which wrere attended with considerable inflammation.  They healed 
CASES.
281
without induration of the cicatrix, but as the patient had not been
seen by  me at this  period, I do  not know what treatment was
adopted.  About two months after this apparent cure, his throat
became dry, particularly the day after any extra indulgence, such
as a dinner party.  To this succeeded ulceration,  several small
ash-coloured spots made their appearance on each tonsil; the nose
became dry and uncomfortable; he could not breathe through it
easily, it appeared obstructed, and  the voice was hoarse and  un-
pleasant.  The hair came off in  small quantities, and the skin was
continually disposed to crack and inflame on the seat of the origi-
nal sores.   This patient had  taken mercury  internally, at inter-
vals, for six months, but, on discontinuing  the  remedy, his symp-
toms always returned;  and, in addition, the medicine, under any
form, after a time, so disordered his stomach that he could not take
it long enough  to have any real  influence over his disease.  No
other  treatment was adopted in this case except the baths: they
were used every other day for three weeks; the head was immersed
at intervals during the time the patient remained  in the  bath, a
practice  which ought always to be followed where the hair comes
off, and  in diseases of the throat and nose.  The gums were ele-
vated, swollen, and  red, but nothing more.  The  cure was com-
plete.   In six months there has not been the slightest relapse.

                            Case L.
Pustular skin disease; induration  of the glands in  the groin on the left side to a
    great extent; ulcer and induration on the penis; severe pains in the head  and
    legs;  tenderness of the bones of the legs; failure of internal mercurial treat-
    ment pursued for four months; cure by the baths and opium.
   A gentleman entered my consultation  room one morning, look-
ing pale and emaciated, and walking with a stick  and  a crutch.
He gave the  following  history of his disease.  Ten months pre-
viously he had contracted a sore, which was situated on the lower
part of the glans  penis, near the frsenum.  For the cure of this,
the primary, or for the prevention of constitutional or secondary
disease, he had taken mercury by the mouth  to some extent, and
for a long period.  Whilst taking this medicine  about fifty or sixty
small pustules broke out in different parts of  the body, chiefly on
the arms, legs, and head.  His throat  about  this period became
sore, and he had  continual discharge from his nose.   For these
symptoms he was recommended  mercury  internally in  another
form.  The throat improved, but did not get quite  well; some of 
282
SECONDARY SYPHILIS.
the pustules also dried up, and disappeared, but were  succeeded
by others. The general health, previously good, now began to fail,
the appetite went, the patient got thin and  suffered from night
sweats;  he was also tormented during the night with severe pains
in the legs and head, those in the ankles and  hips  at  length be-
came so severe that he could  not walk without the assistance of a
stick and a crutch; and yet, ten months previously, the patient had
been in  good health, and was only now thirty-two years of age.
   On examination, I found a small  fissure  near  the frsenum sur-
rounded by considerable induration;  the glands in the left groin
were enlarged, hard, and tender, the whole  mass as large as a tur-
key's egg.   The throat was red, and covered with four or five  su-
perficial, ill-conditioned ulcers; the nostrils were in the same state;
on both sides  there were ulcers; the voice was hoarse, and there
was constantly expectorated a quantity of thick, adhesive phlegm.
There were from twenty to thirty fresh pustules, of small size, on
different parts of the body.   The general health was broken up;
the appetite was bad; there was no rest; the tongue was foul; the
gums spongy; and the breath fetid.  This  patient was  very much
emaciated, and the perspirations in the night were  most profuse,
bed and body linen being completely saturated.
   I looked with considerable anxiety on this case; the local symp-
toms, bad as they were, 1 did not fear; these were easily and cer-
tainly manageable, but the general health of  this poor  gentleman
was so much impaired that I feared for the result.  He  was doubly
poisoned, first by syphilis, and secondly by mercury, very probably
acting upon a system peculiarly inimical to the use of it, as the ge-
neral state of health showed, for I never saw such symptoms pro-
duced by syphilis where mercury had not been given for its cure.
   I ordered this patient to keep his room,  and prescribed for him
a strong decoction of sarsaparilla, with beef-tea, and recommended
him to  take, in addition, seven grains of powdered guaiacum, two
of opium, and three of camphor, night and morning.  The baths
were sent to  his lodgings, and  he took one on the third day after
I first saw him.  The bath produced some exhaustion, but he slept
well that night without perspiration, and the next day  was better.
 On the third day, again, the bath was repeated with still further
improvement; the pustules began to dry up, and  the strength  was
 a little  improved.  Still the appetite continued bad, and the tongue
 foul; the pains in the limbs still  troublesome,  though abated.  The
 baths were repeated every third day, and the medicines were con- 
CASES.
283
tinued.   No alteration was made in the treatment; as the patient
gained strength the  baths were made stronger, and continued for
a longer period.  This patient remained under my care two months,
at the end of which period he left me in tolerable health, which
has continued to improve.  He has had no relapse.
   I do  not think it  would have been possible to have cured this
patient without the  moist mercurial vapour.  The combination of
the vapour bath and  the mercurial fume is in such cases invaluable;
and wherever the patient is able to support himself on a chair, they
may be used with perfect safety, and without risk.  The strength
and heat of the bath  being regulated according to the particular cir-
cumstances of the case.
   It is in such states that ulcerations, generally fatal under ordi-
nary treatments, occur in the larynx, and low down in  the pharynx.
I have seen, in the  earlier  years  of my practice, several patients
die from these ulcerations, whom I firmly believe would have been
saved under the plan I now recommend.   Where  ulcerations are
constitutional, local  remedies have little influence over them, ex-
cept for the  moment   Mercury given  internally  is in such cases
almost altogether forbidden by the condition of the general health
of the patient.   Under the plan I here recommend it may be ad-
ministered in perfect safety, and  is almost the only  hope for the
 patient.

                            Case LI.
 Discharge from the urethra, and excoriations for primary symptoms; subsequently
    spots on the body; loss of hair and voice; ulceration of the throat and nose;
    speedy cure by the  baths, after a prolonged mercurial treatment with  partial
    success.
   A gentleman contracted from  the same connexion a discharge
 from the urethra, and superficial sores upon the penis, which healed
 in a few weeks with very simple treatment  Sometime afterwards
 he experienced a dryness and soreness in the throat when he swal-
 lowed, and his voice became hoarse; these symptoms increased till
 at length the voice was almost altogether lost, and he  merely spoke
 in a whisper.   He  consulted a surgeon, who pronounced the dis-
 ease in the throat to be syphilitic, and recommended mercury to be
 taken by  the mouth, with  the decoction  of sarsaparilla.   These
 medicines were continued for  some time with partial  benefit; but,
 on their discontinuance, the disease in the throat became worse,
 whilst the voice had hardly been benefited at all.   The patient 
284
SECONDARY SYPHILIS.
now, by the advice of his surgeon, who resided at a distance, placed
himself under my care.
  At this period the whole of the throat had a deep red appearance,
the tonsils were  much enlarged and tender externally, and their
surface covered with superficial ash-coloured ulcers, one or two of
these ulcers on each side being deeper than the rest.   The uvula
was  elongated, thickened, and had a tuberose appearance;  on its
extremity were situated two or three small ulcers similar to those
on the  tonsils; there was a difficulty of breathing through the nose,
the mucous membraue of which was intensely red, and superficially
ulcerated.  There were a few small pustules on the body, and one
or two  on the head;  the hair was thinning fast.   The general health
was good.
  This patient took the baths every other day with the head im-
mersed ;  he was directed to take also some decoction of guaiacum
night and morning;  the dose in the evening warm on getting into
bed; the gums became  very  tender after the fifth bath, and his
condition was much amended by this time; the spots had disappeared
from the skin, and the  hair no  longer came off;  the redness was
gone from the throat, and the voice was much improved.   At the
end of three weeks nearly all  the symptoms had  vanished.  The
patient still  remained a little hoarse, and  the  uvula had not
quite assumed its natural appearance.  I heard from this gentle-
man, a month afterwards, to say he was quite  well.
  This is another example of that numerous class of constitutional
venereal diseases which follow  superficial  primary  sores; the
most marked symptoms of which are superficial redness and ulce-
ration  of the throat and nose, with spots upon the skin varying in
their pathological characters, and loss of hair.  These symptoms
are so  constantly grouped together in such cases that I never see
one without looking for the others.  I believe where the hair comes
off', and the disease  of the skin affects its surface only, the mucous
membrane of the nose will be found always  affected  as well as
the throat   These  symptoms generally yield with extraordinary
rapidity to the use of the moist mercurial  vapour, whether this
be  associated with  medicines taken  internally or not.   In some
cases the cure has been expedited by the decoction of sarsaparilla
and guaiacum, but  I never prescribe mercury internally in such
cases, if  the patient can take  the baths. 
CASES.
285
                          Case LII.
Ulceration of the throat; large single pustular blotches on different parts of the body
               at different times; ulcer of the left nostril.
  A respectable female  was unfortunately  diseased by her hus-
band; I know no more of the primary disease, than that  she had
a discharge upon her, and some superficial sores which soon healed.
Her husband and  herself had both afterwards  ulceration of the
throat which  Avas  very  rebellious to treatment, but at  length
healed under a mercurial course.   Some  months afterwards a
large pustule made it3  appearance on the thigh, and on the arm:
these soon dried up, and were covered with large, irregular, black-
looking crusts, which, on falling off, left a foul, excavated ulcer
beneath.  These, after some time healed, leaving a deep  red de-
pression in the skin.  At a subsequent period the left nostril be-
came dry, and rather painful;  and, on examination, there was
found an  ulcer as  large as a  shilling, covered with a white, thick
slough;  the remainder  of  the membrane of the nostril was of a
deep, dark-red colour, which  colour pervaded also the other nos-
tril, but the latter was not  ulcerated.  The ulceration was spread-
ing rapidly, and, the patient  believed, had only  been in existence
about two days.  When  I first saw this ulcer it only affected the
mucous membrane, but its edges were so intensely red, and disease
proceeding with so much rapidity, that I apprehended speedy per-
foration of the cartilage, having more than  once seen the  soft pa-
late eaten through by an ulcer of this kind in twenty-four hours.
I mentioned my fears to my patient, and told her I  knew of but
one method of  speedily, if not immediately, arresting her  disease,
supposing her case should be as fortunate as some others I had
seen submitted to  a similar  plan of treatment;  and  this was by
means of the moist mercurial vapour, which I advised her instantly
to use.
  The head was immersed in the bath; and  the  patient was kept
in it for half an hour.  The vapour  produced, as it sometimes does,
a great discharge from the nose.  On the  next day the redness of
the nose was less.   The bath was again repeated  on this day in the
same manner, and  for the same time.  On the third day the slough
had separated; there was very little redness of  the nose, and the
ulcer looked healthy and disposed to heal.  The baths were now
continued every other day, and by  the time the  eighth  had been
taken the ulcer had healed, and very little complaint remained. 
286
SECONDARY SYPHILIS.
Indeed all that could be said was that the  membrane of the nos-
trils was slightly more red than it ought to be in a perfectly healthy
state.  This patient did not take any medicine during the time she
was using the vapour; the  gums  became  very  tender after the
fourth bath.  She was directed to live on beef-tea, milk, eggs, and
cocoa, and  her  general  health, which was before  bad, became
good; she got fat, and has not relapsed.

                         Case LIII.
Primary sores cured by an internal mercurial course; afterwards, violent pains in
            the head, spots on the skin, ulceration of the nose.
  A gentleman  contracted  a sore  on the penis, for  the cure of
which he was  directed to take  mercury internally; this was done
to some extent, and after a time the sore healed, leaving a thick-
ened condition of the prepuce upon which it was situated.  Before
the termination.of the mercurial course he began to suffer from
violent pains in the head, which were at times so severe as to in-
duce delirium.  The mercury was now given up, the pains became
less, but did not leave him, and in addition the hips and legs were
affected with similar pains; the nose became dry, and discharged
from time to time hard, foul crusts, and there were also a fewT scaly
blotches on  different parts of the skin.
  The patient now placed himself under my care, and I recom-
mended to him the  use of the  moist mercurial  vapour, and  pre-
scribed for him some small doses of opium, and a decoction of the
woods to be drank warm in bed night and morning.   At this pe-
riod there was superficial ulceration in each nostril, and the mem-
brane generally was intensely red.  The patient was in an agony
of distress about his nose, fancying it wrould fall in, in spite of all
my assurances that there  was neither disease  of  the  cartilages or
bones.  His monomania was most distressing;  it rendered his life
miserable.   After a few weeks' treatment the symptoms yielded,
the pains were  gone, and the ulceration of the nose had healed,
though it still  remained red, and, occasionally, discharged a lump
of hard mucus.  This gentleman had no confidence in any treat-
ment  except the baths; and, on two occasions  fancying himself
worse, travelled from the north of Scotland to have them adminis-
tered under my care.  In about three months from the time of my
first seeing this patient he was perfectly well, did not present a
trace of venereal taint, and his  mind had become  more tranquil;
he had confidence in the permanence of his cure, and felt satisfied
that his nose was no longer in danger. 
cases.                        287
                          Case LIV.
Chronic disease of the throat, and loss of hair; failure of ordinary treatments; cure
                          by the baths.
  A commercial gentleman, aged  34, was sent to me by his sur-
geon, for my  opinion  respecting his throat, which had been af-
fected with  syphilitic  ulceration for several months, and had re-
sisted the ordinary  means of cure, or relapsed when  medicines
were discontinued.  This patient had  sufl'ered originally from
several small  superficial  sores on the penis.  Some time after the
healing of which his throat became dry and inflamed, and his hair
began to come off.   When I first  saw this  gentleman the throat
was intensely red, the  tonsils  enlarged, and their  surface covered
with several  ash-coloured ulcers;  the  membrane of the nostrils
was also very red, and he could not breathe easriy through them;
his sense of smell was  much impaired, and he had  entirely lost his
hair, and was obliged to  wear a wig.   I could not learn the exact
mode of treatment that  had  been  employed; but his mouth had
been made sore two or three times by mercury.
   He was directed to use the  baths every other day, and to  take
very small doses of the bichloride of mercury, not exceeding the
twelfth of a grain for a  dose, with some decoction of  guaiacum,
and an  opiate at night.   The plan was pursued for a  month; at
the end of this period  the throat was well, and he  has never again
relapsed.
   It is a singular fact, and one which I have verified in  some hun-
dreds of cases, that the same medicines which have been unsuccess-
ful, before the use of the baths, will speedily act beneficially when
employed in  conjunction with them, though given in very much
smaller doses, and the treatment which has been  followed by re-
peated relapses without the baths,  becomes permanently efficacious
when employed with them.

                          Case LV.
Superficial primary sores; inflammation and enlargement of the glands in the left
    groin; mercurial frictions, &c, without success;  cure  by mercurial frietions
    and the baths.
   A gentleman consulted me respecting some abrasions  on the
penis, which he had perceived after a suspicious intercourse.  They
quickly healed; but after a hard day's hunting he perceived a ten-
derness in the left groin, and the next day walked with  difficulty.
Being at that time in the north of  England he consulted  a surgeon 
288
SECONDARY syphilis.
 who told him he was suffering from bubo, and a mercurial course
 was necessary.  He took mercury by the  mouth, and rubbed in
 some mercurial ointment into the thighs till the mouth was  sore.
 The glands in the groin continued to enlarge, and it appeared pro-
 bable they would suppurate.   Getting alarmed  about his  state, he
 now placed himself under my care.
   At this period  he could not walk, the mass of inflamed glands
 was as large as a turkey's  egg, red  at the summit, exceedingly
 painful and tender, and from a feeling of fluctuation given to the
 finger it appeared probable  that  matter  had already formed.   I
 had, however, so  repeatedly seen  surgeons deceived as to the pre-
 sence of matter in cases like the present, and protracted  diseases
 produced by  incisions, that I abstained from making a puncture in
 this case, and believe that the lancet  in all cases of this descrip-
 tion should be used with extreme caution.   The patient was much
 emaciated, and worn out by pain, wrant of rest,  and night perspi-
 rations.
   I applied a blister over the bubo, gave him  an opiate at bed-
 time, and, after two or three days' rest, recommended that he should
 commence the use of the baths every other day, and rub in every
 night half a scruple of mercurial ointment.  This patient left me
 well in five weeks. He had pursued mercurial treatment for three
 months previously, without the slightest benefit; not the least im-
 pression had  been made upon his disease.   This  gentleman has re-
 mained perfectly well; it is fifteen months since he was under my
 care, and he has had no relapse of any kind.
   It is remarkable what small quantities of mercury are required
 internally to  combat very formidable diseases, when this  remedy
 is  given in conjunction with  the baths.  Mercurial treatments  so
 conducted are never attended with mischief; and salivation or ul-
 ceration of the mouth are never produced, at  least with the  most
 ordinary care, whilst the disease as certainly yields.
   I will now  detail another case where mercury had been taken
 at  intervals for five months for an induration succeeding to the
healing of a venereal sore, whilst the patient got well, placed under
 the same circumstances when he used  similar  remedies, and  took
the baths in conjunction with them. 
CASES.
289
                          Case LVI.
Superficial primary sores, succeeded by an extensive induration, spots on the skin,
   node on the arm ; relapse, after an apparent cure by internal treatment alone;
   permanent cure by the baths.
  A gentleman contracted three  or four superficial sores, which
quickly healed, but soon after there appeared on the substance of
the prepuce an induration which surrounded the upper portion of
the penis.  Under the advice of his surgeon  he took  mercury in-
ternally, and also used it by friction; and, under  this treatment,
continued for three months, the induration disappeared.  About a
fortnight after the discontinuance  of the medicines, the induration
began to reappear, and in a few days was larger, and  harder than
before.  The patient now recommenced the use of medicines, but
after having taken them nearly four months, the  induration still
remained the same, and the periosteum  of the ulna of  the left arm
became inflamed, and a few scaly spots  made their appearance on
different parts of the body.
  The patient, at this period, came under my care: the induration,
the  principal feature of the  disease, was like a piece  of cartilage
under the skin; but the whole of the upper portion of the prepuce
was full and red;  and the induration was tender to the touch.
  I  recommended the baths  every other day, and advised the me-
dicines to be continued, which consisted in a solution of the bichlo-
ride of mercury in the decoction of sarsaparilla.  The spots soon
disappeared, and were  seen  no more: the  tenderness of the arm
next yielded: the induration was longer in giving way: after the
third bath, however, it was manifestly softer and  less tender, but
had not entirely disappeared for ten weeks, the treatment having
been from time  to time interrupted by the business avocations of
the patient
  I do not believe it would have been possible to  have cured this
patient by internal medicines alone.   He had continued them for
three months in the first instance before the induration yielded;
and it was clear that the constitutional  taint still remained, by the
return of disease the moment  the remedies were suspended, with
the addition of fresh symptoms.
  In the second instance the internal remedies were of no avail,
although continued for nearly four months.  Yet the disease yielded
in ten weeks when the  baths were used, and the same medicines
were taken with them.  There has been  no relapse after the second
treatment, and the cure has been perfect.
       19 
290                SECONDARY  SYPHILIS.
                           Case LVII.
, Constitutional syphilis of two years' duration: enlargement of the left testis; noc-
     turnal pains; night perspirations; emaciation; thickening of the bones of the
     nose on the left side;  ulcer of the septum of the nose, and obstruction of the
     naso-lachrymal canal;  failure of the ordinary treatments pursued for two years;
     cured by the vapour in four months, with the exception of one symptom,
   A delicate-looking  young man came to  request my opinion  re-
 specting the symptoms under which he laboured, which had harassed
 him, with little variation, for the last two years.  Latterly he had
 become worse, and the complaint in his nose rendered  him very
 anxious,  more especially as his surgeon had given him a very un-
 favourable opinion with regard to its termination.
   About two years and a half ago he had  contracted superficial
 sores upon the penis,  which had healed under ordinary treatment,
 and for which he had  taken mercury by the  mouth, though I could
 not learn to what  extent.  About two years ago he observed a
 continual discharge from his  nose, and this  was sometimes mixed
 with  matter, and occasionally with  blood:  at intervals of two or
 three days or a week, there came from his nose hard crusts of dry
 mucus, bearing the shape  of the  spongy bones of the nose, and
 having on the surface which had  been adherent, spots of pus, as
 though they had been thrown off from an ulcerated surface.  These
 symptoms were chiefly confined to the left  nostril, and the  bones
 of the nose  on  this side were considerably larger  than  those on
 the right, and  tender to the touch.  After these symptoms had
 continued for some months the eye on  the same side began to wa-
 ter, and the  tears from  time  to time flowed over the cheek.  On
 pressing the lachrymal sac, the tears, with occasionally a few drops
 of  pus, could be  pressed  out through the  puncta.   About  this
 period the bones of the legs became very painful, particularly at
 night when in bed; and the left testicle began to enlarge without
 pain; night perspirations set  in, the appetite was lost, and the ge-
 neral health became altogether impaired and bad.
   At this time the patient came under my care.  He was then pale
 and emaciated:  on examination of the nose I discovered a dirty-
 looking superficial ulcer of the septum, and of the inferior turbi-
 nated bone on the left side: the membrane of the nostrils on both
 sides was intensely  red; the patient spoke thick, and  was at times
 hoarse, doubtless resulting from the condition of the nose.  The
 bones of the  nose arid  cheek, on the left side,  were enlarged, tender
 to the touch, and  the  skin was slightly red over these parts.   The 
CASES.
291
throat was dry and uncomfortable occasionally, though neither in-
flamed nor ulcerated.
  I directed this  patient to use the vapour, with  the head im-
mersed, to continue it for half an hour, using three drachms of the
binoxide of mercury for each bath, which was taken two days to-
gether and then  omitted for one.
  At the  same time I recommended ten  grains of the compound
powder of ipecacuanha, with as much guaiacum, to be taken night
and morning, and  twice in the day a glass of warm decoction  of
sarsaparilla, with five grains of the hydriodate of potass, and  twenty
minims of the wine of colchicum.
  At the  end of a fortnight the improvement was  very marked;
the pains  were gone, the perspiration had ceased; the patient could
eat, and the swelling of  the testicle was nearly reduced.  The
tenderness had  disappeared from the bones of the  nose, and the
fulness  was  much  less.  There  remained, however, still some dis-
charge  from the nose, and the tears still ran over the cheek.
  The treatment wras continued at intervals for three months; and,
at the end of this  time, the patient appeared in very good  health;
he had not a symptom of  constitutional  taint, unless the  partial
obstruction of the  nasal  duct, still remaining, was to  be considered
as such; and. this canal was evidently assuming, though slowly, its
 natural condition.
  1  have  already stated that an inflamed and ulcerated condition
of the mucous membrane of the passages of the nose is a very com-
mon symptom of constitutional  syphilitic taint;  and  I have seen a
number of cases where it  has continued  for a very long period of
time without extending  further than the mucous membrane lining
the nose,  though in other instances its advances are more rapid,
and its  consequences more serious.   In some instances syphilitic
affections  of the nose are  limited to a mere chronic inflammation
of the  membrane  lining the meati, and  are accompanied  by dis-
charges of thickened, dry, mucous crusts, having the shape and ap-
pearance of the bones themselves; and this I have known continue
for many  years without  getting  much worse.   On examining the
nostrils of such patients they are found to be intensely red, covered
with mucous crusts, and the membrane in places slightly ulcerated.
The  previous history of the patient, the co-existence of some other
symptom of  venereal taint, and the effects of appropriate treatment
leave no doubt as to the nature of such diseases.   In other instances
more serious forms of ulceration are present, and these ulcers as- 
292
SECONDARY  SYPHILIS.
sume either a chronic or an acute character.  I have seen two in-
stances, in one of which there had been a constitutional  taint for
six years, and, in the other, for nine; and the nostrils affected the
whole period, where an acute ulcer has perforated the septum in a
few days.
  In some rarer cases  the chronic inflammation of the nose is not
limited  to the meati, but extends from the inferior one up the nasal
duct, and partially or completely obliterates it.  I have seen three
cases of this kind,  one which had existed several years; and the
discharge of tears over the cheek coincided with that of the pecu-
liar syphilitic crust from  the nose on the side on which  the obli-
teration of the duct existed.  This is a  probable, and, I believe,  a
common cause of that disease, known as " stillicidium lachrymarum."

                         Case LVIII.
Superficial primary sore, followed by bubo; ordinary treatment; constitutional taint
    five months afterwards in the shape of copper-coloured blotches en the face,
    head, and back, with loss of hair, and superficial disease of the,throat; the dis-
    ease  stationary under ordinary treatment for six months; cure by the vapour in
    nine  weeks.
  A gentleman  contracted, in  February, 1847, a superficial sore,
which was succeeded  by a bubo which did not suppurate: the pa-
tient was treated in the ordinary manner, and he fancied for three
or four  months that he was quite well.   In June of the same year
he had superficial ulceration of the throat, and about the same time
he  perceived a large copper-coloured, or dark-brown spot  on the
forehead, just above the root of  the nose; another soon appeared
on  the  side  of the nose,  one on  the right cheek, and several of
smaller character on different parts of the face, neck, head, and
back.   The  hair at this  time  came off in large quantities, when
brushed or combed, and soon became very thin.   These spots were
neither preceded, accompanied, or followed by inflammation, ulcera-
tion, or desquamation of the skin, and they are to be distinguished
from  that kind  of  discoloration  of a venereal character, which  is
seated  in the cicatrix of a constitutional ulcer of the skin, after  it
has healed, which cicatrix is always depressed in the substance of
the skin itself and of which I have already related some examples.
   From June to September this  patient underwent various kinds
of  treatment for the spots, which continued stationary, or  rather
increased during this period; and early in October he placed him-
self under my care.  At  this time the spots were dark brown dis- 
CASES.
293
colorations, nearly circular, unaccompanied by pain, uneasiness,
or inflammation of any kind, and did not disappear under pressure.
He had evidently been submitted to a mercurial  course, as there
were two or three ulcers in the mouth; the gums were spongy, and
bled  from the slightest  friction, and there was strong mercurial
fetor of the breath.
   I directed  this gentleman to use the vapour twice a week, with
half an ounce of the bisulphuret for each fumigation.  He also took
a tumbler of the compound decoction of guaiacum twice a day, with
two  drops of the liquor potassse arsenitis.   The treatment was not
varied: at the end of nine weeks the spots could not be perceived,
and  the general health had much improved.
   This is a very rare form of  constitutional venereal taint, and is
to be distinguished from all other varieties of syphilitic disease by
the skin.  Cazenave1 corroborates from his experience the rarity
of its occurrence, and mentions cases in which it has been confounded
with other cutaneous affections.  These copper discolorations, how-
ever, of venereal origin, due to an altered condition of the pigment
of the skin, almost invariably coexist with other symptoms, whose
nature is more unequivocal.   In the case just detailed, the previous
history, the condition of the throat, and the loss of  hair leave no
doubt as to the true  nature  of the disease.  Syphilitic alterations
in the colour of the skin (maculae syphiliticse) are  rarely, if ever,
ushered  in, or  accompanied, by that febrile action which is  com-
mon at the commencement of the ordinary venereal eruptions; they
are not accompanied by any other alteration of the skin beyond
change of colour; there is  neither  inflammation,  ulceration, nor
desquamation.
   These rare forms of disease are slow in their progress, and re-
bellious to all ordinary treatments;  indeed it is rare to find them
cured at all under such circumstances.  Cazenave quotes a case of
this nature from Biett's practice, in which  the patient's health was
entirely destroyed by the means adopted  to remove them, which,
even in the hands of men of such ample experience, was unsuc-
cessful.  The  case I have just detailed, of even aggravated  form,
for the spots on the face and back were  as distinct and deep as
though they had been painted on the skip, and completely banished
the patient from society, was cured  by the vapour in nine weeks,
after five months' treatment by the ordinary remedies, during which

            1 Maladies Ve'ne'riennes de la Peau, p. 575, et seq. 
294
SECONDARY  SYPHILIS.
time the spots rather increased than diminished, and the health was
beginning to fail under the remedies employed.
  Other  forms of " maculae," or discolorations, are less vivid, and
do not even always  attract the patient's attention, though  they
render some others very uneasy.  It is common, during treatment
for other venereal symptoms, to find, on undressing the patient, the
surface of the abdomen, chest, or thighs covered with light, copper-
coloured blotches, which are precisely of the same nature as those
which I have just described.   If the treatment by  the vapour is
being followed, they commonly, if not always,  yield to it, though
sometimes very slowly; but ordinary treatments, though pursued
for months,  appear to have little or  no influence over them.

                           Case LIX.
Constitutional  syphilis of ten years' duration: periodical attacks of disease in the
   throat; affections of the nose and testis; at the end of nine years an acute attack
   of disease iu the throat, with speedy perforation of the soft  palate; failure of
   mercurial  and iodine treatments conducted in the ordinary manner; speedy and
   remarkable improvement of all  the symptoms, and disappearance of many of
   them under the treatment by the vapour.
   Mr. C—,  aged 23, consulted me, when passing through  Birming-
ham in 1840, for a slight eruption  and sore throat which were both
of syphilitic origin: he had had primary sores some months previ-
ously, for which  he had taken  mercury to salivation.   I neither
saw  nor heard  from this patient for  nine years; but, early in 1849,
he again came to me.  He stated  that  he  had never been well
since he  first saw me; that from  time to time he had had  attacks
of inflammation, and ulceration of  the throat, wdiich had yielded
to medicine, (the hydriodate of potass,) but had always recurred
after the medicine had been discontinued for a little time. He had
suffered also from discharges of hard, thick crusts from  the  nose;
the nasal duct  had been obstructed,  and the operation for its resto-
ration had  been attempted and  failed, and the patient suffered,
consequently, from  lachrymal fistula.   He  had enlargement and
induration  of  the  left testis (syphilitic sarcocele,) he  was  pale,
emaciated,  and weak, and suffered from profuse night sweats.
   Such had been the condition of the patient during the nine
years which had elapsed between his first and second visits to me.
The immediate  cause of the second consultation was the  state of
the  throat.   Four days only previous to this visit he began to suf-
fer from pain in the roof of the mouth,  which  was much  inflamed; 
CASES.
295
and, on the second morning after  these symptoms had first been
observed, he discovered a  large hole in the roof of the mouth.
The whole of the roof of the mouth and soft palate were at this
period intensely and lividly red;  and at the junction of the soft
with the hard palate there  existed an ulcer of the  size of a six-
pence, which had  perforated the  velum, and  through which the
nasal  mucus flowed,  as it was close under the posterior nares: the
ulcer  was  rapidly spreading, and threatened destruction  to the
whole of the contiguous parts.  The throat and fauces presented
no  trace of inflammation.
  Encouraged by the success which  had attended the use of the
fumigation in two other cases, I immediately proposed it to my
patient, who was immersed in a powerful bath for half an hour,
for which was used two drachms of the binoxide, and two drachms
of the bisulphuret of mercury.  On the next day the pain was gone,
the ulcer had not extended, and the inflammation was certainly less.
On the second and third days the baths were repeated in the same
manner,  and of the same strength.   The mouth had  now become
so sore that they could not be continued, although neither saliva-
tion nor ulceration  was produced,  merely  an even  redness and
swelling of the gums.
  The patient was directed to take twenty drops of Battley's solu-
tion of opium three times a day, with plenty of sarsaparilla broth.1
  At the end of a fortnight the testis had  recovered its natural
state; the inflammation in the mouth had entirely disappeared, and
the ulcer was granulating  and contracting fast;  the mouth still
continued  sore.
   At the end of two months, this patient did not present any symp-
tom of constitutional taint; the perforation in the palate remained,
though it had much contracted, and did not occasion much inconve-
nience.  There has been no fresh symptom for ten months.
  This case is remarkable, and instructive in many points, and for-
cibly illustrates certain laws in the  history  of secondary syphilis.
It shows, in the first place, that acute and mutilating diseases not
unfrequently occur in constitutions broken down by long-continued
venereal taint.  It shows again that  the condition of the nose, and
the nature of the discharges from  it, are very frequently the chief
symptoms that mark a latent venereal taint: this is a point which

                1 Decoct. Sarsse co., ftss;
                 Carnis bovis, ftss.
                 Coque simul super lent  igne ad dimidium.         v
                 Dose.  Ad libitum. 
296
SECONDARY  SYPHILIS.
I have before had occasion to allude to;  and it is one of very con-
siderable  importance.   The treatment of this case illustrates the
power of the moist mercurial fume in arresting formidable diseases
of this nature, and arresting them so quickly, so  certainly, and so
safely.  I do believe that no other plan of treatment could have
been framed which would have saved the whole of the roof of the
mouth from horrible mutilation.
  This ulcer wras evidently of nasal origin, and the velum had been
perforated from behind: it had not been preceded by any ulcera-
tion in the throat, or on the forepart of the velum: and the first
knowledge the patient had of the existence of the ulcer, was the
sight of the perforation in the  palate.    I repeat,  that  in  all
cases of secondary syphilis  the  passages  of the nose should be
carefully examined, as they furnish some of the  best tests we can
have of the existence of a latent constitutional taint.

                           Case LX.
Constitutional syphilis of three years' duration:  discharge of crusts from the nose,
    with ulceration; great wasting of the body, with hoarseness, difficulty of swal-
    lowing, and pain in the larynx; local employment of the vapour of the binoxide
    of mercury; cure.
  E. F—, aged  36, was admitted into the Queen's Hospital, under
my care, early in 1849.  She had been the subject of secondary
and constitutional syphilis for about  three years,  during which
time she had undergone a great  variety of treatment.  She was,
at the period of her admission, much emaciated,  had night perspi-
rations, and could only speak  in a whisper.  She had superficial
ulceration of the septum of the nose, the whole lining membrane of
which was vividly red, with daily discharges of the characteristic
crusts.  Her chief complaint, however, was of pain deeply seated
in the throat and neck; and the larynx  was very tender  when
handled or pressed.
  I suspected that she  had syphilitic  ulceration of the windpipe.
  By means of  an apparatus, easily contrived, a stream of the va-
pour, made with  half a drachm of the  binoxide of mercury for
each fume, was directed into the fauces and up the nostrils every
morning.   After four or five inhalations, the mouth became sore,
and the remedy was used less frequently.
  The symptoms entirely disappeared under this treatment;  and,
three months afterwards, when the patient  called on me, she had
recovered  her health and strength, and  appeared  perfectly well. 
CASES.
297
  I have, in many instances, employed the vapour of the binoxide,
the iodide, and the gray oxide of mercury locally, in many anoma-
lous symptoms, which were consequent upon protracted and consti-
tutional syphilis, and which did not appear to require the general
application of such remedies.   These diseases have been fissures
and cracks in  the tongue, pains in the throat, fauces, and larynx,
which had previously been the  seat  of ulceration, fissures of the
anus, cracks about the  lips, &c.   One of these cases I have just
detailed, and I could bring forward a very considerable  number,
in almost all of which  one remedy  or the  other  has been per-
fectly successful.   In  cases where it is  wished to employ the
vapour  of mercury locally to affections of the tongue, throat or
nose, it is better to use the binoxide, or the gray oxide, as the
iodide, or the vapour of the bisulphuret, produces so much sneezing
and coughing, that some persons are unable to bear the application
long enough to be useful.

                          Case LXI.
Constitutional syphilis of four years' duration: treatment by the vapour; uneasiness
    and pain in the throat still recurring at times; local application of the vapour
    of the binoxide of mercury; disappearance of the symptoms; no relapse.
  A  commercial traveller placed himself under  my  care  to  be
treated for secondary and constitutional  syphilis, from which  he
had suffered for nearly  four years.
  The symptoms consisted in superficial ulceration of the throat,
pains in the  bones of the nose, with superficial  ulceration of its
mucous membrane, and discharge of pus, blood, and mucous crusts,
writh some suspicious spots on  the skin, and a general cachectic
condition, the result probably of large quantities of mercury  which
he  had taken for the cure of the primary disease.
  He was treated  by the moist vapour of the bisulphuret, and  bi-
noxide of mercury.  In about ten weeks he had perfectly recovered;
and at the end of three months  had become very florid,  and got
very fat.  There remained, however, some uneasiness in the throat,
and from time to time a blush of redness spread over the pharynx
and fauces, accompanied by dryness, and slight pain when  he swal-
lowed.  These symptoms rendered him uneasy, but as they did not
appear to me sufficiently important to condemn him a second time
to a full course  of treatment, I directed half a drachm of the vapour
of the binoxide of mercury to be directed  into the throat  three
times a week.   Each application gave him great relief: at the end 
298
SECONDARY SYPHILIS.
of three weeks the throat no longer troubled him, and for twelve
months there has been no return of disease in any form.
  It not unfrequently happens that a single symptom continues to
annoy patients, when they do not present any appearance of gene-
ral constitutional taint, and where the treatment previously adopted
has been sufficient to render the mind pretty easy on such a point
These  symptoms generally  consist in periodical attacks of red-
ness, and  dryness in  the throat, in  soreness, and  occasional dis-
charge from the nose, in  fissures, and  superficial ulceration of the
tongue, and the anterior of the mouth; in  scaly, dry blotches on
the palms of the hands and  soles of  the feet; and in pains deeply
seated in the neck and throat   In all such cases, and  I could bring
forward instances of every form I have mentioned,  a local  treat-
ment by the vapour almost  invariably succeeds in removing the
symptoms, which, I  believe, in  such  cases,  to be most commonly
local, and where a general treatment is much more likely  to do
harm than good. I bring forward one or two cases in illustration.

                         Case LXIL
Constitutional syphilis of fifteen months' duration: removal of the symptoms under
    treatment by the vapour of the bisulphuret of mercury; subsequently fissure,
    and red elevations upon the tongue; treatment locally by the  vapour of the io-
    dide; permanent and perfect cure.
  A young gentleman who had been suffering from secondary and
constitutional syphilis for about fifteen  months, came under my
care in the  early part of 1848.  He was treated methodically by
the fumigations, and took in addition some decoction of guaiacum,
with the syrup of iodide  of iron, as he was of a weak and delicate
constitution.  About  two months after the disappearance of any
venereal  taint, a long fissure or crack came in the tongue, and
four or five large, red, hard, elevations appeared, having the ap-
pearance  of small strawberries; the tongue was red and painful.
These symptoms appeared to me of venereal origin, although his
health appeared good, and he  presented no other appearance of
taint.
   I suggested to him the use of a local fumigation of the vapour
of five grains of the iodide of mercury every other day.   No other
remedy was  used, and in three weeks the  fissure had  closed, and
the tongue presented its natural appearance.
   I have seen several instances in which fissures, superficial ulcera-
tions, or indurations, thickening, and unevenness of some parts of 
CASES.
299
the tongue, have remained for years  after the  patient had been
cured of all other symptoms of syphilitic taint;  and, I believe, al-
though these are occasionally dependent upon a general affection,
they are, nevertheless, in many instances, local diseases only. They
are almost always rendered worse by mercury given by the mouth,
and probably are merely forms of chronic stomatitis, produced ori-
ginally by the internal administration  of this drug.  It will easily
be discovered whether they are symptoms of general infection, by
the co-existence of  some of the other  symptoms, of which I have
so frequently spoken.  If the health be good, and such symptoms
are absent, thoy are local diseases.   They yield  in a rapid manner
to treatments by vapour, and the cures are permanent.

                        Case LXIII.
Excavated ulcers of the throat; treatment internally by a full course of mercury; re-
    currence of the disease; a second course of mercury; a third attack of ulcera-
    tion ; complete and permanent cure by the vapour of the iodide of mercury.
  S. P----was treated by  a full course of mercury internally for
two deep ulcers of the throat, one  situated on each tonsil, under
which the ulcers healed.  A short time afterwards the throat again
ulcerated, and the  patient  was a  second time submitted to a mer-
curial course, pushed to salivation:  the ulcers again healed, but, in
a short time, again broke  out.   The  patient was, at this period,
placed under my care.   The health was a good deal broken by the
two courses of mercury previously  employed, the  patient was thin
and weak, and the  appetite bad.    I directed the patient to take
the compound infusion of gentian, with dilute nitric acid, and some
of the compound extract of sarsaparilla, with two grains of the
extract of opium every night.  The vapour of three grains of the
iodide of mercury  was  also directed  into the throat every other
day.  In eighteen days the ulcers had  healed, and the patient has
not again relapsed.
  This is not a solitary case: I have seen a great  number, exactly
similar, where ulcers which had healed under mercury, internally
administered, have frequently again broken out, and have at length
rapidly and permanently closed  under treatment by the vapour:
of all local treatments  to venereal ulcers of the  throat, none are
equal to  the moist mercurial fume.   Whether there be mere red-
ness, the excavated ulcer, creeping or  superficial ulcers, this is the
local remedy "par excellence."
  Clara C----, a patient in the Queen's Hospital, had superficial 
300
SECONDARY SYPHILIS.
ulceration, with much  redness of the throat, and shining copper-
coloured blotches on the head and other parts: she had been treated
by a long course of the bichloride of mercury, which had cured the
skin disease; but the ulceration of the throat, although at times
disappearing, kept constantly recurring: she  had also two small
ulcers of the tongue.   Both the ulcers of the throat and  tongue
healed rapidly  under the use of  the vapour of the iodide, and the
cure was permanent.

                         Case LXIV.
Constitutional syphilis of seven years' duration; nocturnal pains, with enlargement
    and tenderness of the bones of the nose, and of the bones of the left arm; sar-
    cocele of the left testis; failure of the ordinary treatments; complete cure by
    the author's method in four months without relapse.
  A dramatic artist of celebrity, who had been married for some
years, and who had not had any primary venereal disease, in any
shape or form, since his marriage, consulted me in the earlier part
of 1849.  He came to me as a forlorn hope, despairing of relief, as
he had constantly relapsed after discontinuing the best-framed or-
dinary treatments, conducted by eminent surgeons, amongst whom
may be mentioned the late Mr. Aston Key.  When I first saw this
gentleman his chief complaint was of the left fore-arm, the bones
of which were much enlarged, very painful and tender to the touch;
but his  sufferings were much increased during the night, when the
pains were at times so excruciating as to deprive him more or less
completely of rest; he  had not slept one night, without pain, for
seven years.   The radius  and ulna near the wrist were  much en-
larged, and were nodulated and uneven.   The bones of the nose
were a  good deal thickened, and he had shooting pains in them.
The left testis was five times the size of the right, heavy and lobu-
lated, but neither painful nor tender.
  I consider this case as one of  a decided venereal character; al-
though  mercury, pushed to salivation, and iodine had previously
failed in affording more than a mere transient and temporary relief.
Knowing the benefit which I had derived in many former cases,
from the use of the baths, I held out to my patient a hope that they
might be serviceable to him also.
   I directed him to use half an ounce of the bisulphuret of mercury
and half a drachm of the iodide of mercury  for each of the first
three baths, which were to be taken every third day, and to take
internally some small doses of the hydriodate of potass with col-
chicum. 
CASES.
301
  After the third bath, which had slightly affected the mouth, the
nocturnal pains had disappeared, and the tenderness was gone from
the arm; he could bear the bones  pressed and handled, although
previously they had been exquisitely tender.   The treatment was
conducted at intervals for three months; sometimes the baths were
taken once a week, at other times not so frequently; the medicines
also were continued.  The pains never returned, and, at the end
of the period I mention, the nose and testis had been long perfectly
well.
   This was a well-marked case of chronic syphilitic periostitis; the
treatment of which, by my method, was rapid, safe, and successful.
Perhaps no forms of constitutional syphilis  are more formidable
than those which are seated in the periosteum and bones; and such
affections are very frequently  due to exposure, neglect, or want of
care during a mercurial course which has been prescribed for the
cure of some  form of secondary disease, but which  not only fre-
quently fails in curing it, but disposes the system to the production
of  new symptoms of a still more formidable character than those
for which the remedies were  originally prescribed.   It has been
said that the iodide of potassium is all but a specific for periosteal
inflammation, more particularly that of syphilitic origin:  it is cer-
tainly, in many cases, an excellent and efficient remedy; but there
are many cases also in which it totally and completely fails; not so
with the plan of treatment I am advocating: it is all but certain
in its influence over such diseases, and the rapidity with which it
cures is very remarkable.
   The patient, whose case I have just detailed, was so convinced of
the superiority of this method, that I could with difficulty prevent
him sending the details of his case, and its treatment, to a Metro-
politan daily paper.  He had  been under the  best ordinary treat-
ment for nearly seven years, with little or no benefit; and he was
completely and permanently cured in three months by my method.
In such  cases I  believe, after several experiments  made on  the
subject, that the best remedies to employ are combinations of the
bisulphuret and the iodide of mercury in the proportions, or nearly
so, which I have mentioned in the details of  the case.

   The next case is equally remarkable in the effects of the  reme-
dies employed, although the  duration of the disease was not  by
any means so  long as the preceding;  but  still, in many respects,
the symptoms were of an equally formidable character. 
302                SECONDARY SYPHILIS.

                          Case  LXV.
Secondary and constitutional disease of six months' duration, consisting in copper-
   coloured scaly blotches on the neck, pustules and tubercles on the face, thick-
   ening, with tenderness of the bones of the right leg, and disease of the testis;
   failure of ordinary treatments;  rapid and permanent cure by the vapour of the
   iodide and bisulphuret of mercury.
  A young  gentleman,  aged  20, contracted gonorrhoea, and a pri-
mary sore, late in the autumn of  1848, for which   he was  treated
by a surgeon in the North of England, where he resided.  The
primary diseases were apparently cured,  but soon  after the disap-
pearance of the discharge from  the urethra, a rash made  its ap-
pearance all over the body (roseola syphilitica?) which soon died
nearly,  but not completely, away.  Some time afterwards, blotches
of a  more decided character appeared on the neck, and on the face,
and he  began to suffer from pains in the right  leg, which were  at
times sufficiently severe to occasion lameness.  About  this time
the patient became languid, and was troubled occasionally with
profuse night perspirations.  For these symptoms he took various
medicines under the direction of experienced surgeons; and, about
six months after the first appearance of the skin disease he  placed
himself under my care.
  When I first examined this gentleman  he presented a most for-
midable array of constitutional symptoms. On the face were forty
or fifty  pustules, with hard, nodular bases; and, in the substance of
the left cheek, two tubercles, each as large as a horse bean, and
one  on  the back  of the neck, still  larger, the surfaces of which
were beginning to  inflame.  On  the forepart of the neck were a
number of copper-coloured scaly blotches of the size of a shilling
and the body generally was  covered with a faint  copper-coloured
mottling, into which the first rash had subsided.  The right testis
was  three times the size of the left, and the tibia of the right leg
much enlarged, very painful  at night, and tender to the touch; the
patient  had evidently taken  mercury, for his gums were spongy,
and the breath  had a strong  fetor; yet  his disease  had gradually
progressed, and new symptoms were  from  time to time added to the
old.
  Formidable as the details of this case must appear, I felt certain
of a speedy and permanent cure under the use of the moist vapour
of the iodide of mercury in a short time.  I directed a bath, with
three drachms of the bisulphuret  of mercury, and one of the iodide 
CASES.
303
to be administered every other day, with the head immersed, and
to be continued for half an hour: the patient was ordered also to
take freely  of the compound decoction of guaiacum, with small
doses of the iodide of potassium, and three grains of the acetic ex-
tract of colchicum, and one of the extract of opium every night.
   The  first  bath relieved the pains in the leg, and other parts:
and, after the second, the tibia might be pressed without flinching;
and  the pains, except at such a time, were altogether gone; the
hard bases of the tubercles, even at this early period, were  less,
and  the tubercles softer.   Very little medicine was taken in this
case.  The patient drank a cup of guaiacum tea two or three times
a day, in which were dissolved three grains of the iodide of potas-
sium, and he took also a dose of opium at bed-time.   Such reme-
dies alone, and  in such doses, would have exerted but little in-
fluence over so  formidable a disease, and many of the symptoms
could not have  been  expected to yield at  all  to such medicines.
The cure was complete  in  five weeks, and  it  has been real and
permanent;  no relapse nor return of complaint in any form.   The
general health has  been also, as it commonly is, much improved
by the treatment.
   In cases of complicated constitutional syphilis, such as the one
just  detailed, we cannot estimate too highly  the plan of treat-
ment by the moist mercurial fume.  In  such and similar cases
the symptoms are so  numerous and  varied, that, in the ordinary
way, we are almost at a loss to know what kind of internal treat-
ment to recommend.   No plan is laid down by authors of the great-
est experience for cases like the present.  In speaking of compli-
cated syphilis, Ricord says, " We must treat the epiphenomenon of
the  disease, let  it be whatever  it may, and the worst treatment
is that which is exclusively directed  towards the removal of one
symptom, when ten others require  modification."
   When the disease has been still further complicated by the inter-
nal administration of mercury, and we find fetor of the breath, with
a spongy condition of the gums, and a certain amount of debility7,
and  malaise,  with night perspirations, which commonly set in at
these periods, the difficulties of treatment are much increased.  In
such states, a further internal treatment by mercury is inadmissible,
and  might even prove fatal,  and  iodine offers but little better pro-
spect of success.
   At these periods, and in such  cases, the moist  mercurial fume, 
304                SECONDARY SYPHILIS.
employed in the manner and with the modifications I have already
detailed, is all but certain in its effects.  The patient soon begins
to amend, the evils caused by the internal administration of mer-
cury soon pass off; the appetite, strength, and  general health  ra-
pidly improve, whilst the symptoms of constitutional taint are
quickly and permanently eradicated. 
INDEX.
 Abortive treatment of gonorrhoea, 66.
                   of chancre, 107.
                   of bubo, 138, 139,
                      147.
 Acid nitrate of mercury, 102.
 Alopecia, 194.
 Ancell, Mr., on syphilitic tuberculosis,
   234.
 Anus, abscesses  in the vicinity of, oc-
   casionally due to gonorrhoea, 84.
 Antimonial solution,  130.
 Aromatic wine, 109.
 Arsenic, in the ulcerated forms of tu-
   bercle, 188.

 Balanitis, 49.
          causes of, 49, 51.
          treatment of, 50.
          symptoms of, 54.
          complications of, 55.
          secondary  symptoms after,
            55.
          cases of, 51, 53,  56, 57, 58.
          recurrence  of, 58.
 Beer, on gonorrhoeal ophthalmia, 87.
 Bennet, Dr. James Henry, on vaginitis,
   98.
 Bennett, Dr. Hughes, microscopic ex-
   amination of the products of irritated
   and inflamed glands, 43.
 Bertin, on infantile syphilis, 237.
 Blisters in gleety discharges, 83.
 Blood, pathology of,  in constitutional
   syphilis, 173.
 Biett, M., on the  treatment by the in-
   sufflation of the chloride of mercury,
   252.
 Bougie recommended in the advanced
             stages of gonorrhoea, 84.
       in gleet, 82.
Bouisson,"M., on syphilitic diseases of
  muscles, 222.
Brachet, M., treatment of some syphi-
  litic symptoms by the chloride of
  mercury, 252.
 Brodie, Sir B., on mercurial treatment
                  by friction, 31.
               on colchicum, 82.
               on gonorrhoeal iritis, 90.
               on orchitis, 91.
 Broussais, aphorisms of, in relation to
   syphilis, 18.
 Bubo, 136.
       not often inoculable, 41.
       varieties of, 136.
       nature of,  inoculation in,  136.
       causes of, 137, 147.
       abortive treatment of, 138.
       mercury in, caution in the use
         of, antiphlogistic treatment of,
         remarks on, 139.
       abortive treatment of, 138, 139,
         H7.
       objections to, 140.
       indolent, 141.
       treatment  when  fluctuation  is
         evident, 142.
       ulcerated—sloughing, 143.
       chronic indolent, 144.
       premonitory symptoms of, and
         their treatment, 147.
       treatment  when  matter  has
         formed, 148.
       how to puncture, 148.

Cachexia, syphilitic,  234.
Causes of secondary syphilis, 155,
Carmichael, Mr.,  doctrines of,  18.
                 on  chancres of the
                   urethra, 119.
Caustics  the  destruction of chancre,
            those recommended, 112.
         when indicated, 113.
         cautions in the use of, in clis-
 *          eases of the throat, 207.
Cazenave, M., on constitutional vene-
  real ulcers,  189.
Ceeley, Mr.,  on  the absorption of
  lymph, 107.
Cellular tissue,syphilitic tumours of, 191.
20 
303
INDEX.
Chancre, see Ulcers.
Chancres of the urethra, 119.
         history of, symptoms of, 119.
         differential diagnosis of, 120.
         complications of.  121, 122.
         cases of, 120, 121, 123,  124,
            126.
         prognosis of, 122.
         consequences of,  122.
         constitutional symptoms pro-
            duced by, 123.
         treatment of, mercury in, 123.
Chancrous excoriation, 49.
Change  in  the  form  of mercurial re-
   medy employed very frequently suc-
   cessful, 35.
Chlorosis, syphilitic, 234.
Churchill, Dr., on the diagnosis of leu-
   corrhoea,  103.
Clare's method  of treatment, 252.
Clarke, Sir C. M., on  the  diagnosis of
   leucorrhoea, 103.
Classification  of  primary  syphilitic
   ulcers, 105.
Condylomata. 189.
              primary forms of, 198.
              secondary,  199.
              treatment of  the consti-
                tutional forms of, 203.
Congenital syphilis, 234.
Constitutional syphilis, 150.
Constitution, state of, to  be watched
   during a mercurial course, 35.
Contagious  character of secondary sy-
   philis, 46, 47, 48, 157.
Colles, Dr., on the period  of discontin-
   uance of specific treatment, 36.
Copaiba, particular forms for its exhi-
   bition, 73.
Cubebae piper, particular forms for the
   exhibition of, 74.
Cubebs  and copaiba,  in gonorrhoeal
   ophthalmia useless, 88.
Cullerier, M., on thetreatment of prima-
               ry syphilitic alcers, 110.
             on local applications to
               primary sores, 116.
             on syphilis in nurses and
               infants, 237.
Cura famis,  20.
Curling, Mr., on gonorrhoeal  orchitis,
   91.

Decoctions of Feltz, of Zittman, 188.
D'Espine, M., on gonorrhoeal orchitis,
   92.
Desruelles,  conclusions on  treatment
   from the examination of 8810 cases,
   27, 37, 38.
Diagnosis of primary syphilitic ulcers,
            106.
          of secondary syphilis, 165.
Diday, M., on the contagious proper-.
  ties of the blood in secondary syphi-
  lis, 173.
Diet, in syphilis, 64.
     cases illustrative of the effects
        of, 22.
     in secondary syphilis, 153.
Dzondi's method of treatment, 253.

Egan, Dr., on inoculation, 42.
           on bubo,  136.
Epididymis, inflammation of, 90.
Erythema, papulous, syphilitic, 175.
Exanthemata, syphilitic, 175.

Faoces,  secondary  syphilitic, ulcera^
  tions of, 205.
Feltz, decoction of, 188.
Fricke,  on the  urethral plug in  some
  forms of gonorrhoea, 79.

Gaussail, M., on gonanrhceal orchitis, 91.
Generative organs, general  weakness
  and irritability of after gonorrhoea, 95.
Glans penis, inflammation of, 49.
Gleet, its nature, local symptoms of, 80.
      constitutional  effect of, and in-
        fluence on virility, 81.
      treatment of some inflammatory
        forms of, 81.
      injections in, mode  of using, 81.
      bougies, blisters, internal reme-
        dies, 82, 83.
Gonorrhoea, external or false, 49.
Gonorrhoea, 59:
           varieties of, 59.
           produced  occasionally by
             healthy females, 60.
           dependent sometimes oh
             an irritable stricture, or
             an irritable urethra, 61.
           illustrative case of, 61.
           a  disease  distinct  from
             chancre, 61.
           causes of, 62.
           pathology of,  63.
           symptoms of, 64.
           differential diagnosis of,65.
           the  four stages of—first
             stage  of, 66.
           abortive treatment of, how
             to be employed, 66.
           strong injections of nitrate
             of  silver condemned—
             fatal case from the  use
             of, 68. 
INDEX.                             307
Gonorrhoea, second and third  stages
              of, 68.
           antiphlogistic treatment of,
              more than an urethritis,
              70.
           specific  remedies in—co-
              paiba, 72.
           piper cubebae, 73.
           various remedies in, 74,75.
           mercury in, 76.
           injections  in, how  to be
              employed, 76, 77.
           secondary symptoms from,
              their nature, illustrative
              cases of, 85.
           rheumatism  from, its  two
              kinds, 85.
           ophthalmia from, 86.
           its causes,  general treat-
            1  "ment, local treatment, 86.
           cubebs and copaiba in, mer-
              cury in, restoration of the
              urethral discharge in, 88.
           iritis from, 90.
           swelled testicle from, 90.
           at what period it occurs,
          *    91.
           causes of, 92.
           differential diagnosis of, 93.
           treatment of, 93.
           strapping in, 94.
           enlargement of  the testis
              from, 95.
           weakness and irritability of
             ' the sexual organs from,
              96.
           of the rectum, 96.
           in the female, seat of, pa-
              thology of, 98,  100.
           varieties of, 98.
           speculum in, 100.
           internal treatment of, local
              treatment of, 100.
           complications of differen-
             tial diagnosis of, 102.
           difficulties  in  treatment,
              103.
Grassi, M., on the state of the blood in
  constitutional syphilis, 173.

Hair, loss of, from syphilitic causes, 194.
     remedies for the restoration of,
       195.
Hamilton, Mr.^on the syphilitic testi-
  cle, 218,219.
Hecker, on the varieties of gonorrhoea,
  59.
Hunt, Mr., on the mercurial treatment
  of syphilis, 31.
 Induration of a primary sore, what it
   is, what is to be understood by it, 29.
 Indurated chancres, treated by moist
   fumigation, 33, 117.
 Indurated cicatrix, 118.
 Infantile syphilis, 237.
                 causes of, 237.
                 primary syphilis in
                    infants, 239.
                 symptoms of, 240.
                 period of the appear-
                    ance of a constitu-
                    tional taintin, 241.
                 treatment of syphi-
                    litic pregnant wo-
                    men, 247.
                 treatment of primary
                    diseases in preg-
                    nant  women—of
                    diseased children,
                    244.
 Injections, forms for, in gonorrhoea in
   the female, 101,  102.
 Inoculation,  39.
             of primary sores, 39.
             only of value when  posi-
              tive, 41.
             of bubo, 42.
             why frequently uncertain
              in bubo, 42.
             in gonorrhoea, 44, 45.
             in sympathetic bubo, 44.
             in secondary syphilis, 45.
 Inoculation in reference to  the thera-
   peutics of  primary syphilis, 45.
 Integuments, various conditions of in
   open bubo, 145. ,
 Iodide  of potassium, its  use in  the
       treatment  of syphilis—inert in
         primary   diseases — when
         most useful, 255.
       frequently suspends symptoms
         but  does  not  cure disease,
         256.
       its combination with mercury,
         256.
     -  its use and dose as a tonic and
         prophylactic; its use and dose
         as an antisyphilitic, 257.
 Iodide of sodium, its use and adminis-
  tration in secondary syphilis, 258.
 Iodide of iron, 258.
 Iritis, gonorrhoeal, 89.
 Itch, venereal, 185.

Johnson, 11. J., on the occasional ef-
  fects  produced by discharges from
  a healthy female  on  the  male,ure-
  thra, 61. 
308
INDEX.
Johnson, H. J., on nitrate of silver in-
  jections, 68.

Lalouette on fumigations, 32.
Larynx, syphilitic ulceration of, 215.
        case and pathology of—treat-
          ment of—tracheotomy in,
          216.
        case of, 236.
Lawrence, Mr., on  the  treatment  of
  gonorrhoeal ophthalmia, 87.
Lugol, M., on  the  effect of the  non-
  mercurial treatment of syphilis, 115.
Lungs, syphilitic diseases of, 234.

Maculae, 189.
Mairion, M., on the diagnosis of ure-
  thral discharges, 121.
Malapert's abortive treatment of bubo,
  139.
Mercurial treatment of syphilis, 28.
Mercury, chloride of, its use in the
            treatment of syphilis, 252.
          bichloride, its  use in  the
            treatment of syphilis, 252.
          iodide of,  253.
          biniodide of,  254.
          bicyanide of,  255.
          when indicated in the treat-
            ment of syphilis, 29.
          when not to be used, 29.
          in what manner to be used,
            31.
          by internal administration,
            by friction, 31.
          by moist fumigation, 32.
          internal remedies to be used
            with the treatment by fu-
            migation, 33.
          when to be discontinued, 36.
          of little  use  in gonorrhoeal
            ophthalmia, 88.
          when to be used in the pri-
            mary syphilitic ulcer, 115.
          in bubo, caution in the use
            of, 138.
Mercier, M., on gonorrhoeal affections
   of the ovaries, 103.
 Mercurial honey, 188.
          vapour - bath,  in  alopecia,
                    195.
                in primary  syphilitic
                  sores, 117.
                in secondary syphilis,
                  162.
                in tubercles of the face,
                  168.
                in  syphilitic  rashes,
                  176.
Mercurial  vapour-bath,  in syphilitic
                 scaly diseases, 176.
               in syphilitic pustules,
                 182.
               in syphilitic tubercles,
                 187.
               in syphilitic stains, or
                 marks in the skin,
                 189.
               in the secondary con-
                 dylomata, 204.
               in secondary syphilitic
                 ulcerations  of  the
                 throat, pharynx, and
                 fauces, 208.
               in the  syphilitic dis-
                 eases  of the  testis,
                 220.
               in pains in the bones,
                 225.
               description of, 246.
               preparations  used in,
                 247.
               diet in—curative  ef-
                 fects of,  248.
               time  under treatment
                 by, 249.
               effects of on the gene-
                 ral  health, 250.
Milton, Mr., on the  use of the prepara-
  tions of potass  in gonorrhoea,  69.
Modern history of syphilis, 17.
Mouth, state of, to be  examined before
          giving  mercury,  37.
        and during its  employment,
          37.
        secondary  syphilitic   ulcera-
          tions of, 205.

Nantes, opinions of  the surgeons  of,
  on the non-mercurial treatment of
  syphilis, 27.
Nasal fossae, secondary  syphilitic  dis-
  eases of, 209.
Naso-lacrymal canal frequently oblite-
  rated in secondary  syphilitic  dis-
  eases of the nasal fossae, 210.
Nails, syphilitic diseases of, 196.
Nodes, 226.
        causes of, 227.
        pathology of,  227.
        terminations of,  228.
        differential  diagnosis of, 229.
        prognosis of—treatment of, 229.
        comparative effects of mercury
          and iodine in, 230.
        local treatment of,  232.
        operative procedures in, 233.
 Nodosities, white, of the tendons, 222. 
INDEX.
309
Nostrils, syphilitic diseases of, 209.
Nurses, wet, should be examined be-
          fore their admission into fa-
          milies, 48.
        syphilis in, 237.

Onyxis, 196.
Opiate cerate,  108.
Opium,  a variable remedy in  many
   forms of  syphilitic cachexia, 185,
   260.
Ophthalmia, gonorrhoeal, 86.

Paget, Mr., on constitutional venereal
   ulcers, 190.
Pains, syphilitic, of bones—nocturnal
            —nature and pathology of,
            224.
         treatment of—by internal re-
            medies—by the  mercurial
            vapour-bath —by operation
            —illustrative case  of  the
            latter, 224.
 Papular syphilis, 185.
 Papulae, general account of—varieties
   of—treatment of, 185.
 Parker, Langston, Mr.,  on  painful af-
   fections of bone, 224.
 Phagedena, ulcerative,  moist fumiga-
               tion in, 34, 132.
             general account of—causes
               of, 128.
             situation of—treatment of,
               129.
             caustics in, 134.
             gangrenous, 130.
             cases of,  131, 132.
 Pharynx, secondary syphilitic  ulcera-
    tion of, 206.
 Phymosis  from balanitis,  question of
              operation for, considered,
              55.
            from primary syphilitic ul-
             cers, 114.
 Plenck, solution of, 204.
 Pregnant  women, on syphilis  in,
    237.
 Primary syphilis,  general remarks on
    the treatment of, in reference to the
    use of mercury, 27.
 Prognosis  of  constitutional syphilis,
    171.
 Pustular syphilis,  179.
 Pustulae, syphilitic, 179.
             history of,  179.
             course of — varieties  of,
               180.
             consequences of, 181.
             complications of, 182.
Pustules, syphilitic, treatment to be mo-
             dified to suit the age and
             constitution  of  the pa-
             tient, and the particular
             form of disease, 182.
           local dressings to  ulcers
             succeeding  the  syphi-
             litic pustule, 183, 184.
           use  of   opium  in  some
             forms of, 184.

Rectum, gonorrhoeal diseases of, 96.
Rheumatism, gonorrhoeal, its two kinds,
  85.
Richter on gonorrhoeal ophthalmia, 86.
Rieord, M., on the period of disconti-
          nuing specific treatment, 35.
        on inoculation, 39.
        on gonorrhoeal ophthalmia, 89.
        on chancres of the bladder, 106.
        on the  abortive treatment of
          chancre,  107.
        on the diagnosis of bubo, 136.
Roe, Dr., non-mercurial treatment, as
  practised by,  24.
Roseola syphilitica, 175.

Scabies venerea, 185.
Scaly venereal disease, 176.
Scarpa, on gonorrhoeal ophthalmia, 89.
Secondary syphilis, cases illustrating its
              occasionally contagions
              character, 46, 47, 157.
            local circumstances neces-
              sary  to  contagion,  48.
              See syphilis, secondary.
 Skey, on the  origin of gonorrhoeal dis-
   charges, 60.
 Skin, syphilitic diseases of, 175.
       classification of, 175.
       syphilitic stains of, 189.
       syphilitic tumours of, 191.
       appendages of, syphilitic diseases
        of, 194.
 Simple, or non-mercurial treatment of
   syphilis, frequently fails,  26, 27.
 Sinuses,  treatment of,  145.
 Smith, Dr. Tyler, microscopic anatomy
   of the  neck of the uterus, 100.
 Soaps, mercurial, 195.
 Sore, condition of. to be frequently ex-
   amined during a  mercurial course,
   34, 35.
 Speculum, cautions in the use of, 100.
 Squamae, syphilitic, 176.
                history of, varieties of,
                  diagnosis of, 177.
                treatment of, 178.
 Sudorifics, 259. 
310                             INDEX.
Swediaur, on gonorrhoeal ophthalmia,
  89.
Syphilida, 175.
Syphilis, modern history of, 17.
         simple, or non-mercurial treat-
           ment of,  17-27.
         mercurial treatment of, 28-38.
         secondary,  150.
         phases of, 150.
         prevention  of, 151.
         complications of, 153.
         general treatment of, 153.
         causes of, 155.
         primary ulcers and discharges
           from the urethra—causes,
           155.
         cases illustrative of the opera-
           tion of this class of causes,
           155, 156.
         contagion a cause, 157.
         hereditary  transmission   a
           cause, 158.
         the  treatment of the  primary
           disease a cause, 158.
        administration of mercury at
           improper periods a cause,
           160.
        incomplete treatment a cause,
           161.
         neglect of baths a cause, 162.
         peculiarity  of constitution, a
           habit  of body, syphilitic
           temperament, acause, 163.
         diagnosis of, 165.
         its difficulties, 166.
         illustrative  cases,  166, 167,
           168.
         prognosis of, 171.
         state of the blood in, 173.
         particular symptoms of, 175.

Temperament, syphilitic, 163.
Testes, gonorrhoeal diseases of, 90.
        strapping of in gonorrhoeal or-
          chitis, 94.
        chronic enlargement of, 95.
        syphilitic diseases of,  217.
        symptoms, diagnosis of, 217.
        pathology of, 219.
        condition of virility in, 220.
        treatment of by iodide  of potas-
          sium—by the  mercurial va-
          pour-bath, 220.
Throat, secondary syphilitic ulcers of,
                 206.   .
               varieties of, 206.
               local treatment of, 207.
               constitutional    treat-
                 ment of, 207.
Tongue, secondary syphilitic diseases
           of, 211.
        iodic diseases of, 211.
        mercurial diseases of, 211.
Treatment, local, of  primary syphilis,
  24, 25.
Tubercles, 186.
           mucous, 199.
Tubercula, 186.
           general description  of, va-
             rieties of, course of, 186,
Tumours, syphilitic,  of muscles, 222.
          treatment  of, mercurial va-
            pour-bath in, 187.
          local treatment of, iodide of
            potassium in the ulcerated
            forms of, 188.

Ulcer, primary indurated, 117.
Ulcers, primary syphilitic, classification
        of, 105.
      diagnosis of, 106.
      question  of their locality con-
        sidered, 107.
      their varied aspect dependent
        on  situation, abortive treat-
        ment of by  escharotics, 107.
      local applications to, 109.
      constitutional  treatment of, 109.
      diet in, 110.
      mild treatment of, recommend-
        ed, 111.
      the author's views on escharo-
        tics in, 111.
      how to be employed, 112.
      when indicated, 113.
      complicated with phymosis—
        with inflammation, 113.
      mercury  in, when to be used,
         115.
      local treatment of the  second
         stage of. 115.
      local  applications to, formulae
        for, 116.
      primary in the female, 134.
      situations of,  134.
      cases of, 135.
      constitutional, or secondary ve-
        nereal,  189.
      of mucous membranes,  205.
Urethra, discharges from the, of various
          kinds, 44.
        alterations in the natural elas-
          ticity of, an occasional con-
          sequence  of gonorrhoea, 84.
        stricture of, 84.
        chancres of, 106, 119.
Urethral discharge, question of its resto-
  ration in gonorrhoeal ophthalmia, 88. 
INDEX.
311
Uterus, gonorrhoeal affections of,  100,
          103.
        syphilitic ulcers of, 135.

Vaginitis, 98.
Vegetable decoctions  and  infusions,
  259.
Vegetations.  See Warts.
Venereal ulcers in the female, 134.
Vesicles on the penis, 179.
Vesiculae, syphilitic,  178.
                    diagnosis of, 179.
Vetch, Dr., on gonorrhoeal ophthalmia,
  86.
Vidal {de Cassis,) on balanitis, 49.
                  on nitrate of  silver
                    injections, 69.
                  on gonorrhoeal affec-
                    tions of the ova-
                    ries,  103.
                  on chancres of the
                    bladder, 106.
 Vincent, Mr., on urethral discharges, 61.
 Virility, to what extent affected, in sy-
          philitic diseases of the testis,
           220.
         in gleet, 81.
Wallace, Dr., on the frequent evils of
               local  mercurial dress-
               ings to primary sores,
               30.
             on balanitis, 49.
             on the use of mercury in
               gonorrhoea, 76.
Waller, M., of Prague, experiments on
  the inoculation  of secondary syphi-
  lis, 48.
Warts, syphilitic,  197.
        their situation, causes, 197.
        varieties,  198, 199.
        secondary forms of, 199.
        contagious character of,  200,
          201.
        local treatment of, 201, 202.
        constitutional   treatment  of,
          mercury in, 203, 204.
Whitehead, Mr.,  on  the contagion of
           secondary syphilis, 48.
         on  the  communicability  of
           leucorrhoeal discharges. 62.
         on the seat  of gonorrhoea in
           the female, 100.

Zittman, decoction of,  188, 260. 
 
INDEX  TO   CASES.
                                                                     PAGE
Case     I.—Illustrates the effects of diet in the treatment of syphilis   .  22
        II.—        Ditto                        ditto              .  22
        III.—Illustrates the occasional contagious character of secondary
               syphilis     .      .       .      ■       •       •      .46
        IV.—        Ditto                        ditto .       .      •  .46
        V.—Shows that when a primary  disease is  communicated, the
               secondary diseases which follow it  are  different in each
               case        .      .       .      •       •       •      .47
        VI.—Gangrene of the prepuce, due to the  occlusion of the pre-
               putial opening from balanitis      .       .       .      .51
       VII.—Balanitis occasionally produced by discharges from the va-
               gina, which  are not specific      .       .       .      .53
      VIII.—Discharges  from the male urethra, after promiscuous inter-
               course, not always specific        .       .       .      .61
        IX.—Death from the  injudicious use of strong injections of the
               nitrate of silver, at the onset of gonorrhoea        .       .  68
        X.—Example of secondary disease succeeding  to gonorrhoea    .  85
        XL—Remarkable case of chancre  of the urethra, with constitu-
               tional disease      .       .      •       •       •       .124
       XII.—Chancre of the fossa navicularis    .       .       .      .126
      XIII.—Illustrates the use of the mercurial vapour-bath  in  arresting
               the spread of ulcerative phagedena, after the failure  of
               ordinary treatment ......  131
      XIV.—Cure  of phagedena by the mercurial vapour-bath, after the
               failure of ordinary treatment      ....  132
       XV.—Primary venereal sore? of the os uteri       .       .      .135
      XVI.__Example of secondary diseases succeeding to urethral dis-
               charges     ...••••  156
      XVII.—        Ditto                        ditto .       .       .157
     XVIII.—Illustrates the difficulties sometimes met within determining
               the character of a symptom supposed to  be syphilitic    .  166
      XIX.—Ulcerating syphilitic tubercle  of the lip and nose resembling
               lupus;  cure  by the mercurial fume, &c.          .       .167
       XX.—Chronic disease of the throat  with ulcerating tubercles, cure
               by the mercurial vapour-bath     .       .       ...  168 
314
INDEX  TO  CASES.
                                                                    Page
Case      XXI.—Examples of hereditary syphilis ....  172
  "      XXII.—Syphilitic ecthyma—illustrations of the use of opium in
                   syphilitic cachexia    .      .      .      .       .184
  "      XXIII.—Dissection of a case of chancre of the urethra  .       . 215
  u      XXIV.—Syphilitic tumour of the muscles       .      .       . 222
         XXV.—Caries of the tibia, with severe pains; failure of ordinary
                   treatment; cure by trephining       .      .       . 225
  "      XXVI.—Syphilitic ulceration of the windpipe; cure by the mer-
                   curial fume    ...... 236
        XXVII.—Case of infantile syphilis; no disease in the mother   . 238
  "    XXVIII.—        Ditto                       ditto    .      . 243
  "      XXIX.—Secondary phagedena of the throat; use of the mercurial
                   vapour-bath    ...... 262
  "      XXX.—Protracted and severe nocturnal pains; failure of the
                   iodide of potassium; cure by the mercurial  vapour-
                   bath   .       .       .      .      .      .       .263
  "      XXXI.—Constitutional symptoms of twenty-four years' standing;
                   prolonged use by the iodide of potassium; great relief
                   from the mercurial vapour-bath     .      .       . 264
  "     XXXII.—Case of syphilitic ecthyma; cure by mercurial vapour . 265
  "    XXXIII.—Constitutional syphilis of seven years' duration;  failure
                   of the iodide of potassium, and  ordinary mercurial
                   treatment; cure by the mercurial vapour-bath and the
                   biniodide of mercury  ..... 266
  "    XXXIV.—Constitutional syphilis, with bad health for seven years;
                   failure  of ordinary iodine and  mercurial treatments;
                   cure  by the mercurial vapour-bath and the biniodide
                   of mercury    ...... 267
  "     XXXV.—Constitutional syphilis for two years; failure of various
                   remedies; cure by the mercurial vapour-bath, without
                   internal medicines    .                            268
  u    XXXVI.—Constitutional  syphilis for eighteen months;  partial
                   amendment only  by ordinary treatments; cure  by
                   mercurial vapour     ..... 268
  u   XXXVII.—Primary and secondary syphilis, co-existing inability to
                   bear mercury;  disappearance  of  all the  symptoms
                   under treatment by the mercurial vapour-bath
  "   XXXVIII.—Secondary phagedena; clinical remarks on its treatment
  "    XXXIX.—Nodes on the forehead; cure by mercurial vapour; clinica
                   remarks on loss of hair and other symptoms of con
                   stitutional syphilis    ....
  T'         XL.—Primary phagedena of the glans penis and urethra; cli
                   nical remarks  .....
  "        XLI.—Syphilitic sarcocele; clinical remarks on treatment
  "      XLII.—Indurated  primary sore; pustular secondary syphilis;
                   bad health; cure by the mercurial vapour-bath, opium,
                   and decoctions of the woods  ....  274
269
269
270

272
273 
INDEX  TO  CASES.
315
                                                                     PAGE
Case XLIII.—Pustular secondary syphilis; nocturnal pains; bad  health;
               use of the vapour; clinical remarks       .      .      . 275
  "  XLIV.—Severe  nocturnal  pains;  clinical remarks  on  protracted
               Byphilitic symptoms       .       .       .      ... 276
  "   XLV.—Scaly peeling of the palms of the hands     .      .       . 277
  "  XLVI.—Scaly peeling of the hands; scaly disease of the  nails; loss
               of the hair, eyebrows, and whiskers; cure by the  mercu-
               rial vapour-bath; clinical remarks        .      .       .277
  (( XLVII.—Induration of the cicatrix; clinical observations on the treat-
               ment of indurations       ..... 278
  " XLVIII.—Formidable symptoms of constitutional syphilis; failure of
               ordinary mercurial  treatments, twice  pursued; cure  by
               the mercurial vapour-bath;  clinical remarks on  the fre-
               quent failure of mercurial treatments, as commonly con-
               ducted      .      .      .      .       .       .      .279
  "  XLIX.—Superficial ulceration of the throat and nose; failure  of ordi-
               nary  mercurial treatment  ..... 280
  11      L.—Syphilitic cachexia;  severe nocturnal pains;  cure by the
               mercurial vapour-bath and opium .       .       .      .281
  11      LI.—Superficial primary sore; for constitutional symptoms, spots
               on the body, loss  of  hair and voice; clinical remarks on
               the secondary diseases which succeed  to superficial pri-
               mary ones  ....... 283
   "    LII.—Ulceration of the nasal fossaB ..... 285
   "    L1IL—       Ditto        ditto     .      .       .       .      .286
   "   LIV.— Chronic disease of the throat;  failure of ordinary treatment;
               cure by the mercurial vapour-bath; clinical remarks on the
               success of this treatment, when associated with varied ex-
               ternal remedies, which  have, before such combination,
               been unsuccessful  ...... 287
   u    LV.—Superficial primary sores; great enlargement  of  the glands
               in the groin ....... 287
   "    LVI.—Indurated cicatrix; failure of ordinary treatment; cure by the
               mercurial vapour-bath; clinical remarks  .       .      . 289
   11  LVII.—Constitutional syphilis for two years; sarcocele; disease of
               the nasal fossae, obliteration of the naso-lacrymal canal;
               clinical remarks   '.       .      .      .        .      . 290
   11 LVIII.—Constitutional syphilis stationary for six years; speedy cure
               by the mercurial vapour-bath;  clinical remarks on syphi-
               litic stains of the skin      ..... 292
   "   LIX.—Constitutional  syphilis for nine years;  disease  suspended,
               not cured, by the iodide of potassium; clinical remarks  . 294
   "    LX.—Local employment of the vapour by  the binoxide  of mer-
               cury  in diseases of the throat and nose    .       .      . 296
   "   LXI.—Clinical remarks on the  local use of the vapours  of mercury 297
   "  LXII.—Secondary  syphilitic disease  of the tongue,  local  employ-
               ment of the vapour of the iodide of mercury      .      . 298 
316
INDEX  TO  CASES.
                                                                    PAGE
Case LXIII.—Recurrent secondary syphilitic ulcerations of the throat, per-
              manent cure by the local application of the vapour of
              mercury    ...•••• "99
  "  LXIV.—Nocturnal pains for seven years; failure of ordinary treat-
              ments; cure by the mercurial vapour-bath; clinical re-
              marks in diseases of the periosteum and bones   .       . 300
  "   LXV.—Tubercular secondary  syphilis; cure by the vapours  of the
              iodide and  bisulphuret of mercury; clinical remarks on
              complicated secondary syphilis   .              •       • 302 
 
 
                    CATALOGUE
                               OF

               BLANCHARD  &  LEA'S

MEDICAL  AND   SURGICAL  PUBLICATIONS.
                  TO THE MEDICAL  PROFESSION.

  In submitting the  following catalogue of our publications in medicine and the

collateral sciences, we beg to remark that no exertions are spared to render the issues

of our press worthy a continuance of the confidence which they have thus far enjoyed,

both as regards the high character of the works themselves, and in respect to every

point of typographical accuracy, and mechanical and artistical execution.  Gentlemen

desirous of adding to their libraries from our list, can in almost all cases procure the

works they wish from the nearest bookseller, who can readily order any which may

not be on hand; and who, as well as ourselves, will be  happy to answer any

inquiries as to price, &c.
                                                BLANCHARD & LEA.
  Philadelphia, July 1, 1854.
TWO MEDICAL  PERIODICALS,  FREE  OF  POSTAGE,
       FOR  FIVE  DOLLARS  PER  ANNUM.
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, subject to
  postage, when not paid for in advance,.......$5 00

THE MEDICAL NEWS AND LIBRARY, invariably in advance,   -    -    1 00
  or, both periodicals furnished, free of postage, for Five Dollars remitted
  in advance.
  THE AMERICAN  JOURNAL OF  THE MEDICAL SCIENCES,

                  Edited by  ISAAC  HAYS,  M. D.,

is published Quarterly, on the first of January, April, July, and October.  Each number contains
at least two hundred and eighty large octavo pages, appropriately illustrated, wherever necessary,
bv engravings.  It has now been issued regularly for a period of thirtt-five years, during a quarter
of a century of which it has been under the control of the present editor.  Throughout this long
space of time, it has maintained its position in the highest rank of medical periodicals both at home
and abroad, and has received the cordial support of the entire profession in this country.  Its  list of
Collaborators will be found to contain a large number of the most distinguished names of the pro-
fession in every section of the United States, rendering the department devoted to

                ORIGINAL  COMMUNICATIONS
full of varied and important matter, of great interest to all practitioners.
  As the aim of the Journal, however, is to combine the advantages  presented by all the different
varieties of periodicals, in its

                     REVIEW  DEPARTMENT

will be found extended and impartial reviews of all important new works, presenting subjects of
novelty and interest, together with very numerous

                BIBLIOGRAPHICAL  NOTICES,

including nearly all the medical publications of the day, both in this country and Great Britain, with
a choice selection of the more important continental works.  This is followed by the 
2
BLANCHARD & LEA'S MEDICAL
                           QUARTERLY SUMMARY,

being a very full and complete abstract, methodically arranged, of the

           IMPROVEMENTS  AND DISCOVERIES IN TIIE  MEDICAL  SCIENCES.

  This department of the Journal, so important to the practising physician, is the object of especial
care on the part of the editor.  It is classified and arranged under different heads, thus facilitating
the researches Ibf the  reader in pursuit of particular subjects, and will be found to present a verv
full and accurate digest of all observations, discoveries, and inventions recorded in every branch of
medical science. The very extensive  arrangements of the publishers are such as to afford to the
editor complete materials for this purpose, as he not only regularly receives

     ALL  THE AMERICAN  MEDICAL  AND SCIENTIFIC  PERIODICALS,

but also twenty or thirty of the more important Journals issued in Great  Britain  and on the Conti-
nent, thus enabling  him to present  in a convenient compass a thorough and complete abstract of
everything interesting or important  to the physician occurring in any part of the civilized world.
  An evidence  of the success which has  attended these efforts may be found in the constant and
steady increase in  the subscription list, which  renders it advisable for gentlemen desiring the
Journal, to make known their wishes at an early day, in order to  secure a year's set with certainty,
the publishers having frequently been unable to supply copies when ordered late  in the year.  To
their old subscribers, many of whom have been on their list for twenty or thirty years, the publish-
ers feel that no promises are necessary; but those who may desire for the first time to subscribe,
can rest assured that no exertion will be spared to maintain the Journal in the high position which
it has occupied for so long a period.
  By reference to the terms it will be seen that, in addition to this large amount of valuable and
practical  information on every branch of medical science,  the subscriber, by paying in advance,
becomes entitled, without further charge, to

            THE  MEDICAL  NEWS  AND LIBRARY,

a monthly periodical of thirty-two large octavo pages. Its "News Department" presents the
current information of the day, while the " Library Department" is devoted to presenting stand-
ard works on various branches of medicine.  Within a few years,  subscribers have thus received,
without expense, the following works which have passed through its columns :—

WATSON'S LECTURES ON THE PRACTICE OF PHYSIC.

BRODIE'S CLINICAL LECTURES ON  SURGERY.

TODD AND BOWMAN'S PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN.
  724 pages, with numerous wood-cuts, being all that has yet appeared in England.

WEST'S LECTURES ON THE DISEASES  OF INFANCY AND  CHILDHOOD.

MALGAIGNE'S OPERATIVE SURGERY, with wood-cuts, and

SIMON'S LECTURES ON GENERAL PATHOLOGY.

                               While the year 1854, presents

          BENNETT  ON  PULMONARY  TUBERCULOSIS,
                           BEAUTIFULLY  ILLUSTRATED ON WOOD.

  $3T Subscribers for 1853,  who do not possess the commencement  of Todd and  Bowman's
Physiology, can obtain it, in a handsome octavo volume, of 552 pages, with over 150 illustrations,
by mail, free of postage, on a remittance of $2 50 to the publishers.
  It will thus be seen that for the small sum of FIVE DOLLARS, paid in advance, the subscriber
will obtain a Quarterly and a Monthly periodical,

            EMBRACING ABOUT FIFTEEN HUNDRED LARGE  OCTAVO  PAGES

mailed to any part of the United States, free of postage.
  These very favorable terms are now presented by the publishers with the view of removing all
difficulties and objections to a full and extended  circulation of the Medical Journal to the office of
every member of the profession throughout the United States.  The rapid extension of mail facili-
ties, will now place the numbers before subscribers  with a certainty  and dispatch not heretofb»e
attainable;  while by the system now proposed,  every subscriber  throughout the Union is placed
upon an equal footing, at the very reasonable price  of Five Dollars  for two periodicals, without
further expense.
  Those subscribers who do not pay in advance will bear in mind that their subscription of Five
Dollars will entitle them to the Journal only, without the News, and that they will be at the expense
of their own postage on the. receipt of each number.  The advantage of a remittance when order-
ing the Journal will thus be apparent.
  As the Medical News and Library is in no case sent without advance  payment, its subscribers
will always receive it free of postage.
  It should also be borne in mind that the publishers will now take the risk of remittances by mail,
only requiring, in cases of loss, a certificate from the subscriber's Postmaster, that the money was
duly mailed and forwarded.
  EP* Funds at par at the subscriber's place of residence received in payment of subscriptions.
                                  Address,      BLANCHARD &  LEA, Philadelphia. 
AND  SCIENTIFIC PUBLICATIONS.
3
                         ANALYTICAL  COMPENDIUM

OF MEDICAL  SCIENCE, containing Anatomy, Physiology, Surgery, Midwifery,
  Chemistry, Materia Medica, Therapeutics, and Practice of Medicine.  By John Neill, M. D.,
  and F. G. Smith, M. D.  Second and  enlarged edition, one  thick volume royal 12mo. of over
  1000 pages, with 350  illustrations.   1^ See Neill.
                              ABEL  (F. A.),  F. C. S.
                Professor of Chemistry in the Royal Military Academy, Woolwich.
                                           AND

                                  C.  L.  BLOXAM,
                  Formerly First Assistant at the Royal College of Chemistry.

HANDBOOK OF CHEMISTRY, Theoretical,  Practical,  and  Technical, with a
  Recommendatory Preface by Dr.  Hofmann.  In one large octavo volume of 662 pages, with
  illustrations.  (Now Ready.)

  There was still wanting some book which should  who resolves to pursue for himself a steady search
aid the young analytical chemist through all the i into the chemical  mysteries of creation. For such
phases of the science. The " Handbook" of Messrs. j a student He ' Handbook' will prove an excellent
Abel and Bioxam appears to supply that want.  As j guide, since he will find in it, not merely the most
Dr. Hofmann says in his brief Preface, " The pre- , approved modes of analytical  investigation,  bat
sent volume is a synopsis of their (the authors') ex- i descriptions of the apparatus necessary, with such
perience in laboratory teaching;  it gives the neces-  manipulatory details as  rendered Faraday's ' die-
tary instruction in chemical manipulation, a concise  tnical Manipulations' so valuable at the time of its
account of general chemistry as far as it is involved ' publication.  Beyond this, the  importance of  the
in the operations of the laboratory, and lastly, quali- i work is increased by the introduction of much of the
tative and quantitative analysis.  It must be under- 1 technical chemistry of the  manufactory."__Athe-
stood that this is a work fitted for the earnest student,  ntzum.
                          ASHWELL  (SAMUEL),  M.D.

A PRACTICAL TREATISE ON THE DISEASES PECULIAR TO WOMEN.
  Illustrated by Cases derived from Hospital and Private Practice.  With Additions by Paul Beck
  Goooard, M. D.  Second American edition.  In one octavo volume, of 520 pages.
                            ARNOTT  (NEILL),  M.  D.

ELEMENTS   OF  PHYSICS;  or  Natural  Philosophy, General  and Medical.
  Written for universal use, in plain or non-technical language.  A new edition, by Isaac Hays,
  M. D.  Complete in one octavo volume,  of 484 pages, with about two hundred illustrations.

                BENNETT  (J.  HUGHES),  M. D., F.  R. S. E.,
                Professor of Clinical Medicine in the University of Edinburgh, &c.

THE  PATHOLOGY AND  TREATMENT  OF PULMONARY  TUBERCU-
  LOSIS, and on the Local Medication of Pharyngeal and Laryngeal Diseases frequently mistaken
  for or associated with, Phthisis.  In one handsome octavo volume, with beautiful wood-cuts.
Now publishing  in the ''Medical News and Library" for 1854, and furnished gratis to advance-
  paying subscribers  to the American Journal of the Medical Sciences.
  How it may be most effectually carried into prac-
tice, our readers will learn from Dr. Bennett's pages,
especially from the histories of the valuable and in-
teresting cases which he records. Indeed, if the au-
thor had only reported  these cases he would  have
benefited his profession, and deserved our thanks. As
it is, however, his whole volume is so replete with
valuable matter, that we feel  bound to recommend
our readers, one and all, to peruse it.—Lond. Lancet.
  The elegant little treatise before us shows how
faithfully and intelligently these investigations have
been pursued, and how  successfully the author's
studies have resulted in clearing up some of the most
doubtful points and conflicting doctrines hitherto
entertained in reference to the history and treatment
of pulmonary tuberculosis.—N. Y. Journal of Medi-
cal and Collateral Science, March, 1854.
                           BENNETT  (HENRY), M. D.

A PRACTICAL  TREATISE  ON  INFLAMMATION  OF  THE UTERUS,
  ITS CERVIX AND APPENDAGES, and on its connection with Uterine Disease.  Fourth
  American, from the third and revised London edition.  In one neat octavo volume, of 430 pages,
  with wood-cuts.   (Now Beady.)
  This edition will be found materially improved  oyer its predecessors, the author having carefully
revised it, and made considerable additions, amounting to about seventy-five pages.
  This edition has been carefully revised and altered, . that the bulk of the profession are not fully alive to
and various additions have been made, which render
it more complete, and, if possible, more worthy of
the  high  appreciation in which it is  held by the
medical profession throughout the world.  A  copy
should he in the possession of every physician.—
Charleston Med. Journal and Review, March, 1854.
  We are firmly of opinion that in proportion as n
knowledge of uterine diseases becomes  more appre-
ciated, this work will be proportionably established
as a text-book in the profession.—The Lancet.

  When, a few years back, the first edition of the
present work was published, the subject  was one
almost entirely unknown to the obstetrical celebrities
of the day; and even now we have reason to know
the importance and frequency of the disease of which
it takes cognizance.  The present edition is so much
enlarged, altered, and improved, that it can scarcely
be considered the same work.—Dr. Banking's Ab-
stract.

  Few works  issue  from the  medical press which
are at once original and sound in doctrine ;  but such,
we feel assured, is the admirable treatise now before
us.  The  important practical precepts which the
author inculcates are all rigidly deduced from faets.
. . . Every page of the book is good, and eminently
practical. . . . So far as we know and believe, it is
the best work on the subject of which it treats.—
Monthly Journal of Medital Science. 
4
BLANCHARD & LEA'S  MEDICAL
                BEALE  (LIONEL  JOHN), M. R. C. S., &.C.

THE  LAWS  OF   HEALTH  IN  RELATION  TO  MIND  AND  BODY.
  A Series of Letters from an old Practitioner to a Patient.  In one handsome volume, royal 12mo.,
  extra cloth.
                       BILLING  (ARCHIBALD), M.  D.
THE PRINCIPLES 'OF MEDICINE.   Second American,  from  the Fifth and
  Improved London edition.  In one handsome octavo volume, extra cloth, 250 pages.
               BLAKISTON (PEYTON), M. D., F. R. S.,  &c.

PRACTICAL  OBSERVATIONS  ON   CERTAIN  DISEASES   OF  THE
  CHEST, and on the Principles of Auscultation.  In one volume, 8vo., pp. 384.


                        BURROWS (GEORGE), M. D.

ON  DISORDERS OF  THE CEREBRAL CIRCULATION, and on  the Con-
  nection between the Affections of the Brain and Diseases of the Heart.  In one 8vo. vol., with
  colored plates, pp. 21t>.

                      BUDD  (GEORGE),  M. D.,  F. R. S.,
                     Professor of Medicine, in King's College, London.

ON  DISEASES  OF  THE  LIVER.   Second American, from the  second  and
  enlarged London edition.   In one very handsome octavo volume, with four beautifally  colored
  plates, and numerous wood-cuts.  pp. 468.  New edition.   (Just Issued.)
  The reputation which this work has obtained as a full and practical treatise on an important class
of diseases will not be diminished by this improved  and enlarged edition.  It has been carefully and
thoroughly revised by the author; the number of plates has been increased,  and the style of its me-
chanical execution will be found materially improved.
  The full digest we have given of the new matter
introduced into the present volume, is evidence of
the value we place on it.  The fact that the profes-
sion has required  a second edition of a monograph
such as that before  us, bears  honorable testimony
to its usefulness.  For  many years, Dr. Budd's
work most be the authority of the great mass of
British practitioners on the hepatic diseases ; and it
is satisfactory that the subject has been taken up by
bo able and experienced a physician.—British omA
Foreign Medico-C'himrgical Review.
                           BUCKLER (T. H.), M. D.,
                 Formerly Physician to the Baltimore Almshouse Infirmary, &c.

ON  THE  ETIOLOGY,  PATHOLOGY, AND  TREATMENT  OF  FIBRO-
  BRONCHITIS AND RHEUMATIC PNEUMONIA.  In one handsome octavo volume, extra
  oloth.  (Now Ready.)
  The concluding chapter on Treatment is full of
sound practical suggestions, which make this emi-
nently a book to be prized by the " working doctor"
rather than the mere closet student.—N. J. Medical
Reporter, March, 1854.
                   BLOOD AND URINE (MANUALS  ON).
BY  JOHN  WILLIAM  GRIFFITH,  G. OWEN  REESE,  AND ALFRED
  MARKWICK.  One thick volume, royal 12mo., extra cloth, with plates,  pp. 460.

                 BRODIE (SIR  BENJAMIN C), M. D.,  &c.

CLINICAL LECTURES ON SURGERY.   1  vol. 8vo., cloth.   850 pp.

                                BY THE  SAME AUTHOR.

SELECT  SURGICAL WORKS, 1 vol. 8vo. leather, containing Clinical Lectures
  on Surgery, Diseases of the Joints, and Diseases of the Urinary Organs.
                     BIRD (GOLDING), A. M.,  M.  D., &c.
URINARY   DEPOSITS:   THEIR   DIAGNOSIS,   PATHOLOGY,  AND
  THERAPEUTICAL INDICATIONS.  A new and enlarged American, from the last improved
  London edition.  With over sixty illustrations.  In one royal 12mo. volume, extra cloth.
  The new edition of Dr. Bird's work, though not
increased in size, has been greatly modified, and
much of it rewritten.  It now presents, in a com-
pendious form, the gist of all that is known and re->
liable in this department. From its terse style and'
convenient size, it is particularly applicable to the
Btudent, to whom we cordially commend it.— The
Medical Examiner.
  It can scarcely be necessary for us to say anything
of the merits of this well-known Treatise, which so
admirably brings into practical application the re-
sults of those microscopical and chemical researche*
regarding the physiology and pathology of the uri-
nary secretion, which have contributed so much to
the  increase of our diagnostic powers, and to the
extension and satisfactory employment of our thera-
peutic resources.  In the preparation of  this new
edition of his work, it is obvious that Dr. Golding
Bird has spared no pains to render it a faithful repre-
sentation of the present state of scientific knowledge
on the subject it embraces.— The British and Foreign
Medico-C hirurgical Review.
                               BY THE SAME AUTHOE.

ELEMENTS  OF NATURAL  PHILOSOPHY;  being  an Experimental Intro-
  duction to the Physical Sciences.  Illustrated with nearly four hundred wood-cuts.  From the
  third London edition.  In one neat volume, royal 12mo.  pp. 402. 
AND SCIENTIFIC  PUBLICATIONS.                 5
                        BARTLETT (ELISHA), M. D.,
      Professor of Materia Medica and Medical Jurisprudence in the College of Physicians and
                                Surgeons, New York.

THE  HISTORY,  DIAGNOSIS, AND TREATMENT  OF THE  FEVERS
  OF THE UNITED STATES. Third edition, revised and improved.  In one octavo volume,
  of six hundred pages, beautifully printed, and strongly bound.
  In preparing a new edition of this standard work, the author has availed himself of such obser-
vations and investigations as have appeared since the publication of his last revision, and he has
endeavored in every way to render it worthy of a continuance of the very marked favor with which
it has been hitherto received.
                                           Of the value and importance of such a work, it is
                                         needless here to speak; the profession of the United
                                         States owe  much to the author for  the very able
                                         volume which he has presented to them, and for the
                                         careful and judicious manner in which he has exe-
                                         cuted his task.  No one volume with which we are
                                         acquainted contains so complete a history of our
                                         fevers as this.  To Dr. Bartlett we owe our best
                                         thanks for the very able volume he has given us, as
                                         embodying certainly the most complete, methodical,
                                         and satisfactory account of our fevers anywhere to
                                         be met  with.— The Charleston Med. Journal  and
                                         Review.
 The masterly and elegant treatise, by Dr. Bartlett
is invaluable to the American student and practi-
tioner.—Dr. Holmes's Report to the Nat. Med. Asso-
ciation.
 We regard it, from the examination we have made
of it, the best work on fevers extant in our language,
and as such cordially recommend it to the medical
public.—St. Louis Medical and Surgical Journal.

 Take it altogether, it is the most complete history
of  our fevers which has yet been published,  and
every practitioner should avail himself of its con-
tents.—^The Western Lancet.
In  one neat
                        BOWMAN (JOHN  E.),  M.D.
PRACTICAL  HANDBOOK OF MEDICAL   CHEMISTRY.
  volume, royal 12mo., with numerous illustrations,  pp. 288.
                               BY THE SAME AUTHOE.

INTRODUCTION TO  PRACTICAL  CHEMISTRY,  INCLUDING  ANA-
  LYSIS.  With numerous illustrations.   In one neat volume, royal 12mo.  pp. 350.
                       BARLOW  (GEORGE  H.),  M.D.
A MANUAL OF THE  PRINCIPLES  AND PRACTICE  OF  MEDICINE.
  In one octavo volume.  (Preparing.)

              CYCLOP/EDIA OF  PRACTICAL  MEDICINE.
Edited by Dunglison, Forbes, Tweedie, and Conolly,  in  four large  octavo
   volumes, strongly bound.   JB^* See Dunglison.
                         COLOMBAT DE  LMSERE.
A TREATISE  ON  THE  DISEASES  OF  FEMALES, and on  the Special
  Hygiene of their Sex.  Translated, with many Notes and Additions, by C. D. Meigs, M. D.
  Second edition, revised and improved. In one large volume, octavo, with numerous wood-cuts.
  pp. 720.
  The treatise of M. Colombat is a learned and la- |  M. Colombat De L'lsere has no^ponsecrated ten
borious commentary on these diseases, indicating i years of studious toil and researcfrno the frailer sex
very considerable research, great accuracy of judg- i in vain; and although we regret to hear it is at the
ment, and no inconsiderable personal  experience. [ expense of health, he has imposed a debt of gratitude
With the copious notes and additions of its experi- j as well upon the profession, as upon the mothers and
enced and very erudite translator and  editor, Dr. daughters of beautiful France, which that gallant
Meigs, it presents, probably, one of the most corn- | nation knows best how to acknowledge.—New Or-
plete and comprehensive works on the  subject we leans Medical Journal.
possess.—American Med. Journal.

                 COPLAND (JAMES), M. D., F. R. S., &.C.

OF  THE  CAUSES, NATURE, AND TREATMENT OF PALSY  AND
  APOPLEXY, and of the Forms, Seats, Complications, and Morbid Relations of Paralytic and
  Apoplectic Diseases.   In one volume, royal 12mo., extra cloth,  pp. 326.
                CHAPMAN (PROFESSOR N.), M. D., Sec.
LECTURES  ON  FEVERS,  DROPSY,  GOUT,  RHEUMATISM,  &c.  &c.
  In one neat 8vo. volume,  pp. 450.

                    CLYMER (MEREDITH),  M. D., &.C.

FEVERS;  THEIR  DIAGNOSIS,  PATHOLOGY,   AND  TREATMENT.
  Prepared and Edited, with large Additions, from the Essays on Fever in Tweedie's Library of
  Practical Medicine.  In one octavo volume, of 600 pages.

                         CARSON (JOSEPH),  M. D.,
          Professor of Materia Medica and Pharmacy in the University of Pennsylvania.

SYNOPSIS  OF THE  COURSE  OF  LECTURES ON MATERIA  MEDICA
  AND PHARMACY, delivered in the University of Pennsylvania.  In one very neat  octavo
  volume, of 208 pages. 
6
BLANCHARD & LEA'S  MEDICAL
              CARPENTER (WILLIAM  B.), M. D., F.  R. S.,  &c,
           Examiner in Physiology and Comparative Anatomy in the University of London.

 PRINCIPLES  OF  HUMAN  PHYSIOLOGY;  with  their chief applications to
   Psychology, Pathology, Therapeutics, Hygiene, and Forensic Medicine.  Fifth American, from
   the fourth and enlarged London edition.  With three hundred and fourteen illustrations. Edited,
   with additions, by Francis Gurney Smith, M. D., Professor of the Institutes of Medicine in the
   Pennsylvania Medical College, &c.  In one very large and beautiful octavo volume, of about 1100
   large pages, handsomely printed and strongly bound in leather, with raised bands.  New edition.
   (Lately Issued.)

   This edition has been printed from sheets prepared for the purpose by the  author, who has
 introduced nearly one hundred  illustrations not in the  London edition; while it has also enjoyed
 the advantage of a  careful superintendence on the part of the editor, who has added notices of such
 more recent investigations as had escaped the  author's attention.  Neither care nor expense has
 been spared in the mechanical execution of the work to render it superior to former editions, and it
 is confidently presented as in every way one of the  handsomest volumes as yet placed before the
 medical profession in this country.

  The  most complete work on the science in  our
 language.—Am. Med. Journal.

  The most complete exposition of physiology which
 any language can at present  give.—Brit, and For.
 Med.-Chirurg. Review.

  We have  thus adverted to some of the leading
 "additions and alterations," which have been in-
 troduced by the author into this edition of his phy-
 siology.  These will be found, however, very far to
 exceed the ordinary limits of a new  edition, " the
 old materials having been incorporated with  the
 new, rather than the new with the old."  It now
 certainly presents the most complete treatise on the
 subject within the reach of the American  reader;
 and while, for availability as  a text-book, we may
 perhaps regret its growth in bulk, we are sure that
 the student of physiology will feel  the impossibility
 of presenting a  thorough digest of the facts of  the
 science within a more limited compass.—Medical
 Examiner.

  The greatest, the most reliable, and the best book
 on the  subject which we know of in the English
 language.—Stethoscope.

  The most complete work now extant in our lan-
 guage.—N. O. Med. Register.

  The changes are too numerous to admit of an ex-
 tended notice in this place.  At every point where
 the recent diligent labors of organic  chemists and
 micrographers have furnished interesting and valu-
able facts, they have been appropriated, and no pains
have been spared, in so incorporating and arranging
them that the work may constitute one harmonious
system.—Southern Med. and Surg. Journal.
  The best text-book  in the language on this ex-
 tensive subject.—London Med. Times.
  A complete cyclopaedia of this branch of science.
 —N. Y. Med. Times.
  The standard of authority on physiological sub-
 jects. * * * In the present edition, to particularize
 the alterations  and additions which huve been made,
 would require  a review of the whole work, since
 scarcely a subject has not been revised and altered,
 added to, or entirely remodelled to adapt  it  to the
 present state of the science.—Charleston Med. Jovrn.
  Any reader who desires a treatise on physiology
 may feel himself entirely safe in ordering  this.—
 Western Med. and Surg. Journal.
  From this hasty and  imperfect allusion it will be
 seen by our readers that the  alterations and addi-
 tions to this edition render  it almost a new work—
 and we can assure our readers that it is one of the
 best summaries of the existing facts of physiological
 science within  the reach of  the English student and
 physician.—N.  Y. Journal of Medicine.
  The  profession of this country, and perhaps also
 of Europe, have anxiously and for some time awaited
 the announcement of this new edition of Carpenter's
Human Physiology. His former editions  huve for
 many years been almost the only text-book on Phy-
 siology in all our medical schools, and  its circula-
 tion among the profession has been unsurpassed by
 any work in any department of medical science.
  it is quite unnecessary for us to speuk of this
work as  its  merits -would  justify.  The mere an-
nouncement of  its appearance will afford the highest
pleasure to  every student of Physiology, while its
perusal will be of infinite service in advancing
physiological science.—Ohio Med. and Surg. Joum.
                             BY THE SAME  AUTHOR.   (In PreiS.)

PRINCIPLES  OF  GENERAL  AND  COMPARATIVE   PHYSIOLOGY.
  Intended as an Introduction to the Study  of Human Physiology;  and as a Guide to the Philo-
  sophical pursuit of Natural History.  New and improved edition.   In one  large and  handsome
  octavo volume, with several hundred beautiful illustrations.

  The very thorough revision, and extensive alterations made by the author, have caused a delay
in the promised appearance of this work.  It is now, however, at press, and may be expected for
 Eublication during the ensuing summer.   A very large  number of new and important illustrations
 ave been prepared for it, and the publishers trust to render the volume worthy of its extended
reputation in every point of/ typographical finish, as one  of the handsomest productions of the
American press.  A few notices of the former edition are appended.

  Without pretending to it, it is an Encyclopedia of
the subject, accurate and complete in all respects—
a truthful reflection of the advanced state at which
the  science has now arrived.—Dublin Quarterly
Journal of Medical Science.
  A truly magnificent work—in itself a perfect phy-
siological study.—Ranking's Abstract.

  This work stands without its fellow.  It is one
few men in Europe could have undertaken; it is one
no man, we believe, could have brought to so suc-
cessful an issue as Dr.  Carpenter.  It required for
its production a physiologist at once deeply read in
the  labors of others, capable of taking  a general,
critical, and unprejudiced view of those labors and
of combining the varied, heterogeneous materials at
his  disposal, so as to form an harmonious whole.
We feel that this abstract can give the reader a very
imperfect idea of the fulness of  this work, and no
idea of its unity, of the admirable manner in which
material has been brought, from the most various
sources, to conduce to its completeness, of the lucid-
ity of the reasoning it contains, or of the clearness
of language in which the whole is clothed.  Not the
profession only, but the scientific world at large,
must feel  deeply indebted to Dr. Carpenter  for this
great work.  It must, indeed,  add  largely even to
his high reputation.—Medical Times.
                            BY the same author.  (Preparing.)

THE MICROSCOPE AND  ITS REVELATIONS.   In one handsome volume,
  beautifully illustrated with plates and wood-cuts. 
AND SCIENTIFIC PUBLICATIONS.                    7
                CARPENTER (WILLIAM  B.)| M. D.,  F. R. S.,
          Examiner in Physiology and Comparative Anatomy in the University of London.

ELEMENTS  (OR MANUAL) OF PHYSIOLOGY, INCLUDING  PHYSIO-
  LOGICAL ANATOMY.  Second American, from a new and revised London edition.  With
  one hundred and ninety illustrations.  In one very handsome octavo volume.

  In publishing the first edition of this work, its title was altered from that of the  London volume,
by the substitution of the word " Elements" for that of " Manual," and with the author's sanction
the title of " Elements" is still retained as being more expressive of  the scope of the treatise.  A
eomparison of the present edition with the former one will show  a material improvement, the
author having revised it thoroughly, with a view of rendering it completely on a level with the
most advanced state of the science.  By condensing the less important portions, these numerous
additions have been introduced without materially increasing the bulk of the volume, and while
numerous illustrations have  been added, and the general execution of the work improved, it has
been kept at its former very moderate price.
  To say that it is the best manual of Physiology
now before the public, would not do sufficient justice
to the author.—Buffalo Medical Journal.

  In his former works it would seem that he had
exhausted the subject of Physiology. In the present,
he gives the essence, as it were, of the whole.—JV. Y.
Journal of Medicine.

  Those who have occasion for an elementary trea-
tise on Physiology, cannot do better than to possess
themselves of the manual of Dr. Carpenter.—Medical
Ex<uniner.
  It is not needful that we should compare it with
the other pharmacopeias extant, which enjoy and
merit the confidence of the profession :  it is enough
to say that it appears to us as perfect as a Dispensa-
tory, in the present state of pharmaceutical science,
oould be made.  If it omits any details pertaining to
this branch of knowledge which the student has a
right to expect in such a work, we confess the omis-
sion has escaped our scrutiny. We cordially recom-
mend this work to such of our readers as are in need
of a Dispensatory.  They cannot make choice of a
bettes>—Western Journ. of Medicine a.nd Surgery.
  The best and most complete expose* of modern
Physiology, in one volume, extant in the English
language.—St. Louis Medical Journal.

  With such an aid in his hand, there is no excuse
for the ignorance often displayed respecting the sub-
jects of which it treats. From its unpretending di-
mensions, it may not be so esteemed by those anxious
to make a parade of their erudition; but whoever
masters its contents will have reason to be proud of
his physiological  acquirements.  The illustrations
are well selected and finely executed.—Dublin Med.
Press.
I   There is not in any language a more complete aad
 perfect Treatise.—N. Y. Annalist.
   In  conclusion, we  need scarcely say that we
 strongly recommend this work to all classes of our
 readers.  As a Dispensatory and commentary on the
 Pharmacopoeias, it  is unrivalled in the English or
 any other language.—The Dublin Quarterly Journal.

   We earnestly recommend Dr. Christison's  Dis-
 pensatory to all onr  readers, as an indispensable
 companion, not in the Study onlyx but in the Surgery
 also.—British and  I"or*ign Medical Review.
                                  BY THE SAME AUTHOR.

A PRIZE ESSAY ON THE USE OF ALCOHOLIC LIQUORS IN  HEALTH
  AND DISEASE.  New edition, with a Preface by D. F. Condie, M. D., and explanations of
  scientific words.  In one neat 12mo. volume.   (Now Ready.)

  This new edition has been prepared with a view to an extended circulation of this important little
work, which is universally recognized as the best exponent of the laws of physiology and pathology
applied to the subject of intoxicating liquors, in a form suited both for the profession and the public.
To secure a wider dissemination of its doctrines the publishers have done up copies  in flexible
cloth, suitable  for mailing, which will be forwarded through the  post-office, free, on receipt of fifty
cents.  Societies and others supplied in quantities for distribution at a liberal  deduction.
                             CHELIUS (J. M.), M. D.,
                    Professor of Surgery in the University of Heidelberg, &«.

A SYSTEM OF SURGERY.  Translated  from the  German,  and accompanied
  with additional Notes and References, by John F. South. Complete in three very large octavo
  volumes, of nearly 2200 pages, strongly bound, with raised bands and double titles.
  We do not hesitate to pronounce it the best and
most comprehensive system of modern surgery with
which we are acquainted.—Medico-Chirurgical Re-
view.

  The fullest and ablest digest extant of all that re-
lates to the present advanced state of surgical pa-
thology.—American Medical Journal.

  As complete as any system of Surgery can well
be.—Southern Medical and Surgical Journal.
  The most learned and complete systematic treatise
now extant.—Edinburgh Medical Journal.

  A complete encyclopaedia of surgical science—-a.
very complete surgical library—by far  the most
complete and scientific system of  surgery in  the
English language.—N. Y. Journal of Medicine.

  Th« most extensive and comprehensive account of
the art and  science of Surgerv in our language.—
Lancet.
             CHRISTISON  (ROBERT), M. D., V. P. R. S. E.,  &o.

A DISPENSATORY;  or,  Commentary on the  Pharmacopoeias of Great Britain
  and the United States; comprising the Natural History, Description, Chemistry, Pharmacy, Ac-
  tions, Uses, and Doses of the Articles of the  Materia Medica.   Second edition, revised and im-
  proved, with a Supplement containing the most important New Remedies.   With copious Addi-
  tions, and two hundred and thirteen large wood-engravings.   By R. Eglesfeld Griffith, M. D.
  In one very large and handsome octavo volume, of over 1000 pages. 
8
BLANCHARD  &  LEA'S MEDICAL
                          CONDIE (D. F.), M. D., &c.

A PRACTICAL  TREATISE ON THE DISEASES OF CHILDREN.   Fourth
  edition, revised and augmented.   In one large volume, 8vo., of nearly 750 pages.  (Just Issued.)

                             From the Author's Preface.
  The demand for another edition  has afforded the author an opportunity of again subjecting the
entire treatise to a careful revision,  and of incorporating in it every important observation recorded
since the appearance of the last edition, in reference to the pathology and therapeutics of the several
diseases of which it treats.
  In the preparation of the present edition, as in those which have preceded, while the author has
appropriated to his use every important fact that  he has found recorded in the works of others,
having a direct bearing upon either  of the subjects  of which he treats, and the numerous valuable
observations—pathological as well  as  practical—dispersed throughout the pages of the medical
journals  of Europe and America, he has, nevertheless, relied chiefly upon his own observations and
experience, acquired during a long and somewhat extensive practice, and under circumstances pe-
culiarly  well adapted for the clinical study of the diseases of early life.
  Every species of hypothetical reasoning has, as much as possible, been avoided.  The author has
endeavored throughout the work to  confine himself to a simple statement of well-ascertained patho-
logical facts,  and plain therapeutical directions—his chief desire being to render it what its title
imports  it to be, a practical treatise on the diseases of children.

                                              We feel assured from actual experience  that no
                                            physician's library can be complete without a copy
                                            of this work.—N. Y. Journal of Medicine.

                                              A veritable pediatric encyclopaedia, and an honor
                                            to American medical literature.—Ohio Medical and
                                            Surgical Journal.

                                              We feel persuaded that the American medical pro-
                                            fession will soon regard it not only as a very good,
                                            but as  the very best " Practical Treatise on the
                                           Diseases of Children."—American Medical Journal.
  Dr. Condie"s scholarship, acumen, industry, and
practical sense are manifested in this, as in all his
numerous contributions to science.—Dr. Holmes's
Report to the American Medical Association.
  Taken as a whole, in our judgment, Dr. Condie's
Treatise is the  one from the perusal of which the
practitioner in this country will rise with  the great-
est satisfaction —Western Journal of Medicine and
Surgery.
  One of the best works upon the Diseases of Chil-
dren in the English language.—Western Lancet.
  Perhaps the most full and complete work now be-
fore the profession of the United States; indeed, we
may say in the English language. It is vastly supe-
rior to most of its predecessors.—Transylvania Med.
Journal.
  We  pronounced the first edition to be the best
work  on the diseases of children in the English
language, and, notwithstanding all that has heen
published, we still regard it in that light.—Medical
Examiner.
                       COOPER  (BRANSBY B.), F. R. S.,
                           Senior Surgeon to Guy's Hospital, &c.

LECTURES  ON  THE  PRINCIPLES  AND  PRACTICE  OF  SURGERY.
  In one very large octavo volume, of 750 pages.  (Lately Issued).
  For twenty-five years Mr. Bransby Cooper has
been  surgeon to Guy's Hospital;  and the volume
before us may be said to consist of an account of
the results of his surgical experience during that
long period   We cordially recommend Mr. Bransby
Cooper's Lectures as a most valuable addition to
our surgical literature, and one which cannot fail
to be of service both to students and to those who
are actively engaged in the practice of their profes-
sion.—The Lancet.
                    COOPER  (SIR ASTLEY  P.),  F. R. S.,  &c.

A TREATISE ON DISLOCATIONS AND FRACTURES  OF THE JOINTS.
  Edited by Bransby B. Cooper, F. R. S., &c.  With additional Observations by Prof. J. C.
  Warren.  A new American edition.  In one handsome octavo volume, with numerous illustra-
  tions on wood.


                                 BY THE SAME AUTHOR.

ON THE  ANATOMY AND TREATMENT OF  ABDOMINAL  HERNIA.
  One large volume, imperial 8vo., with over 130 lithographic figures.


                                 BY THE SAME AUTHOR.

ON  THE  STRUCTURE  AND  DISEASES  OF  THE  TESTIS, AND ON
  THE THYMUS GLAND.   One vol. imperial 8vo., with 177 figures, on 29 plates.
BY THE  SAME AUTHOR.
ON THE  ANATOMY AND DISEASES  OF  THE  BREAST, with twenty-
  five Miscellaneous and Surgical Papers.   One large volume, imperial 8vo., with 252 figures, on
  36 plates.                                                                    D    '
  These last three volumes complete the surgical writings of Sir Astley Cooper.  They are very
handsomely printed, with a large number of lithographic plates, executed in the best style, and are
presented at exceedingly low prices. 
                      AND SCIENTIFIC PUBLICATIONS.                     9

               CHURCHILL  (FLEETWOOD),  M. D.,  M. R. I. A.

ON THE  THEORY AND  PRACTICE OF MIDWIFERY. A new American,
  from the last and improved English edition.  Edited, with Notes  and Additions, by D. Francis
  Condie, M. D., author of a "Practical Treatise on  the Diseases of Children," &c.  With 139
  illustrations.  In one very handsome octavo volume, pp. 510.  (Lately Issued.)
  To bestow praise on a book that has received such
marked approbation would be superfluous. We need
only say, therefore, that if the first edition was
thought worthy  of a  favorable reception  by the
medical public, we can confidently affirm that this
will be found much  more  so.  The lecturer, the
practitioner, and the student, may all have recourse
to its pages, and derive from their perusal much in-
terest and instruction in everything relating to theo-
retical and practical midwifery.—Dublin Quarterly
Journal of Medical Science.

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

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

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

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

  Certainly, in our opinion, the very best work on
the subject which exists.—N.  Y. Annalist.
  We regard this volume as possessing more claims
to completeness than any other of the  kind  with
which we are acquainted.  Most cordially and earn-
estly, therefore, do we commend it to our profession-
al brethren, and we feel assured that the stamp of
their approbation will in due time be impressed  upon
it.  After an attentive perusal  of its contents, we
hesitate not to say,  that it is one of the most com-
prehensive ever written upon the  diseases of  chil-
dren, and that, for copiousness of reference, extent of
research, and perspicuity of detail, it is scarcely to
be equalled,  and  not to be excelled, in any  lan-
guage.—Dublin Quarterly Journal.

  After  this  meagre, and we know, very imperfect
notice of Dr.  Churchill's work, we shall conclude
by saying, that it is one that cannot fail from its co-
piousness, extensive research, and general accuracy,
to exalt  still higher the reputation of the author in
this country.  The American reader will be particu-
larly pleased to find that Dr.  Churchill has done full
justice throughout his work to the various A mericun
authors  on this subject.  The names of Dewees,
Eberle,  Condie, and  Stewart, occur on nearly every
page, and these authors are constantly referred  to by
the author in  terms of the highest  praise, and  with
the most liberal courtesy.—The  Medical Examiner.
  No work holds a higher position, or is more de-
serving of being placed  in the hands of the tyro,
the advanced student, or the practitioner.—Medical
Examiner.

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

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

  The clearness and precision of style in which it is
written, and the great amount  of statistical research
which it contains, have served to place it in the first
rank of works in this departmentof medical science.
— N. Y. Journal of Medicine.

  Few treatises will be found better adapted as a
text-book for  the  student, or  as a manual for the
frequent consultation of the young practitioner.—
American Medical Journal.
  The present volume will sustain the reputation
acquired  by the author from his  previous works.
The reader will find in it full and judicious direc-
tions for  the management of infants at birth, and a
compendious, but clear account of the diseases to
which children are  liable, and the most successful
mode of treating them. We must  not close this no-
tice without calling attention to the author's style,
which is  perspicuous and polished to a degree, we
regret to say, not generally characteristic of medical
works. We recommend the work of Dr.  Churchill
most cordially, both to students and  practitioners,
as a valuable and reliable guide in the treatment of
the diseases of children.—Am. Journ. of the Med.
Sciences.

  We know of no work on this department of Prac-
tical Medicine which presents so candid and unpre-
judiced a statement or posting up of our  actual
knowledge as this.—N. Y. Journal of Medicine.,

  Its claims to merit both as a scientific and practi-
cal work, are  of  the highest order.  Whilst we
would not elevate it above every other treatise on
the same  subject, we certainly believe that very few
are equal  to it, and none  superior.—Southern Med.
and Surgical Journal.
demies of that disease.  The whole forms a very
valuable collection of papers, by professional writers
of eminence, on some of the most important accidents
to which the puerperal female is liable.—American
Journal of Medical  Sciences.
                                    BY THE SAM

ESSAYS ON  THE  PUERPERAL  FE
  CUL1AR TO WOMEN.   Selected from the w
  the Eighteenth Century.  In one neat octavo vo

  To these papers Dr. Churchill has appended notes,
embodying whatever  information has been laid be-
fore the profession since their authors' time.  He has
also  prefixed to  the  Essays on Puerperal  Fever,
which  occupy the lnrger portion of the volume, an
interesting historical sketch of the principal epi-
                                   BY THE SAME AUTHOR.

ESSAYS ON THE  PUERPERAL FEVER, AND OTHER DISEASES  PE-
  CULIAR TO WOMEN.  Selected from the writings of British Authors previous to the close ol
  the Eighteenth Century.  In one neat octavo volume, of about four hundred and fifty pages.
BY THE SAME AUTHOR.
ON THE  DISEASES  OF  INFANTS  AND CHILDREN.   In one large and
  handsome volume of over 600 pages. 
10
BLANCHARD  & LEA'S  MEDICAL
          CHURCHILL (FLEETWOOD),  M. D., M. R. I. A.,  &.C.

ON THE  DISEASES OF WOMEN;  including those of Pregnancy and Child-
  bed.  A new American edition, revised by the Author.  With Notes and Additions, by D Fran-
  cis Condie, M. D., author of "A Practical Treatise on  the Diseases of Children."  In one large
  and handsome octavo volume,  with wood-cuts, pp. 684.   (Just Issued.)

                               From the Author's Preface.
  In reviewing this edition, at the request of my American publishers, I have inserted several new
sections and chapters, and I have added, I believe, all the  information we have derived from recent
researches; in addition to which the publishers have been fortunate enough to secure the services
of an able and highly esteemed editor in Dr. Condie.
 We now regretfully take leave of Dr. Churchill's
book.  Had our typographical limits  permitted, we
should gladly have borrowed more from its richly
stored pages.  In  conclusion, we heartily recom-
mend it to the profession, and would at the same
time express our firm conviction that it will not only
add to the reputation of its author, but will prove a
work  of great and extensive utility to obstetric
practitioners.—Dublin Medical Press.

  Former editions of this work have been noticed in
previous numbers of the Journal. The sentiments of
high commendation expressed in those notices, have
only to be repeated in this; not from the fact that
the profession  at large are not awure of the high
merits which this work really possesses, but from a
desire to see the principles and doctrines therein
contained more generally recognized, and more uni-
versally carried out  in practice.—N. Y. Journal of
Medicine.

  We know of no author who deserves that appro-
bation, on " the diseases  of females,"  to the  same
extent that Dr. Churchill does. His, indeed, is the
only thorough treatise we know of on the subject;
and it may be commended to practitioners and stu-
dents as a masterpiece in  its particular department.
The former editions of this work have been  com-
mended strongly in this journal, and  they have won
their way to an extended, and a well-deserved popu-
larity.  This fifth edition, before us. is well calcu-
lated to maintain Dr. Churchill's  high reputation.
It was revised and enlarged by the authoT, for his
American publishers, and it seems to us that there is
scarcely any species of desirable information on its
subjects that may not be found in this work.—The
Western Journal of Medicine and Surgery.

 We are gratified  to announce a  new and revised
edition of Dr. Chorchill's valuable work on the dis-
eases of females   We have ever regarded it as one
of  the very best works on the subjects embraced
within its scope, in the English language;  and the
present edition, enlarged and revised by the author,
renders it still more entitled to the confidence of the
profession.  The valuable notes  of Prof. Huston
have been retained, and contribute, in no small de-
gree, to enhance the value of the work.  It is a
source of congratulation  that the publishers have
permitted the author to be,  in this instance, his
own editor, thus securing all the revision which
an author alone is capable of making.—The Western
Lancet.

  As a comprehensive manual for students, or a
work of reference  for practitioners, we only speak
with common justice when we say that it surpasses
any other that has ever issued on the same sub-
ject from the British press.—The Dublin Quarterly
Journal.
                         DEWEES  (W.  P.),  M.D.,  &c.

A  COMPREHENSIVE  SYSTEM  OF  MIDWIFERY.   Illustrated  by occa-
  sional Cases and many Engravings.  Twelfth edition, with the Author's last Improvements and
  Corrections.  In one octavo volume, of 600 pages.  (Just Issued.)

                                 BY THE SAME AUTHOR.

A TREATISE ON  THE  PHYSICAL AND  MEDICAL  TREATMENT OF
  CHILDREN.  Tenth edition.  In one volume, octavo, 548 pages.  (Just Issued.)

                                 BY THE SAME AUTHOR.

A TREATISE ON  THE  DISEASES OF  FEMALES.   Tenth  edition.   In
  one volume, octavo, 532 pages, with plates.  (Just Issued.)
                   DICKSON (PROFESSOR  S.  H.),  M.D.
ESSAYS ON LIFE, SLEEP,  PAIN,  INTELLECTION,  HYGIENE,  AND
  DEATH.  In one very handsome volume, royal 12mo.
                               DANA  (JAMES  D).
ZOOPHYTES  AND  CORALS.   In  one  volume, imperial  quarto, extra  cloth,
  with wood-cuts.
ALSO,
AN ATLAS  TO THE ABOVE, one volume, imperial folio, with sixty-one mag-
  nificent plates, colored after nature.  Bound in half morocco.
ON  THE  STRUCTURE  AND  CLASSIFICATION  OF  ZOOPHYTES.
  Sold separate, one vol., cloth.
              DE  LA  BECHE  (SIR HENRY  T.), F.  R. S., &c.

THE  GEOLOGICAL OBSERVER.   In  one very large  and  handsome octavo
  volume, of 700 pages.  With over three hundred wood-cuts.  (Lately Issued.) 
A«u SCIENTIFIC PUBLICATIONS.
11
                      DRUITT  (ROBERT),  M.  R. C. S.,  &c.

THE  PRINCIPLES  AND PRACTICE  OF  MODERN  SURGERY.  A new
  American, from  the  improved London edition.  Edited by F. W. Sargent,  M. D., author of
  " Minor Surgery," &e.   Illustrated  with one hundred and ninety-three wood-engravings.   In
  one very handsomely printed octavo volume, of 576 large pages.
  Dr. Druitt's researches into the literature of his
subject have been not only extensive, but well di-
rected ; the most discordant authors are fairly and
impartially quoted, and, while due credit is given
to each, their respective merits  are weighed with
an unprejudiced hand.  The grain of wheat is pre-
served, and the chaff is unmercifully stripped off.
The arrangement is simple and philosophical, and
the style, though clear and interesting, is so precise,
that the book contains more information condensed
into a few words than any other surgical work with
which we  are acquainted.—London  Medical Times
and Gazette, February 18, 1654.

  No work, in  our  opinion, equals it in presenting
so  much valuable  surgical matter  in so small  a
compass.—St. Louis Med. and Surgical  Journal.

  Druitt's Surgery  is too well known to  the Ameri-
can medical profession to require its announcement
anywhere. Probably no work of the kind has ever
been more cordially received and extensively circu-
lated than this  The fact that it comprehends in a
comparatively small compass, all the essential ele-
ments of theoretical and practical Surgery—that it
m found to contain  reliable and authentic informa-
tion on the nature and treatment of nearly all surgi-
cal affections—is a sufficient reason for the liberal
patronage it has obtained.  The editor, Dr. F. W.
Sargent, has contributed much to enhance the value
of the work, by such American improvements as ure
calculated  more perfectly  to adapt it to our own
views and practice in this  country.  It abounds
everywhere with spirited and life-like illustrations,
which to the  young surgeon, especially, are of no
minor consideration. Every medical man frequently
seede just such a work as this, for immediate refe-
rence in moments of sudden emergency, when he has
not time to consult more elaborate treatises.—The
Ohio Medical and Surgical Journal.

  The author  has evidently ransacked every stand-
ard treatise of ancient and modern times, and all that
is really practically useful at the bedside will be
found in a form at once clear, distinct, and interest-
ing.—Edinburgh Monthly Medical Journal.

  Druitt's work, condensed, systematic, lucid, and
practical as it is, beyond most works on Surgery
accessible to the American student, has had much
currency in this country, and under its present au-
spices promises to rise to yet  higher favor.—The
Western Journal of Medicine and Surgery.

  The most accurate and ample resume of  the pre-
sent state of Surgery that we are acquainted with.—
Dublin Medical Journal.

  A belter book on  the principles and  practice of
Surgery as now understood in England and America,
has not been given to the profession.—Boston Medi-
cal and Surgical Journal.

  An unsurpassable compendium,  not only of Sur-
gical, but of Medical Practice.—London Medical
Gazette.
  This work merits our warmest commendations,
and we strongly recommend it to young surgeons as
an admirable digest of the principles and practice of
modern Surgery.—Medical Gazette.

  It may be  said with truth that  the work of Mr.
Druitt affords a  complete, though brief and con-
densed view, of the entire field of  modern surgery.
We know of no work on the same subject having the
appearance  of a manual, which includes so many
topics of interest to the surgeon ; and the terse man-
ner in which each has been treated evinces a most
enviable quality of mind on the part of  the author,
who  seems  to have  an innate  power of searching
out and grasping the leading facts and features of
the most elaborate productions of the pen.   It is a
useful handbook for the practitioner, and we should
deem a teacher of surgery unpardonable who did not
recommend  it to his pupils.  In our own opinion, it
is admirably adapted to the wants  of the student.—
Provincial Medical and Surgical Journal.
           DUNGLISON,  FORBES, TWEEDIE,  AND CONOLLY.

THE CYCLOPAEDIA  OF  PRACTICAL MEDICINE:  comprising Treatises on
  the Nature and Treatment of Diseases, Materia Medica, and Therapeutics, Diseases of Women
  and Children, Medical Jurisprudence,  &c. &c.  In four large  super  royal octavo volumes, of
  3254 double-columned pages, strongly and handsomely bound.
  *** This work contains no less than four hundred and eighteen distinct treatises, contributed by
sixty-eight distinguished physicians.

  The most complete work on Practical Medicine
extant;  or, at least,  in  our  language.—Buffalo
Medical and Surgical Journal.

  For reference, it is above all  price to every prac-
titioner.—Western Lancet.

  One of the most valuable medical publications of
the day—as a work of reference it is invaluable.—
Western Journal of Medicine and Surgery.

  It has been to us, both as learner and teacher, a
work for ready and frequent reference, one in which
modern  English medicine is exhibited  in the most
advantageous light.—Medical Examiner.

  We rejoice that this work is to be placed within
the reach of the profession in this country, it being
unquestionably one of very great value to the prac-
titioner.  This estimate of it has not been formed
from a hasty examination, but after an intimate ac-
quaintance derived from frequent consultation of it
during the past nine or ten years.  The editors are
practitioners of established reputation, and the list
of contributors embraces many of the most eminent
professors and teachers of London, Edinburgh, Dub-
lin, and Glasgow.  It is, indeed, the great merit of
this work that the principal articles have been fur-
nished by practitioners who have not only devoted
especial attention to the diseases about which  they
have written, but have also enjoyed opportunities
for an extensive practical acquaintance with them,
and whose reputation carries the assurance of their
competency justly to appreciate the opinions of
others, while  it stamps their own  doctrines with
high and just  authority.—American Medical Journ.
                          DUNGLISON  (ROBLEY),  M. D.,
        Professor of the Institutes of Medicine, in the Jefferson Medical College, Philadelphia.

HUMAN HEALTH;  or, the Influence  of Atmosphere  and  Locality, Change of
  Air and Climate, Seasons, Food, Clothing, Bathing, Exercise, Sleep, &c.&c., on Healthy Man;
  constituting Elements of Hygiene.   Second edition, with many modifications and additions
  one octavo volume, of 464 pages.
In 
12                      BLANCHARD &  LEA'S MEDICAL
                          DUNGLISON  (ROBLEY),  M.D.,
          Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia.

MEDICAL  LEXICON;  a Dictionary  of Medical Science, containing a concise
  Explanation of the various Subjects and Terms of Physiology, Pathology, Hygiene, Therapeutics,
  Pharmacology, Obstetrics, Medical Jurisprudence, &c.  With the French and otber Synonymes;
  Notices of Climate and of celebrated Mineral Waters;  Formulas for various Officinal, Empirical,
  and  Dietetic Preparations, etc.  Eleventh edition, revised.   In one very  thick octavo volume, oi
  over nine  hundred large double-columned pages, strongly bound in leather, with raised bands.
  (Just Issued.)
  Every successive edition of this work bears the marks of the industry of the author, and of his
determination to keep it fully on a level with the most advanced state of medical science.  Thus
nearly fifteen thousand words  have been added to it within the last few vears.   As a complete
Medical  Dictionary, therefore, embracing over FIFTY THOUSAND  DEFINITIONS, in all the
branches of the science, it is presented as meriting a continuance of the great favor  and popularity
which have carried it, within no very long space of time, to an eleventh edition.
  Every precaution has been laken  in the preparation of the present volume, to render its mecha-
nical  execution and typographical accuracy worthy of its  extended reputation  and universal use.
The very extensive additions have been accommodated, without materially increasing the bulk  of
the volume by the employment of a small but exceedingly clear type, cast  for this purpose.  The
press has been watched with great care, and every effort used to insure the verbal accuracy so ne-
cessary to a work of this nature.   The whole is printed on fine white paper; and, while thus exhi-
biting  in every respect so great an improvement over former issues, it is presented at the original
exceedingly low price.
                                                valuable work,  we directed the attention of onr
                                                readers to  its peculiar  merits;  and we  need  do
                                                little more than  state, in reference to the present
                                                reissue, that, notwithstanding  the  large additions
                                                previously  made to it, no fewer than four thou-
                                                sand terms, not to be found in the preceding edi-
                                                tion, are contained in  the volume before us__
                                                Whilst it is a wonderful monument of its  author's
                                                erudition and industry, it is also a work  of great
                                                practical  utility, as we can testify from our own
                                                experience; for we keep  it constantly within our
                                                reach,  and  make very frequent reference to  it,
                                                nearly always finding in it the information we seek.
                                                —British and Foreign Med.-Chirurg. Review.
  We welcome it cordially; it is an admirable work,
and indispensable to all literary medical men. The
labor which has been bestowed upon it is something
prodigious.  The work,  however,  has now been
done, and we are happy in the thought that no hu-
man being will have again to undertake the same
gigantic task.  Revised and corrected from time to
time, Dr. Dunglison's '; Medical Lexicon" will last
for centuries.—British and Foreign Med. Chirurg.
Review, July, 1853.

  The fact that this excellent and learned work has
passed  through eight editions, and that a ninth is
rendered necessary by the demands of the pnblic,
affords a sufficient evidence of the general apprecia-
tion of Dr.  Dunglison's labors by the medical pro-
fession in England and America.  It is a book which
will be of great service to the student, in  teaching
him the meaning of  all the technical terms used in
medicine, and will be of no less use to the practi-
tioner who  desires to keep himself on a level with
the advance of medical  science.—London Medical
Times  and Gazette.

  In taking leave of our author, we feel compelled
to confess that his work  bears evidence of almost
incredible labor having been bestowed upon its com-
position.— Edinburgh Journal  of Med. Sciences,
Sept. 1853.

  A miracle of labor and industry in one who has
written able and voluminous works on nearly every
branch of medical science. There could be no more
useful  book to the student or  practitioner, in the
present advancing age, than one in which would be
found,  in addition to the ordinary meaning and deri-
vation of medical terms—so many of which are of
modern introduction—concise descriptions of their
explanation and employment; and all this and much
more is contained in the volume before us.  It  is
therefore almost as indispensable to the other learned
professions as to our own. In fact, to all who may
have occasion to ascertain the meaning of any word
belonging to the many branches of medicine.  From
a careful examination of the present edition, we can
vouch  for  its accuracy,  and  for  its  being brought
quite up to the date of publication ; the author states
in his preface that he lmsadded to it about four thou-
sand terms, which are not to be found in the prece-
ding one. — Dublin Quarterly  Journal of Medical
Sciences.
  On  the  appearance of the last edition  of this
  It has the rare merit that it certainly has no rival
in the English  language  for accuracy and extent
of references.  The  terms generally include short
physiological and pathological descriptions, so that,
as the author justly observes, the reader does not
possess in this work a mere dictionary, but a book,
which, while it instructs him in medical  etymo-
logy, furnishes  him with a large amount of useful
information.  The author's labors  have been pro-
perly  appreciated by his own countrymen ; and we
can only confirm their judgment, by recommending
this most useful volume to  the notice of our cisat-
lantic readers. No medical library will be complete
without it.—London Med. Gazette.

  It is certainly more  complete and comprehensive
than any with  which  we  are acquainted in  the
English language.  Few, in fact, could be found
better qualified than Dr. Dunglison for the produc-
tion of such  a  work.  Learned, industrious, per-
severing, and accurate, he brings  to the task all
the peculiar  talents necessary  for  its  successful
performance;  while, at the same time, his fami-
liarity with the writings of  the ancient and modem
" masters of our art," renders him skilful to note
the exact usage of  the several  terms of  science,
and the various modifications which medical term-
inology has  undergone with the change of theo-
ries or the  progress of improvement. — America*
Journal of the Medical Sciences.
  One of the most complete and copious  known to
the cultivators  of medical  science.—Boston Med.
Journal.

  The most comprehensive  and best English Dic-
tionary of medical terms extant.—Buffalo Medical
Journal.
                                    BY THE SAME AUTHOR.

THE PRACTICE  OF MEDICINE.   A Treatise on  Special Pathology and The-
  rapeutics.  Third Edition.  In two large octavo volumes, of fifteen hundred pages.
  Upon every topic embraced in the work the latest
information will be found  carefully  posted up.—
Medical Examiner.
  The student of medicine will find, in these two
elegant volumes, a mine of  facts, a gathering of
precepts and advice from the world of experience,
that  will nerve him with courage, and faithfully
direct him in his efforts to relieve the physical suf-
ferings of the race—Boston Medical and Surgical
Journal.
  It is certainly the most complete treatise of which
we have any knowledge.— Western Journal of Medi-
cine and Surgery.

  One of the most elaborate treatises of the kind
we have.—Southern Med. and Surg. Journal. 
A"ND SCIENTIFIC PUBLICATIONS.                   13
                        DUNGLISON (ROBLEY),  M.D.,
          Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia.

HUMAN   PHYSIOLOGY.   Seventh  edition.  Thoroughly revised  and exten-
  sively modified and enlarged, with nearly five hundred illustrations.  In two large and hand-
  somely printed octavo volumes, containing nearly 1450 pages.
  It has long  since taken rank as one of the medi- I Physiology in the English language, and is  highly
<?al classics of oar language.  To say that it is by  creditable to the author and publishers.—Canadian
far the best text-book of physiology ever published  Medical Journal.
in this country, is but echoing  the general testi-
mony of the profession.—N. Y. Journal of Medicine.

  There is no single book we would recommend to
the student or physician, with greater confidence
than the present, because in it will be found a mir-
ror of almost every standard physiological work of
the day.  We most cordially recommend the work
to every member of the profession, and no student
should be without it. It is the completest work on
  The most complete  and  satisfactory  system of
Physiology in the English  language.—Amer. Med.
Journal.

  The best work of the kind  in the  English lan-
guage.—Silliman's Journal.

  The most full and complete system of Physiology
in our language.—Western Lancet.
                           BY THE SAKE AUTHOR.  (Just Isstied.)

GENERAL  THERAPEUTICS  AND  MATERIA MEDICA;  adapted for a
  Medical Text-book.  Fifth edition, much improved.  With  one hundred and eighty-seven illus-
  trations.  In two large and handsomely printed octavo vols., of about 1100 pages.
  The new editions of the United States Pharmacopoeia and those of London and Dublin, have ren-
dered necessary a thorough revision of this work.   In accomplishing this the author has spared no
pains in rendering it a complete exponent of all that is new and  reliable, both in the  departments
of Therapeutics and Materia Medica.  The book has thus been somewhat enlarged, and a like im
provemeut will be found in every department of its  mechanical execution.  As a convenient text-
book for the student, therefore, containing within a moderate compass a satisfactory resume of its
important subject, it is again presented as even more worthy than heretofore of the very great favor
which it has received.
  In this work of Dr. Dunglison, we recognize the
same untiring industry in the collection and em-
bodying of facts on the several subjects of which he
treats,  that has heretofore distinguished him, and
we cheerfully point to these volumes^ as two of the
most interesting that we
  As a text-book for students, for whom it is par-
ticularly designed,  we know of none superior to
it.—St. Louis Medical and Surgical Journal.

  It purports to be a new edition, but it is rather
additions to this, the fourth  edition, there is very
little in the periodical or annual  literature of the
profession, published in the interval which  has
elapsed since the issue of the first, that has escaped
the careful search of the author.  As a  book> for
reference, it is invaluable.—Charleston Med. Jour-
nal and Review.

  It may be said to be the work  now upon the sub-
jects upon which it treats.— Western Lancet.
knVwT fn noticine  he » «w book, so greatly has it been improved, both
,S™.u>\.JDtl°,1 "11^ i in the amount and quality of the matter which it
contains.-
        quality
N. O. Medical and Surgical Journal.
  We bespeak for this edition, trom the profession,
an increase of patronage over any of its former
ones, on account of  its increased merit. — N. Y.
Journal of Medicine.
        •
  We consider this work unequalled.—Boston Med.
and Surg. Journal.
                                  BY THE SAME AUTHOR.

NEW  REMEDIES, WITH FORMULAE FOR THEIR ADMINISTRATION.
  Sixth  edition, with extensive Additions.   In one very large octavo volume, of over 750 pages.
  One of the most useful of the author's works.—
Southern Medical and Surgical Journal.

  This well-known and  standard book has now
reached its sixth edition, and has been enlarged and
improved by the introduction of all the recent gifts
to therapeutics which the last few years have so
richly produced, including the anaesthetic agents,
ice.  This  elaborate and useful volume should be
found in every medical library, for as a book of re-
ference, for physieians, it is  unsurpassed by any
other work  in existence, aud the double index for
diseases nnd for remedies, will be found greatly to
enhance its value.—iVeto York Med. Gazette.

  The great learning of the author, and his remark-
able industry in pushing his researches into every
source whence information is derivable, has enabled
him to throw together an extensive mass of facts
and statements,  accompanied by full reference to
authorities; which last feature renders the work
practically valuable to investigators who desire to
examine the original papers.—The American Journal
of Pharmacy.
                             DURLACHER  (LEWIS).
A  TREATISE  ON  CORNS,  BUNIONS,  THE   DISEASES   OF  NAILS,
  AND THE  GENERAL MANAGEMENT OF THE FEET.  la one 12mo. volume, cloth.
  pp. 134.

                          DE JONGH  (L. J.), M. D., &c.

THE THREE  KINDS  OF COD-LIVER OIL, comparatively considered,  with
  their  Chemical and  Therapeutic  Properties. Translated,  with  an Appendix and Cases, by
  Edward Carey, M D.  To which is added an article  on the subject from " Dunglison on New
  Remedies."   In one small 12mo. volume, extra cloth.
                             DAY (GEORGE  E.),  M. D.

A PRACTICAL TREATISE ON THE DOMESTIC  MANAGEMENT AND
  MORE  IMPORTANT DISEASES OF ADVANCED  LIFE.   With an Appendix on a new
  and successful mode of treating Lumbago and other forms of Chronic Rheumatism.  One volume
  octavo, 226 pages. 
14                     BLANCHARD  &  i^A'S MEDICAL
                            ELLIS  (BENJAMIN),  M.D.
THE  MEDICAL  FORMULARY:  being a Collection of  Prescriptiona, derived
  from the writings and practice of many of the most eminent physicians of Ameriea and Europe.
  Together with the usual Dietetic Preparations and Antidotes for Poisons.   To which is added
  an Appendix, on the Endermic use of Medicines, and on the use of Ether and Chloroform.  The
  whole accompanied  with a few brief Pharmaceutic and Medical Observations.   Tenth edition,
  revised and much extended by Robert P. Thomas, M. D., Professor of Materia Medica in the
  Philadelphia College of Pharmacy.   In one neat octavo volume, of two  hundred and ninety-six
  pages.  (Now Ready.  Revised and enlarged to 1854.)
  This work bas received a very complete  revision at the bands of the editor, who has made what-
ever alterations and additions the progress of medical and pharmaceutical science bas rendered ad-
visable, introducing fully the new remedial agents, and revising the whole by the latest improvements
of the Pharmacopoeia.   To accommodate these additions, the size of the page has been increased,
and the volume itself considerably enlarged, while every effort has been made to secure the typo-
graphical accuracy which has so long merited the confidence of the profession.
  After an examination of the new matter and the
alterations, we believe the reputation of the work
built up by the author, and the late distinguished
editor, will continue to flourish under the auspices
of the present editor, who has the industry and accu-
racy,  and, we would  say, conscientiousness requi-
site for the responsible task.—American Journal of
Pharmacy, March, 1851.
  It will prove particularly useful to students nsd
young practitioners, as the most important prescrip-
tions employed in modern  practice, which lie scat-
tered through our medical  literature, are here col-
lected and conveniently arranged for  reference.—
Charleston Med. Journal and Review.
                                ERICHSEN (JOHN).,
                     Professor of Surgery in University College, London, Ac.

THE SCIENCE AND ART OF SURGERY; being a Treatise on Surgical
  Injuries, Diseases, and Operations.  With Notes and Additions by the American Editor.  Il-
  lustrated with over three hundred  engravings  on  wood.   In one large and handsome octavo
  volume, oi nearly nine hundred closely printed pages.   (Now Ready.)
                        This is a new work, brought up to May, 1854.
  This work, which is designed as a text-book for the student and practitioner, will be found a very
complete treatise on the principles and practice of surgery.  Embracing both these branches of the
subject simultaneously, and elucidating the one by the other, it enables the reader to take a compre-
hensive view of the objects of his study, and  presents the subjects discussed in a clear  and con-
nected manner.  The author's  style will be found easy  and flowing, arid  the illustrations having
been drawn under his especial supervision, are with few exceptions new, and admirably adapted
to elucidate the text to which they refer.  In every point  of mechanical execution, it will be one of
the handsomest works issued from the American  press.
  The aim of Mr. Evichsen appears to be to improve
npoa the plan of Samuel Cooper;  and by connecting
in one volume the science and art of Surgery, to
supply the student with a text-book and the practi-
tioner with a work of reference, in which scientific
principles and practical  details are alike included.
We may say, afier a eareful  perusal  of some of
the chapters, and a more hasty examination of the
remainder, that  it must raise the  character of the
author, and reflect great credit upon the College to
whjch he is Professor, and we can cordially recom-
mend it as a work of reference, both to students and
practitioners.—Medical Times and Gazette.

  " We do not hesitate to say that the volume before
us gives a very admirable practical view of the sci-
ence and art of surgery of the present day, and we
have do doubt that it will be highly valued as a sur-
gical guide as well by the surgeon as by the studenl
of surgery.—Edinburgh Med. and Surg. J»»r»oJ.
                       FERGUSSON (WILLIAM), F.  R. S.,
                      Professor of Surgery in King's College, London, &e.

A  SYSTEM  OF  PRACTICAL SURGERY.   Fourth American, from the third
  and enlarged London edition.  In one large and beautifully printed octavo volume, of about seven
  hundred pages, with three hundred and ninety-three handsome illustrations.   (Just Issued.)
  The most important subjects in connection with
practical surgery which have been more  recently
brought under the notice of, and discussed by, the
surgeons of Great Britain, are fully and dispassion-
ately considered by Mr. Fergusson, and that which
was before wanting has  now been supplied, so that
we can now look upon it as a work on practical sur-
gery instead of one on operative surgery alone. And
we think the author has shown a wise discretion in
making the additions on surgical disease which are
to be found  in  the present volume, and has very
much enhanced its value; for, besides two elaborate
chapters on the diseases of bones  und joints, which
were wanting before he has headed each chief sec-
tion of the work by a general description of the sur-
gical disease and injury of that region of the body
which is treated of in each, prior to entering into the
consideration of the more special  morbid conditions
and their treatment.  There is also,  as in former
editions, a sketch of the anatomy of particular re-
gions.  There was some ground  formerly for the
complaint before alluded to, that it dwelt too exclu-
sively on operative surgery ; but this defect is now
removed, and the book is more than ever adapted for
the purposes of the practitioner, whether he confines
himself more  strictly to the operative department,
or follows surgery on a more comprehensive seale.—
Medical Times and Gazette.

  No work was ever written which more nearly
comprehended the necessities  of  the  student  and
practitioner, and was more carefully  arranged to
that single purpose thaVi this.—2V. Y. Med. and Surg.
Journal.

  The addition of many new pages makes this work
more than ever indispensable to the student and prac-
titioner.—Ranking's Abstract.

  Among the  numerous works upon surgery pub-
lished of late years, we know of none  we value
more highly than the one before us. It is perhaps
the very best we have for a text-book and for ordi-
nary reference, being concise  and eminently practi-
cal.—Southern Med. and Surg. Journal.,
                             FRICK (CHARLES), M. D.
RENAL  AFFECTIONS;   their Diagnosis and Pathology.
  Qne volume, royal 12mo., extra cloth.
With illustrations. 
AND SCIENTIFIC  PUBLICATIONS.                   15
                        FOWNES  (GEORGE), PH. D., &c.
ELEMENTARY   CHEMISTRY;   Theoretical  and Practical.   With  numerous
  illustrations.   A new American, from the last and revised London edition.  Edited, with Addi-
  tions, by Robert Bridges, M. D.  In one large royal 12mo. volume, of over 550 pages, with 181
  wood-cuts, sheep, or extra cloth.  (Now Ready.)
  The lamented death of the author has caused the revision of this edition to pass into the hands of
 tnose distinguished chemists,  H. Bence  Jones and A. W.  Hofmann, who have fully sustained its
 reputation by the additions which they have made, more especially in the portion devoted to Organic
 Chemistry, considerably increasing the size of the volume.  This labor  has been so thoroughly
 performed, that the American Editor has found but little to add, his notes consisting chiefly of such
 matters as the rapid advance of the science has rendered necessary, or of investigations which had
 apparently been overlooked by the author's  friends.
  The volume  is therefore again presented  as an exponent of the most advanced state of chemical
 science, and as not unworthy a continuation of the marked favor which it has received as an ele-
 mentary text-book.
  We know of no better text-book, especially in the
 difficult department of  organic  chemistry,  upon
 which it is particularly full and satisfactory.  We
 would  recommend it to  preceptors as a capital
 ■' office book" for their students who are beginners
 in Chemistry.  It is copiously illustrated with ex-
 cellent wood-cuts, and altogether admirably " got
 op."—N. J. Medical Reporter, March, 1854.
  A standard manual, which  has long enjoyed the
reputation of embodying much knowledge in a small
space.  The author has achieved the difficult task of
condensation with masterly tact.  His book is con-
cise without being dry, and brief without being too
dogmatical or general.— Virginia Med. and Surgical
Journal.
  The work of Dr. Fownes has long been before
the public, and its merits have been fully appreci-
ated  as  the best  text-book on chemistry now in
existence.  We do not, of course, place it in a rank
superior to the works of Brande, Graham, Turner,
Gregory, or Gmelin, but we say that, as a work
for students, it is  preferable to any of them.—Lon-
don Journal of Medicine.

  A work well adapted to the wants of the student.
It is an excellent exposition of the chief doctrines
and facts of modern chemistry. The size of the. work,
and still more the condensed yet perspicuous style
in which it is written, absolve it from the charges
very properly urged against most manuals termed
popular.—Edinburgh Monthly Journal of Meiieal
Science.
                          GRAHAM  (THOMAS),  F. R. S.,
                   Professor of Chemistry in University College, London, te.

THE ELEMENTS OF CHEMISTRY.   Including the application of the Science
  to the Arts.   With numerous illustrations.  With Notes and Additions, by Robert Bridges,
  M. D., &c. &c.  Second American, from the second and enlarged London edition
PART I. (Lately Issued) large 8vo., 430 pages, 185 illustrations.
PART II. (Preparing) to match.
  The great changes which the science of chemistry has undergone within the last few years, ren-
der a new edition of a treatise like the  present, almost a new work.  The author has devoted
several years to the revision of his treatise, and has endeavored to embody  in it every fact and
inference of importance which has  been observed and recorded by the  great body of chemical
investigators who are so rapidly changing the face of the science.  In this manner the work has
been greatly increased in size, and the number of illustrations doubled; while the labors of the editor
have been directed towards the introduction of such matters as have escaped the attention of the
author, or as have arisen since the publication of the first portion of this edition in London, in 1850.
Printed in handsome style, and at a very low price, it is therefore confidently  presented  to the pro-
fession and the student "as a very complete and thorough text-book of this important subject.


                           GROSS (SAMUEL D.),  M. D.,
                   Frofessor of Surgery io the Louisville Medical Institute, Sec.

A  PRACTICAL TREATISE ON  THE DISEASES  AND  INJURIES  OF
  THE  URINARY ORGANS.  In  one large and beautifully printed octavo volume, of over seven
  hundred pages.  With numerous illustrations.
  A volume replete with truths and principles of the I this department of art. We have, indeed, unfeigned
atraost value in the investigation of these diseases.—  pleasure in congratulating all concerned in this pub-
American Medical Journal.                       lication, on the result of their labours; and expe-
  „  _     ,   .    u. ii i.;. !«»,,,,.  »™/>n   rience a feeling something like whutanimates a long-
  Dr. Gross has brewght all hu ta™^.  ««*«£  expectanthusbandman.who.oftentimesdisappointett
eace, tact, and judgment to  the  iask andlhas pro-   F    prodace „f a favorite field, is at last agree-
daeed a work worthy of his high reputation;  We   >   ,uHr„rlged by a stately crop which may bear
feel perfectly safe » w<OTmB^W »ti*°J^'"^j  comparison with any of its former rivals.  The
ers  as a monograph u"c^ua"ed. '"'"^^ *™ ' grounds of our high appreciation of the work will
practical value by any other on the  subject in our  ^ obvi0us  as we proceed; and we doubt not that
 tanguage.-WMter* Journal of Med. and Surg.    | t[)e pregent  fa<.iUties for obtaining American books
  It has remained for an American  writer to wipe . wl\\ jn(juce many of our  readers to verify our  re-
away this reprouch ; and so completely has the task I commendation by their own perusal of it.—Britisk
been fulfilled, that we venture to predict for Dr. ; an<i Foreign Medieo-Chirurgical Review.
Gross's treatise a permanent place in the literature I                                 , ,  .   ..
of surirerv, worthy to rank with the best works of ]  Whoever will peruse the vast amount of valuable
the present  age.  Not merely is the matter good,  practical information it contains, and which  we
 but the srettine up of the volume is most creditable  have  been  unable even to notice, will, we think,
 to  traasatlantic enterprise;  the paper and print  agree with us, that there is no work in the English
 would doeredittoa first-rate London establishment;  language which can make any just pretensions to
and the numerous wood-cuts which illustrate it, de-  be its equal.—N.  Y. Journal  of Medicine.
 monstraus that America is making rapid advances in I

                              BY THE SAME AUTHOR.   (In Press.)

 A  PRACTICAL  TREATISE  ON FOREIGN BODIES IN  THE  AIR-PAS-
   SAGES.   In one handsome octavo volume, with illustrations.

                              by the same author.  (Preparing.)

 A  SYSTEM  OF  SURGERY; Diagnostic, Pathological, Therapeutic, and Opera-
   tive.  With very numerous engravings on wood. 
16
BLANCHARD  & LEA'S  MEDICAL
                           GLUGE  (GOTTLIEB),  M.D.,
        Professor of Physiology and Pathological Anatomy in the University of Brussels, &c.

AN  ATLAS OF  PATHOLOGICAL  HISTOLOGY.   Translated, with  Notes
  and Additions, by Joseph Leidy, M. D., Professor of Anatomy in the University of Pennsylva-
  nia.  In one volume, very large imperial quarto, with  three hundred and twenty figures, plain
  and colored, on twelve copperplates.
  This being, as far as we know, the only work in
which pathological histology is  separately treated
of in a comprehensive manner, it  will, we think, for
this reason, be of infinite service to those who desire
to investigate the subject systematically, and who
have felt the difficulty of arranging  in their mind
the  unconnected observations of a great number of
authors.  The development of the morbid tissues,
and the formation of abnormal products, may now
be followed  and studied with the same ease and
satisfaction as the best  arranged system  of phy-
siology.—American Med. Journal.
                     GRIFFITH (ROBERT  EJ,  M. D., &c.

A UNIVERSAL FORMULARY, containing the methods of Preparing and Ad-
  ministering Officinal and  other Medicines.  The whole adapted to Physicians  and Pharmaceu-
  tists.  Second Edition, thoroughly revised, with numerous additions, by Robert P. Thomas,
  M.D., Professor of Materia Medica in the Philadelphia College of Pharmacy.  In one large and
  handsome octavo volume, of over six hundred pages, double columns.   (Just Ready.)

  The speedy exhaustion of a large edition, and the demand for a second, sufficiently show the posi-
tion which this work has so rapidly attained as an authoritative and convenient work of reference for
the physician and'pharmaceutist.  The opportunity thus afforded for its improvement has not been
neglected.  In its revision, Professor Thomas (to whom this task has been confided in consequence
of the death of the author), has spared no labor, in the hope of rendering it the most complete and
correct work on the subject as yet presented to the profession  All the  newly introduced articles
of the Materia Medica have been inserted, such forinulse as bad escaped the attention of the author
have been added,  and the whole has been most carefully read and examined, to insure the absolute
correctness, so indispensable in a work of this nature.  The amount of these additions maybe esti-
mated from the fact that not only has the page been considerably enlarged, but the volume has also
been increased by about fifty pages,  while  the arrangement of the formulas and the general typo-
graphical execution will be found to have undergone great  improvement.  To the practitioner, its
copious collection of all the forms and combinations of the articles of the Pharmacopoeia render it
an invaluable book of reference, while its very complete embodiment of officinal preparations of aH
kinds, derived from all sources, American, English, and Continental, make it an indispensable assist-
tant to the apothecary.
  Dr. Griffith's Formulary is worthy of recommen-
dation, not only on account of the care which has
been bestowed on it by its estimable author, but for
its general accuracy, and the richness of its details.
—Medical Examiner.

  Most cordially we  recommend this  Universal
Formulary, not  forgetting  its adaptation to drug-
gists and  apothecaries, who would find themselves
vastly improved by a familiar acquaintance with
this every-day book of medicine.—The Boston Med.
and Surg. Journal.

  A very useful work, and a most complete compen-
dium on the subject of materia medica.  We know
of no work in our lang-uage, or any other, so com-
prehensive in all its details.—London Lancet.
  Pre-eminent among the best and most useful com-
pilations of the present day will  be found the work
before us, which can have been  produced only at a
very great cost of thought and labor. A short de-
scription will suffice to show that we do not put
too high an estimate on this work. We are not cog-
nizant of the existence of a parallel work. Its valae
will  be apparent to our readers  from the sketch of
its contents above given.  We strongly recommend
it to all who  are engaged either in practical medi-
cine, or more exclusively with its literature.—Land.
Med. Gazette.

  A valuable, acquisition to the medical practitioner,
and a useful book of reference to the apothecary on
numerous occasions.—Amer. Journal of Pharmacy.
BY THE SAME  AUTHOR.
MEDICAL BOTANY; or, a Description of all the  more important Plants used
  in  Medicine, and of their Properties, Uses, and Modes of Administration.  In one large octavo
  volume, of 704 pages, handsomely printed, with nearly 350 illustrations on wood.
  One of the greatest acquisitions to American medi-
cal literature. It should by all means be introduced,
at the very earliest period, into our medical schools,
and occupy a place in the library of every physician
in the land.—South-western Medical Advocate.
  Admirably calculated for the physician and stu-
dent — we have seen  no  work which  promises
greater advantages to the  profession.—N. O. Med.
and Surg. Journal.
  One of the few books which supply a positive de-
ficiency in our medical literature.—Western Lancet.

  We hope  the day is not distant when this work
will not only be a text-book in every medical school
and college  in the Union, but find a place  in the li-
brary of every private practitioner.—N. Y. Journal
of Medicine.
                       GREGORY  (WILLIAM), F.  R. S. E.,
                   Professor of Chemistry in the University of Edinburgh, &c.

LETTERS   TO  A CANDID  INQUIRER   ON  ANIMAL
  Description and Analysis of the Phenomena.  Details of Facts and Cases.
  royal 12mo., extra cloth.
 MAGNETISM.
In one neat volume,
                        GARDNER (D. PEREIRA),  M. D.

MEDICAL CHEMISTRY, for the use of Students  and  the Profession:  being a
  Manual of the Science, with its Applications to Toxicology, Physiology, Therapeutics, Hygiene,
  &c.  In one handsome royal 12mo. volume, with illustra'ions. 
AND SCIENTIFIC  PUBLICATIONS.                 17
                            HASSE  (C.  E.),  M. D.

AN  ANATOMICAL  DESCRIPTION OF THE  DISEASES  OF RESPIRA-
  TION AND CIRCULATION. Translated and Edited by Swaine.  In one volume, octavo.

                         HARRISON (JOHN), M.D.

AN  ESSAY  TOWARDS  A  CORRECT  THEORY OF  THE  NERVOUS
  SYSTEM.  In one octavo volume, 292 pages.

                              HUNTER (JOHN).

TREATISE Oj^.THE  VENEREAL DISEASE.   With copious  Additions, by
  Dr. Ph. Ricord, surgeon to the Venereal Hospital of Paris. Edited, with additional Notes, by
  F. J.  Bumstead, M. D.  In one octavo volume, with plates  (Now Ready.) (3^ See Ricord.
Also, HUNTER'S COMPLETE WORKS, with Memoir, Notes, &c. &c.  In  four neat octavo
  volumes, with plates.

                          HUGHES  (H. M.),  M. D.,
                        Assistant Physician to Guy's Hospital, &c.
A CLINICAL INTRODUCTION  TO  THE  PRACTICE  OF AJJSCULTA-
  TION, and other Modes of Physical Diagnosis, in Diseases of the  Lungs  and Heart.  Second
  American from the Second and Improved London Edition. In one royal 12mo. vol. (Just Ready.)
  It has been carefully revised throughout.  Some small portions have been erased; much has
been, I trust,  amended;  and  a great deal of new matter has  been added; so  that, though funda-
mentally it is the same book,  it is in many respects a new work.—Preface.
                      HORNER (WILLIAM  E.), M. D.,
                  Professor of Anatomy in the University of Pennsylvania.
SPECIAL  ANATOMY  AND  HISTOLOGY.  Eighth edition.  Extensively
  revised and modified.  In two large octavo volumes, of more than one thousand pages, hand-
  somely printed, with over three hundred illustrations.
  This work has enjoyed a thorough  and laborious revision on the part of the author, with the
view of bringing it fully up to the existing state of knowledge on the subject of general and special
anatomy.  To adapt it more perfectly to the wants of the student, he has introduced a large number
of additional wood-engravings,  illustrative of the objects described, while the publishers have en-
deavored to render the mechanical execution of the work worthy of the extended reputation which
it has acquired.  The demand which has carried it to an EIGHTH EDITION  is a sufficient evi-
dence of the value of the work, and of its adaptation to the wants of" the student and professional
reader.

                      HOBLYN  (RICHARD D.), A. M.

A DICTIONARY  OF  THE  TERMS  USED  IN MEDICINE  AND  THE
  COLLATERAL SCIENCES.  Second and Improved American Edition. Revised, with nu-
  merous  Additions, from the  second London edition, by Isaac Hays, M. D., &c.  In one large
  royal 12mo. volume, of over four hundred pages, double columns.  (Nearly Ready.)
  In  passing this work a second time through the press, the editor has subjected it to a very tho-
rough revision, making such additions  as the progress of science has rendered desirable, and sup-
plying any omissions that may have previously existed. As a concise and convenient Dictionary
of Medical Terms, at an exceedingly low price, it will therefore be found of great value to the stu-
dent  and practitioner.              _________________

                      HOPE (J.),  M. D., F. R. S., &.C.

A TREATISE  ON THE  DISEASES  OF  THE  HEART AND  GREAT
  VESSELS.  Edited by Pepinock.  In one volume, octavo, with plates, 572 pages.

               HERSCHEL  (SIR JOHN  F. W.),  F. R.  S., &.C.

OUTLINES OF ASTRONOMY.  New American, from the third  London edition.
  In  one neat volume, crown octavo, with six plates and numerous wood-cuts.  (Just Issued.)

                        HUMBOLDT (ALEXANDER).
ASPECTS OF   NATURE  IN  DIFFERENT  LANDS  AND  DIFFERENT
  CLIMATES.  Second American edition, one vol. royal 12mo., extra cloth.


                   JONES (T.  WHARTON), F. R. S.,  &c.

THE  PRINCIPLES AND  PRACTICE OF  OPHTHALMIC  MEDICINE
  AND SURGERY. Edited by Isaac Hats, M. D., &c.  In one very neat volume, large royal
  12mo., of 529 pages, with four plates, plain or o»lored, and ninety-eight wood-cuts.
                                         might  become, a manual for daily reference and
                                         consultation by the student  and the general practi-
                                         tioner. The work is  marked by that correctness,
                                         clearness, and precision of style which distinguish
                                         all the productions of  the learned author.—British
  The work amplv sustains, in every point the ul<
reedy high reputation of the author as an ophthalmic
surgeon as well as a physiologist and pathologist.
The book is evidently the result of much labor and
research, and has been  written with  the greatest
oare and attention. We entertain little doubt that
this book will  become what its author hoped it
and Foreign Medical Review. 
18
BLANCHARD  & LEA'S MEDICAL
JONES (C. HANDFIELD),  F. R. S., &.  EDWARD H. SIEVEKING, M. D.
A MANUAL OF  PATHOLOGICAL ANATOMY.  With numerous engravings
  on wood.  In one handsome volume.  (Preparing.)
                   KIRKES (WILLIAM SENHOUSE),  M. D.,
             Demonstrator of Morbid Anatomy at St. Bartholomew's Hospital, &c; and

                             JAMES  PAGET, F.  R. S.,
            Lecturer on General Anatomy and Physiology in  St. Bartholomew's Hospital.

A  MANUAL  OF   PHYSIOLOGY.   Second  American, froiTthe second and
  improved  London edition.  With one hundred and sixty-five illustrations.  In one large and
  handsome royal 12mo. volume,  pp. 550.  (Just Issued.)

                                              that it is important to know, without special details,
                                              which  are  read with interest  only by those wfib
                                              would make a specialty, or desire to possess a criti-
                                              cal knowledge of the subject.—Charleston Medical
                                              Journal.
                                               One of the best treatises that can be put into the
                                              hands of  the student.—London Medical Gazette.

                                               The general favor with which the first  edition of
                                              this work was received, and its adoption as a favor-
                                              ite text-book by many of  our colleges, will insure a
                                              large circulation to this  improved edition. It will
                                              fully meet  the  wants of the  student. — Southern
                                              Med. and Surg. Journal.

                                               Particularly adapted to those -who desire to pos-
                                              sess a concise digest of the facts of Human Physi-
                                              ology.—British and Foreign Med.-Chirurg. Review.

                                               We conscientiously recommend  it as an admira-
                                              ble "Handbook of Physiology."—London Journal
                                              of Medicine.
  In the present edition, the Manual of Physiology
has been brought up to the actual condition of the
science, and fully sustains the reputation which it
has already so deservedly attained.  We consider
the work of MM. Kirkes and Paget to constitute one
of the very best handbooks of Physiology we possess
—presenting just such an outline of the science, com-
prising an account of its leading facts and generally
admitted principles, as the student  requires during
his attendance upon a course of lectures, or for re-
ference whilst preparing for examination.  The text
is fully and ably illustrated by a series of very supe-
rior wood-engravings, by which a comprehension of
some of the more intricate of the subjects treated of
is greatly facilitated.—Am. Medical Journal.

  We need only say, that, without entering into dis-
cussions of unsettled questions, it contains all the
recent improvements in this department of medical
science.   For the student beginning  this study, and
the practitioner who has but leisure to refresh his
memory, this book is invaluable, as it contains all
                             KNAPP  (F.),  PH. D.,  &.C.

TECHNOLOGY; or, Chemistry applied to the Arts and to Manufactures.  Edited,
  with numerous Notes and Additions, by Dr. Edmund Ronalds and Dr. Thomas Richardsob.
  First American edition, with Notes and Additions, by Prof. Walter R. Johnson.  In two hand-
  some octavo volumes, printed and illustrated in the highest style of art, with about five hundred
  wood-engravings.
PHYSIOLOGICAL
  (Preparing.)
            LEHMANN.
CHEMISTRY.   Translated  by George E.  Day,  M. D.
                      LEE (ROBERT),  M. D.,  F. R. S.,  &c.

CLINICAL  MIDWIFERY;  comprising  the  Histories of  Five  Hundred  and
  Forty-five Cases of Difficult, Preternatural, and Complicated Labor, with Commentaries.
  the second London edition.  In one royal 12mo. volume, extra cloth, of 238 pages.
From
                           LA  ROCHE  (R.),  M. D.,  &c.

PNEUMONIA; its Supposed Connection, Pathological  and  Etiological, with Au-
  tumnal Fevers, including an Inquiry into the Existence and Morbid Agency of Malaria.  In one
  handsome octavo volume, extra cloth, of 500 pages.

                                             the periodical press, and yet in the work before us
                                             he has exhibited an amount of industry and learning,
                                             research and ability, beyond what we are accustomed
                                             to discover in  modern medical writers; while his
                                             own extensive opportunities  for observation and
                                             experience have been improved by the most laudable
                                             diligence,  and  display a familiarity with the whole
                                             subject in  every aspect, which commands both our
                                             respect and confidence. As a corrective of prevalent
                                             and mischievous error, sought to be propagated by
                                             novices and innovators, we could wish that Dr. La
                                             Roche's book could be widely read.—N. Y.  Medical
                                             Gazette.
  A more simple, clear, and forcible exposition of
the groundless nature and dangerous  tendency of
certain pathological  and etiological heresies, has
seldom been presented to our notice.—2V. Y. Journal
of Medicine and  Collateral Science, March, 1854.

  This work should be carefully studied by Southern
physicians, embodying as it does the reflections of
an original thinker and close observer  on a subject
peculiarly their own.—Virginia Med. and Surgical
Journal.
  The author had prepared us to expect  a  treatise
from him, by his brief papers on kindred topics in
                                  LONGET (F. A.)

TREATISE  ON  PHYSIOLOGY.   With  numerous Illustrations.   Translated
  from the French by F. G. Smith, M. D., Professor of Institutes of Medicine in the Pennsylvania
  Medical College.  (Preparing.) 
                     AND  SCIENTIFIC  PUBLICATIONS.                   19
      M>___________________________________________________________________■

                         LAWRENCE (W.),  F. R. S., Sec.

A TREATISE  ON  DISEASES  OF  THE  EYE.  A   new edition,  edited,
  With numerous additions, and 243 illustrations, by Isaac Hays, M. D., Surgeon  to Wills Hospi-
  tal, &c.  In one very large and handsome octavo volume, of 950 pages, strongly  bound in leather
  with raised bands.  (Now Ready.)
This work is thoroughly revised and brought up to 1854.
  This work is so universally  recognized as the standard authority on the subject, that  the pub-
lishers in presenting this new edition have only to remark that in its preparation the editor has
carefully revised every portion, introducing  additions  and  illustrations wherever the advance of
science has rendered them necessary  or desirable.  In this  manner it  will be found  to  con-
tain  over one hundred pages  more than  the last  edition, while the  list  of wood-engravings
has been  increased by sixty-seven  figures, besides  numerous  improved illustrations substituted
for such as were  deemed imperfect or  unsatisfactory.  The various important  contributions to
ophthalmological science,  recently made by  Dalrymple, Jacob, Walton, Wilde,  Cooper,  &c,
both  in the form of  separate treatises  and contributions to  periodicals, have been carefully
examined by the editor,  and, combined with the  results of his  own  experience, have been
freely introduced  throughout the  volume, rendering  it  a  complete and  thorough  exponent of
the most advanced state of the subject.  Among the  most important additions may be mentioned
a full account of the recent microscopical investigations into  the structure and pathology of the
eye;  the description of several affections  not  treated  of in  the original;  an  account of the
catoptric investigation of the eye, and of  its employment as a means of diagnosis ; a description
of recently invented instruments for illuminating the retina, and of some new methods for  examin-
ing the interior structures of the eye.   Very  great improvements will likewise be found in the
typographical and mechanical execution of the work.
  In a future number we shall notice more at length j octavo pages—has enabled both author and  editor to
this admirable treatise-the safest guide and most l do justice to all the details of this subject,  and con-
comprehensive work of reference, which is  within  dense in this single volume the present state of our
the reach of all  classes of the profession.—Stetho- ' knowledge of  the whole science in this department,
scope, March, lb54.                             j whereby its practical value cannot be excelled. We
                                              heartily commend it, especially as a book of refe-
  This standard  text-book  on  the department of j rence, indispensable in every medical library.  The
which it treats, has not been superseded, by any or | additions of the American editor  very greatly en-
all  of the numerous publications on the subject  hance the value of the work, exhibiting the learning
heretofore issued. Nor with the multiplied improve-
ments of Dr. Hays, the American editor, is it at all
likely that this great work will cease to merit the
confidence and preference of students or  practition-
ers.  Its ample extent—nearly one thousand large
and experience of Dr. Hays, in the light in which he
ought to be held, as a standard authority on all sub-
jects appertaining to this specialty, to which he has
rendered so many  valuable contributions.—N. Y.
Medical Gazette.
                                  BY THE SAME AUTHOR.
A TREATISE ON  RUPTURES;  from the fifth London edition.  In one octavo
  volume, sheep, 480 pages.

                        LISTON (ROBERT),  F. R. S.,  &c.
LECTURES ON  THE  OPERATIONS OF SURGERY,  and  on  Diseases and
  Accidents requiring Operations.  Edited, with numerous Additions and  Alterations, by T. D.
  Mutter, M. D.  In one large and handsome octavo volume, of 566 pages, with 216 wood-cuts.
                                 LALLEMAND (M.).
THE  CAUSES,  SYMPTOMS,   AND   TREATMENT   OF  SPERMATOR-
  RHOEA.  Translated and edited by Henry J. McDougal.  In one volume, octavo, 320 pages.
  Second American edition.  (Now Ready.)

                    LARDNER  (DIONYSIUS), d. C. L., See.

HANDBOOKS   OF   NATURAL   PHILOSOPHY  AND   ASTRONOMY.
  Revised, with numerous Additions, by the American editor.  First Course, containing Mecha-
  nics, Hydrostatics, Hydraulics, Pneumatics, Sound,  and Optics.  In one  large royal 12mo.
  volume, of 750 pages, with 424 wood-cuts.  Second  Course, containing Heat, Electricity, Mag-
  netism,  and Galvanism, one  volume, large royal 12mo.,  of  450 pages, with 250 illustrations.
  Third Course ( now ready), containing Meteorology and Astronomy, in one large volume, royal
  12mo. of nearly eight hundred pages, with thirty-seven plates and two hundred wood-cuts. The
  whole complete in three volumes, of about two thousand large pages, with over one thousand
  figures on steel and wood.
  The various sciences treated in  this work will be found brought thoroughly up to the latest
period.
  The work furnishes a very clear and satisfactory I faotory manner  the information they desire.—The
account of our knowledge in the  important depart- j Virginia Med. and Surg. Journal.
ment of science of which it treats.  Although the
medical schools of this country do not include the
study of physics in their course of instruction, yet
no student or practitioner should  be ignorant of its
laws. Besides being of constant application inprac-
sice, such knowledge is of inestimable utility in fa
  The present treatise is a most oomplete digest of
all that has been developed in relation to the great
forces of nature, Heat, Magnetism, and Electricity,
Their laws are elucidated in a manner both pleasing
and familiar, and at the same time perfectly intelli.
Mutating the study of other branches of science. To | gible to the student.  The illustrations are sum-
students, then, and to those who, having already en
tered upon the active pursuits of business, are desir-
ous to sustain and improve their knowledge of the
general truths of natural philosophy, we can recom-
mend this work as supplying in a clear and satis
ciently numerous and appropriate, and altogether
we can cordially recommend the work  as well-de-
serving the notice both of the practising physician
and the student of medicine.—The Med. Examiner. 
20
BLANCHARD  &  LEA'S  MEDICAL
                         MEIGS (CHARLES  D.),  M. D.,
            Professor of Obstetrics, &c, in the Jefferson Medical College, Philadelphia.

WOMAN: HER DISEASES AND THEIR  REMEDIES.   A Series of  Lee-
  lures to his Class.  Third  and Improved edition.  In one large and beautifully printed octavo
  volume.  (Just Ready.   Revised and enlarged to 1854.)

  The gratifying appreciation of his labors, as evinced by the exhaustion of two large impressions
©f this work within a few years, has not been lost upon the author, who has endeavored in every
way to render  it worthy of the favor with  which it has been received.  The opportunity thus
afforded for a second revision has been improved, and the work is now presented as in every way
superior to its predecessors, additions and alterations  having been made whenever  the advance of
science has rendered them  desirable.  The typographical execution of the work will also be found
to have undergone a similar improvement and the work is  now confidently presented as in every
way worthy the position it has  acquired as the standard American text-book on the Diseases of
Females.
  It contains a vast amount of practical knowledge,
by one who has accurately observed  and retained
the experience of many years, and who tells  the re-
Bult in a free, familiar, and pleasant manner.—Dub-
lin Quarterly Journal.
  There is an ofT-hand fervor, a glow,  and a warm-
heartedness infecting the effort of Dr. Meigs, which
is entirely captivating, and which absolutely hur-
ries the reader through from beginning to end. Be-
sides,  the book teems with solid instruction, and
it shows the very highest  evidence of  ability, viz.,
the  clearness with which the information  is pre-
sented. We know of no better test of one's under-
standing a subject than the evidence of the power
of lucidly explaining  it.  The most elementary, as
well as the obscurest subjects, under  the pencil of
Prof. Meigs,  are isolated  and made to stand out in
such bold relief, as to produce distinct impressions
upon the  mind and memory of the reader. — The
Charleston Med. Journal.
  Professor  Meigs has enlarged and amended this
great work,  for such it unquestionably is, having
passed the ordeal of criticism at home and abroad,
but been improved thereby ; for in  this  new edition
the author has introduced real improvements, and
increased the  value and utility of  the book im-
measurably.  It  presents  so many novel, bright,
and sparkling thoughts; such an exuberance of new
ideas on almost  every page, that  we confess ou»-
selves to have become enamored with the book
and its author; and cannot withhold our congratu-
lations from our Philadelphia confreres, that such a
teacher is in  their  service. We  regret that our
limits will not allow of a more extended notice of
this work, but must content ourselves with thus
commending it as worthy of diligent perusal  by
physicians as well as students, who are seeking to
be thoroughly instructed in the important practical
subjects of which it treats.—N. Y.  Med. Gazette.
                                  BY THE SAME AUTHOR.

OBSTETRICS:  THE  SCIENCE  AND  THE  ART.   Second  edition,  revised
  and improved.  With one hundred and thirty-one illustrations.   In one beautifully printed octavo
  volume, of seven hundred and fifty-two large pages.  (Lately Published.)

  The rapid demand for a second edition of this work is a sufficient evidence that it  has  supplied
a desideratum of the profession, notwithstanding the numerous treatises on the same subject which
have appeared within the last few years.  Adopting a system of his own, the author has combined
the leading principles of his interesting and difficult subject, with a thorough  exposition of its rules
of practice, presenting the results of long and extensive experience  and of  familiar  acquaintance
with all the modern writers on this department of medicine.  As an American Treatise on Mid-
wifery, which has at once assumed the position of a classic, it possesses peculiar claims to the at-
tention and study of the practitioner and  student, while the numerous alterations and revisions
which it has undergone in the present edition are shown by the great enlargement  of the work,
which is not only increased as to the size of the page, but also in the number.  Among other addi-
tions may be mentioned
          A NEW  AND IMPORTANT CHAPTER ON "CHILDBED FEVER."


                          BY THE SAME author.  (Now Ready.)

A  TREATISE ON ACUTE  AND  CHRONIC DISEASES  OF THE  NECK
  OF THE UTERUS.  With numerous  plates, drawn and colored from nature in the highest
  style of art.  In one handsome octavo volume, extra cloth.

  The object of the author in this work has been to  present in a small compass the practical results
of his long experience in this important and distressing class of diseases.  The great changes intro-
duced into practice, and the accessions to our knowledge on the subject, within  the last few years,
resulting from the use of the metroscope, brings within the ordinary  practice of every physician
numerous cases which were formerly regarded as incurable, and renders of great value a work like
the present combining practical directions for diagnosis and treatment with an ample series of illus-
trations, copied  accurately from colored drawings made by the author, after nature.  No such accu-
rate delineations of the pathology of the neck of the uterus have  heretofore  been given, requiring,
as they do the rare combination of physician and artist, and their paramount  importance  to the
physician in whose  practice such cases  are frequent, is too evident  to be dwelt upon, while in
artistic execution they are far in advartce of anything of the kind as yet produced in this country.
                                 BY THE SAME AUTHOR.

OBSERVATIONS  ON   CERTAIN  OF  THE   DISEASES   OF  YOUNG
  CHILDREN.  In one handsome octavo volume, of 214 pages.

                           by the  same author.  (Preparing.)

ON  THE   NATURE,   SIGNS,  AND   TREATMENT   OF  PUERPERAL
  FEVER.  In one handsome octavo volume. 
AND SCIENTIFIC  PUBLICATIONS.
21
                           MILLER (JAMES),  F. R. S. E.,
                     Professor of Surgery in the University of Edinburgh, tee.

PRINCIPLES  OF  SURGERY.   Third American, from the  second and revised
  Edinburgh edition.  Revised, with Additions, by F. W. Sargent, M. D., author of " Minor Sur-
  gery," &c.  In one large and very beautiful volume, of seven hundred and fifty-two pages, with
  two hundred and forty exquisite illustrations on wood.
  The publishers have endeavored to render the present edition of this work, in every point of me-
chanical execution, worthy of its very high reputation, and they confidently present  it to the pro-
fession as one of the handsomest volumes as yet issued in this country.
  This edition is far superior, both in the abundance
and quality of its material, to any of the preceding.
guage.  This  opinion,  deliberately formed after a
careful study of the first edition, we have had no
cause to change on examining the second.  This
edition has undergone thorough revision by the au-
thor;  many expressions have been modified, and a
mass of new matter introduced.  The book is got up
in the finest style, and is an evidence of the progress
of typography in our country.—Charleston Medical
Journal and Review.
  We recommend it to both student and practitioner,
feeling assured that as it now comes to us, it pre-
sents the most satisfactory exposition of the modern
doctrines of the principles of surgery to be found in
any volume  in any  language.—N. Y. Journal of
Medicine.
We hope it will be extensively read, and the sound
principles which are herein taught treasured up for
future  application.  The work takes  rank with
Watson's  Practice of Physic; it certainly does not
fall behind that great work in soundness of princi-
ple or depth of reasoning and research.  No physi-
cian who values his reputation, or seeks the interests
of his clients, can acquit himself before his  God and
the world without making himself familiar with the
sound and philosophical views developed in  the fore-
going book.—New Orleans Medical and Surgical
Journal.
  Without doubt the ablest exposition of the prin-
ciples of that branch of the healing art in  any lan-

                            by the same author.  (Now Ready.)

THE PRACTICE  OF  SURGERY.   Third  American  from the second  Edin-
   burgh edition.   Edited, with Additions, by F. W. Sargent, M.D ,  one of the Surgeons to Will's
   Hospital,  &c.   Illustrated  by three hundred and nineteen engravings on wood.  In one large
   octavo volume, of over seven hundred pages.
   This new edition will be  found greatly improved and enlarged, as well by the addition of much
 new matter  as by the introduction of a large and  complete series of handsome illustrations.  An
 equal improvement exists in  the mechanical execution  of the work, rendering it in every respect
 a companion volume to the "Principles."
   No encomium of ours could add to the popularity
 of Miller's Surgery.  Its reputation in this country
 is unsurpassed by thatof any other work, and, when
 taken in connection with the  author's Principles of
 Surgery, constitutes a whole, without reference to
 which  no conscientious surgeon would be willing
 to practice his art.  The additions, by Dr. Sargent,
 have materially enhanced the value of the work.—
 Southern Medical and Surgical Journal.
   It is seldom that  two volumes have ever made so
 profound  an impression in so short a time as the
 '•Principles" and  the "Practice" of Surgery by
 Mr. Miller—or so richly merited the reputation they
 have acquired.  The  author is an eminently sensi-
 ble, practical, and well-informed man, who knows
 exactly what he is talking about and exactly how to
 talk it.—Kentucky Medical Recorder.
   The two volumes together  form a complete expose
                                                By the almost unanimous voice of the profession,
                                              his works,  both on the principles and practice of
                                              surgery have been assigned the highest rank.  If we
                                              were limited to but one work on surgery, that on«
                                              Bhould be Miller's, as we regard it superior to all
                                              others.—St. Louis Med. and Surg. Journal.

                                                The author distinguished alike as a practitioner
                                              and writer, has in this and his " Principles,"' pre-
                                              sented to the profession oneof the most complete and
                                              reliable systems of Surgery extant.  His style of
                                              writing is original, impressive, and engaging, ener-
                                              getic, concise, and lucid.  Few have  the faculty of
                                              condensing so much in small space, and at the same
                                              time so persistently holding the attention; indeed,
                                              he appears to make the very process of condensation
                                              a means of eliminating attractions.  Whether as a
                                              text-book for students or a book of reference for
                                            c practitioners, it cannot be too strongly recommend-
ed the present state of Surgery, and they ought to be ed.—Southern  Journal of the Medical and Physical
on the shelves of every surgeon.—iV. J.  Med. Re- Sciences.
porter.                                        '

                                 MALGAIGNE (J. F.).
OPER \TIVE  SURGERY, based on Normal and Pathological Anatomy.  Trans-
  lated from the French,  by Frederick Brittan, A. B., M. D. With numerous illustrations on
  wood.  In one handsome octavo volume, of nearly six hundred pages.
                                                 To express in a few words our opinion of Mai-
                                               gaigne's work, we unhesitatingly pronounce it the
                                               very best guide in surgical operations that has come
                                               before the profession in any language.—Charleston
                                               Med. and Surg. Journal.
  We have long been accustomed to refer to ifas one
of the most  valuable text-books in our library.—
Buffalo Med. and Surg. Journal.
  Certainly one of the best books published on ope-
rative surgery.—Edinburgh Medical Journal.
      MOHR (FRANCIS),  PH. D., AND REDWOOD (TH EOPH I LUS).

PRACTICAL  PHARMACY.   Comprising the  Arrangements, Apparatus,  and
  Manipulations of the Pharmaceutical Shop and Laboratory.   Edited, with extensive Additions,
  by  Prof. William Procter, of the Philadelphia  College of Pharmacy.  In  one handsomely
  printed octavo volume, of 570 pages, with over 500 engravings on wood
  It is a book, however, which will be in the hands
of almost everyone who is much interested in phar-
maceutical operations, as we know of no other pub-
lication so well calculated to fill a void long felt.—
Medical Examiner.
  The book is strictly practical, and describes only
manipulations or methods of performing the nume-
rous processes the pharmaceutist has to go through,
in the preparation and manufacture of medicines,
together with all the apparatus and fixtures neces-
sary thereto.  On these matters, this work is very
full and complete, and details, in a style uncom-
monly clear and lucid, not only the more compli-
cated and difficult processes, but those not less im-
portant ones, the most simple and common.—Buffalo
Medical Journal.
  The country practitioner who is obliged to dis-
pense his own medicines, will find it a most valuable
assistant.—Monthly Journal and Retrospect. 
82
BLANCHARD  & LEA'S MEDICAL
                       MACLISE  (JOSEPH),  SURGEON.

SURGICAL  ANATOMY.   Forming  one  volume,  very  large  imperial  quarto.
  With sixty-eight large and splendid Plates, drawn in the best style and beautifully colored. Con-
  taining one hundred and  ninety Figures, many of them the size of life.  Together with copious
  and explanatory letter-press.   Strongly  and handsomely bound in extra cloth, being one of the
  cheapest and best executed Surgical works as yet issued in this country.

               Copies can be  sent by mail, in five parts, done up in stout covers.

  This great work being now concluded, the publishers confidently present it to the attention oflhe
profession as worthy in every respect of their approbation and patronage.  No complete work of
the kind has yet been published in the English language, and it therefore will  supply a want  long
felt in this country of an accurate and comprehensive Atlas of Surgical Anatomy to which  the
student and practitioner can at  all times refer, to ascertain the exact relative position of the various
portions of the human frame towards each other and to the  surface, as well as  their abnormal de-
viations.   The importance of such a work to the student in the absence of anatomical material, and
to the practitioner when about  attempting  an operation, is evident, while the price of the book, not-
withstanding the large size, beauty, and finish of the very numerous illustrations, is so  low as to
place it within the reach of every member of the profession.   The publishers  therefore confidently
anticipate a very extended circulation for this magnificent work.
  One of the greatest artistic  triumphs of the age
in Surgical Anatomy.—British American Medical
Journal.
  Too much cannot be said in its praise; indeed,
we have not language to do it justice.—Ohio Medi-
cal and Surgical Journal.
  The most admirable surgical atlas we have seen.
To the practitioner deprived of demonstrative dis-
sections upon the human subject, it is an invaluable
companion.—N. J. Medical Reporter.
  The most accurately  engraved  and beautifully
colored  plates we have  ever seen in an American
book—one of the best and  cheapest surgical works
ever published.—Buffalo Medical Journal.
  It is very rare that so elegantly printed, so well
illustrated,  and so useful a work, is  offered at so
moderate a price.—Charleston Medical Journal.
  Its  plates can boast a superiority which places
them almost beyond the reach of competition.—Medi-
cal Examiner.
  Every practitioner, we think, should have a work
of this kind within reach.—Southern  Medical and
Surgical Journal.
  No such lithographic illustrations of surgical re-
gions have hitherto, we think, been given.—Boston
Medical and Surgical Journal.

  As a surgical anatomist,  Mr. Maclise has proba-
bly no superior.—British and Foreign Medico-Chi-
rurgical Review.

  Of great value to the student engaged in dissect-
ing, and to the surgeon at a distance from the means
of keeping up his anatomical knowledge.—Medital
Times.
  The mechanical execution cannot be excelled.—
Transylvania Medical Journal.

  A work which has no parallel in point of accu-
racy and cheapness in the English language.—jV. y.
Journal of Medicine.
  To all engaged in the study or practice of their
profession, such a work is almost indispensable.—
Dublin Quarterly Medical Journal.

  No practitioner whose means will admit should
fail to possess it.—Ranking's Abstract.

  Country practitioners will find  these plates of im-
mense value.—N. Y. Medical Gazette.
  We are extremely gratified to announce to the
profession the completion of this truly magnificent
work, which, as a whole,  certainly  stands unri-
valled, both for  accuracy of drawing, beauty of
coloring, and all the requisite explanations of the
Bubject in hand.—The New Orleans  Medical and
Surgical Journal.

  This is by far the ablest work on Surgical Ana-
tomy  that has come  under  our observation.  We
know of no other work that would justify  a stu-
dent, in any degree, for neglect of actual dissec-
tion.  In those  sudden  emergencies that so often
arise, and which require the instantaneous command
of minute anatomical knowledge, a work of this kind
keeps the details of the dissecting-room perpetually
fresh in the memory.—The Western Journal of Medi-
cine and Surgery.
  Bg^ The very low price at which this work is furnished, and the beauty of its execution,
require an extended sale to compensate the publishers for the heavy expenses incurred.
                        MULLER (PROFESSOR  J.),  M.D.

PRINCIPLES  OF  PHYSICS  AND  METEOROLOGY.   Edited, with Addi-
  tions, by R. Eglesfeld Griffith, M. D.  In one large and handsome octavo volume,  extra
  cloth, with 550 wood-cuts, and two colored plates.    .
  The Physics of Mflller is a work superb, complete, j tion to the scientific records of this country may be
unique: the greatest want known to English Science | duly estimated by the fact that the cost of the origi-
could not have been better supplied.  The work is I nal drawings and engravings alone has exceeded the
of surpassing interest.  The value of this contribu- | sum of £2,000.—Lancet.
                       MAYNE (JOHN), M.  D., M. R. C. S.,

A DISPENSATORY AND  THERAPEUTICAL  REMEMBRANCER.  Com-
  prising the entire lists of Materia Medica, with every Practical  Formula contained in  the three
  British Pharmacopoeias. With relative Tables subjoined, illustrating,  by upwards of six hundred
  and sixty examples,  the Extemporaneous Forms and Combinations suitable for the different
  Medicines.  Edited, with the addition of the Formulas of the United States Pharmacopoeia, by
  R. Eglesfeld Griffith, M. D.  In one 12mo. volume, extra cloth, of over 300 large pages.
                              MATTEUCCI (CARLO).
LECTURES  ON  THE  PHYSICAL PHENOMENA  OF  LIVING BEINGS.
  Edited by J. Pereira, M. D.  In one neat royal 12mo. volume, extra cloth, wilh cuts, 388 page*. 
AND  SCIENTIFIC  PUBLICATIONS.                  23
                             NEILL  (JOHN), M. D.,
                        Surgeon to the Pennsylvania Hospital, ie.; and
                     FRANCIS GURNEY  SMITH,  M.D.,
             Professor of Institutes of Medicine in the Pennsylvania Medical College.

AN ANALYTICAL  COMPENDIUM   OF  THE   VARIOUS  BRANCHES
  OF MEDICAL SCIENCE; for the Use and Examination of Students. Second edition, revised
  and improved.  In  one very large and handsomely printed royal 12mo. volume, of over one
  thousand pages, with three hundred and fifty illustrations on wood.  Strongly bound in leather,
  with raised bands.
  The speedy sale of a large impression of this work has afforded to the authors gratifying evidence
of the  correctness of the views which actuated them in its preparation. In meeting the demand
for a second edition, they have therefore been desirous to render  it more worthy of the favor with
which it has been received.  To accomplish this, they have spared neither time nor labor in embo-
dying in it such discoveries and improvements as have been made since its first appearance, and
such alterations as  have  been suggested by its practical use  in the  class and examination-room.
Considerable modifications have thus been introduced throughout  all the  departments treated of in
the volume, but more especially in the portion devoted to the "Practice of  Medicine," which has
been entirely rearranged and rewritten. The authors therefore again  submit their work to the
profession, with the hope that their efforts may tend, however humbly, to advance the great cause
of medical education.
  Notwithstanding the enlarged size and  improved execution of this work,  the price has not been
increased, and it is confidently presented as  one of the cheapest volumes now before the profession.
  In the rapid  course  of lectures, where work for
she students is heavy, and review necessary for an
examination, a compend  is not only valuable, but
  Having made free use of this volume in our ex-
aminations  of pupils,  we can speak from experi-
ence in recommending it as an admirable compend
for students, and as especially useful to preceptors
who examine their pupils.  It will save the teacher
much labor by enabling him readily to recall all of
the  points  upon which his pupils should be ex-
amined.  A work of this sort should be in the hands
of every one who takes pupils into his office with a
view of examining them; and  this is unquestionably
the best of its class.  Let every practitioner who has
 ftupils provide himself with it, and he will find the
 abor of refreshing hisknowledge so much facilitated
that lie will be able to do justice to his pupils at very
little cost of time or trouble to himself.—Transyl-
vania Med. Journal.
it is almost a sine qua non.  The one before us is,
in most of the divisions, the most unexceptionable
of all books of the kind  that we know  of.  The
newest and  soundest doctrines and the latest im-
provements and discoveries are explicitly, though
concisely, laid before the student.  Of course it is
useless for us to recommend it to all last course
students, but there is  a  class to whom we very
sincerely commend this cheap book  as worth its
weight in silver — that class is the  graduates  in
medicine of more than ten years' standing,  who
have not studied medicine since.  They will perhaps
find out from it that the science is not exactly now
what it was when they left it off.—The Stethoscope

               NELIGAN (J.  MOORE), M. D., M. R. I. A., &c.

A  PRACTICAL  TREATISE  ON   DISEASES  OF  THE  SKIN.   In one
  neat royal 12mo. volume, of 334 pages.

                                OWEN  (PROF.  R).
ON  THE  DIFFERENT FORMS  OF  THE  SKELETON.    One vol. royal
  12mo., with numerous illustrations.  (Preparing.)

                           POPULAR  PHYSIOLOGY.
THE PHYSIOLOGY  OF  ANIMAL  AND VEGETABLE  LIFE.   In  one
  neat royal 12mo. volume, of about 200 pages, with 100 wood-cuts.  (Just Ready.)
  The latest information on physiological subjects will be found in this work, popularly and clearly
explained, rendering it suitable for schools and school libraries, as well as for private readers.

                    PHILLIPS (BENJAMIN), F. R. S.,  &c.
SCROFULA;  its Nature, its  Prevalence, its Causes,  and the Principles of its
  Treatment.   In one volume, octavo, with a plate.

                             PANCOAST  (J.), M.D.,
             Professor of Anatomy in the Jefferson Medical College, Philadelphia, &c.

OPERATIVE  SURGERY; or, A Description and Demonstration of the various
  Processes of the Art; including all the New Operations, and exhibiting the State of Surgical
  Science in its present advanced condition.  Complete in one royal 4to. volume, of 380  pages of
  letter-press description and eighty large 4lo.  plates, comprising 486 illustrations. Second edition,
  improved.
  Blanchard & Lea having become the publishers of this important book,  have much pleasure in
offering it to the profession.
  This excellent work is constructed on the model
of the French Surgical Works by Velpeau and Mal-
gaigne; and, so far as the English language is con-
cerned, we are proud as an American to say that,
ov its kind it has no superior.—N. Y. Journal of
Medicine.
                            PARKER (LANGSTON).,
                        Surgeon to the Queen's Hospital, Birmingham.
THE  MODERN TREATMENT  OF  SYPHILITIC  DISEASES, BOTH PRI-
  MARY AND SECONDARY; comprising the Treatment of Constitutional and Confirmed Syphi-
  lis, by a safe and successful method.  With numerous Cases, Formulae, and  Clinical Observa-
  tions.  From the Third and entirely rewritten  London edition.  In one neat octavo volume.
  (Nearly Ready.) 
24
BLANCHARD  & LEA'S  MEDICAL
                                      (Now Complete.)
             PEREIRA  (JONATHAN),  M. D.,  F. R.  S., AND L.  S.

THE  ELEMENTS  OF  MATERIA   MEDICA   AND  THERAPEUTICS.
  Third American edition, enlarged and improved by the author;  including Notices of most of the
  Medicinal Substances  in  use  in the  civilized world, and forming an Encyclopaedia of Materia
  Medica.  Edited, with Additions, by Joseph Cakson, M. D., Professor of Materia Medica  and
  Pharmacy in the University of Pennsylvania.   In two very large octavo volumes of 2100 pages,
  on small type, with over four hundred and fifty illustrations.
Volume I.—Lately issued,  containing the Inorganic  Materia Medica, over 800 pages, with  145
  illustrations.
Volume II.—Now ready, embraces the Organic Materia Medica, and forms a very large octavo
  volume of 1250 pages, with  two plates and three  hundred handsome wood-cuts.
  The present  edition of this valuable and Standard work will  enhance  in every respect its well-
deserved reputation.  The care bestowed upon its revision by the author may be estimated by the
fact that its size has been increased by about five hundred pages.   These additions have extended
to every portion of the work, and embrace not only  the materials  afforded by the  recent editions of
the pharmacopoeias, but also all the important information accessible to the care and industry of
the author  in treatises, essays, memoirs, monographs, and from correspondents in various parts of
the globe.  In this manner the work comprises the most recent  and reliable information respecting
all the articles of the  Materia Medica, their natural and commercial history, chemical and thera-
peutical properties, preparation, uses, doses, and modes of administration, brought up to the present
time, with  a completeness not to  be  met with  elsewhere.  A considerable portion  of the work
which preceded the remainder in London, has also  enjoyed the advantage of a further revision by
the author  expressly for this country, and in addition to this the  editor, Professor Carson, has made
whatever additions appeared desirable to adapt it  thoroughly  to the U  S. Pharmacopoeia, and to
the wants of the American profession.   An equal improvement will likewise be observable in every
department of its mechanical execution.  It  is printed from new type, on good white paper, with a
greatly extended and improved series of illustrations.
  Gentlemen who have the  first volume are recommended to complete their copies without delay.
The  first volume will no longer be sold separate.
  When we remember that Philology, Natural His-
tory, Botany, Chemistry, Physics, and  the Micro-
scope, are all brought forward to elucidate the sub-
ject, one cannot fail to see that the reader has here
a work worthy of the name of an encyclopedia of
Materia Medica.  Our own opinion of its merits is
that of its editors, and also that of the whole profes-
sion, both of this and foreign countries—namely,
" that  in copiousness of details, in extent, variety,
and accuracy of information, and in lucid explana-
tion of difficult and recondite subjects, it surpasses
all  other works on Materia Medica  hitherto pub-
lished." We cannot close this notice without allud-
ing to the special additions of the American editor,
which  pertain  to the prominent vegetable produc-
tions of this country, and to the directions of the
United States Pharmacopoeia, in connection with all
the articles contained in the volume which are re-
ferred to by it. The illustrations have been increased,
and this edition by Dr.  Carson cannot well be re-
garded in any other light than that of a treasure
which should be found in the library of every physi-
cian.—New York Journal of Medical and Collateral
Science, March, 1854.

  The  third  edition of his  "Elements of Materia
Medica, although completed under the supervision of
others, is by far the most elaborate treatise in the
English language, and will, while medical literature
is cherished, continue a monument alike honorable
to  his  genius, as  to  his  learning and  industry.—
American Journal of Pharmacy, March, 1851.

 The work, in its present shape, and  so far as can
be  judged from the portion before the public, forms
the most comprehensive and complete  treatise on
materia medica extant in the English language.—
Dr. Pereira has been at great pains to introduce
into his work, not only all the information on the
natural, chemical, and commercial history of medi-
cines, which might be serviceable to the physician
and surgeon, but whatever might enable his read-
ers to understand  thoroughly the  mode of prepar-
ing and manufacturing various articles employed
either for preparing medicines,  or for certain  pur-
poses in  the arts connected with materia medica
and the practice of medicine. The accounts of the
physiological and therapeutic effects of remedies are
given with great clearness and accuracy, and in a
manner calculated to interest as  well  as instruct
the reader.—The Edinburgh Medical  and  Surgical
Journal.
                              PEASELEE (E.  R.),  M. D.
                  Professor of Anatomy and Physiology in Dartmouth College, &c.

HUMAN HISTOLOGY, in its applications to Physiology and General Pathology,
  designed as a Text-Book for Medical Students.  With numerous illustrations.  In one handsome
  royal 12mo. volume.  (Preparing.)
  The subject of this work is one, the growing importance of which, as the basis of Anatomy and
Physiology, demands for  it a separate volume.  The book will therefore supply an acknowledged
deficiency in medical text-books, while the name of the author, and  his experience as a teacher for
the last thirteen years, is a guarantee that it will be thoroughly adapted to the use of the student.

                          PIRRIE (WILLIAM), F.  R. S. E.,
                       Professor of Surgery in the University of Aberdeen.

THE  PRINCIPLES  AND  PRACTICE  OF  SURGERY.   Edited  by  John
  Neill,  M. D., Demonstrator of Anatomy in the  University  of  Pennsylvania,  Surgeon to the
  Pennsylvania Hospital, &c.  In one very handsome octavo volume, of 780 pages, with 316 illus-
  trations.   (Just Issued.)
  We know of no other surgical work of a reason-
able size, wherein there is so much theory and prac-
tice, or where subjects are  more soundly or clearly
taught.—The Stethoscope.
  There is  scarcely a disease of the bone or soft
parts, fracture, or dislocation, that is not illustrated
by accurate wood-engravings.  Then, again, every
instrument  employed by the surgeon is thus repre-
sented.  These engravings are not only correct, but
really beautiful, showing the astonishing degree of
perfection to which the art of wood-engraving has
arrived.  Prof. Pirrie, in the work before ns, has
elaborately discussed the principles of surgery, and
a safe and effectual practice predicated upon them.
Perhaps no work upon this subject heretofore issued
is so full upon the science  of the art of surgery.—
Nashville Journal of Medicine and Surgery.
  One of the best treatises on surgery in the English
language.—Canada Med. Journal.
  Our impression is, that, as a manual for students,
Pirrie's is the best work extant.—Western Med. and
Surg. Journal. 
AND  SCIENTIFIC  PUBLICATIONS.                   25
                     RAMSBOTHAM (FRANCIS  H.), M.D.

THE PRINCIPLES  AND PRACTICE OF OBSTETRIC MEDICINE AND
  SURGERY, in reference to the Process of Parturition.  Sixth American, from the last London
  edition.  Illustrated with one hundred and forty-eight Figures, on fifty-five Lithographic Plates.
  In one large and handsomely printed volume, imperial octavo, with 520 pages.
  In this edition, the plates have all been redrawn, and the text carefully read and corrected.  It
is therefore presented as in every way worthy the favor with which it has so long been received.
                          From Prof. Hodge, of the University of Pa.
  To  the American  public, it is most valuable, from its intrinsic undoubted excellence, and as being
the best authorized exponent of British Midwifery.  Its circulation will, I trust, be extensive throughout
our country.
  We recommend the student who desires to mas-
ter  this difficult  subject  with  the  least  possible
trouble, to possess himself at once of a copy of this
work.—American Journal of the Med. Sciences.
  It stands at the head of the long list of excellent
obstetric works published in the last few years in
Great Britain, Ireland, and the Continent of  Eu-
rope. , We consider this book indispensable to the
library of every physician engaged in the practice
of midwifery.—Southern Med. and Surg. Journal.
  When the whole profession is thus unanimous
in placing such a work  in the very first rank as
regards the extent and correctness of all the details
of the theory and practice of so important a branch
of learning, our commendation  or condemnation
would be of little consequence;  but regarding  it
as the  most useful of all works of the  kind, we
think it but an act of justice to urge its claims
upon the profession.—N. O. Med. Journal.
                                RICORD (P.), M. D.,
                          Surgeon to-the Hopital du Midi, Paris, &c.

ILLUSTRATIONS  OF  SYPHILITIC DISEASE.  Translated from the French,
  by Thomas F. Betton, M. D.  With the addition of a History of Syphilis, and a complete Bib-
  liography and Formulary of Remedies, collated and arranged, by Paul B. Goddard, M. D.  With
  fifty large quarto plates, comprising one hundred and  seventeen beautifully colored illustrations.
  In one large and handsome quarto volume.
  Blanchard &  Lea having purchased the remainder of this valuable work, which was originally
sold as a subscription book,  are now prepared to offer it to the profession.   It is universally known
as one of the handsomest volumes as yet presented in this country, and as containing the only ex-
tended and thorough series of illustrations on the subject.

                          by the  same author.  (Now Ready.)              '

A TREATISE  ON THE VENEREAL DISEASE.   By John Hunter, F. R. S.
  With copious Additions, by Ph. Ricord, M. D.  Edited, with Notes, by Freeman J. Bumstead,
  M. D.  In one handsome octavo volume, with plates.

                              From the Translator's Preface.
  " M.  Ricord's annotations to Hunter's Treatise on the Venereal Disease were first published at
Paris, in 1840, in connection with Dr. G. Richelot's translation of the work, including the contri-
butions  of Sir Everard Home and  Mr. Babington.  In a second edition, which has recently ap-
peared, M. Ricord has thoroughly  revised his part of the work, bringing it up to the knowledge of
the present day, and so materially increasing it that it now constitutes  full one-third of the volume.
  " This publication has been received with great favor by the French, both because it has placed
within  their reach an important work of Hunter, and also because it is the only recent practical
work which M. Ricord  has published, no edition of his Traite des Maladies Veneriennes having
appeared for the last fifteen years."

  Every  one will recognize the  attractiveness and
value which this work derives from thus presenting
Ihe opinions of these two masters side by side.  But,
it must be admiited, what has made  the fortune of
the book, is the fact that it comains the " most com-
plete embodiment of the  veritable doctrines of the
Hopital du Midi," which has ever been made public.
The doctrinal ideas of M.  Ricord, ideas which, if not
universally adopted, are incoutesiably dominant, have
heretofore only been interpreted by more or less skilful
secretaries, sometimes accredited and sometimes not.

                                  BY THE SAME  AUTHOR.

LETTERS ON SYPHILIS, addressed to the Chief Editor of the Union  Medicale.
   With an Introduction, by Amedee Latour.  Translated by W. P. Lattimore, M. D.  In one neat
  octavo volume.
                Blanchard & Lea  are now the publishers of this valuable work.

                               From the Translator's Preface.
   To those who have listened to the able and interesting lectures of our  author at the Hopital da
Midi, this volume will need no commendation; while to those who have  not had the pleasure to
which we allude, the book will commend  itself by the truths it contains, told  as they are  in the
same inimitable style in which M.  Ricord delivers his clinical lectures.

                                  BY THE SAMS  AUTHOR.

A  PRACTICAL TREATISE ON  VENEREAL DISEASES.   With a Thera-
  peutical Summary and Special Formulary.  Translated by Sidney Doane, M. D.  Fourth edition.
  One volume, octavo, 340 pages.
  In the notes to Hunter, the master substitutes him-
self for his interpreters, and gives his original thoughts
to the world, in a summary form it is true, but in a
lucid and perfectly intelligible manner. In conclu-
sion we  can say that this is  incoutesiably the  best
treatise on syphilis with which we are acquainted,
and, as we do nol often employ the phrase, we may
be excused for expressing the hope that ii may find
a place in the library of every physician — Virginia
Med. and Surg  Journal. 
26
BLANCHARD &  LEA'S  MEDICAL
                            RIGBY  (EDWARD),  M. D.,
                       Physician to the General Lying-in Hospital,  &e.

A  SYSTEM  OF MIDWIFERY.   With  Notes and  Additional  Illustrations.
  Second American Edition.  One volume octavo, 422 pages.
                            ROYLE (J.  FORBES),  M.D.

MATERIA MEDICA AND  THERAPEUTICS; including the Preparations of
  the Pharmacopoeias of London, Edinburgh, Dublin, and of the United States.   With many new
  medicines.  Edited by Joseph Carson, M. D., Professor of Materia Medica  and Pharmacy in
  the University of Pennsylvania. With ninety-eight illustrations.  In one large octavo volume,
  of about seven hundred pages.
  This work is, indeed, a most valuable one, and
will fill up an important vacancy that existed be-
tween Dr. Pereira's most  learned and complete
system of Materia Medica,  and  the class of pro-
ductions on the other extreme, which are neoes-
sarily imperfect from their small  extent.—British
and Foreign Medical Review.
                     SKEY (FREDERICK C),  F. R. S., &c.
OPERATIVE SURGERY.  In one very handsome  octavo volume of over  650
  pages, with about one hundred wood-cuts.
  Its literary execution is superior to most surgical
treatises. It abounds in excellent moral hints, and
is replete with original surgical expedients and sug-
gestions.—Buffalo Med. and Surg. Journal.

  With high talents, extensive practice, and a long
experience, Mr. Skey is perhaps  competent to the
task of writing a  complete work  on operative sur-
gery.—Charleston Med. Journal.
 We cannot withhold from this work our high com-
mendation. Students and practitioners will find it an
invaluable teacher and  guide upon every topic con-
nected with this department.—N. Y. Medical Ga-
zette.

  A work of the very highest importance—a work
by itself.—London Med. Gazette.
       SHARPEY  (WILLIAM),  M. D.,  JONES  QUAIN, M. D., AND
                        RICHARD  QUAIN,  F. R.  S., &.c.

HUMAN  ANATOMY.   Revised, with Notes and Additions, by Joseph  Ledy,
  M. D.  Conjplete in two large octavo volumes, of about thirteen hundred pages.  Beautifully
  illustrated with over five hundred engravings on wood.
  It is indeed a work  calculated to make an era in
anatomical study,  by placing before the student
every department of  his science, with  a view to
the relative importance of each; and so skilfully
have the different parts been interwoven, that no
one who makes this work the basis of his studies,
will  hereafter have any excuse for  neglecting or
undervaluing any important particulars connected
with  the  structure  of  the  human  frame;  and
Whether the bias of his mind lead him  in a more
especial manner to surgery, physic, or physiology,
he will find here a work at once so comprehensive
and practical as to defend him from exclusiveriess
on the one hand,  and  pedantry on  the other.—
Monthly Journal and Retrospect of the Medical
Sciences.
  We have no hesitation in recommend ing this trea-
tise on anatomy as the most complete on that sub-
ject in the English language; and the only one,
perhaps, in any language, which brings the stale
of knowledge forward to the most recent disco-
veries.—The Edinburgh Med. and Surg. Journal.

  Admirably calculated to fulfil the object for whieh
it is intended.—Provincial Medical Journal.

  The most complete Treatise on Anatomy in the
English language.—Edinburgh Medical Journal.

  There is no work in the English language to be
preferred to Dr. Quain's Elements of Anatomy.—
London Journal of Medicine.
   SMITH (HENRY  H.), M. D., AND HORNER (WILLIAM E.), M. D.

AN ANATOMICAL  ATLAS, illustrative  of the Structure of the Human Body
  In one volume, large imperial octavo, with about six hundred and fifty beautiful figures.
  These figures are well selected, and present a
complete and accurate representation of that won-
derful fabric, the  human body. The plan  of this
Atlas, which renders it so  peculiarly convenient
for the student, and its superb artistical execution,
have been already pointed out.  We must congratu-
late the student upon the completion of this Atlas,
as it is the most convenient work of the kind that
has yet appeared ; and we must add, the very beau-
tiful manner in which it is " got up" is so creditable
to the country  as to be flattering to our national
pride.—American Medical Journal.
                             SARGENT  (F. W.), M. D.

ON BANDAGING AND  OTHER POINTS OF  MINOR  SURGERY.
  one handsome royal 12mo. volume of nearly 400 pages, with 128 wood-cuts.
In
  The very best manual of Minor Surgery we have
seen; an American volume, with nearly four hundred
pages of good practical lessons, illustrated by about
one hundred and thirty wood-cuts.  In these days
of " trial," when a doctor's reputation hangs upon
a clove hitch, or the roll of a bandage, it would be
well, perhaps, to carry such a volume as Mr. Sar-
gent's always in our coat-pocket, or, at all events,
to listen attentively to his  instructions at home.—
Buffalo Med. Journal.
  We have carefully examined this work, and find it
well executed and admirably adapted to the use of
the student.  Besides the subjects usually embraced
in works on Minor Surgery, there is a short chapter
on bathing, another on anaesthetic agents, and an
appendix of formulas.  The author has given an ex-
cellentwork on this subject,and his publishers have
illustrated and printed it in most beautiful styl«»—
The Charleston Medical Journal.
                              STANLEY (EDWARD).
A TREATISE ON DISEASES  OF  THE BONES.   In  one volume, octavo,
  extra cloth, 286 pages. 
AND  SCIENTIFIC PUBLICATIONS.                  27
                            STILLE (ALFRED),  M. D.
PRINCIPLES OF THERAPEUTICS.   In one handsome volume. (Preparing.)

                             SIMON (JOHN), F.  R. S.
GENERAL  PATHOLOGY,   as  conducive  to the   Establishment of  Rational
  Principles for the  Prevention and  Cure of Disease.  A Course of Lectures delivered  at St.
  Thomas's Hospital during the summer Session of 1850.  In one neat octavo volume.  (Lately
  Issued.)
                           SMITH (TYLER W.), M. D.,
                   Lecturer on Obstetrics in the Hunterian School of Medicine.
ON  PARTURITION,  AND   THE  PRINCIPLES  AND   PRACTICE  OF
  OBSTETRICS.  In one large duodecimo volume, of 400 pages.
                           SIBSON (FRANCIS),  M.D.,
                             Physician to St. Mary's Hospital.

MEDICAL  ANATOMY.   Illustrating the  Form, Structure, and Position of the
  Inlernal Organs in Health and Disease.   In large imperial quarto, with splendid colored plates.
  To match "Maclise's Surgical Anatomy." (Preparing.)

                           SOLLY (SAMUEL),  F. R. S.
THE  HUMAN  BRAIN;  its Structure,  Physiology, and  Diseases.   With  a
  Description of the Typical Forms of the  Brain in the Animal Kingdom.  From the Second and
  much enlarged London edition.  In one octavo volume, with 120 wood-cuts.

                      SCHOEDLER  (FRIEDRICH),  PH.D.,
                       Professor of the Natural Sciences at Worms, &c.  •

THE  BOOK  OF  NATURE;  an  Elementary  Introduction  to the  Sciences of
  Physics, Astronomy, Chemistry, Mineralogy, Geology, Botany, Zoology, and Physiology.  First
  American edition, with a Glossary and other Additions and Improvements; from  the second
  English edition.  Translated from the sixth German edition, by Henry Mkdlock, F. C. S., &c.
  In one thick volume, small octavo, of about seven hundred pages, with 679 illustrations on wood.
  Suitable for the higher Schools and  private students.  (Now Ready.)
  This volume, as its title shows, covers nearly all I seen presents the reader with so wide a range of els-
the sciences, and embodies a vast amount of informa-  mentary knowledge, with so full illustrations, at so
tion for instruction.  No other work that we have | cheap a rate.—Silliman's Journal, Nov. 1853.

                    TAYLOR (ALFRED S.), M. D., F. R. S.,
                Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital.

MEDICAL JURISPRUDENCE.   Third  American, from the fourth and improved
  English Edition.  With Notes and References to American Decisions, by Edward Hartshorne,
  M. D.  In one large octavo volume, of about seven hundred pages.  (Just Issued.)
                                            reference, that would be more likely to afford the aid
                                            desired. We therefore recommend it as the best and
                                            safest manual for  daily use.—American Journal of
                                            Medical Sciences.
                                              We have heretofore had  reason to refer to it in
                                            terms of commendation,  and need now only state
                                            that, in the edition before us, the author has com-
                                            pletely revised the whole work, making many addi-
                                            tions and alterations, and brought it fully up to the
                                            present state of knowledge. The task of the Ameri-
                                            can editor has been  to present all the  important
                                            facts and cases that have recently occurred in our
                                            own country, bearing on the subjects treated of.
  We know of no work on Medical Jurisprudence
which contains in the same space anything like the
same amount of valuable matter .—N. Y. Journal of
Medicine.
  The American editor has appended several  im-
portant facts, the whole constituting by far the best.
most reliable,  and interesting treatise on Medical
Jurisprudence, and one that we cannot too strongly
recommend to all who desire to become acquainted
with the true and correct exposition of this depart-
ment of medical literature.—Northern Lancet.
  No work upon the subject can  be put into the
hands of students either of law or  medicine which
will engage them more closely or profitably; and  No better work can be placed in  the hands of th.
none couW be offered to  the busy practitioner of  physician or jurist.—St. Louts Medical and Surgical
either calling, for the purpose of casual  or hasty I Journal.
                                 BY THE SAME AUTHOR.

ON POISONS,  IN  RELATION  TO MEDICAL  JURISPRUDENCE  AND
  MEDICINE.  Edited, with Notes and Additions, by R. E. Griffith, M. D. In one large octavo
  vol ume, of 688 pages.
                                              One of the most practical and trustworthy works
                                            on Poisons in our language.—Western Journal of
                                            Medicine.
                                              It is, so far as our knowledge extends, incompa-
                                            rably the best upon the subject; in the highest de-
                                            gree creditable to the author, entirely trustworthy,
                                            and indispensable to the student and practitioner.—
                                            N. Y. Annalist
  The most elaborate work on the subject that ou*
literature possesses.—British and Foreign Medico-
Chirurgical Review.
  It contains a vast body of facts, which embrace
all that is  important in  toxicology, all  that is
necessary to the guidance of the medical jurist, and
all that can be desired by the lawyer. — Medico-
Chirurgical Review.
                    THOMSON (A. T.), M. D., F. R. S., &c.
DOMESTIC  MANAGEMENT  OF  THE  SICK  ROOM,  necessary in  aid of
  Medical Treatment for the Cure of Diseases.  Edited by R. E. Griffith, M. D.  In one large
  royal 12mo. volume, with wood-cuts, 360 pages. 
88                     BLANCHARD & LEA'S MEDICAL
                            TOMES  (JOHN),
A MANUAL OF DENTAL PRACTICE.
  on wood.  In one handsome volume.   (Preparing.)
F. R. S.
Illustrated by numerous engravings
        TODD  (R. B.),  M. D.,  AND BOWMAN (WILLIAM),  F. R. S.
PHYSIOLOGICAL  ANATOMY  AND   PHYSIOLOGY  OF  MAN.  With
  numerous handsome wood-cuts.  Parts I, II, and III, in one octavo volume, 552 pages.  Part IV
  will complete the work.
  The distinguishing peculiarity of this work is, that the authors investigate for themselves every
fact asserted; and it is  the immense labor consequent upon the vast number of observations re-
quisite to carry out this plan, which has so long delayed the  appearance of its completion.  The
first portion of  Part IV,  with numerous original illustrations, was published in  the Medical News
and Library for 1853, and the completion will be issued immediately on its appearance in London.
Those who have subscribed since  the appearance of the preceding portion of the work can have
the three parts by mail,  on remittance of $2 50 to the  publishers.

  TRANSACTIONS OF THE AMERICAN  MEDICAL  ASSOCIATION.
VOLUME VI, for 1853, large 8vo., of 870 pages, with  numerous  colored plates
  and wood-cuts.
Also to be had. a few sets of the Transactions from 1848 to  1853, in six large octavo volumes,
  price $25.  These volumes are published by and sold on account of the Association.

                       WATSON (THOMAS), M.D., &.c.
LECTURES  ON  THE  PRINCIPLES   AND  PRACTICE  OF  PHYSIC.
  Third American, from the last London edition.  Revised, with Additions, by D. Francis Condie,
  M. D , author of a " Treatise on the Diseases of Children," &c.  In one octavo volume, of nearly
  eleven hundred large  pages, strongly bound with raised bands.
  To say that it is  the very best work on the sub-
ject now extant, is but to echo the sentiment of the
medical  press  throughout the country.— N. O.
Medical Journal.
  Of the text-books recently republished Watson is
very justly the principal favorite.—Holmes's Rep.
to Nat. Med. Assoc.

  By universal consent the work ranks among the
very best text-books in our language.—Illinois and
Indiana Med. Journal.

  Regarded on all hands as one of the very best, if
not  the very best, systematic treatise on practical
medicine extant.—St. Louis Med. Journal.
  Confessedly one of the very best works on the
principles and practice of physic  in the English or
any other language.—Med. Examiner.
  Asa text-book it has no equal;  as a compendium
of pathology and practice no superior.—New York
Annalist.
  We know of no work better calculated for being
placed in the hands of the student, and for a text-
book; on every important point  the author seems
to have posted  up his  knowledge to the day.—
Amer. Med. Journal.
  One of the most practically useful books  that
ever was presented to the student. — N. Y. Med.
Journal.
                             WALSHE (W.  H.),  M. D.,
         Professor of the Principles and Practice of Medicine in University College, London.

DISEASES  OF  THE   HEART,  LUNGS,   AND   APPENDAGES;  their
  Symptoms and Treatment.   In one handsome volume, large royal 12mo., 512 pages.
  We consider this as the ablest work in the En- I  the author being the first stethoscopist of the day.—
glish language, on the subject of which it treats; |  Charleston Medical Journal.

                              WHAT TO  OBSERVE
AT  THE   BEDSIDE   AND  AFTER DEATH, IN  MEDICAL  CASES.
  Published under  the  authority of the London  Society  for Medical Observation.  In one very
  handsome volume, royal 12mo , extra cloth   (Just Issued.)
  We hail the appearance of this book as the grand
desideratum.—Charleston Medical Journal.

  This is truly a very capital  book.  The whole
medical world will reap advantages from its publi-
cation.  The medical journals will soon show its
influence on the character of the " Reports of Cases''
whioh they publish.  DrB. Ballard and Walshe have
given  to the world,  through a small  but useful
medical organization, a cheap but invaluable book.
We do advise every reader of this notice to buy it
and use it.  Unless he is so vain as to imagine him-
self superior to the ordinary human capacity, he will
in six  months  see its  inestimable advantages.—
Stethoscope.
                                  WILDE  (W. R.),
                 Surgeon to St. Mark's Ophthalmic and Aural Hospital, Dublin.
AURAL  SURGERY,  AND  THE  NATURE  AND TREATMENT OF DIS-
  EASES OF THE EAR.  In one handsome octavo volume, with illustrations.   (Now Ready.)
  So little is generally known in this country concerning  the  causes, symptoms, and treatment of
aural affections, that a practical and scientific work on that subject, from a practitioner of Mr.
Wilde's great experience, cannot fail  to be productive of much benefit, by attracting attention
to this obscure class of diseases, which too frequently escape attention until past relief.  The im-
mense  number of cases which have come under Mr. Wilde's observation for many years, have
afforded him opportunities rarely enjoyed for investigating this branch of medical science, and his
work may therefore be regarded as of the highest authority.
  This work certainly contains more information on
the  subject to which it is devoted  than any other
with which we are acquainted.  We feel grateful to
the author for his manful effort to rescue this depart-
ment of surgery from the hands of the empirics who
nearly monopolize it. We think he has successfully
shown that aural diseases  are not beyond the  re-
sources of art; that they are governed by the same
laws, and amenable to the same general methods of
treatment as other morbid processes. The work is
not written  to supply the cravings of popular patro-
nage, but it is wholly addressed to the profession,
and bears on every page the impress of the reflections
of a sagacious and practical surgeon.— Va. Surg, and
Med. Journal. 
AND  SCIENTIFIC  PUBLICATIONS.                  29
                     WILSON  (ERASMUS),  M. D.,  F. R. S.,
                               Lecturer on Anatomy, London.

A SYSTEM OF  HUMAN ANATOMY, General and Special.   Fourth Ameri-
  can, from the last English edition.   Edited by Paul B. Goddard, A. M., M D.  With two hun-
  dred and fifty illustrations.   Beautifully printed, in one large octavo volume, of nearly six hun-
  dred pages.
  In many, if not all the Colleges of the Union, it
has become a standard text-book.   This, of itself,
is sufficiently expressive of its value.  A work very
desirable to  the student;  one, the  possession of
which  will greatly facilitate his  progress  in the
study of Practical Anatomy.—New  York Journal of
Medicine.

  Its author ranks with the highest on Anatomy.—
Southern Medical and Surgical Journal.
  It offers to the student all the assistance that can
 be expected from such a work.—Medical Examiner.
  The most complete and convenient manual for the
 student we  possess.—American Journal of Medical
 Science.
  In every respect,  this work  as  an  anatomical
 guide for the student and  practitioner, merits our
I warmest and most decided praise.—London Medical
I Gazette.
                                  BY THE SAME AUTHOR.

THE  DISSECTOR;  or, Practical and Surgical Anatomy.   Modified  and  Re-
  arranged, by Paul Beck Goddard, M. D.  A new edition, with  Revisions and Additions.  In
  one large and handsome volume, royal 12mo., with one hundred and fifteen illustrations.

  Id passing this work again through the press, the editor has made such additions and improve-
ments as the advance of anatomical knowledge has rendered necessary to maintain the work in the
high reputation which it has acquired in the schools of the United States, as a complete and faithful
guide to the student of practical anatomy.   A number of new illustrations have  been  added, espe-
cially in the portion relating to the complicated  anatomy of Hernia.  In mechanical execution the
work will be found superior to former editions.

                                  BY THE SAME AUTHOR.

ON  DISEASES  OF  THE   SKIN.   Third  American,  from  the third London
  edition.  In one neat octavo volume, of about five hundred pages, extra cloth.  (Just  Issued.)
Also, to be had done up with fifteen beautiful steel plates, of which  eight are exquisitely colored j
  representing the Normal and Pathological Anatomy of the Skin, together with accurately colored
  delineations of more than sixty varieties of disease, most of them the size  of nature.  The Plates
  are also for sale separate, done up in boards.
  The increased size of this edition is sufficient evidence that the author  has not been content
with a mere republication, but has endeavored to maintain the high character of his  work as the
standard text-book on  this interesting and difficult class of diseases.  He has thus introduced such
new matter as the experience of the last three or four years has suggested, and has made  such
alterations as the progress of scientific investigation has rendered expedient.   The illustrations have
also been materially augmented, the number of plates being increased from eight to sixteen.
  The "Diseases of the  Skin," by Mr. Erasmus
Wilson, may now be regarded as the standard work
in that department of medical literature.  The
plates by which this edition is accompanied leave
nothing to be desired, so far as excellence of delinea-
tion  and perfect accuracy of  illustration are con-
cerned.—Medico-Chirurgical Review.
  Of these plates it is impossible to speak too highly.
The representations of the various forms of cuta-
neous disease are singularly accurate, and the color-
ing exceeds almost anything we have met with in
point of delicacy and finish.—British and Foreign
Medical Review.
                                  BY THE SAME AUTHOR.

ON  CONSTITUTIONAL  AND  HEREDITARY   SYPHILIS,  AND  ON
  SYPHILITIC ERUPTIONS.  In one small octavo volume, beautifully printed, with four exqui-
  site colored plates, presenting more than thirty varieties of syphilitic eruptions.

  Dr.  Wilson's  views  on the  general subject of
Syphilis appear to us in the main sound and judi-
cious, and we commend the book as an excellent
monograph on the subject.  Dr. Wilson has pre-
sented  us a very faithful and lucid description of
Syphilis and has cleared up many obscure points in

                                  BY THE SAME AUTHOR.

A  TREATISE ON THE  MANAGEMENT  OF  THE  SKIN  AND
  IN  RELATION  TO HEALTH.  Second American, from the fourth London edition.
  volume, royal 12mo.
connection with its .transmissibility, pathology and
sequelae. His facts and references will, we are satis-
fied, be received us decisive,  in regard to many
questiones vexatte. They appear to  us  entitled to
notice at some length.—Medical Examiner.
 HAIR
One neat
                    WHITEHEAD  (JAMES), F. R. C. S.,  &c.

THE CAUSES AND TREATMENT  OF ABORTION  AND  STERILITY;
  being the Result of an Extended Practical Inquiry into the Physiological and Morbid Conditions
  ofthe Uterus.  Second American Edition.  In one volume, octavo, 3t>8 pages.  (NowRemdy.)
                                             this department of our profession, that the practi-
                                             tioner who does not consult the recent works on the
                                             complaints of females, will soon find himself in the
                                             rear of his more studious brethren.  This  is one of
                                             the works which  must be studied by those who
  The simple title of this work gives a very imper.
feet idea of its contents.  The  subject of sterility
occupies a mere fraction of  space, and upwards of
one-half of the whole volume is taken up with an
elaborate account of menstruation as a physiological
process, and of the  disorders which its deviations
from health are apt  to produce.—Medical Chtrurg.

  Such are the advances made from year to year in
would know what the present state of our knowledge
is respecting  the causes and treatment of abortion
and sterility.—The Western Journal of Medicine and
Surgery. 
30
BLANCHARD &  LEA'S  MEDICAL
                           WEST (CHARLES),  M. D.,
                        Physician to the Hospital for Sick Children, &c

LECTURES  ON THE  DISEASES  OF INFANCY AND  CHILDHOOD.
  Second American, from the second and enlarged London edition. (Now Ready.) In one volume,
  octavo, of nearly five hundred pages.

                         From the Preface to the Second Edition.
  In the preparation of the second  edition of these Lectures, the whole work has been carefully
revised.  A few formulae have been introduced and a minute alphabetical index has been appended
while additions amounting altogether  to fifty pages, have been made, wherever I felt that more
extended observation, or  more careful reflection had enabled me to supply some of those deficiencies
which I am well aware, are still far  too numerous.  The work now contains the result of 640
observations,  and 199 post-mortem examinations, chiefly made among 16,276 children who came
under my notice during the ten years of my connection with the Children's Infirmary in Lambeth.
  We take leave of Dr. West with great Tespect for
his  attainments, a due appreciation of his acute
powers of observation, and a deep sense of obliga-
tion for this valuable contribution to our profes-
sional literature.  His book is undoubtedly in many
respects the best we possess on diseases of children.
The extracts we have given will, we hope, satisfy
our readers of its value; and yet in all candor we
must say that they are even inferior to  some other
parts, the length of which prohibited our entering
upon them.   That the book will shortly be in  the
hands of most of our readers we do not doubt, and it
will give us much pleasure if our strong recommend-
ation of it may contribute towards the result.—The
Dublin Quarterly Journal of Medical Science.

  Dr. West has placed the profession under deep ob-
ligation  by this able, thorough, and finished work
upon a subject which almost daily taxes to the ut-
most the skill of the general practitioner. He has
with singular felicity threaded  his way through all
the tortuous labyrinths of the difficult subject he has
undertaken to elucidate, and bas  in many of th*
darkest corners  left  a light, for the benefit of suc-
ceeding travellers, which will never be extinguished.
Not the least captivating feature in this admirable
performance is its easy, conversational style, which
acquires force from  its very simplicity, and leaves
an impression upon  the memory, of the truths it
conveys, as clear nnd refreshing as its own purity.
The author's position secured him extraordinary fa-
cilities for the investigation of  children's diseases,
and his powers of observation and discrimination
have enabled him to make  the  most of these great
advantages.—Nashville Medical Journal.
                    WILLIAMS (C.  J. B.),  M.D.,  F. R. S.,
                Professor of Clinical Medicine in University College, London, &c.

PRINCIPLES  OF  MEDICINE;  comprising  General Pathology and Therapeu-
  tics, and a brief general view of Etiology, Nosology, Semeiology, Diagnosis, Prognosis, and
  Hygienics.  Edited, with Additions, by Meredith Clymer, M. D.  Fourth American, from the
  last and enlarged London edition.  In one octavo volume, of 476 pages.  (Now Ready.)

  This new edition has been materially enlarged and brought up by the editor.
  It possesses the strongest claims to the attention of the medical student and practitioner, from
the admirable manner in which the various inquiries in the different branches of pathology are
investigated, combined, and generalized by an experienced practical physician, and directly applied
to the investigation and treatment of disease.—Editor's Preface.
  The best exposition in our language, or, we be-
lieve, in any language, of rational medicine,  in its
present improved and  rapidly  improving state.—
British and Foreign Medico-Chirurg. Review.
  Few books have proved more useful, or met with
a more ready  sale than  this, and no practitioner
should regard  his library as complete without it.
—Ohio Med. and Surg. Journal.
                                 BY  THE SAME  AUTHOR.

A PRACTICAL TREATISE  ON  DISEASES  OF  THE  RESPIRATORY
  ORGANS; including Diseases of the Larynx, Trachea, Lungs, and Pleurse.  With numerous
  Additions and Notes, by M. Clymer, M. D.  With wood-cuts.  In one octavo volume, pp. 508.
                           YOUATT (WILLIAM), V. S.

THE  HORSE.    A new edition, with numerous illustrations;  together with a
  general history of the Horse;  a Dissertation on the American Trotting Horse ; how Trained and
  Jockeyed; an Account of his Remarkable Performances; and an Essay on the Ass and the Mule.
  By  J. S. Skinner, formerly  Assistant Postmaster-General,  and Editor  of  the  Turf Register.
  One large octavo volume.

                                 BY THE SAME AUTHOR.

THE  DOG.   Edited  by  E.  J. Lewis,  M. D.  With numerous  and beautiful
  illustrations.  In one very handsome volume,  crown 8vo., crimson cloth, gilt.
              ILLUSTRATED  MEDICAL  CATALOGUE,
  BLANCHARD & LEA are preparing a Catalogue of their Medical, Surgical, and Scien-
tific Publications, containing descriptions  of the works, with Notices of the Press, and
specimens of the Illustrations, making a pamphlet of  sixty-four large octavo pages.   It will
be prepared with great care, and without regard to expense, forming one of  the most beau-
tiful specimens of typographical execution as yet issued in this  country.  Copies will be
sent by mail, and the  postage paid, on application to  the Publishers, by inclosing  two three
cent postage stamps. 
AND SCIENTIFIC  PUBLICATIONS.
31
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NATURAL  SCIENCE.
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32        BLANCHARD &  LEA'S  SCIENTIFIC  PUBLICAT IONS.
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