ARMY MEDICAL LIBRARY
       WASHINGTON
          Founded 1836
 
 
 
Or
3 : '<si
TREATISE
ON
VENEREAL   DISEASES.
BY
           A. VIDAL,  (db Cassis,)
SURGEON OF THE VENEREAL HOSPITAL OF PARIS; AUTHOR OF THE TRAIT*
     DE PATHOLOGIE EXTERNE ET DE MEDECINE OPERATOIRE,
                 ETC.  ETC.
WITH COLORED PLATES.
     TRANSLATED  AND EDITED

                   BY

         GEORGE C. BLACKMAN, M.D.,
«LLOW OF THE ROYAL MEDICAL AND CHIRUROICAL SOCIETY OF LONDON ; FORMERLY ONE OF THB
     PHYSICIANS TO THE EASTERN AND NORTHERN DISPENSARIES, NEW YORK.
        NEW, YORK:
SAMUEL S. & WILLIAM WOOD,
      261  PEARL STREET
            1854. 
W2r\
        Entered, according to Act of Congress, in the year 1854, by
               SAMUEL S.  &  WILLIAM WOOD,
In the Clerk's Office of the District Court for the Southern District of New York.
   stereotyped by                                        printed by
THOMAS B.  SMITH.                                HOLM AN  ic  GRAY,
  216 William St., N. Y.                                   Cor. White & Centre Sts. 
PREFACE  OF  THE  EDITOR.
   In preparing the Treatise on Venereal Diseases of M. Vidal for the
press, the American editor has aimed to furnish the reader not only with
a  faithful translation,  but  also with  the views of some of the leading
British and  American syphilographers.  Messrs.  Vidal and Ricord are
both  attached to the Hopited dn Midi, the  great venereal hospital of
Paris, but in many respects the  doctrines of our author  are directly
opposed  to  those of his distinguished rival.  The annotations of the
editor will be found  to correspond, generally, with the  views  of the
author, and he has been personally assured by many of the most promi-
nent surgeons in Great Britain  and this country of their cordial assent
to the doctrines here inculcated.   To Mr. Samuel A. Lane, of the Lock
Hospital, London, and  to Mr. Langston  Parker the distinguished  syphil-
ographer of Birmingham, he would return his warmest acknowledgments,
as well as to Dr. Byrne of the Westmoreland Lock Hospital, Dublin, and
to Messrs. Cusack, Porter,  Adams, Egan, Fleming and Wilmot of this
city, for their very polite attentions and  for the communication of many
valuable facts by which the object of his visit was greatly promoted.
   Although   American surgery can boast  of none to whom  the  term
syphilographer  can properly apply,  yet we  may justly claim for Dr.
Phy^iek priority in the treatment of orchitis by  tile so-called Frieke's
method, compression, and it is with pride that we  refer to  the  contribu-
tions of Dr. John  Watson of the New York Hospital, " On some of tlie
Remote Effects of Syphilis" published in the first and fifth volumes of 
IV                      EDITOR'S PREFACE.
the New York  Journal of Medicine  and  Collateral Sciences, and to the
elaborate paper of Dr. H. D. Buckley, " On Syphilis in Infants,"  in the
first volume of the New York Journal  of Medicine and Surgery for
October, 1840.  The value of these can be better appreciated in another
part of this work.   Through the politeness of Dr. Van Buren, the editor
has recently had an opportunity of seeing (though too late to incorporate
the details in his Notes) an instance  of that exceedingly rare  affection,
tertiary syphilis in the infant.   In this patient, there were nodes  on the
ulna and forehead, and enlargement of both testicles!  To Profs. Mott,
Mussey, Gross, and Willard Parker, the editor would express his obliga-
tions.  The  article on Strictures of the Uretha, omitted in the Treatise
of M. Vidal, has been supplied by a somewhat free translation of that in
the author's  well-known work  on External Pathology.  For the remarks
under the head of Urinary Infiltration, and Urinary Abscess'es, the editor
is alone responsible.   In  illustration  of these subjects he has also added
a few woodcuts, borrowed from various sources, and although some may
consider these  topics as  foreign to a special Treatise on Venereal Dis-
eases, he is  disposed to believe that the junior practitioner will not re-
gret the liberality of  his  publishers which  has enabled him to make these
additions.

                                     GEORGE C. BLACKMAN.
  New Yoke,  Jan. 1st, 1854.
I 
                                                                       PAOI
Preface..............................................................   1
Introduction..........................................................  13
  Synonyms...........................................................  13
  Historical Sketch...........................■........................  14
  Syphilitic Virus.....................................................  19
  Observation.........................................................  26
  Experiment.........................................................  32
  Inoculation.......................%..................................  33
  Inoculation of Animals................................................  36
  Syphilization.........................................................  40
  Transmissibility of Secondary Accidents.................................  45)


                             --------*-♦•♦--------


                               PART  I.

                   PRIMITIVE  VENEREAL  DISEASES...............  67

                              CHAPTER  I.

Blennorrhagia.........................................................  68


                              CHAPTER II.

Blennorrhagia in  the Male..............................................  72
Section I.—Blennorrhagia  of the Urethra................................  72
  Consequences of Blennorrhagia........................................  88
        Blennorrhea..................................................  88
        Uretrorrhagia................................................. 119
        Urethral Pains................................................ 122
  Perverted Sensations in  the Urethra—Absence of Sensations............. 124
        Blennorrhagic Orchitis.........................t................ 126
        Blennorrhagic Prostatitis........................................ 139
        Blennorrhagic Cystitis.......................................... 146
        Blennorrhagic Nephritis........................................ 149
        Blennorrhagic Ophthalmia...................................... 1 S3
        Blennorrhagic Arthritis......................................... 158
Bwmox IL—Blennorrhagia Balano-preputial............................... 163 
VI                     TABLE OF CONTENTS.
                          CHAPTER III.
                                                                PA OB
Blennorrhagia in the Female............................................ 172
                          CHAPTER IV.

Blennorrhagia in both Sexes............................................ 188
       Anal Blennorrhagia............................................ 189
       Buccal Blennorrhagia........................................... 190
                           CHAPTER V.
Chancre.............................................................. 190
  Diseases which may be regarded as accidents of Chancre, Phimosis, and Para-
         phimosis..................................................... 227
       Phimosis...................................................... 227
       Paraphimosis.................................................. 229
                           CHAPTER VI.
Bubo,................................................................ 234


                          CHAPTER VII.'
Vegetations........................................................... 255


                          CHAPTER VIII.
Mucous Tubercles..................................................... 261
PART   II.
CONSECUTIVE  VENEREAL DISEASE (VEROLE).

                 CHAPTER I.
General Remarks.
277
Section I.—Symptoms........................................          277
Section II.—Period and Order of Appearance.......................      < 278
  Primary Aeeidents...........................................         281
  Secondary Accidents..........................................        281
  Tertiary Aeeidents............................................        281
Section III.—Exciting Causes.....................................      _ 283
Section IV.—Syphilitic Fever.....................................       285
Section V.—Blood of Syphilitic Patients...........................      ^ 286 
                          TABLE OF CONTENTS.                       yii

                                                                       PAGE
Section VI.—Can a person have syphilis more than once ?................ 290
Section VII.—Therapeutics............................................. 292
  I. Mercury......................................................... 293
        External employment.......................................... 293
        Internal use of Mercury......................................... 300
        Mercurial Compounds........................................... 301
  II.  Other Mercurial Preparations...................................... 305
  IIL  Accidents produced by Mercury................................... 305
        Salivation and  Stomatitis........................................ 305
        Cholic and Diarrhoea, Mercurial Tremors......................... 315
  IV. Iodine."!........................................................ 316
  V.  Iodide of Potassium............................................... 317
        Accidents  attributed  to Iodide  of Potassium...................... 322
  VI. Iodide  of Iron.................................................... 324
  VII. Gold,  Silver, Platina............................................. 325
  VIII. Double Salts.................................................. 328
  IX. Sudorific Woods................................................329
  X.  Compounds, partly mineral, partly vegetable........................330,


                              CHAPTER II.

On Special Consecutive Venereal Affections............................ 331
Section I.—Syphilitic Eruptions—Syphilides.............................. 331
  I. General  Characters................................................ 332
  II.  Varieties....................................................... 336
        Exanthematous Syphilitic Eruptions............................. 337
        Syphilitic Papular Eruption.................................... 338
        Syphilitic Squamous Eruption.................................. 340
        Syphilitic Vesicular  Eruption................................... 341
        Syphilitic Bullae................................................ 344
        Syphilitic Pustular Eruption..................................... 347
        Syphilitic Tubercule...........................................365
  III. Causes........*..................................................370
  IV. Diagnosis....................................................... 372
  V.  Prognosis........................................................ 374
  VI. Treatment.............................,......................... 375
        Internal Treatment............................................. 375
        External Treatment............................................ 37.6
Section II.—Diseases of the Appendages of  the Skin....................... 378
  I. Loss  of  the Epidermis............................................. 378
  II. Alopecia......................................................... 378
  III. Onyxis........................................................... 380
Section III.—Affections of the Mucous  Membranes........................ 383
  I. Mucous  Membrane  of the Mouth..................................... 384
  II.  Mucous Membrane of the Nose...................................... 392
  III. Mucous Membrane  of the  Genital Organs........................... 394
  IV. Mucous Membrane  of the  Epiglottis  and Larynx.................... 396
  V.  Mucous Membrane of the Ear..................................... 397
  VI. Mucous Membrane  of the  Anus  and  Rectum........................ 397
Section IV.—Affections of the Eyes..................................... 399
        Syphilitic Iritis................................................ 399 
Viii                 TABLE OF CONTENTS.

                                                                  PAOl
Section V.—Diseases of the Testicles....................................  407
       Syphilitic Sarcocele............................................  407
Section VI.—Diseases of the Cellular Tissue..............................  418
Section VII.—Affections of the Muscles, Tendons, and Aponeuroses.........420
Section VIII—Affections of the Bones and Periosteum....................  427
  I. Osteocopes........................................................428
  II. Periostitis  and Ostitis.............................................481
       Periostitis.....................................................481
       Ostitis.........................................................  433
  III. Exostosis.....................................'...................  435
  IV. Caries and Necrosis..............................................443
Section IX.—Affections of the Viscera...................................447
  I. Cerebral  Affections................................................448
  IL Hepatic Affections.................................................450
  III. Cardiac Affections...............................................  451
  IV. Pulmonary Affections.............................................452
   PART   III.

INFANTILE SYPHILIS.....................458
                           PART  IV.

              PROPHYLAXIS  OF VENEREAL  DISEASES.

                            CHAPTER  I.
Private Prophylaxis...........................................      #  4gg

                            CHAPTER II.
General Prophylaxis—Medical Police.............................    .  493 
ERRATA.
Page 3, line 15, for this city, read that city.
  p. 23, line 14 of Editor's Notes, for indulated. read indurated.
  p. 28, line 27, for coitres, read coitus.
  p. 33, line 24. for insert forms, read invest forms.
  p. 55, after last line of the text; the following quotation from the Thesis of
        M. Helot, has been omitted: " My dear master, you have established
        the value of inoculation upon the petitio principii.   This is always
        the case with those who are wedded to particular systems.   For such
        I write not;  but for those who seek the truth; and I believe that  in
        this  Essay, I have furnished them with the elements of conviction,
        drawn from three sources, viz.: analogy, observation, and experience."
  p. 72, line 5, for vagnitis, read vaginitis.
  p. 90, line 46, for stained liver, read stained linen.
  p. 93, lines 18, 19, 25, for diatheses, read diathesis.
  p. 95, 3d line from  foot of page, for secreting, read  secretion.
  p. 107, 2d line of Editor's Note, for dilations, read  dilatations.
  p. 137, line 9, omit that.
  p. 153, 4th line from  foot, for ophthalmias, read affections.
  p. 207, line 10, for involved into, read changed to.
  p. 217, line 18, for preventative, read preventive.
  p. 227, line 13, for  reset, read resect.
  p. 235, line 4, omit more.
  p. 257, line 6, for concrous, read concours.
  p. 263, line 20, for does, read do.
  p. 268, line 37, for ecclusion, read occlusion.
  p. 269, line 26, for  certainly, read certainty.
  p. 360, line 14, ior\transferred, read transformed. 
 
PREFACE.
  Innumerable are the works on venereal diseases, but the majority have
been written for the purpose, more or less candidly admitted, of establish-
ing or overthrowing some particular doctrine.  Many volumes  have been
devoted to the vindication or subversion of the dogmas that emanated from
idealism, and the school of Galen, as well as from his successors, the chem-
ists and the vitalists.  The same is true of the school of Broussais, which
so recently denied the existence of a venereal virus, and of those who be-
lieved, on the other hand, in the entity  of this virus.   These productions
have sometimes exhibited marks of genius, and have been distinguished by
their elevated and splendid diction,  but they were designed only for those
acquainted with the subject.  I write for a different class, and for those
who have but little time to devote to the study of these affections.   I  pro-
pose to collect such facts and opinions as  are of practical application, and
which  have survived the wreck of systems, the founders of some of which
showed themselves profound observers.  With this view, I have selected a
plan sufficiently extensive to embrace the most important practical details,
and yet which, without having too wide a scope, will,  I trust, enable all to
comprehend the substance of our knowledge on the speciality now termed
syphilography.
   From  the time  that  venereal diseases were first somewhat carefully
studied, it has been admitted, that, shortly after the application  of the
virus, certain lesions are generally  produced on the parts contaminated;
these are  the primitive venereal accidents.  Again, there are certain other
morbid conditions,  which  are  ordinarily observed subsequently to  the
above; these are  the consecutive venereal accidents.   Under  this by no
means modern division, these affections may be advantageously studied.
I have adopted it, believing it to be the most rational and best adapted to
the purposes of instruction, and  not  as serving as the basis of any particu-
lar system.
   Hunter recognized two varieties of the consecutive or constitutional dis-
ease, and  M. Ricord  having availed himself of this  subdivision, includes
all the accidents under the heads of primary, secondary, and tertiary vene- 
X                             PREFACE
 real disease.  In this species of triad, of ancient date,* this writer fancied
 that  he had discovered the basis of a true classification, on which he has
 engrafted not only a system, but a system  the  exact  symmetry of which
 was well calculated- to  captivate an  age inclined to absolute certainty,
 whilst its apparent simplicity has been greatly  admired by certain minds,
 which it is  unnecessary here to characterize.  A distinguished writer has
 remarked, that  system and hypothesis  are synonymous terms;  now  we
 know  the result of subjecting the latter to a  somewhat rigid  criticism.
 Still this system seemed to withstand not only the force of reason, but of
 arguments based on clinical observation.  It rested its claims upon exper-
 iment, the influence of which may be imagined during the period  to which
 we have alluded.  Its opponents were therefore compelled to descend to
 the same ground, and it was attacked with the same instrument, as it were,
 that had  been employed in its establishment.   Various were the experi-
 ments performed, and the proceedings adopted.   Some of these  proved,
 that chancre was not the only accident  that admitted of inoculation, but
 that those  termed  consecutive might also be thus transmitted.   Now as
 the system  was  based essentially upon the exclusive inoculability of chan-
 cre, these results struck  at its very foundations.   They  likewise seriously
 compromised  the classification dependent on it, as the only admitted dis-
 tinction between chancre and  the  other accidents  was thus  destroyed.
 Other experiments showed  that chancre itself, or the most virulent syphi-
 litic poison, from some natural or accidental cause, was perfectly harmless
■when applied  to certain  individuals; therefore, as the  system  boasted as
 its test for syphilis, the infallibility of chancrous inoculation,  it found
 itself wanting in view of its practical application.
   Thus, the immutable laws of experiment, proclaimed by M. Ricord, were
 annulled by experiment  itself, and the promised certainty resulted in  un-
 certainty.!  It required but a slight knowledge of medical philosophy, and
 a little reflection upon the results of experiments, according as  they  are
 performed in  the exclusively physical, or in the exclusively pathological
 order, to have anticipated what here occurred.   Then came the cases prov-
 ing that the secondary might appear after the tertiary accidents, and vice
 versa.  The order of the system being thus compromised, what remained ?
 In the body of  this work may be found  the pi-oofs of what has been here
 asserted.   However, I shall  be brief upon these points, for the main  ob-
 ject of this work is to collect, the practical truths which are the results of
-observation, and those which have survived the downfall of systems.  Still

   * Vid. "La methode curatoire de la maladie venerienne" of Thiery de Herry, and p.
■259 of this work,  where I have exposed this triad in its author's own words.
   f In the Introduction, under the heads of Inoculation and Syphilization, behold the
 glimmer thrown by the eloquence of M.  Malgaigne, over the enormous breaches in
 the system of which this Professor was at one time a defender, and which had for
 its leader a friend of twenty years' standing I 
PREFACE.
xi
I have thought  it my duty to warn the young practitioner against disap-
pointments and  regrets, there being nothing, in my opinion, more  danger-
ous, either in study or in  practice, than  to  invest  mere forms  with cer-
tainty, and to pronounce that to be infallible which  can be but probability
or uncertainty.   After the two  principal divisions,—primitive  and  con-
secutive venereal diseases,— .vill follow the section on  infantile syphilis.
In this, we shall discuss the questions of the hereditary descent of  the dis-
ease ; its  transmissibility from the child to the nurse,  and from the nurse
to the child.   The importance  of this chapter is evident, for, in the opin-
ions there examined, the interests of the family, of  justice, and of  society
in general, are involved, and yet the majority of French works on  these
topics are very incomplete ?  In the fourth part,  we shall consider the
prophylaxis of venereal diseases, including  general and private prophy-
laxis, and regulations of medical police.
   In the  Introduction, after a few observations upon  the synonyms, may
be found  an  historical sketch of the venereal disease.   I shall express an
opinion on the nature of the syphilitic virus, and its principal effects.  The
causes of error in observation will  be  shown;  experiment justly appre-
ciated ; the process of inoculation explained, whilst syphilization  will be
judged.   This  introductory chapter will  conclude  with  some general ob-
servations on the transmissibility of secondary accidents.
   Since  I have stated, in the commencement, that I propose to  make a
resume of the facts, opinions, and therapeutics, constituting syphilography,
my great indebtedness to my  predecessors will be  obvious.  All shall be
quoted with  acknowledgment.   I will submit  to  the reader what  expe-
rience has taught  me at  the Lourcine, in the  female wards;  and what I
have learned at the Hopital du Midi, during a service  of more than ten
years, since I became the successor of Cullerier,—the honest man, the sage
practitioner.
   Placed in  a theatre so vast,  I  could not remain  indifferent to questions
by which science  was agitated.  I have ventured  to discuss one of the
most important, the transmissibility of  the secondary disease.   I  think
that, by experiment, I have decided it in favor of the contagionists.  My
experiments have been repeated  in France and in Germany; all have pro-
duced a brilliant  discussion in  the Academy of  Medicine.  MM.  Vel-
peau, Lagncau, Gibert, Gerdy, and  Roux,* maintained, with their well-
known abilities, the transmissibility of the secondary accidents, and what
is without a  parallel in the annals of the Academy, the opposite  side of
the question had but one defender !   If  from France we pass to  foreign
lands we shall find that the opinions of learned academicians are generally

  * It will be observed that among these orators are two  distinguished syphilogra-
phers, and three professors of the Faculty of Paris.   Read their discourses  in the
Bulletin de VAcademie de Medicine, where they are correctly reported. (Nos. for
Oct, et suiv. 1852. 
xii
PREFACE
divided.  We may see, particularly in the German press, how ably  this
doctrine has been sustained by Waller, Simon, and Droste.
  To facilitate the study of  the venereal accidents, the most important to
be known, I  have illustrated them by  colored engravings, from designs
which it  is unnecessary for me to praise since they were executed by M.
Bion.  The necessity of these will be admitted when we come to the chap-
ter on the cutaneous  affections, for we know the importance of the syphi-
litic  tint in forming our diagnosis, and the difficulties which the student
encounters who wishes a tableau of the  principal varieties.  He will  find
it here, .true to nature.
  Lately, some syphilographers whose tenets have  been  shaken, have
allowed themselves to  descant bitterly, or in a jesting tone.  They have
even written in the same style.   Having no motive for sharing in the  sen-
timents which have inspired a literature of this  kind, having, besides, re-
marked that it has neither thrown light upon, nor advanced the questions
in dispute, I  have abstained from it, and  have endeavored to  speak as
clearly as possible, the language of science, since it is the latter only which
I have in view, and the interests of those who would become her earnest
votaries 
INTRODUCTION.
  The object of this is to  assist the  comprehension of matters
which constitute the body of the work; it contains also a critical
exposition of the method of investigation, and generalities on the
great questions of syphilography.  Thus, after a fe*v remarks upon
the synonyms, and a brief history of the venereal disease, I will
describe  the  method, observation, and experiment applicable to
this specialty.  I will speak of syphilization, and conclude with an
article on the transmissibility of secondary accidents.


                          SYNONYMS.

  The diseases which I am about to investigate have received an
infinity of names, sometimes originating from their mode of propa-
gation, sometimes from a  prominent  symptom, sometimes from
the country accused of giving birth to the malady, or from the peo-
ple who communicated it to strangers; sometimes,  indeed, from
fable.  Thus it was called venereal disease, from the fact that it was
generally contracted during the venereal act; verole  signifies pus-
tules on the skin,  which are observed in  certain stages of the
disease, and  which have been  considered analagous to those  of
variola;  and it was called Mai francaise, Mai napolitain, because
the French and the Neapolitans were supposed to have communi-
cated the malady to other nations.  Other people,  too, have, in
their turn, been accused, and have contributed in giving a name
to this disease; the Turks as well as  the Germans, the Poles as
well as the Moscovites, &c, &c.  But  it must be admitted that
the French,  in this respect,  have gained the greatest notoriety.
Syphilis is the creation of Fracastor;  in his poem he imagines that
the shepherd Syphilus, was the first who was smitten with the
disease, which the gods, in their wrath,  invented. I will not
exhaust this subject, which might be made to fill many pages; with-
out interest,  however, either in a scientific or  practical point of
view.  The names  still employed are these:  Venereal Disease,
Syphilis,  Verole.   Some physicians use them indifferently.  Never-
theless,  the first  is  generally adopted, as  it indicates  the most
common  source of the disease, viz., coitus, or other libidinous
connections.   Syphilis denotes  that a virus, a  morbid poison, has
intervened, and that it plays a  principal part, whilst verole or con-
stitutional syphilis signifies that this virus has produced a profound 
14
INTRODUCTION.
change in the organism, constituting, indeed, a diathesis, a disposi-
tion, a temperament.   This virus  is sometimes inoculated by acci-
dent, by a wound, and the affections to which it gives rise may be
entirely independent of any libidinous act.   At present, there is
a patient under my care, at the venereal hospital, who, in a strife,
was bitten on the thumb by his comrade, and who was thus, at the
same time, inoculated with a chancre.
                          HISTORY.

  I shall be brief in my sketch of the history of syphilus, shrouded
as it is in darkness, and from no point shedding light upon doctrine
or practice.   The point most  obscure  in its history is that of its
origin.  Is it as'old as humanity ?  Is it modern, and did it origin-
ate towards the end of the fifteenth  century ?  The vast learning
of Astruc, the dates by him collected, and the commentaries which
he has written in his efforts to solve these questions, have not in
the least advanced our progress.  "We know, it is true, that Astruc
is a believer in the modern origin of  the  disease, but we do not
become  acquainted with this fact until we have carefully  perused
his work unto the end.  The  majority of  writers are  opposed to
Astruc,  and maintain the doctrine  of its ancient origin.   To sim-
plify the question, I should, in the first place, remark, that there are
venereal affections  which are  not  virulent or specific, as well as
those that are.  Now, no one can deny that the first have always
existed; for in every age,  inflammations,  discharges, and ulcera-
tions of the genital organs  have been observed, caused by the too
frequent indulgence in the venereal act,  or by  its performance
during the menstrual period, or pregnancy, &c, &c.  Thus, certain
venereal affections had their origin in the earliest  antiquity.  The
question remains to be settled, whether  the specific  disease, syphilis,
in fine, is equally old, or whether it originated towards the end of
the fifteenth century.   In passing over the three  principal phases
in the history of these diseases, I  shall endeavor to throw some
light upon both of these questions.
  Antiquity.—It is  true that in antiquity the venereal disease had
neither  name, therapeutics, nor a special treatise.   But Moses pre-
scribed the observance of certain precautions to prevent the con-
tagion of gonorrhoea (profluvium seminis,) the blennorrhagi of
modern times.   Hippocrates alludes not  only to  ulcers  on the
penis, but to pustules  and the loss of the hair.  Celsus  is more
remarkable  still,  for if rightly interpreted, we find that he  was
acquainted with almost every kind of ulceration on the penis, and
with our present notions, it is  possible to recognize in his descrip-
tions, not only chancre but  several of its varieties; as the common
and even  the indurated chancre.  Still further, Celsus points out
the complication of phimosis, and of paraphimosis.  But scientific
distinctions could not have been established by Celsus, and it would
be unjust to exact from him a diagnosis, to which many physicians
even in our own day, are incompetent. 
INTRODUCTION.                     J5
  In  ancient  times, everything was regarded  as  a result, and
variety, of inflammations;  a specific cause was unknown, and the
connection of the different symptoms was not recognized.   How-
ever,  one fact, that of contagion,  known to the most  eminent,
should have aroused the attention of the ancients; thus,  Galen,
with  his genius, traced  blennorrhagia to contagion, and his fol-
lowers, in this as in other matters, adopted the opinions of their
leader.   As we depart from antiquity the elements of the disease
become more distinct,  and so connected as to constitute the vene-
real disease with  its  special forms.  Thus  the Arabs  and the
Arabists are very instructive in a historical point of view; Avicenna
and Aretus describe a peculiar disease  of the  throat, which the
latter calls the Egyptian  disease, and supposed it to be confined to
young people.  The fact  of its being  contagious is distinctly
noticed, and William of Salicet, Lanfranc, and B. Gordon had some
idea of a specific cause: they note the deplorable consequences of
carnal connection with unclean females, affected with discharges
which even then  they designated  as virulent, (virulentes;) they
refer to  inguinal abscesses, genuine buboes having their starting
point, the penis, and marked the cutaneous eruptions as  constitu-
tional affections, classing them with lepra.  These abscesses were
noticed not only as cold  or hot, and distinct from their cause, but
as having their starting point on the penis. Thus, we find this
remarkable passage in William of Salicet;  " And the bubo occurs
when a  man  has  a disease of the penis from connection with  an
unclean woman, or from every other  cause, which gives rise to  an
accumulation of corruption in this organ, which corruption being
unable to find an exit, returns to the  groins, according to that law
of affinity which these parts have with the infected organ."   Lan-
franc, who was a pupil of William, speaks of abscesses  in the
groin that follow ulcers on the penis: JScepe provenit aposthema  in
inguine propter uhera virgce, proptera quod est  decensus humorum  ad
ilia loca*   Further, Lanfranc advises a method of  prevention,
which I will mention when I discuss the subject of prophylaxis.
I will add, that  even before the fifteenth century there existed, as
for example in  London, regulations of medical police for  certain
houses of prostitution.
   There can  then be  no doubt of the existence, in antiquity,  of
local non-virulent venereal diseases, and there is strong  presump-
tive evidence also, that there were those of a specific nature, which
produced both  local and  constitutional symptoms.   Thus, it is
very probable, that more than one  syphiloid affection might have
been found in that confused mass of cutaneous diseases, and among
those lepers so often noticed among the ancients, and which have
not yet disappeared, as is maintained by the hygienists.   What led
to the use of mercury after the epidemic of the  fifteenth  century?
It was the success obtained in the earlier ages, when it was em-
ployed for the cure of those diseases  which were confounded with
lepra, and among which were the syphilides.   Is this not another
* Pract III., doctr. IX, cap. IL 
16                     INTRODUCTION.
proof  showing the  connection  existing between the affections
observed before the fifteenth century and those which occurred
subsequently to this period?  Further, as I have already stated,
the diseases called leprous, have not yet disappeared; but, having
been more carefully studied, and better specialized,  the part that
lepra plays in the production of these affections, has been reduced
to so narrow a compai  ,thft it would seem no longer to exist.
That belonging to  sypL as  Jould not be  shown  without under-
standing the  dependence -exiting between the primitive and the
consecutive accidents, the cutaneous eruptions; now this depend-
ence was  unknown to the ancients;  ignorant of  the interval
between the phenomenon of inoculation (primitive accident), and
that of infection (consecutive accident), these two elements of the
same  malady have passed for  two distinct diseases, proceeding
from a different cause.   Perhaps this kind  of incubation of the
consecutive affection, was in  ancient times of longer duration, from
circumstances which we cannot appreciate, and thus a new obstacle
has been added to our progress.
  Fifteenth Century.—During this epoch many persons were smit-
ten with a  scourge which has been represented as cruel and dis-
gusting.  The skin of the  afflicted was covered with numerous
pustules, agonizing pains racked their limbs and head, resembling
those now called osteocopes rhumatoi'des; these were accompanied
with sleeplessness, scalding of the urine, and fever.   It was partic-
ularly  during the latter part of this century (1495), and at Naples,
whilst  it was occupied by the French army commanded by Charles
VIII.,  that this scourge was most violent, and counted its greatest
numbers of victims.  The rapidity with which the disease spread,
the extent  of country over which it travelled, gave to it the char-
acter of an epidemic; on which account, this period in the history
of syphilis has always been known under the name of the epidemic
of the fifteenth century.
  But  if, as was thought by some authors, this was a new malady,
others  again  regi. ~ded  it as a degeneration or aggravation of an-
other  disease.  It was  a kind of maranique pest, or indeed,  an
affection analagous  to  the epidemic lichen of Hippocrates,  or a
meyltagra, having also an epidemic character.  It is not surprising
that, at this epoch, a certain conjunction of the stars should have
been regarded as its cause;  and still less that the atmosphere, the
breath of speech, should have been considered the vehicle of the
morbific principle.  What first struck the observer, was the state
of the skin covered with pustules, and the pains in the limbs with
which  the patient was tormented.  The lesions of the genital or-
gans were  unknown, or appeared of but little consequence, com-
pared  with those which shortly followed.   It  is even probable
that these lesions, which at this day are called primitive accidents,
were sometimes completely absent.   For my own part, I am in-
clined  to think that such was  the case, especiaUy since I have
       in so positive a_manner, the transmissibility'of the^pustuTnr
       rthesyphiKdesofthepusMaxformTli^eecLTat a certain pe- 
INTRODUCTION.                     17
riod, the pustules on theskin_may_be trdnsmitted from a diseased
to a sound person]
   Whatever may  be the explanation, the disease was considered
not only as epidemic, but contagious, and different nations ac-
cused  each  other of having spread the plague.   When the
American  origin of the disease was invented, these mutual accu-
sations of  European nations were so'  ;what  checked.   It was
supposed that the Spaniards, on t' eir return from the conquest
of the new world, had brought wita them a new malady, which
they scattered in Italy, where, at that time, was stationed a French
army.  This opinion of the American importation, has found and
still counts, many advocates.   Numerous serious objections have
been urged against it.   M. Ricord, for example, who bdtieves in
the exclusive inoculability of the primitive affection, thinks it very
astonishing that this should have  retained its virulence during the
long voyage of the Spanish sailors, and the long time which must
have passed before their arrival in Italy.  To this  we may reply,
that the consecutive affections may also be inoculated, and that the
disease of the army in Italy having  been specially characterized
by the existence of pustules, these might  have occurred among
the Spaniards during the voyage.   But there is a  still more em-
barrassing  objection  against the doctrine  of importation, based
upon the immunity of the Spanish ports, when  these voyagers
first landed, and where they resided, and this too,  after the long
continence which had been forced upon them.  Thus, it is well
known that the greater part of the crews of Columbus remained -  ,
at Seville,  and yet this city did not suffer from the disease sup-
posed to have been  imported by these navigators. They could,
therefore, have been  dangerous only to the Neapolitans, and this
too after  having failed  to  contaminate the Spaniards!   Besides,
when the  Spaniards  arrived in Italy, this, like other European
countries, was already infected.   Swediaur  goes so far, indeed, as
to assert, that Europeans, the Spaniards—carried the disease to the
new world.  But I know not why the believers i  che American im-
portation of syphilis, would find no trace of it in antiquity; for, ad-
mitting their opinions to be true, we are compelled to ask, how did
it originate in the new world.  The question then of the first origin
of syphilis, according to this view of it, is only shifted,  not solved.
   However this epidemic of the fifteenth century may have orig-
inated, to us it appears to have been accompanied with symptoms,
in many respects different from those of the syphilis of antiquity,
or of our own day.   The  illustrations given by those who ob-
served the epidemic under consideration, show us, indeed, many  \
traits in common with the  modern disease, but certain tints and
colors prove that  the lesions  really  belonging to  syphilis,  were
blended with certain other  lesions and general symptoms, which
render probable the existence  of serious complications,  arising
from unfortunate hygienic  conditions, or from very corrupt man-
ners.  Finally, it is quite probable that other diseases of a serious
character prevailed at the same time with syphilis, and that they
were mutually complicated with each other; thus lepra, typhus, 
18
INTRODUCTION.
  farcy, blended with syphilis, have been supposed to have given
  to the scourge of the fifteenth century the fearful character which
  it assumed.  A strong argument in favor of this hypothesis, is,
  that the worst cases of syphilis  observed  at the present day, are
  found among the unfortunate beings who are compelled to suffer
  great privations, or who are laboring under a  strumous or  scorbu-
  tic diathesis.   Under these circumstances,  we sometimes find re-
  produced more than one feature in the horrible picture furnished
  by the fifteenth century:  for example, I  have at present under
  my care  an excessively feeble young man, of a scrofulous habit,
  whose body is covered with pustules, whilst his lower extremities
  are affected with rupia, deeply excavated ecthyma, with cracked
  black mists.   Under these scabs,,ulcerations have burrowed, some
  of which have taken the  serpiginous form, and  are the seat  of
 atrocious pains.   Has this case not more than one feature in com-
:  mon with the scourge of the fifteenth century, which has been de-
!  nominated morbus pustularum f  The pathognomonic signs of sy-
 philis become more distinct and easy of recognition, in proportion
  as we isolate them from the diseases with which  they were com-
 plicated,  and from the epidemic influences by which  they were
 modified.  Then indeed, we may collect the elements of syphilis,
  and establish a form of disease entitled to a  scientific  nomencla-
 ture.   In alluding to the earliest period in the history of the vene-
 real disease,  I have stated, that it could then boast neither  of
 name,  therapeutics, nor of books; but from the commencement
 of the sixteenth century, it has  received many names, has had a
 special, therapeutics, and has given rise to innumerable volumes.
f  Sixteenth Century.—A great genius now appears; his name forms
 an epoch; it  is Fernel.   Now a specific cause is discovered, the
 local and general symptoms are recognized.  True, in 1552 James
" Bethemont had furnished Fernel with a hint of the fact; and Para-
 celsus, during the prevalence of the epidemic had seized upon the
 symptoms peculiar to syphilis, with the design of forming  a new
 species in pathology.   But Fernel will always maintain his place
  at the head of the truly scientific epoch of syphilis, and this too,
 with the  greater justice as subsequent ages have made but few
  additions to his teachings.  Not  only did  Fernel scientifically es-
 tablish the necessity, and the existence of  a specific cause,  but he
 traced it from a diseased to a sound person ;  he demonstrated its
 transmissibility by different modes of contact,  especially  by the
• venereal  act,  whence the  name  of Lues Veneris.  The  disease
 had its name, and its cause;  symptoms were recognized and de-
 scribed ;  they were the primitive, and the consecutive or constitu-
 tional symptoms; in fine, the application of the poison, its local
 effects and general results, were traced with a masterly hand by
 Fernel.   But, when he attempted to classify the effects of the virus
 according to  the depth which it had invaded, when he had  the
  presumption to establish four varieties of the malady, according as
 it progressively attacked the four layers of  tissue between the skin
  and the bone; then, and then only, was he misled, as are all those
 who would imitate him, and  number the varieties of the disease. 
INTRODUCTION.
19
The fundamental part of his doctrine, however, still reigns in the
schools to which it has descended, especially through the labors of
Astruc.

                      SYPHILITIC VIRUS.

  This, according to  Hunter, is a morbid poison, resulting from
disease, which poison, unlike other toxic agents, may reproduce a
similar disease.
  The syphilitic  virus, in substance, cannot  be detected; in its
simple unmixed state, it eludes all our efforts at observation; here,
micrography and  chemistry have shown their  impotence.  This
poison, is manifested only by its effects, of which the most remark-
able is its great facility of reproduction.   Brought into certain re-
lations with the living tissues,  and in certain conditions, the virus
develops a morbid action, the  result of which is its reproduction,
its multiplication.   It is there a kind of germination, for the cause
produces an effect which becomes of itself again the cause.   Obser-
vation has demonstrated the existence of a syphilitic virus, for the
number is infinite who have  contracted  chancres by connection
with those affected with chancres.   But to remove the doubts of
certain minds, a resort must be made to experiment.  In fact, pus
from a chancre, inserted on the point of a lancet beneath the epi-
dermis, has given rise to the  same form of ulceration, possessing
the same property of reproduction.
  The syphilitic  virus has ordinarily for its vehicle a thin, sero-
sanious, mal-assimilated pus, in which  organic detritus is more or
less apparent.  But pus the most laudable, muco-pus, may also be
the means of conveying the virus, and it would seem to possess no
influence  in  modifying its nature.  The virus may exist not only
in the morbid secretions, but it  has not been proved that it may
not change the normal secretions.   It unites with the blood, and
there undergoes certain  modifications by which it becomes inti-
mately blended with it.  A particular kind of pus, that produced
by gangrene, seems to neutralize the virus.
  Virulent pus may, like vaccine matter, for a long time be pre-
served in  tubes, or between two glass plates, without  losing its
properties; of this Percy has furnished the proof.  But to develop
these properties of pus, it must be applied in a liquid state, or be
so placed that it will be rendered such by the moisture of the part
in which it is inserted.  Even when  greatly diluted, a solution of
this pus may be inoculated, and M. Puche has shown that one
drop  in a glass of water suffices to render this liquid virulent.
This is worthy of note, as it sanctions what I denominate physio-
logical absorption of the virus, and will place us on our guard
against the use of water which has been used for bathing or for
washing by those affected with the venereal disease.
  The gastric juice, or a solution of  the sulphate of iron, does not
change the properties of the  virus (Hernandez).  Certain acids
destroy it.  This  however will be more fully  noticed when we
come  to the subject of prophylaxis. 
20                     INTRODUCTION.
  Is there more than one virus ?   The existence of a virus is no
longer doubted, but the question constantly arises, Is there more
than one virus possessing different strength and different qualities?
This question has been proposed by every syphilographer who has
sometimes met with such different effects from the virulent matter.
Thus, thev have asked, Is there not one virus which inflames, and
another which gives rise to  ulceration ?  Or,  to speak more cor-
rectly, Is not Menorrhagia produced by one kind of virus, and
chancre by another?  To  these, Hunter replied  in the negative,
and explained the different effects by the difference in the surfaces
to Avhich it is applied.  If specific pus is brought into contact with
secreting surfaces, Menorrhagia is the result (these surfaces are the
lining membranes of the vagina and urethra) ; if the  same pus is
applied to the skin and the mucous membranes bordering upon it
(as, for example, those of the glans, the prepuce, the vulva, and the
lips), a chancre will follow.  But as chancres have been observed
in all the mucous membranes to which it has been applied, the
theory of Hunter was  necessarily  abandoned.  A double  virus
was then adopted as a substitute, and this doctrine was defended
by Benjamin Bell and Hernandez.   I shall notice this theory when
I treat of blennorrhagia, but I feel bound here to show how it has
been defended by Hernandez, in the face of arguments deemed most
weighty, since they were derived from the  results of experiments.
  An experimenter by the name of Andre' inoculated himself with
gonorrheal matter, which produced a chancre. To this fact Hernan-
dez replies that it is of but little importance as it is an isolated one,
and because it has been  reported by an  unknown surgeon.  But
Hunter likewise produced chancres in the same manner.  The ob-
jection now  raised b}r Hernandez, is, that these ulcers healed
spontaneously, and consequently they could not have been chancres!
But he had a bubo which was followed  by consecutive symptoms.
The bubo, replies Hernandez, might have arisen "from  the irri-
tation of the ulcer of the glans."  The consecutive accidents, such
as ulcers in the  throat and pustules, might have  proceeded from
other causes.   We  have just seen, that Hernandez would not be-
lieve Andre, because he was unknown; should we not suppose
that  the name of Hunter, so widely known, would therefore in-
spire  him with  the  greatest  confidence ?   Far from it, however,
and  he concludes  by saying;  " can we moreover  place much de-
pendence on the syphilitic nature of all the affections pronounced
venereal by distinguished physicians?"
  Still farther, Hernandez believes not even his own experiments.
Thus, he inoculated convicts who preferred the operation to the
labor of the arsenal.  In seventeen,  ulcers occurred which had no
appearance of syphilis, and which  were promptly cured without
internal treatment.   "In the others," says Hernandez,  "it pro-
duced obstinate ulcers, some of which had every appearance of
syphilis, with the general symptoms which would seem to establish
it.  Two were cured only after using mercury.   Should we not
suppose that our experimenter having inoculated twelve out of
seventeen of these  convicts  with chancre, and that too with the 
INTRODUCTION.
21
muco-purulent discharge of gonorrhea, would have believed in the
possibility of producing chancres with this same pus ?  But no,
these ulcers  could not have been venereal, as they occurred in
scorbutic and scrofulous subjects!   Now Hernandez himself se-
lected his own subjects for these experiments.  Of course, he must
have known previously that they were the victims of scurvy and
the king's-evil!  I have quoted the above remarkable passage from
Hernandez to prove not only the  identity of the pus of blennor-
rhagia and chancre, but also to show for once that experiments, no
more than observation, can destroy systematic prejudices, or guard
against subtilities, since we here see Hernandez, possessed with
this  idea of a double virus, resisting the most substantial proof
drawn not from the experiments of two physicians only, but even
from his own.  For  him, theory was stronger than proof.*  It
is generally  supposed that it is peculiarly in  our own day that
imagination  plays so active  a part  in positivity (jpositivisme), but
this is a great mistake.
   Hernandez having besides at his disposal the chancre larve—since
he invented the term—availed himself of it, but without abusing j
it.   M. Ricord has again brought this forward, but he has abused '
it.   According to his views, there is but one virus, that of chancre.
Blennorrhagia is  but a  catarrhal inflammation, like any  other
arising from a simply irritating cause, but  it has no connection
with syphilis.  When by accident, we succeed in inoculating  a
chancre  from the urethral discharge, and when this discharge has
been followed by constitutional  symptoms, then the patient could
not have had blennorrhagia proper; the discharge comes from  a
chancre  hidden from our observation,  deep in the urethra—a
chancre  larve—since we must call it by its name.*  Now, although
some of these hidden chancres may be discovered, others cannot be
found.   I have stated that Hernandez invoked their aid, and we \
know that before Hernandez and M. Ricord, when evidence was to \
be destroyed, in the absence of  other arguments recourse was had
to occult causes.   The  human  mind has never been more fertile
than in  this respect; generally it retards, when it would advance
our  progress.  Thus  we cannot be accused of sustaining our views
by superannuated TJieses.                                         ,
   Let us see, moreover,  if the admission of a  single primary ac-
cident, that of chancre,  removes the difficulty.  Granted, for the
sake of  argument, that the specific virus, which gives rise to con-
secutive symptoms—to syphilis—is secreted by chancre alone.  But
there will always remain a disease of the mucous membranes, with-
out ulceration, occurring under the same  circumstances as chancre,

  * Under the  head of Blennorrhagia, we shall attempt to show that our author's
observation applies with equal force to 31. Ricord, and we think that we shall be
able to prove, even by the experiments of this distinguished surgeon, that blennor-
rhagia is occasionally inoculable, and that too, under circumstances in which he
does not intimate his suspicion of the existence of a concealed chancre.—G. C. B.
   f I am satisfied, as must be those who have carefully examined the two patho-
logical specimens on which M. Ricord relies to  establish his theory, that they -_J
were tubercular ulcerations of the uilehra, similar to those observed in the prostate  (
glands of the same patient.        ' /\ 
22
INTRODUCTION.
and which in the same  individual produces metastatic  affections,
such as opthalmic and arthritic inflammations; there will always re-
main a disease, caused by contagion, which is not a simple ymeg-
masia, and which gives rise to primitive effects, such as 1 s&aii in
another place describe.   Hin this we do not see a specific disease,
if we refuse to admit that the two lesions  are produced by the
same virus, we must find some other cause, some other virus, ana
with Benjamin Bell, we must adopt the doctrine of a double virus,
one for gonorrhea, one for chancre.  Still, even here, we originate
nothing, we only revive the doctrine.            t
  To explain the difference between blennorrhagia and  chancre—-
their primitive  and consecutive accidents—a virus of different
strength has been  admitted, a  whole virus,  and a demi-virus.
MM. Lagneau and  Baumes seem  inclined to this hypothesis, to
which I shall again advert.   Instead of a double virus, Carmiehael
contends for four kinds, which produce four different accidents.  1
repeat  the lesions which sometimes follow a suspicious connection,
are sometimes of such different forms, and so varied m their re-
sults  that we cannot be surprised that they should have been
attributed to a  different cause.  But, thus far, we have  arrived
only at hypothesis,  as  we have  studied under the  influence of
theory only.  The experiments lately made to prove the mocula-
bility of secondary accidents, or to show that the system may ar-
rive at such a point of saturation as to resist all kinds of syphilitic
action, or  that chancre may be communicated to animals, have re-
newed the questions, whether the virus is of  different strength,
whether it is modified by the blood, or in passing through the
various organs,  or from one individual to another,  or from one
kind of animal  to  another kind,  and indeed  if the virus is not
changed by the  different conditions of the organism with which it
is brought into contact.   Finally, it has been asked, are the differ-
ent  products due to the seed or  to  the soil.  It has been justly
maintained  that differences, and these  too very great, may arise
from certain peculiarities of the organism created by a particular
hygeine, by affections which preceded the invasion of the syphili-
tic poison, by an immethodical treatment, administered without re-
gard to time or  quantity; thus long privations, excesses, scrofula,
scurvy, a badly-managed mercurial treatment, may exert an in-
fluence on the progress and the form of a chancre.  But, even among
the numerous chancres produced by inoculation on the same indi-
vidual, on the same organism, at  short intervals, for the purpose
of syphilising or saturating the individual, some have  been ob-
served to be very rapid in their march, others to  remain a long
time stationary,  others, in fine, to become phagedenic, whilst others
assumed the form of the real indurated, classic chancre; and what is
worthy of note,  these varieties have not always put on  the charac-
ter of the ulcers which furnished the matter for their inoculation.
 Thus just as the day would seem  to dawn, darkness reappears, as
 has almost always been the case in syphilography, especially since
 it has made pretensions to positiveness.  But, in this place, we can
 only glance at the questions.  In  studying the different forms of 
INTRODUCTION.                        23
syphilis, they will  again come under our consideration.   Then,
whilst  studying them in connection with cases, we may perhaps
be permitted to have a glimpse at their solution.  In investigating
the nature of chancre, I shall particularly notice the connection of
induration with constitutional  infection,  as this, form of ulcer has
been regarded  as  that which alone furnishes a contagious matter,
or a specific virus.*
  Modes of Propagation.—Each virus, has, so to speak, its  peculiar
method of propagation.   In the great majority  of cases it  depends*
upon sexual connection, and the genital  organs  are those most
commonly affected.  But debauchery has  devised other forms of
connection, other methods  of contagion, involving other parts, as
for example, the arms, the mouth, the lips.  Lactation  may like-
wise favor  contagion.   The touchft operations with the fingers
denuded of their cuticle, and wouncls, have been the means of com-
municating the virus.   The more intimate and  prolonged  the con-
nection the greater the risk of contagion;  it is from this cause that
it is most frequently communicated by coitus and lactation.  The
chances will be still greater if there be a solution of  continuity, a
wound or laceration;  thus  coitus with organs of disproportionate
size is attended with more hazard than  is the  act under  opposite
circumstances, for  the first-mentioned condition may be the cause
of lacerations, which singularly facilitate the  introduction  of the
virus;  this is the  reason that, all things being equal, there is less
risk in having connection with a woman who has born children,
than with those who  have not, particularly young  females.  So
much 'for immediate  contagion.  The  possibility  mentioned,  of

  * An impression generally prevails that the question of the plurality  of poisona
has been definitely settled in favor of  a doctrine of a single virus.   It is admitted,
however, by M. Ricord (Lett, xviii. p. 143), that it is far from being yet solved,
and in his xixth Letter (p. 145), he acknowledges that his experiments have failed
to establish the doctrine. Mr. Acton recognizes the connection between the indu-
rated chancre and the scaly eruption. (Treatise, 2d Amer. Ed. p. 285.)  Mr. Egan is
disposed to  adopt with but slight modifications the views of Mr. Carmichael, and
with the latter  regards the experiments made by M. Ricord as lending a support
to the doctrine of a plurality of poisons (op. cit. pp. 49, 52; and Carmichael's Clin.
Lcct. p. 52). M. Ricord, indeed, states that in his  experiments—"always per-
formed on the  patients themselves1—the ulceration produced by inoculation has
invariably assumed the form  and character of that with the inoculable matter."
(Lett, xviii. p. 142.)  Mr. Herbert Mayo, on the other hand, has reported a case in his
work on Syphilis, p. 38, in which a clearjy-marked indulated chancre was produced
upon the forearm of a patient, from the matter of a bubo following unindurated chan-
cre.  Again, whilst the experiments instituted in Dublin, furnish proof in favor of
the doctrine of  plurality of poisons (Egan, p. 54), those made at Turin (Sperino, on
Syphilization, p. 300), tend decidedly to support the theory of a single virus!
  We may attribute the varieties, the characters of mildness or severity of primary
6ores, to constitutional influences, but of the nature of these influences we are, and
probably must long remain ignorant.  Still, as observed by Mr. Porter,  in his ad-
mirable lectures on syphilis, published in the Dublin Medical Press for 1846-7 (vid.
Lect. viii.),  "we are in this respect no worse off with syphilis than with many
other affections; out of fifty patients, the subjects of operation, we know not the
few that may be seized with erysipelas;  out of a hundred wounded on the field of
battle, we cannot point out the one or two that may subsequently die of tetanus ;.
neither can  we explain the occurrence when it has happened, otherwise than by
saying it depended on the constitution."—G. C B.
  ' (Case viii. p. 198, in his Treatise, is reported as an Inoculation on  a healthy
person.—G. C. B.) 
24
INTRODUCTION.
     preserving the virus for a long time, would lead us to suspect that
     of its transmissibility by mediate contagion, by means of objects
     on which it has been deposited, as, for example, the tubes or edges
     of glass in which it has been preserved.  The story is familiar, of
     the young girl, who, to disguise herself, put  on the breeches of a
     man, and thus contracted syphilis.  A mask, the clothes of  a per-
     son infected, the seats of a privy, it  is said, have each been  the
     means of conveying the disease.  The authenticity of these cases,
     however, is not beyond reproach, and  even if it were, it would
     furnish an argument in favor of the communicability of the second-
     ary disease.  The  sexual organs of the female may serve, so to
     speak, as a depot, from which the virus  may be extracted.   A
     man having connection with this female may contract the disease,
     and yet the woman herself escape infection.   This has long been
     known.  Thus, we read in Astruc (torn. IL, p. 16): "A woman
     having connection  with a man diseased, if repeating the act shortly
     afterwards with a  sound man, may infect  the latter, and yet her-
     self escape."  Hernandez, with those who, in turn, have copied
     from him, makes use of this fact, and of this hypothesis, to support
     the doctrine that chancre alone can produce constitutional syphilis.
     For  example, when a  man contracts  a chancre  from a woman
 '   affected only with  blennorrhagia, this woman must, according to
fp,   them, have had a chancre larvd; if this  cannot be found they
     invoke the aid of  this doctrine of recently-deposited virus in -the
     organs of the female, a virus which the man carries off to his own
     great detriment, but to the decided advantage of the woman, who
     thus escapes infection.  Ever thus do  conjectures come in to the
     support of hypothesis.
       Action of the  Virus.—What is the  modus operandi of the virus?
     To this question Fernel gave an answer, which, even at this day,
     is not without its value.  He asserted that it acts like other poison-
     ous agents, producing a venomous effect, similar to that resulting
     from the sting of an asp, the bite of a mad dog, or from the  small-
     pox virus.  Chemistry and vitalism have furnished their explana-
     tions, of which the  exposition here would be of no real value.  The
     solution which has met with most favor is that by Hunter; accord-
     ing to him, the virus produces  upon the living tissues a peculiar
     irritation, and determines a particular kind of inflammation, the
     special product of  which is virulent pus.  (I use here the  words
     of the French translation).  In another place Hunter adds:  " The
     presence of inflammation is not necessary to the continuance of
     this peculiar action, for the poison is  still formed long after the
     signs of inflammation  have disappeared."  Besides the specific
     action, he adds, " it acts as an irritant, then it excites new inflam-
     mations, the products of which are  not contagious."  This first
     supposition, which has been reproduced in  our day for the purpose
     of concealing the  mistakes of experimenters,  has singularly ob-
     scured the questions concerning the nature of buboes and blen-
     norrhagia.
       Hunter admits the absorption of virus without any lesion of the
     surface to which it is applied, that is, without ulceration, without 
INTRODUCTION.
25
 previous inflammation; this I call physiological absorption.  After
 its absorption the virus passes into the blood, reaches every part
 of the organism, and may produce a double poisoning;  one, which
 is acute, with local reaction in  the point contaminated, character-
 ized by what we call the primitive accident; the other,  chronic,
 more profound, and maintained by the persistence of the first, and
 according to  M. Cazenave,  capable of being constantly aggravated
 by  new infections until the state of cachexy is reached; this is
 characterized by the consecutive accidents.  I have mentioned that
 some would restrict the terms primitive accidents to chancre; thus
 implying that only through its surface can the syphilitic virus be
' absorbed.   But chancre is  not indispensable to infection.  Indeed,
 as I have  already advanced and as  Hunter  himself taught,  the
 virus applied to certain points of the mucous membranes may
 readily reach the circulation, without  any solution of continuity in
 the tegumentary surface;  the  mucous membranes may easily be
 impregnated, and the absorption which it  irresistibly exercises
 over most toxic agents which are presented to it in a liquid form,
 and over  semi-fluid substances,  is  not confined to  the syphilitic
 virus alone, since we see the virus of glanders, and that of variola,
 enter the  blood from their simple  application to sound surfaces.
 Physiological absorption does therefore occur.
   Once absorbed, the  syphilitic virus  may rest dormant, and
 remain  a  cause without  effect.   This is the period of incubation.
 When it becomes developed, independent of the primitive symp-
 toms, it is  called primary or non-consecutive  syphilis, {verole d'em-
 blee.)  In  this  case the general infection has preceded the appear-
 ance of the symptoms which have erroneously been called local.
 Thus,  as  M. Bousquet has proved, the vaccine pustle does  not  U
 appear until  the organism has been modified by the Vaccine virus.
 .31M. Lagneau,  Baumes, de Castelnau, and Cazenave,  are those,
 who, by their observations, have lately most  contributed to estab-
 lish the fact of the incubation and the reality of the non-consecu-
 tive syphilis, (verole d'embtie).  When I treat of chancre I shall
 reproduce  the  facts which  are  peculiarly my own,  and which   )
 harmonize with those of my confreres.  Furthermore, analogy was  £.
 already in favor of the incubation, for every virus possessing con-
 tagious properties lies dormant  for awhile, and then  reproduces
 itself for a certain time, the cause produces  no effect, at least no
 perceptible effect.  M. Ricord denies  both  the incubation and the
 non-consecutive syphilis, (verole d'emblee).  According to him, it is
 fundamentally  and radically a local effect, that is produced by the
 virus in the  part  to which it is  applied.  And here this author
 rests upon experiment.  Immediately that the lancet has placed
 the virus in contact with the living tissue, this virus acts, and then
 commences at once the evolution of the primary symptom, which
 is attended with redness, like that of  a flea-bite, a pimple scarcely
 raised above the level of the skin, which  uninterruptedly passes
 into the pustule and chancre.   But  the operation by which  the
 skin has been  divided and more or less irritated,  a  proceeding
 which places the pus in direct contact with the divided tissues, is 
26                      INTRODUCTION.
not the physiological act that applies the virus to the surface, and
subjects this surface to a kind of friction, thus promoting absorp-
tion, which remains physiological in proportion as the tissues  are
intact.  Inoculation cannot justly be compared with coitus, except
when a laceration occurs during the  latter act." Then,  indeed,
there is immediately a pathological condition; a local action is at
once begun without incubation;  or,  in other words, the  general
does not precede the local action, but they are simultaneous.
                        OBSERVATION.

  The surest foundation of all theory and practice, is derived from
the observation  of natural phenomena;  but observation, always
in pathology difficult, presents still greater difficulties when it re-
lates to the accidents produced by the syphilitic virus.  It must be
acknowledged that it is rare to find patients whose statements can
be believed, and certain facts escape the attention of the observer,
either  from his  inability or want of capacity in observing them
accurately.  Let us first examine the causes of error dependent on
the patient, after which we will notice those which may be attrib-
uted to the observer.
  Patients attempt to deceive, or are themselves deceived.  It is
particularly the  case in syphilis that we  encounter deception on
the part of the patient; the reason of which is obvious.  But this
source of  error has been  singularly exaggerated, and when  it is
found  that by the statements of the patient certain theories  are
compromised, the patients veracity is too readily doubted.  Gene-
rally, this disposition  to deceive springs from interested  motives,
and not from any pleasure  in the act.  Now, the circumstances in
which a patient can find it for his interest  to conceal the truth, are
not numerous ;  it is generally, when they would repel the charge
of having transmitted the disease,  or when the manner in which
they have become infected is  regarded disgraceful or wounds their
pride; thus, the story of the nurse who  accuses the nursling as
the cause of her  infection, that of the libertine, who  denies having
had connection  or having been guilty of other libidinous acts,
should be  received with allowance., But patients of this class may
still furnish us with useful information; indeed, if we  question
them with care,  to their affirmations they will add  an exposition
of a series of phenomena which have had their influence, and in
this manner  sometimes conduct us to the truth.   M. Castelnau,
who has written a work on the observation and  interpreta-
tion of facts in syphilography,*  cites  in  support of  this
opinion, the following:
  A grandmother took her grandson to wean ; the child was in a
wretched condition and had an eruption of pimples over the whole
body, with excoriations  in  the mouth;  after some weeks it died
and two months after its death, the grandmother as well as her
  * Vid. Annates des maladies de lapeau et de la syphilis, No. 1. I  have profited bv
this work.                                                    ^ 
INTRODUCTION.
27
daughter (the aunt of the child) became affected with a squamous
syphilitic eruption*
  Here, the only testimony we have in reference  to  the antece-
dents of the case, was that of the two patients themselves ; how-
ever,  it was hardly possible to doubt their accuracy, as, besides
their own assertions, we find a series of morbid phenomena which
often occur in a 'natural order; and the patients, as M. de Castel-
nau  remarks, could not have known how to arrange them so as to
give an appearance of truth, consequently we must  admit the veri-
similitude of their own statements.
  Sometimes there exists another reason for believing the patient's
own history of the case, as in the instance already quoted; it is,
that it will be very difficult to understand the nature of the affec-
tion, if for their supposed falsehoods, we  can substitute only ex-
planations which are more or less  improbable.   In the case just
noticed, the only other explanation left us, would be the existence
of primitive symptoms in the aunt (the grandmother was about 70
years of age, and it is not very probable that she was thus affect-
ed) ;  to establish the truth of this supposition, the aunt must have
infected the child;  and the latter must have communicated  prim-
itive  symptoms  to its grandmother, without her knowledge of the
fact (which is still more difficult to believe, as  these symptoms
must have shown themselves as evidence in certain parts, such as
in the mouth, or in  some other part of the face or hands); that
this child had been so promptly affected by the virus as to die in
two months, and this too while the grandmother and aunt were in
excellent health ; that, in fine, these two women, of such opposite
ages, had been attacked at the same time with constitutional symp-
toms, although according to  this hypothesis, the period of primi-
tive infection must have been very different in the two cases.  We
see  how  similar explanations would be improbable, and how it
would be more  natural to believe the statements of the patients,
especially when we  know that they correspond with what  many
physicians have observed in cases where they have been able to fol-
low, step by step, the development of all the phenomena. (Loc. cit.)
   At the same time, in approving the distrust  with which those
facts should be received, the authenticity of which  rests solely on
the  patients honesty,  I am  far from  justifying the  conduct of
those who reject them altogether,  no matter what their source,
provided they tend  to  conflict with their  preconceived theories.
Do we not, in the most serious affairs of life find that certainty is
established by testimony which has no other warrant than the
honesty of the witness ;  why should we not in the same manner
arrive at  a scientific certainty ?  Are there not men whose moral-
ity is above suspicion, and whose testimony is equivalent to the
most scientific demonstration?  When Hourmann, observes M.
de Castelnau, declared that he could not have contracted syphilis,
except in the  discharge of  his duties as a  physician, no  one
thought of doubting his veracity, and had any one dared so to do,
  * This case was communicated to the author by M. Alph. Robert, surgeon to
the hospital Beaujon. 
28                     INTRODUCTION.
he would have provoked but a just and universal feeling of in-
dignation, among all who were acquainted with that virtuous man.
I was the colleague of Hourmann at the Lourcine, and I can but
repeat the language of his pupil.  Besides, we shall remark, that
the syphilographers who are least disposed to admit moral proof,
and who subject every female to suspicion, do not hesitate to  in-
voke  the chastity of a husband when it is necessary to support
their theory.
  We will now consider the statements given by those patients
who, without having any  interest in so doing, yet deceive them-
selves.  Here, as in  the study of other diseases, some of which
present  still greater obstacles to their investigation than syphilis,
we are  obliged to have  recourse to the recollection of the patient
for the  causes, the first phenomena which appeared, and for the
termination.  It is evident, from the concordant results of differ-
ent observers, that these  may often lead us to the truth.   Here,
indirect means, artificial methods of arousing the patient's memory,
every precaution, in fine, which is recommended in the best trea-
tises on  general pathology, must be made subservient to our pur-
pose.  Besides, there is a class of patients so intelligent, so careful
of their  persons, who are, indeed, such good observers, that their
statements  merit the greatest confidence, at least in the establish-
ment of certain facts.  Thus we shall see in examining the subject
of incubation, that  we do meet with patients capable of furnishing
us with  the most precise  information on  this point.   Moreover,
what  is  here  required  to be  established ?  Two capital circum-
stances :  1st. The precise date of the coitres; 2d.  The time of the
appearance of  the  first  symptoms.   A  number of patients may
very satisfactorily establish these circumstances.   It is true that
others require to be noted; it is well also to take  into account the
habitual frequency of the  coitus, for what is due to one of these
acts may be attributed to another; we must know if there was any
preceding infection, and if any excesses have  thrown the system
into such a commotion as to disturb the  natural order of the phe-
nomena.  But  all  this is  not  only possible, but sometimes unat-
tended with difficulty, and we  shall discover, in  treating of incu-
bation, that certain patients have been  able,  by their  own  state-
ments, to furnish  the elements  essential  to the  solution of this
important question.  Still further, on this point, it is  curious to
observe these  same systematists who deny a patient the necessary
intelligence to establish a compromising fact,  afterwards find this
same patient quite  competent to furnish details most difficult to be
known,  but which  are  favorable  to their views.   We shall have
occasion to admire this inconsistency when we come to the chap-
ter on the Syphilida.  Some of these are not easily diagnosed;  we
know that the syphilitic eruption appears after chancre  and before
exostosis, that  it is, in  fine, a  secondary  symptom.   Now, if in
interrogating a patient, who has had these three symptoms, there
is the least shadow of an eruption at the epoch required by their
theory,  his story is at once accepted, for the patient merits all con-
fidence; he is then intelligent, and his memory has not deceived 
INTRODUCTION.
29
him.  But if, on  the  other  hand, he  places the most strongly-
marked eruption after the exostosis, for example, then no matter
what the  precision or the number of  his facte, the patient is no
longer intelligent, his memory fails him, he  is incompetent to de-
scribe the eruption on his skin, he is mistaken  in its form, color,
&c, &c.  We see, then, that  confidence is given or refused to a
patient, not according to the degree of his intelligence, but accord-
ing as his story is favorable or unfavorable to a particular theory.
Would it not be better then to disregard in toto the testimony of
the patient ?
  Away with all exaggeration, and let us try  to distinguish the
patient who can, from the one that cannot instruct us.  We should
not always judge of a patient's  intelligence by the reply  given to
our first question, nor to  our direct questions,  but  only after we
have  become better acquainted with them, and have subjected
them to a cross-examination.   In this manner certain patients
may furnish  us  with valuable assistance  in eliciting  the  truth.
This, however, may be  much  more surely attained  when we can
see the patient  at  the  outset of the disease, and can follow  it
through  all  its  evolutions and note all the phenomena  which it
may present.   Unfortunately, every observer does not feel the ne-
cessity of collecting the minutest details; indeed, some are content
with  the  most prominent facts, which, in their estimation, are
quite sufficient to  establish the  character of  the disease.  The
young practitioner should let  nothing escape  his attention, not
even  the  most trifling  circumstances, for  the absence of one of
them, though it may not be essential, may prove a prize  to those
whose theory may be impaired by the facts  of  the case, and may
afterwards unexpectedly compromise its authenticity forever.
  The ignorance and  unskilfulness of the observer may be ad-
mitted; but  sometimes  he is unjustly accused:  thus, in the ques-
tions to which blennorrhagia gives rise, it is all important that the
facts  in favor of, or against its specific character, should be col-,
lected with the greatest care; no means of aiding our diagnosis
should be neglected.  In the case of  a female, for example, not
only the external parts of generation should be explored, not only
should we press with the finger the urethra from behind forwards,
expose  the vagina with the speculum, explore  it both when the
instrument is introduced and when it is withdrawn, but we should
bring into view the neck of the  uterus, cleanse its mouth with a
brush, and all this to see if we can discover no chancre to explain
the specific nature of the symptoms which  may  occur, or to prove
that they may arise, in the absence of chancre, from the inflamma-
tion of a mucous membrane.   It  cannot be denied that formerly
this physical examination was  too much neglected, and  even in
our own day it  is not always thoroughly made.  But since Hun-
ter duly warned  us of the sources of error in his remarks  on blen-
norrhagia in the  female, since the speculum has been so frequently
employed, and especially since it was known that chancre might
be hidden from our sight, our investigations have been more accu- 
30
INTRODUCTION.
rate, and there is daily less cause for the reproaches which have
been made against observers.
   To complete the subject,  I will borrow the conclusions of M. de
Castelnau, as  contained  in the  first  part of the  work  already
quoted:
   1. Patients, with but few exceptions, do not attempt to deceive,
except when  they  are  driven by interest,  shame  or  fear.  2.
Such cases are exceedingly rare in porportion to the number of
persons affected with venereal disease.   3. Patients placed in  such
circumstances may still furnish us with reliable information, either
because their testimony is corroborated by the fact of its conform-
ing to the natural order of a series of pathological phenomena, or
because we have  no right to suspect their honesty.  4. There are
patients who, by their intelligence and regard  for their  persons,
may impart  precise  and  sufficient details, respecting the diseases
with which  they are,  or have  been affected.  5. The physician
may sometimes have the opportunity of witnessing all the morbid
actions which  constitute the disease in question, and then collect
his facts without  any  doubt of their  exactness, provided he has
devoted to their study sufficient time and care.*
   Observation is therefore difficult, and when not beyond reproach,
may be productive of  error; but there is still greater difficulty, in
that operation of  the mind by which we form our induction from
the facte observed.   There are facts, the connections of which are
so simple, so evident, that their expression alone forms the axiom.
But there  are others which are not self-evident; these  must be
subjected to  our reason, before they can attain a scientific value.
This process is attended with serious difficulties; if the mind have
not a proper bent, if it be biassed or imbued with some particular
theory, error is sure  to be the result.  In this operation, we must,
first of all, never lose sight of the facts themselves, and must guard
against substituting suppositions in their place.  Thus, in the ques-
tion of the dependence of syphilitic blennorrhagia upon chancre, we
should seek  on  all  sides for the ulcer, and when found, note it
particularly in interpreting our facte, but we should guard against
supposing its existence, because a certain  system positively re-
quires that it shall figure in every case of the  kind.f  We must

  * Annates des maladies de la peau et de la syphilis.  No. 1, p. 10.
  f The following remarkable instance of substituting supposition for facts is
worthy of record. Dr. Richet, the family physician of a Parisian merchant, met
M. Ricord in consultation.  The case was that of a child, affected with syphilitic
ulcerations in the ano-genital regions.  Both parents and nurse being apparently
perfectly sound, much perplexity was  felt in deciding upon the origin of these
ulcerations.  The fact was mentioned, that ten  clerks lodged in the same house,
and perhaps one of these might be affected!  Seizing upon this happy suggestion
M. Ricord at once attributes the infection to the dandling of the child upon the
naked hands of one of these clerks.  M. Velpeau,  in his  communication to the
Academy of Medicine, Sept. 21st, 1852, states that by accident he had learned from
Dr. Richet, that this  story  of the poxed clerk was a mere invention, having no
other foundation than the circumstances above mentioned.  In a  letter subse-
quently addressed to M. Velpeau, Dr. Richet observes: "No, positively, no, neither
M. Ricord nor myself saw any such clerk!"  M. Ricord's apology, as furnished in
his communication to the  Academy, Oct. 12th, 1852, is, that his report of the case
was given from  memory, which report in his Letters (xiii., p. 104), is followed by 
INTRODUCTION.                       31
not reject  certain facts, or deny the importance which  they really
possess, because they do not accord with those which have gener-
ally been observed.   Admit that they are exceptional, but if well
established, nothing can  destroy them, for  a thousand negative
facts  cannot destroy one  positive fact: this is an axiom that has
been  admitted since  men have known the  art of reasoning.  Is
more than one fact required  to prove  that  wounds of the heart
admit of recovery ?
   It  is not inappropriate to notice in this place a part of the dis-
course of M.  Gijfbert, in support of the doctrine of the transmissi-
bility of the secondary acoidents. The orator,  wishing to show what
errors may result from interpreting facts whilst  swayed by the
narrowing influence of theory, exclaims:  " Thus, to limit primary
syphilis to chancres, an urethral chancre in  certain cases of blen-
norrhagia must be supposed, and chancres with flat primary tubercles,
or muscous pustules, the occurrence of primary bubos (d'emblee),
be denied as  well as the contagious character of certain vegetations,
and we must metamorphose into chancres certain consecutive ulcer-
ations of the tonsils, mouth or skin ;  thus, must we torture and in-
terpret the instances of the tardy appearance of the  secondary ac-
cidents of syphilis, and the cases in which some of these accidents
have been transmitted, a transmission which has occurred more than
once from the habitual and intimate relations which exist between
the husband  and the wife, the nurse and her nursling, and between
the latter and other children under the same roof.  The testimony
of most credible witnesses must be rejected, and those  who do not
wish  to explain clinical facts  in the most difficult  and irrational
manner, must be accused of error  or  credulity.  In  a  word, we
must cull, prune, strike off, polish, and reduce to a certain measure
marked in advance, all the materials of the science that they may
fit the famous square,* without dragging its regular fines, or chang-
ing its solidi&Qty.r
   The difficulties in the way of observation, the qualities of mind,
the time  and patience required to render it  complete, the sound-
ness of judgment and intelligence necessary to a correct interpre-
tation of facts, the doubts which  cannot be removed, even by the
union of all these qualities on the part of the observer, have some-

some observations upon the tact and skill required to discover the true origin of
the disease in these perplexing cases!  For all the details connected with this case
the reader may  consult the collection of Reports and Discussions, entitled " De la
Syphilization, &c,  <fec, pp. 304, 357, 378.  To complete the history of this case we
should add, that M. Ricord very modestly requests M. Velpeau, if he is not satisfied
with his supposed cause (the poxed clerk), to furnish a  more rational explanation.
We read in the  "Novum Organon" Aph. xix., lib. 1st, that "duo: via sunt ad inqui-
rendam et inveniendam veritatem."  Whether the method adopted in the above
instanoe be the "via vera," we leave for the reader to decide!   We would also
humbly submit whether M. Ricord himself has not furnished  us with a more
rational supposition of the true cause of the infection of this child, in his history
of the case, {Letters xiii. p. 105,) where a child was born affected with syphilis, the
legal parents of  which, and the cavalry officer, the real father, were, to all appear-
ance, perfectly sound, though the latter had been diseased ?—G. C. B.
   * The orator here alludes to a confrere who has compared the  system of M. Ri-
cord to square.
   f Oazcttedes Hopitaux, Seance of 22d Sept. 1852. 
32
INTRODUCTION.
times led  syphilographers to prefer experiment, and to give to
facte thus  obtained, a preference over those acquired by clinical
observation.  This leads us to the subject of experiment.
                        EXPERIMENT.

  By this, we are not limited in our observations to facts naturally
produced, but we provoke  the manifestations of  the disease, by
trifling  operations,  by experiments.   Hunter chiefly contributed
to introduce experiment into syphilography, for the purpose of
facilitating our investigations.  Attempts have since been made
to base upon it a doctrine, a treatment, a system.  Now, we  have
already remarked, that a system is but an hypothesis.  By experi-
ment, a completely imaginary syphilis has been created.  This was
a natural consequence, for they knew not how to discriminate be-
tween experiment purely physical,  and that based on facts, partly
physiological, partly pathological.   If living nature had  the  uni-
formity of that which is dead, the deductions from the experiments
made upon it, would possess the same characters of certainty and
simplicity, as do those which are entirely physical,  and by them,
laws might  be deduced  to  establish a  natural scientific system.
But, as  in the problems which Ave have to solve  by experiment,
the vital forces are concerned, as well  as idiosyncrasies and morbid
phenomena often very complex, the results must differ from those
obtained in trying to solve the problems of physics or of chemistry.
Besides, these results have not the character of simplicity which
can prevent systematic interpretations, and the cavils of men of
preconceived opinions.  Indeed, opinions most opposite are daily
expressed on the results of  an inoculation.   What I have related
of Hernandez, has probably not been forgotten.  Again, the pro-
ceedings adopted for the purpose of provoking syphilitic manifes-
tations, are on a very limited scale.   We shall sooa discover,  that
those of nature are very diversified, and who  can tell how numer-
ous are the modes of  propagating the disease ?  Our proceedings,
again, are very unlike those which we would imitate ; for example,
there is a great difference between the insertion of the virus beneath
the skin with the point of the lancet, and the contagion from coi-
tus.  The results must vary accordingly.   We find, indeed,  that
the pus from  a  chancre which is  inserted in our tissues by the
operation, always produces  a chancre, while that from a chancre
the result of  a  coitus, sometimes produces  a mucous pustule,
sometimes a vegetation, sometimes a chancre.  Certain accidents
which are transmitted by coitus or other intimate connections, are
not communicable by inoculation or any artificial proceedings.
  I am far, however, from rejecting experiment as a means of
investigation; I know too well the services which it may render;
but for  myself it has no real value  except when its results cor-
respond  with the facts observed  in natural pathology.  Ao-ain
experiment being at present greatly in vogue, and many physicians
having neither time nor disposition to test the questions in syphil- 
INTRODUCTION.                     33
ography by the clinique, and by the rules of philosophy,  prefer
the demonstrations by the lancet.  Unfortunately some of the most
distinguished syphilographers, trusting in their reason  and their
clinical  observations, condemn  experiments as  being immoral.
They reason much, and reason very justly, but perform no experi-
ments, hence their  limited success  contrasted with that of those
who require actual  demonstration.   Other syphilographers, how-
ever, relying chiefly on observation, despise not experiments, and
believe, that when used within certain limits, they may prove use-
ful to science,  without  infringing upon the laws  of  morality,
properly understood.  They experiment then  more  philosoph-
ically, that is to say, without losing sight of clinical observation,
they  are  no longer content to address the mind exclusively,
but they speak to the senses, and it is  chiefly by experimental
means, indeed,  that they successfully attack the  errors of experi-
ment.   Next come those who carry their experiments to extremes.
Experiment is  now no longer confined to the hands  of M. Ricord
and his pupils; it is made in a different spirit, and by methods
more varied, whence the results  which I shall soon mention.
   I speak not  of the clangers of experiment, and my aversion to
everything not directly scientific must have been observed.   The
dangers which  it is my duty here to notice, as I write for instruct
tion,  are of another kind.  I have stated, in another place, that
nothing is more injurious to study, to true progress, than to insert
forms with certainty, and particularly to  designate those methods
of exploration which may sometimes conduct us to it by the name
of certain ty, as these means are far from being infallible, especially
if they are trusted to alone, and are not based upon observation.
Delusions are thus prepared for  the student, and disappointments
for the practitioner.  I think, therefore,  that in speaking  of the
immutable laios of experiment,  M. Ricord is  guilty  of error, and
exposes his pupils, who take him at his word, to disappointments
innumerable.   Those laws  only are  immutable which are not
made:  they are from all eternity; by them was chaos dissipated;
his laws, those which he has created, if possible, would cause it to
reappear.  Again, by experiment we produce  pathological facts,
the interpretation of which is as difficult as that of natural facts;
the proof lies in the want of unanimity, and the doubts which have
arisen from the experiments lately performed to test the doctrine
of syphilization, and which we shall soon proceed to notice.
                        INOCULATION.

  The experiments instituted for the  purpose of producing the
various forms of syphilis, have chiefly consisted in inserting the
virus or the supposed virulent humor, according to the method
adopted in vaccination.  The lancet  has been charged with the
matter which we would apply to  the living tissues, and by it the
skin is punctured.   Sometimes  incisions  have been  practiced,
some scrape the skin so as to remove the epidermis; some make 
34
INTRODUCTION.
   scarifications;  and in some  instances an infected part has been
   fixed against a sound part; thus,  Luna-Calderon scraped the skin
   before he applied the virulent pus in his experiments for the pre-
 |  vention of syphilis;  M.  Auzias removed only the epidermis of
 /  animals with the curved scissors;  Wallace often denuded the skin
 1  with a blister, and dressed the wound with charpie saturated with
   the pus of a pustule.   This  proceeding has been repeated by M.
   Bouley, who has thus inoculated with the matter from a pustule,
   and produced a second syphilitic infection in a woman whose sys-
   tem had  already been  completely contaminated with  the disease.
   I have performed the same experiment with success. Waller scar-
   ified healthy individuals, and dressed the little wounds with the
   blood from a syphilitic patient, or, with the pus from mucous pus-
   tules, and in both cases he succeeded in producing constitutional
I   syphilis.  M. Velpeau fixed the prepuce upon a portion of a glans
   affected with vegetations,  and in this way produced a vegetation
   on the  part.   The methods  may be ever so diversified, yet can
   they never reach the same variety as the natural proceedings, and
   particularly is it true, that the latter can never be completely im-
   itated.  This is the reason why experiments often  fail.
     Again, two conditions are  indispensable to the success of an in-
   oculation : 1. A virulent  matter;  2. An organism, with a  certain
   susceptibility to the action of the virus.  There must be good seed,
   and a soil favorable to its germination.  Now these two conditions
   may be wanting, and nothing can previously indicate their ab-
   sence ;  therefore,  inoculation cannot be infallible, as  some have
   pretended;  it can be but a  means of investigation, and never a
   practical measure, and a system which rests solely upon it, should
   fall.  M. Ricord has pretended by inoculation to distinguish affec-
   tions apparently similar;  to  establish the difference between the
   primitive and  consecutive accidents, to aid  the cause of justice,
   and, in fine, to establish a  classification, a system ;  further, still he
   maintains that by the same proceeding, he has proved  that syphi-
   lis is confined.to the human system.  Now, to effect all this, it is
   necessary both in a practical  and scientific point of view, to estab-
   lish the infallibility of inoculation, to give to it the character of a
ff  test.  M. Ricord believes in this infallibility, and has had the bold-
I   ness to proclaim the equality of the human species before a chan-
   cre, before that  ulceration which, in his opinion, is the  only inocu-
 1  lable form of syphilis.  Now it has been proved,  that there are
 i  chancres, real chancres, which do  not contain inoculable matter,
   whilst there are true consecutive accidents which may be inoculat-
   ed ; it has been demonstrated that the most virulent pus produces
   no  effect on certain individuals, that there are, in  fine, some per-
;  sons who from  accident or idiosyncracy are  insusceptible of any
/   syphilitic infections.  To  give, therefore, to inoculation the value
   of  a chemical test is a most unfortunate idea, for in a  theoretical
   point of view, it leads to deception, and as regards practice to cruel
   disappointments; whilst in legal medicine, which is of  serious im-
   portance, it may divert justice.  True re-agents have  a negative
   and a positive value; an infusion of turmeric when changed to a 
INTRODUCTION.                         35
red color, shows  the presence of an acid;  and  thus furnishes the
certainty of its existence; but if it be not changed to red, then the
absence of the acid is positively indicated.   Do these observations
apply to inoculation ?   No.   If, therefore, inoculation produces a
positive result, we must say to justice—yes, the accused is affected
with syphilis, he is guilty ;  but if inoculation produces no effect,
we cannot say—the person is not infected, he is innocent; we can-
not say it, for it has  been proved, that this person might have one
of the most infectious of all chancres, which nevertheless, under
certain circumstances, would not be inoculable.   I must remark,
however, that I have made a concession in accepting the positive
results of inoculation as weighty evidence  in the cause of justice.
I must add, that these positive results may be differently  inter-
preted, since they are pathological facts, which are not simple,  and
which may possess different  characters, for we know that there  is
no characteristic pustule, the first effect of the inoculation of chan-
cre.   In fact, there never was a characteristic pustule, and it will
be shown, in treating of the first period of chancre, that this ulcer-
ation may be  established at once (d'emblee), and  that if it is pre-
ceded by another lesion, this lesion is  sometimes a pustule, some-
times a vesicle, sometimes a bulla.   Still further, when chancres
were produced on the ape, M. Ricord declared that he could  not
there recognize a form of syphilis, unless such chancres were  fol-
lowed by consecutive accidents!  We see then what becomes of in-
oculation, even in  the opinion of M. Ricord, since, according to
his own views, the existence of chancre is not  proved until con-
secutive symptoms shall have supervened.*

   * Were a practitioner  required for medico-legal purposes to give a, positive test
of syphilis, could he comply with  such a requisition? In  corroboration  of our
authors remarks in reference to the insufficiency of inoculation, we may quote the
numerous experiments  made by Dr. Egan, at the Westmoreland Lock Hospital,
Dublin.  In his recently-published and excellent work " On Syphilitic Diseases" p.
27, he remarks that he was not unfrequently foiled in obtaining the characteristic
pustule,1 " although, from the appearance of the primary sore, and the subsequent
effects upon the constitution, conclusive evidence wa3 afforded of the contaminating
influence of the disease."  He states that every possible care and attention were
bestowed upon these experiments, and the matter was always taken before the
reparative process had commenced.  No one acquainted with Mr. Egan, can, for a
moment, doubt  his  competency or credibility. Mr.  Langston  Parker,  in  his
"Modern Treatment of Syphilitic  Diseases,"  (2d Ed. 1845,  p. 26,) very happily
expresses the true value of inoculation as a test, as follows:  " In the present state
of the 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 fol-
lowed by secondary symptoms, and are equally benefited,  under many circum-
etances, by  mercury.   In alluding to Mr. Egan's experiments we should have
observed that those made witli the matter of buboes led to the same result, viz., a
frequent failure in producing the characteristic pustule. (Vide op. cit. p. 22.)
  The physical characters of the primary ulcer are so diversified that no absolute
diagnosis can be formed from them alone  Although M Ricord (Lett. xxi. p.  162)
states that the physiognomy of the primary sore is generally so expressive that we
may recognize it at a glance, yet m Letter viii.  p. 140, as well as in his Treatise,
(ith American Ed. p. 48), he is very decided as to the impossibility of forming  a
correct opinion from the physical characters alone. For the most complete account,

  1 In discussing the question as to the existence of a  blennorrhagic virus, we shall
prove, even by M. Ricord himself, that there is no characteristic pustule.—G. C. B. 
36
INTRODUCTION.
                      INOCULATION OF ANIMALS.

     Hunter, Turnbull, MM. Ricord, Cullerier, de Castelnau, and
/   other experimenters have tried  in  vain, they assert, to inoculate
   animals with syphilis; hence they have concluded that the inocu-
   lable principle of syphilis is peculiar to man and cannot be trans-
   mitted to the brute.   M. Ricord has reduced this proposition to a
   formula, and more than all others, has labored to  defend it, relying
   upon  Hunter's experiments and his own, which, he asserts, have
   been very numerous.  Now, as regards Hunter's experiments, we
   quote his own words : " In whatever manner it  arose, it certainly
   began in the human race, as we know of no other animal that is
   capable of being infected with this poison."  In another place,
   Hunter adds : " We know of no other animal that is susceptible
   of the venereal irritation, for repeated trials have shown that it is
   impossible to give it to a dog, a bitch, or an ass."   He then subjoins
   the following  note: " I have repeatedly soaked lint in matter from
   a gonorrhoea, chancre and bubo, and introduced it into the vagina
   of bitches and of asses and under the prepuce of dogs, without pro-
   ducing any effect.   I have also made incisions   and introduced it
   under the skin, and it has produced only a common sore.  I have
   made the same experiments upon asses, with the  same result."*
     It is evident that these  experiments are  neither numerous nor
   varied, and  that the  operation here referred to by Hunter, is not
   of a very decided character.
     M. Ricord asserts that he has performed numerous experiments.
   I think that we shall search in vain for a detailed account of these
   experiments.  In his  writings, I have been able to find but the
   following passage:  "I have tried, with syphilitic pus, procured in
   every possible condition, to inoculate dogs, cats, rabbits, guinea pigs,
   and pigeons, which are said to be soon destroyed by the  absorp-
   tion of the syphilitic poison.  In no instance, notwithstanding the
   variety of the experiments, has it been possible to transmit the
   disease."  We might, without seeming too sceptical, demand some
   details as regards  the proceedings followed, in order to compare
   them with those which at the present time have produced positive
   results,  for  animals have  been  inoculated  with  success.   We
   might,  without appearing too exacting, inquire if, in this enuncia-
   tion there is that on which a law, or even a proposition, under a

   however, of the varieties presented by the external characters of a primary sore,
   we would refer the reader to the admirable lectures of Mr. S. Lane, in the London
   Lancet, for 1842, vol. xi. p. 497.  Mr. Porter proposed, as the one undeniable test
   of syphilis, the capability of the individual supposed to be affected, of transmitting
   the disease to the foetus in utero,  (Led. on Syphilis, Dub. Med. Press, leb. 24th, 1847,
   p. 114;)  but in a note on the same page he adds: "As if to destroy the possibility
   of ever establishing a test of syphilis, I have, this day, (Aug. 25th, 1846,) been
   informed, by an authority on which I place implicit reliance, of the case of a woman
   having twins;  one of the infants was deeply infected, and  the other apparently
   quite sound and healthy."  The value of mercury, a3 a test, has long since been
   settled, and need not occupy our time.  Are we not, therefore, justified in assuming
   that a positive test of syphilis remains to be discovered?—G. C. B.
     * Hunter, (by Babington, Am. Ed. pp. 20, 31.) 
INTRODUCTION.                     37
formula  somewhat absolute, could be based.  We shall  see that
M. Ricord, in admitting more recently the possibility of inoculat-
ing animals with chancre, himself annuls this law, and in so doing
makes a  breach in his own system.
   M. Cullerier has  also made  numerous experiments, which he
has been particular to relate.  These experiments were performed
in part with the assistance even of M. Auzias, and  M. Cullerier
says that he has failed.  For my part, I think that  my honorable
colleague has  not always failed.   But these experiments are de-
tailed and  published, and the  public can judge for themselves.
Almost all are negative.
   M. Auzias himself has  met  with  numerous failures;  but,  in
certain cases, he  has succeeded,  as  have MM.  Langlebert and
Diday.   The experiments of this last  physician, those of  M. Rob-
ert de Weltz, leave  no doubt  of the possibility of  transmitting
chancre to the brute ; and chancre,  according to M. Ricord,  is the
essence  of  primary syphilis.   M.  Langlebert, in  describing his
experiments to show the efficacy  of a  prophylactic,  positively
asserts:  " I scraped  the left arm  with a lancet which  had been
dipped in the same pus, the virulence of  which I had proved by
inoculating a monkey which had a perfectly developed chancre.*
I  have seen,  on the arm of M. Robert de Weltz,  a well-marked
chancre,  which was  inoculated by M. Ricord himself,  who took
the  pus  from a chancre on  a monkey.   M. Robert was already
inoculated with a chancre from pus derived from the same source.
After these results, M. Ricord presented the hardy German physi-
cian to the students who attend his course, and in  their presence
declared, " that the  experiments of M. Auzias Turenne had fully
succeeded,  and that the two ulcerations with which I was affected
were true chancres."   These are the very wards of M. Robert  de
Weltz himself, f  M. Diday also experimented; he inoculated a
cat with pus from a chancre of  the second generation on the same
animal, having applied it to the prepuce; and from this proceed-
ing resulted  a very serious  phagedenic chancre.   With the pus
from chancre, M. Diday inoculated two  rabbits on the ear, with
success; one of these chancres  became indurated.;}:  The experi-
ments of M. Diday, which are fully detailed in the journal quoted,
leave no room for doubt.
   The following is the proceeding of M.  Auzias, as described by
himself.   This physician chose the  central part of the pavilion  of^
the ear, being that possessed of the greatest vitality.  '• My place
"ofeleeTTon was the mastoid surface of the pavilion of the ear.  The
principal reasons for so doing were the following:
   " 1, The part is easy of management;  2, the animal cannot lick
it; 3, it does  not  see  our manipulations, consequently it  labors
under no fear; 4,  the cellular  tissue of this part being loose and
serous, we may easily perceive  induration, when it assumes a de-

   * A Letter addressed to the Academy of Medicine, July 22, 1851.
   f Vide De F Inoculation de la Syphilis aux Animav.x,  (extrdit de la Gazette Medi-
cate, ann. 1850.)
   f Vide Gazette Medicate de Paris,  Dec. 22, 1851. 
38
INTRODUCTION.
 cided character.  The induration, in my opinion, is the rule, and
 not  the  exception.  This is a point, the explanation  of which I
 reserve for  further consideration.  Two instruments only are re-
 quired for this operation.
   " 1.  A spatula, or some flat instrument, to take up the pus, and
 to apply it to the part to be inoculated.
   " 2.  Small scissors curved on the flat surface, and pointed.
   " I much  prefer this instrument to the lancet.  The puncture of
 the lancet excites in the animal a sudden movement, which it is
 important for the precision of the operation, and the security of
 the operator to avoid.  The animal, on the contrary, appears not
 to feel the  action of the  scissors, which, besides, we  are always
 able to control.
   "If the animal is troublesome1, I have it held, while  I shave the
 part selected,  to  the  extent required.   The excision  of the  hair
 with the  curved scissors is a still more simple proceeding.   The
 following is  the operation:
   " With the point of the scissors, I remove the epidermis to the
 extent of two-fifths of a line.  The  more superficial the  incision,
 provided  the  epidermis is excised,  the better  the operation  suc-
 ceeds.  If blood  is drawn, I consider its  success compromised,
 and I repeat the operation in another place.   Sometimes I make
 several sections at certain distances from each other.
   " On the denuded portion of the dermis, I deposit the pus from
 a chancre, either pure,  or mixed with a small quantity of saliva.
   " 3. For a minute I keep the part  moist, either by means of the
pus or  saliva; • at the same time I rub with a blunt instrument the
periphery of the part.
   " In the next place, I abandon the animal to itself.
   " I never fear  mixing the pus with saliva, whenever it is not
sufficiently abundant to carry it away.   The  important point is,
that  a certain degree of humidity prevents the coagulation of the
fluids, by which the virus would become imprisoned.
   " The day after this trifling operation, a pimple appears at the
 oint inoculated. On the next a vesicle, which, in twenty-four hours,
 ecomes  converted into a pustule.   These phenomena, perfectly
regular, require more or less time for their production.  Finally,
the perfection of this evolution is a chancre covered with a crust
or scab.  This chancre becomes round, excavated, and increases
in extent: a pus, abundant in quantity and of a deep color, raises
the scab, and  the  epidermis to a certain distance from the scab.
The adjoining skin is hot, red, and tumefied.  The abundance of
the pus, which occupies and irritates the parts,  induces the animal
to scratch itself, and this fluid passes under the edges of the scab
which  it raises and detaches.   As soon as a certain quantity has
escaped, the parts are rendered  less tense.  The edges of the scab
become glued again, or if it has been  carried away, a new scab is
formed.  The  epidermis retracts, and shrinks concentrically to the
chancre, and is detached by pellicles.   The chancre then progresses
for several  days, and the order of the latter phenomena (I mean
 those which follow the  pustule) is  reoeated several times.   The 
INTRODUCTION.
39
ulceration is finally arrested; it gradually diminishes in size, and
at length disappears, having constantly retained the physiognomy
and characteristics of chancre of the skin."
  M. Ricord has  entertained several  opinions  on the results of
inoculation in animals, as he has upon  almost  all the important
questions in syphilography.  At first he denied the results, then
he admitted and  proclaimed in full  clinique the success of M.
Auzias.  But soon retracing his steps,  and finding the theory of
transplantation already made by M. Cullerier, he  seizes upon it,
without  claiming aught of the invention, showing  for once the
good sense of my colleague.   According  to this hypothesis, the
ulceration produced on the animal was not specific; it was a wound
like any other in which virulent  pus is deposited;  only it is  a
soil, in which it cannot germinate"; it may germinate when trans-
planted into  another soil, such as that  furnished by the human
system.  I should add, that I have myself heard M. Ricord aban-
don this theory, an  act which  has greatly amused M. Malgaigne.
Now, indeed, M. Ricord admits chancre in the brute, that is, pri-
mary syphilis, but not the consecutive  disease.   Thus, then, we
behold a law abrogated even by the legislator himself.*
   We may here  insert with  propriety part of a discourse pro-
nounced by M. Malgaigne  before the Academy of Medicine dur-
ing  the  discussion  of the subject of syphilization, a discourse
which, as  has been  remarked, formed  an event,   M. Malgaigne
produced  a profound sensation, especially when he  attacked the
system of M. Ricord.  The friendship which for twenty years had
united these academicians, and the well-merited eulogies which,
 on  several occasions, had* been  mutually pronounced on  each
 other, were  known.   M.  Malgaigne  could not therefore be sus-
 pected of anything like hostile  feelings.   Now,  listen to the words
 of this eloquent  professor: " Often had I seen  the  doctrine of M.
 Ricord vigorously attacked; and often these attacks had revived
 my doubts; never had  I  seen him  conquered, forced to beat a
 retreat, still less to surrender.   That  time, gentlemen, has arrived.
 One of the doctrinal points of M. Ricord  is that syphilis belongs
 exclusively to man, that it cannot be  communicated to animals.
 I will not go back  to  the  first experiments of M. Auzias: for a
 long  time their  results were  denied; I myself plead guilty to a
 part of this injustice.  On another occasion I have said, When
 we have  produced  chancres in the  monkey,  what  then?   Such
 prejudice, gentlemen, is to be regretted; a fact is a fact, though it
 may remain for a long time unapplied ; but most frequently this
 apparent  inutility but proves our ignorance of its relations.   For
 myself,  I have already stated, this fact is henceforth incontestable.
 In  listening to  the  discourse  of  M.  Ricord, I could not discover

   * We are informed by M. Sperino, in his recently-published work (1853) on
  " Si/phiUzation," p. 27, that M. Sigmund, of Vienna, has successfully inoculated
  warm-blooded animals, and  that in the dog, rabbit, and horse, the primary acci-
  dents were followed by a syphilitic  eruption.  On the  same page, he gives the
  details of a case in which he himself successfully inoculated the horie.  This
  question would, therefore, seem to be definitely settled.—G. C. B. 
40                     INTRODUCTION.
whether he admitted or rejected it.  (M. Ricord: / admit it.)  I
am then most happy to find myself once more in unison with him.
But if he admits it, should he not spare those sarcastics attacks by
the aid of  which he  seems  to struggle against his own true con-
victions, and to cease to bring forward still that strange theory of
transplantation, which, in eccentricity surely, does not yield to
any among the advocates of syphilization.
  " This fact, so puerile in appearance, was the first breach in the
system of M. Ricord.  For the first time, he was conquered, and,
mark it well, he now found himself attacked with the same weapon
which had so often enabled him to conquer, viz., experiment!'
                       SYPHILIZATION.

  I shall not repeat the declamations  which have been made
against syphilization.   I will not defend it.  I shall attempt only
to ascertain  whether, from all this agitation, from all the experi-
ments to which syphilization has given  rise, some facts  have not
been elicited,  some light been shed, by which  the advance of
science may be promoted.
  According to M.  Auzias, " Syphilization  is a condition of the
organism, in which, owing to a kind of saturation, the phenomena
of syphilis can no longer be evolved.  This same experimenter
employs the word syphilisme to denote the capability of being
syphilized;  we may say, for example, of an individual, that the
degree of syphilism which he possesses, is  in proportion to the
facility with which he may be syphilized."  I copy literally from
M. Auzias.
  Syphilization is produced by inoculating a certain number of
chancres, which perform the part of the vaccine pustule ; they
vaccinate them, that is, they produce an exemption from syphilis.
Starting from this  hypothesis, chancres have been given to sound
individuals with a prophylactic end, to exempt them  from the
liability, not only of primitive, but consecutive accidents.  Then
the syphilizers, having imagined that " the syphilitic virus was the
best remedy against the action of the syphilitic virus," they have
proposed to syphilize, that is, to inoculate chancres with a thera-
peutic end, to cure syphilis, both primitive and consecutive.  This
double application  of syphilization has been  particularly defended
by MM. Auzias and  Sperino.  M. Marchal confines himself to a
recommendation of curative syphilization.
  M. Diday  has invented another vaccination.  Believing in the
unity of syphilis, he would subject it to the same laws which gov-
ern variola,  rubeola, &c,  by which a person can be affected but
once 'during life, and the surgeon  of Lyons  has inoculated not
only chancre,  but  the blood of individuals in the last  stages of
syphilis, or rather,  who are laboring under a constitutional condi-
tion which will no longer tolerate the  syphilitic action.  The first
system, that of the inoculation of chancre, has  roused the pas-
sions and the indignation of learned societies and the press.  The 
INTRODUCTION.
41
second, that of vaccination with the blood of a patient  affected
with tertiary  symptoms, has  been regarded as the dream of an
honest man, and has been passed over in silence.*  Even before
the sixteenth century, the consoling idea was entertained of the
disappearance of syphilis, by the exhaustion of the  virus, or the
saturation  of  the  human race.   Thus the  universal syphilization
which  this good  M. Auzias would now realize,  was long since
announced to us.   In  the work of Astruc we may find this opin-
ion often expressed: "The venereal disease, having had a begin-
ning, should have an end."  It is known that  Astruc  was  an
advocate of the modern origin of syphilis.  What is regarded as
being  favorable to this  author's opinion is, that time diminishes
the virulence of syphilis, which at present is more benign  than it
was formerly.  Its effects being really less deplorable than at the
end of the fifteenth century, hopes  were  therefore indulged of its
complete extinction.  But, to share in this hope, and to adopt the
hypothesis of Astruc, we must  also accept his erroneous opinion
on the origin of the disease; for, if it be really of ancient origin,
the question changes, as it has lost nothing of its force in descend-
ing towards us; on the contrary, at certain  epochs it has assumed
an aggravated form, particularly during  the close of the fifteenth
century.
   After the idea of universal saturation  followed that of the satu-
ration of  certain  nations; and I will  soon  show  that the human
race may  be  both partially and  generally saturated.  Swediaur
among modern writers'has most clearly expressed this idea of the
saturation or syphilization of certain nations.  Thus, according to
his views, the virus imported into a country yet uncontaminated,
whatever its climate may be, produces at first very violent effects
upon  its population;  effects  which gradually diminish,  because
the people become more or  less saturated: the  disease  loses its
violence.  But, he justly observes, if  a  foreign people invade a
country in progress of syph ilizaUon, its victory is dearly purchased.
Thus  the Portuguese became gradually  syphilized by long famili-
arity with the disease, and  yet they transmitted it to the English
invaders in all its virulence.
   These facts when not closely examined, and whilst yet in their
rough state, seem favorable to the modern doctrine  of syphiliza-
tion.  But the question here arises, are there  countries free from
syphilis.  The varieties  produced by difference of climate and of
regimen, in the manifestations of the disease, will hereafter be no-
ticed.   Thus, an army in a foreign land  always suffers more than
the natives, from the diseases  of the country, and generally it
finds  less  assistance, is less acquainted with the means of protec-
tion, and the best modes of treatment;  hence the aggravation of
the symptoms, by which attention is most directed  to the strangers.
The natives, on the other hand,  more easily escape observation.
The treatment followed, and the malady itself exhibiting less vir-
ulence in them, excite but little notice.
* Vide my Lettres sur les Inoculations Syphilitiques. 
42                     INTRODUCTION.
 /  However, I would not absolutely deny the  syphilization  even
f of a  people, for analogy, from the truth remote, sanctions its ad-
V mission.  There are natural facts respecting the saturation of soils,
  which may daily be observed; thus, seed committed to the  same
  soil for two successive years begins to degenerate;  if it be not
  changed, if the soil be  not  allowed to rest,  the results are hybrid
  and even naught, for the seed will not germinate.  But let the soil
  rest, and  in the language of the  agriculturist, let it lie fallow for
  some years, then we  shall find that the same seed which the soil
  refused, germinates better than before.
    It  may be the same with the organism, which becomes insensi-
  ble to a poison, to which as it were it has been accustomed, and
  which, after a certain repose, will not be the less susceptible to the
  influence of the same poison.   We find, therefore, that saturation
  considered in the most  general manner, presents characters which
  are neither  definite, nor absolute.  As the  soil which permits
  not the germination of one kind of grain,  shows itself favorable
  to that of another, it  is  possible that the organism insensible
  to one virus  or one quality of virus, may be affected by another
  kind.  Thus, if there were  several kinds of virus, the question of
  syphilization would be much less complicated, much less obscure,
  than it is according to the hypothesis of a single virus, which leaves
  it in very great perplexity.
    Instead of inveighing furiously against the advocates of syphi-
  lization, I have observed, with  their hypotheses in view, in  order
  that  I might decide coolly  and philosophically.   Now, a fact
  which in my opinion is unquestionable, is the syphilization of a
  certain sphere; in fine, local syphilization.  Thus,  I have seen a
  very active chancre on the summit of the glans spread the pus
  which it secreted over the  rest of the organ, bathe the whole pre-
/ pnce which was much elongated, and yet these parts were not in-
/ oculated.   This same  pus  imbrued the penis and  the  scrotum,
  which resisted its action.  But one day there appeared on the su-
  perior and  internal part  of the  thigh, a well-marked chancre
  which furnished an inoculable pus.  It was produced by the end
  of the penis which several times rested in contact with this part
  of the thigh.  Thus, the same pus which on the genital organs
  was  inert, had inoculated the thigh.   The genital sphere was here
  syphilized, in other words, it was under the influence of a vital re-
  action, which resisted the extension of the  ulceration on the sum-
  mit of the  glans, as well as the  production of other  chancres.  It
  was thesame prophylactic power that prevented M.  Sperino from
  prolonging the ulcerative stage of a chancre by the application for
  six days of virulent pus, because it was in the reparative  stage.
  This  kind of local syphilization must,  in  all cases,  be admitted,
  otherwise every chancre  would increase  indefinitely, it  would
  know no limits.   The  more decided this  local syphilization, the
  more limited the chancre; phagedenic ulceration shows the ab-
  sence in a  certain sphere of this syphilization.  But let it not be
  supposed, on this account, that  syphilization is permanent.   These
  same parts, this  same  sphere,  which in the patient  above  men- 
                        INTRODUCTION.                      43

tioned could not be inoculated by the pus of the chancre on the
summit of the glans, became so one  month afterwards from an
impure coitus.  This patient, in fact, left the hospital cured of his
first chancre; but,  in one month, after a single connection,  re-
turned with three chancres on the prepuce, of which one was three
times the size of that of the former one on the glans.  Here we find
a part at one time effectually resisting the action of the virus with
which it was in contact, and yet at a later period, becoming inocu-
lated with several chancres from a single coitus!   This case fur-
nishes one of the strongest proofs of the possibility of local syphi-
lization, but at the same time, a proof of the short duration  of
the immunity produced by it.  The case proves  also that  second
chancres may be more numerous, and larger than the first, con-
trary to the opinion which has been entertained, that the  ulcera-
tion of chancre becomes  more limited in extent,  in  proportion to
the frequency of its occurrence.
  Had these facts in local syphilization been known by those ex-
perimenters who have inoculated  subjects that  presented them-
selves as  individuals who had been syphilized, they would  have
applied their lancets to some point remote from the sphere already
inoculated, and would thus have avoided some mistakes to which
they have appeared very sensitive.
  It .will be  perceived, that by greatly multiplying chancres in
several different regions, we may arrive at a general syphilization.
This effect  may even be obtained  by  inoculations less numerous
and limited to one or two regions ; thus, it is evident that  M. La-
val * was completely syphilized by inoculations  practised on the
superior extremities.
  Those who have followed the discussions in  the Academy on
syphilization,  know that the case of M. Laval has been  differently
interpreted.   This young confrere  has served for the battle-field
between M. Auzias  and M. Ricord.  More than two hundred spec-
tators have witnessed this contest;  it has been fought, as is always
agreeable to M. Ricord, coram populo, and yet we  know not who
has been the victor !  But of one thing I am perfectly convinced,
viz. that M. Laval has been inoculated  by our honorable colleague,
M.  Gosselin, and that too with pus which readily produced chan-
cres on a woman at the Lourcine affected  with syphilis, whom
they proposed to treat by syphilization.   Now, this same pus  re-
mained impotent, inert, when it was inserted beneath the skin of
M.  Laval, and this too,  after three inoculations.  This fact was
communicated to me by M. Gosselin himself, and I believe  it as
fully as though I myself had performed the experiment; for, be-
sides his knowledge and integrity, this colleague cannot be accused
of b.ung a partisan of syphilization, since the  only  part which he
took in the debates, was to give publicity to a  fact which is unfa-
vorable to the system.  Indeed,  M. Gosselin  has published the
cas." of this same woman on whom he succeeded in inoculating

  •  M. Laval, now a doctor in Medicine, was syphilized whilst he was a student;
and  he defended a Thesis on the subject of syphilid.lion. 
44
INTRODUCTION.
chancres, and he has shown that her disease only increased during
these inoculations.                                          .
  It mavbe answered, that if the fact of the patients system being
already infected  is unfavorable to  curative syphilization, that of
M. Laval is decidedly in favor of prophylactic syphilization. But a
distinction must be made between temporary and permanent im-
munity.  For example, this same confrere, M. Laval, who with im-
punity defied the lancet of MM. Ricord, Gosselin, and other experi-
menters, has at length been lately inoculated with success, at least
M. Ricord has so stated to the whole Academy.   And here I have
no hesitation in believing M. Ricord, for the fact which he has re-
lated, was under my own observation.   Perhaps what I have men-
tioned respecting the saturation of the soil, when the same seed has
several times been sown upon it, may be recollected ;  in that case
it produces only hybrids,  and  ends by refusing all germination.
But, after a certain period of repose, this same soil is no less favor-
able to the germination of the seed, than it was before inert.  I be-
lieve therefore that the system of M. Laval had been placed in the
same condition as the soil of which  I have spoken: after the labors
of M.  Auzias with the lancet, it yielded only hybrid products,
pustules which never became chancres; then it became totaly bar-
ren.   But after a certain period of repose,  M. Laval's system be-
came like that of most men,  susceptible to the action of the virus.
I have said, like that of most men, and not of  all, because in cer-
tain  subjects there may exist an immunity, natural or acquired, as
is the case with other morbid poisons.
  The fact, that persons are often exposed with impunity to syph-
ilitic contagion, is known, though in a vague manner, to every prac-
titioner.  I will  here particularize one which  at the  time made
a strong impression on my mind.
  A man who acted a certain part in the revolutions of 1830 and
1848 (he is known to many of my confreres who ^in^led in the de-
bate on s}rphilization), had a  remarkably fine and robust constitu-
tion.  He was a great libertine, and not at all particular with what
females he had connection.   lie never, however, became infected,
as was frequently the case with his friends who had intercourse
with the same woman, for I was often called upon to treat them.
Having became  acquainted with the fact, and knowing well this
brazen  man, as  he  was called,  it happened that I attended two
flower-girls  with whom he  had had habitual  connection, which
girls had inoculated other persons.   They both had chancres.  I
sought no further  proof, and  believed in  this man's immunity.
However, he made  his boasts  that he could not catch the pox;
some one offered to  give it to him provided that he would consent
to submit to a trifling experiment, a proposition which he at once
accepted ; two inoculations were made on his arm with pus taken
from a chancre then in a progressive state, but without effect, abso-
lutely without any result whatever.
  Here then was a natural immunity resembling that produced in
M. Laval, and still  more  complete, for Mr. Laval was subjected
only to experimental inoculation, whilst this person was exposed to 
INTRODUCTION.
45
physiological inoculation, to true contagion.   But time may work
a change in this man's constitution, or from  circumstances impos-
sible now to  be appreciated, he may become as vulnerable  as M.
Laval.
  Thus the fact of a temporary immunity, established by observa-
tion, and by experiment, is of importance, especially from its bearing
on that system  in syphilography which is based upon inoculation.
  We  may here with propriety insert an extract from the discourse
of M. Malgaigne pronounced before the Academy of Medicine, on
the question of syphilization.   M. Malgaigne, alluding to the natu-
ral  immunity possessed by certain  individuals, proceeds : " Now,
can this immunity be artificially produced?   Henceforth, the  reply
to this question  cannot be in the negative; and I am surprised
that the orators on the part of the commission, should have thrown
so entirely into the shade, a fact of such capital importance.   You
remember  the  case of the patient  of M. Marchal (de Calvi); he
presented this  condition of immunity.  How rapidly M. Ricord
passed over this subject!  The patient of M. Telaschi, so often re-
ferred to, had acquired the same immunity: neither M. Ricord nor
M. Begin have  noticed it; their attention was called to it by M. de
Castelnau, who, however, can  never be ranked among the parti-
sans of syphilization.  And then  there is the  case of M. Laval.
We shall come to that in a moment gentleman, but I must reply
to a previous objection.
  " Supposing  the fact to be  well demonstrated, after all  what
consequence is  it ?  Those who propose such a question cannot be
very thoroughly acquainted with the actual state of the science on
this subject.  I  have briefly pointed out some of the most important
doctrines of M.  Ricord; for the most part, gentlemen, they rest at a
greater or less distance, on a common basis, that is, inoculation limit-
ed to the pus of chancre, and the impossibility of resisting the action
of this pus.  Here are no circumlocutions, no doubtful expressions.
The pus of chancre, says M.  Ricord, is inevitably inoculable.   The
matter of variola and vaccina finds those who absolutely resist its
action, the pus of chancre none.  This doctrine he has admirably
expressed by a kind of aphorism so forcible in its conciseness. All
men are equal before chancre.  It was, as you will  observe, a  kind
of political constitution which he imposed upon syphilis, it was his
constitutional chaiL                                          «
  " Now, behold, fff a certain day, he is startled by a revolution-
ary  fact, which suddently  breaks  down  this promised equality,
rends his chart, and subjects his patients to other laws.  I can well
understand then gentlemen, why this legislator has resisted this
new fact: I appreciate his warlike ardor; I comprehend why he
would have his battle of Saltzbach, and why before this tribunal
he has attempted, to use his  own words, a new campaign in  Italy.
This resistance, moreover, was not shown during the discussion
which  really drew forth this  fact.   At the first announcement of
the threatening immunity, he entered his protest, and the amphi-
theatre of the Iwpital du Midi re-echoed his defiance, his challenges.
Besides, it was for its verification that he provoked his adversaries. 
46
INTRODUCTION.
 'I wait,' he remarked,  'that they may show me  an individual
 syphilized  and insusceptible of the action of the virus, who will
 go before the clinique of the hvpital du Midi, and defy me in camp
 with weapons of my choice /'
  " This challenge was repeated on the 12th August by the Union
 Mcdicale.  On the 22d Aug. M. Auzias accepted it; on the 23d
 Sept. M. Ricord declared that he was waiting.   The Editor of the
 Union Medicate exclaimed:  Facts, facts/ give us, rather than theo-
 ries !   And then, gentlemen, then the 4th  November M. Ricord
 proclaimed that  the  experiments had  been commenced, and that
 the result would be communicated to the journal.   Search it well,
 and this communication cannot be found.   Eight days afterwards
 M. Ricord presented M. L. to the Surgical Society, and on the 18th
 November to the Academy of Medicine.  But not one word about
 the experiments.  On the 20th, M. Latour gave the case of M. L.
 as the only public and authentic experiment then known.  As if
 to break this silence, on the 9th  December M. Marchal wrote to
 the Gazette dcs Ilupitaux that M. Laval had presented  himself to M.
 Ricord, that the latter had made on him, at two different localities, seven
 punctures, and had inserted three kinds of pus, of undoubted virulence,
 without any results.  M. Ricord made no reply; the  Union Medicate
 lisped not a word. You are aware that the report of the commit-
 tee maintained the same silence.
  "For myself,  gentlemen, this silence amounts to a defeat, and
 yet, I should have preferred a frank and public acknowledgment.
 For  this reason I have provoked explanations upon this point.
 They have come from various sources;  I will not dwell upon them;
 I wish to speak of M. Ricord.  And what has  he told us ?  That
 he produced on M. Laval an ecthymatous pustule so well marked
 as to require no counter proof, and that  the other inoculations
 which had failed on the person syphilized, had also failed on those
 from whom the matter was taken.   No other  details.  M. Ricord
 declared that he  should be wanting in dignity to say more.  This
 course,  gentlemen, does  not satisfy me.  What connection can
 there be between M.  Ricord's dignity and the details of an experi-
 ment?  In all, from his own admission, on his own ground, in
 camp, and with, weapons of his choice, he succeeded  but once in
seven inoculations.   But other  patients were equally refractory,
thus showing that his  pus was not good.   Who could have be-
lieved, gentlemen, that  M. Ricord, after so  sTflemn a defiance, in
his vast field, would be under the necessity of saying that he could
not find good pus ?  But, at last, an  inoculation has succeeded.
Succeeded! when you  yourself, sir, have not  made  the counter-
proof which on  all occasions you declare to be indispensable, in
order to know that the pus produced  can  be re-inoculated.  For
my own part, gentlemen, I consider this acquired immunity in
certain persons as proved, demonstrated, and incontestable.  If
 M. Ricord still has doubts upon the subject, I pledge myself to fur-
nish him with all the  elements required for  conviction.   If the
committee consent to witness the experiments, I pledge my honor
to bring forward a young man who professes to be syphilized and 
INTRODUCTION.                      47
who defies M. Ricord to produce on him a single atom of inocula-
ble pus.   M. Ricord shall take his precautions; and if he fails the
first time, he  can try again; my subject declares his readiness to
submit to twelve hundred inoculations, and even more if it be re-
quired.   Now I trust that  no person will deny  the facts without
subjecting it to  the test.  Here, then, is a truth of capital import-
ance elicited  by this discussion.   You  have read  the  excellent
treatise of M.  Ricord on syphilitic inoculation; you have seen the
valuable results which he has obtained in diagnosis, prognosis, and
therapeutics;  you will  recall to mind his nice deductions in legal
medicine; all these are shaken, all totter when chancre is no longer
fatally inoculable; diagnosis becomes uncertain,  prognosis decep-
tive, and treatment doubtful; above all, can legal medicine, which
requires  absolute  certainty, longer dare  to trust, as heretofore, to
inoculation?  These  remarks apply directly to  primary syphilis
only; there is reason to  apprehend that the system is soon to suffer
another check as regards constitutional syphilis."*
   This part of M. Malgaigne's discourse produced a profound sen-
sation.   M. Castelnau, who,  in the  Gazette des Hopitaux,  had
warmly  defended M.  Ricord, in this contest with the partisans of
syphilization, in  the  same journal addressed a  letter to M. Mal-
gaigne,   in which we find  the  following passage,  showing  some
modification  in his views:  "Yes, you have had reason to insist
upon the fact that the pus of chancre is not fatally inoculable, even
when it  is contagious, and that certain individuals,  either from ac-
cident or idiosyncrasy,  are  not  susceptible of its action; you had
reason to proclaim boldly that this is a fact of capital importance,
subverting, as it does,  the ingenious scaffolding  of our illustrious
confrere, M.  Ricord."  (Gazette des Hopitaux, Aug. 26th, 1852.)
This is the result of the efforts made to establish an imaginary sys-
tem* ; the object could not be accomplished, but another resting
upon a false basis has been overthrown.  It is not the first instance
in which the  object sought has not  been found, but in its place
something of more value has been discovered.
   Again, to justify prophylactic syphilization, we must first es- \
tablish the unity of the syphilitic virus, and the necessity of sub-  I
jecting the organism to this saturation; it is necessary, in fine, that
the analogy  between syphilis  and variola should be complete.
Now, in the second part of this work, we shall find the experiment-
al and logical proof of  the possibility of several  attacks of consti-
tutional  syphilis.  Of this we may become convinced by what has
been said of  the  temporary saturation of the system, and of the
susceptibility which it again acquires of being infected by the dis-
ease. Thus, as I have  already stated, the person whom we would
syphilize may really have  the malady that  we would give him,
and that which  he might otherwise contract.  That syphilis will
inevitably follow contagion is far from being established.  On the
contrary, it has been found that the half of those most exposed
escape, a fact observed  by Parent Duchatelet.  It would therefore
• Bulletin de I'Academie de Medecine, t xvii. p. 1046. 
48                      INTRODUCTION.
be irrational and inhuman to give positively to an individual a
disease to protect him from that to which he is not fatally con-
demned.  Prophylactic syphilization,  therefore,  is  an irrational
project.
   As to curative syphilization, I have earefully examined the ar-
guments adduced pro et contra, and in  my estimation they are yet
insufficient  to  decide  the question.    For example, M. Telaschi
treated a phagedenic chancre, which,.it is asserted, had been ag-
gravated  by cauterization.  It was of thirty-six days' duration.
Nineteen  inoculations were made, yet the chancre continued to
progress.   An  eruption and osteocopes supervened.  M. Sperino,
a surgeon of note, and well  versed in this subject, directed a re-
newal of the inoculations.  In the course of eight days forty-three
of these were made.   On the twelfth day, the progress of the erup-
tion was arrested, and the pains had diminished.  On the seven-
teenth, the pain had increased; the chancre began to cicatrize, and
in less than two months the cure was  complete. t This is  the re-
port of the case as presented  by the partisans "of  syphilization.
Observe, it is that of a chancre which in two months became cica-
trized, of a syphilide which was arrested, and of osteocopes which
were mitigated, all of which might have occurred in the complete
absence of treatment.   I do not regard this, with M. Ricord, as a
lamentable case, but it  certainly deserves not to be called admira-
ble, as some advocates of syphilization would seem to imagine.
That furnished by M. Marchal (de  Calvi) of a  patient who had
been for a long time diseased, and who had taken iodide of potas-
sium and mercury without benefit, was one of tubercular ulcera-
tion of the tongue, was improved in four or five days by  inocula-
tion, and seems to me worthy of attention.  But the occurrence of
spontaneous and even rapid cures after the discontinuance of all
treatment, greatly modifies the importance of this case.  It should
be observed, besides, that this patient was not cured, as there was
a relapse.
  In another part of this work, we have recorded the remarkable
case of a barber,  affected with a consecutive ulceration, which
involved nearly the whole external surface of the inferior extremity.
Every effort was  made to  arrest  and to  cure  this painful and
debilitating ulcer.   Combinations of mercury, iodine and iron, cod
liver oil, and different topical applications, were  tried in vain.   It
was then proposed to syphilize this patient.  I replied that he had
sufficiently syphilized  himself, and  I applied narrow bands  of
emplastrum, "de vigo" plasters, folding them one over another, as
in the method  of  dressing par occlusion, and in less than a month
this patient was cured.  This fortunate result may fairly be attrib-
uted to the absorption, by a large surface, of the mercury con-
tained in the plaster.*   But perhaps  it may be  said that  in this
instance the reparative stage of the ulcer had  arrived, that  the
system was in  a condition to react  effectively, and that nature
alone had effected a cure.  Had I syphilized this patient he would
* Something similar to the Emp. ammon. cum hydrarg.__G. C. B. 
INTRODUCTION.
49
have been cured; it may be a little less rapidly, but still he would
have been cured;  ana  then!—From what  I  have stated the
reader may surmise my views on the so-called lamentable cases of
syphilization, which cases may have been unfortunate, independent
of syphilization.  Thus  M. Laval, whose name is so frequently
mentioned in  this work, this German physician, who has  been
pronounced the victim of syphilization, became infected from the
matter of a consecutive accident in one of his confreres.  After the
inoculation a papular eruption  appeared, which he desired  to be
treated by the successive  inoculations  of several varieties  of
chancrous pus.  In this manner he produced on himself an infinite
number of chancres.   The  progress of his disease, however, was
not  arrested, as would probably have been  the  case  had he not
been inoculated, and especially if he had followed no plan of treat-
ment.   The facts yet produced by this prophylactic or  curative
syphilization are far from entitling it to a  place in medical science,
but  may be of real value in assisting to  destroy a system resting
on a false basis.*
          TRANSMISSIBILITY OF SECONDARY ACCIDENTS.

  This question,  viewed in connection with  public or private
hygiene,  is one of vast importance; it presents itself daily in
ordinary practice, and not unfrequently  in courts of justice.   Re-
garded purely in its scientific bearings, it  is one of the most interest-
ing in etiology.
  The earlier writers on syphilis believed that the disease might!
be communicated by everything which surrounds, and by all that!
is within man; thus, they  supposed that the  atmosphere, every)
emanation of  the body, the breath,  perspiration, the natural ori
morbid secretions, the blood, in fine that anything might serve as
a vehicle for the poison.  Syphilis was  regarded as an epidemic,
and capable of being propagated in every possible manner.  With
such views, they must  have admitted for facte fictions, sometimes
absurd, as for  example, that it might be communicated through
the  grates of a confessional, by the perfume  of a bouquet, and a
minister was actually put to death, because, knowing that he had
the disease, he had dared, nevertheless, to breathe  into the ear of
the king.
  The absurdity of such notions  was early discovered, and it was
exposed even by Fernel; at a later period they were attacked, and

  *  The Treatise of M. Sperino, to which we  have already alluded, contains the
results of some 94 cases of syphilization, performed for curative purposes, which
results this surgeon regards as highly favorable to the practice.  Permission having
been granted by the Government to institute a series of experiments on this subject,
M. Sperino, who is at the head of the venereal  hospital at Turin, immediately
availed himself of the means at his disposal, and in his elaborate work, the reader
interested  in this matter will find copious  details. Fifty-three of these 94 cases
were primary syphilis, the remainder being constitutional  syphilis.  Fifty of the
former, and twenty-five of the latter cases  are reported as cured!  But we must
refer the reader to the work itself,  and will  only add that syphilization, as yet, has
found but few if any advocates either in Great Britain or this country.—G. C. B.
                             4 
50                     INTRODUCTION.
in our own day tne truth has been revealed.   Not only has the
idea of an epidemic and fantastic  contagion been  abandoned, but
some  have gone so far as to admit but one mode of propagation,
but one vehicle of the poison, viz. the pus of chancre.   Thus, the
atmosphere, the human breath, and perspiration are very properly
no longer regarded as the mediums of propagating the poison, but
with these some would include the blood, the  normal secretions,
as well as those  that are morbid, except pus, a question which is
by no means settled, as Hunter and his disciples would seem to
believe.  According to M.  Ricord, who  has  given an absolute
character to the doctrines of his  master, infection can occur only
from the matter secreted by a chancre, which  matter  alone is the
medium of the virus; the latter can enter the system only by a
chancre, and its infecting properties do not reach beyond the first
lymphatic ganglion in direct relation with the chancrous surface.
Beyond this ganglion, the virus  may  still injuriously affect the
individual  inoculated, producing secondary symptoms,  such as
pustules  and syphilitic ulcers over his body, but can  do no harm
to others, as it no longer exists as a contagious agent.   Of course,
if but one individual could be found, whose chancres had cicatrized,
but who was still covered with ulcers  and pustules, who,  in fine,
was completely saturated with syphilis, the disease would die with
him, he could not communicate it to those thrown into contact the
most frequent, intimate and prolonged, and the syphilization of the
world  would then  be complete!   This is the latest doctrine
advanced by the disciples of Hunter.   But a grave and incontest-
able fact here presents itself, it is that of the infection  of the child
in its  mother's womb, a fact admitted by all syphilographers.  It is
unquestionable, that a woman, having  neither chancre nor bubo,
but that form of syphilis only, which it is asserted,  can no longer
be infectious,  may give birth to syphilitic children,  which may
infect their nurses, whilst the latter, in turn, may communicate the
disease to their families.  This is the  same syphilis  that should
have  disappeared with the cicatrization of the last chancre, but
which here reappears and recommences its ravages.  The principle
of contagion may therefore exist elsewhere than in  the  pus of
chancre,  and other than the primary ulceration.
  Analogy could not fail to seize upon a fact so widely known, and
should have led to its admission, since, even after the cicatrization
of a chancre, the system may still contain an  infectious principle
capable of being transmitted to another being;  by multiplying the
relations,  diversifying  the experiments, and employing difterent
humors, we may expect to prove the transmissibility of syphilitic
accidents independent of chancre or its products.   Observation
here confirming analogy should  have anticipated the results of
experiment, and, doubtless, in any other epoch than  the present,
would have rendered it unnecessary, for the instances  of the infec-
tion of the nurse by the child, which is seldom affected with  other
than  secondary accidents,  are  exceedingly numerous, and MM.
Bouchacourt and Bardinet de Limoges, have recently  reported cases
with details so precise as to leave no room for doubt.   Again  the 
INTRODUCTION.
51
transmissibility of the mucous tubercle by means of intimate rela-
tions and contact is generally admitted.   On this subject the works
of MM. Lagneau, Baumes, Cazenave, Gibert, and of other unpreju-
diced observers, may be consulted.  Among  the  patients which
come under the practitioner's care, opportunities  will occur, if the
two be treated together, of seeing the mucous  tubercle in both, in
its different stages of origin, seat, and  isolation from  other acci-
dents, thus removing all doubts of its  contagious character.  In
another place I shall appeal to M. Ricord himself.  We shall find
that he admits the infection of the  nurse by  the  child,* and the
contagiousness  of the  mucous tubercle in the  adult,  but, as he
expresses himself in his Treatise, it is by some incomprehensible
vital  process.f   He admits contagion only, that is, physiological
inoculation, and still denies the fact of experimental inoculation.
   As it is chiefly with contagion itself that we  are now concerned,
and not with this or that method of it, in my opinion the question
is settled by M. Ricord's own admission, and for this reason, I am
the more astonished that he still persists in opposing my views.
Thus, the clinical fact is known  even  to my  opponent, that sec-
ondary accidents  are contagious, since  M. Ricord acknowledges
the contagion of the mucous tubercle, an accident which he classes
among those regarded by him as secondary.  It remained, how-
ever, to establish the fact by experiment, a  matter of importance
in an age so given to experiment. I cannot too  often repeat, that
for those whose minds have been trained to observation and legit-
imate induction, the question needed no experimental proof.  But
for the school, especially as it was not long ago, we were compelled
to descend to experiment.  I  have experimented, and for the first
time in France, have succeeded in inoculating the pustule of sec-
ondary ecthyma.
   At the simple announcement of this result,  whilst the case was
still in my cartons, the attacks commenced, and they were directed
chiefly against the experimenter. I saw the position in which
they would place me, and for  a long time I submitted in  silence,
knowing that sooner or  later the end would come, and I continued
to observe, to experiment.  During  this period, men of indepen-
dent minds, whose attention had been  awakened  to the subject,
also  observed and experimented; they were attacked in the same
manner.  In the body of this work may be  found, indeed, an  ac-
count of observations made in Paris, and in Germany, observa-
tions which accord entirely with my own.  These formed the basis
of an essay which I read to the surgical society, and which drew
forth a discussion.  At a later period, a German physician was
presented to the  Academy of Medicine, who had inoculated him-
self with a consecutive affection ;  this gave rise to another discuss-
ion, the results of which, in the estimation of  every unprejudiced
person, must have been a condemnation of the doctrines I op-
pose.

          * Vid. section of this work on Infantile Syphilis, p.
          f Vid. p. 182, of M. Ricord's Treatise. 
52                      INTRODUCTION.
  Objections have been made to the  small number of facts which
experimentally prove the transmissibility of the secondary aeei-
dents.   It  has been stated, especially by *M. Ricord, that if these
accidents can be  inoculated once, they can always be  inoculated.
Now, it is  not correct to say that the facts of inoculation are rare.
A different impression will follow the perusal  of the writings of
Wallace, reprinted  in the Annates de* Maladies  de  Ja peau et de la
syphilis, as well  as of the contents of this book.   These facts,  as
my opponents have lately been forced to admit, are  rare and ex-
ceptional, only when  they chance to possess  great weight in this
question.   It  is well  known, indeed,  that  all the  negative facts  in
the world cannot destroy one positive fact.   M. Diday, whom M.
Ricord  persists  in citing  as a partisan of his doctrine,  referring
to the experiments by which Wallace proved the transmissibility
of the  secondary accidents, remarks : " These cases are not very
numerous, but more  are not required to shake  the security which
reposes on negative facts."* f
  M. Ricord, who had asserted before the  Surgical Society, that if
the secondary accidents could once be inoculated, they could al-
ways be inoculated, no longer repeats this argument before the
Academy of Medicine, because, during the interval which passed
between the two discussions, the question  was settled experiment-
ally, since  which he has been  silent on this point.
  It has been proved, to my certain knowledge, that chancre, even
when inoculated according to the most approved method, and by
the most  skilful experimenter, is not always reproduced.   Chan-
cre, then, can be transmitted only under certain  conditions.  Now,
the same observations  should apply to the  secondary accidents.
However, as the principal conditions which are favorable to tho
success of  the inoculation of a  chancre are known,—witness the
great number of experiments already made for this purpose—those
which affect that of the secondary accidents have been less studied,
and are almost  completely unknown.  Further, the secondary af-
fection, which should be especially inoculable, is that which is of a
purulent character; now, this is represented by ecthyma, which is
rare.   This form of cutaneous disease consists of several varieties;
there is one which appears shortly after the chancre is healed;  it
resembles varicella; the pustules have a thin scab, which, in fall-
ing, leave  no ulceration, or that but trifling.  I am almost certain
that this variety is more easily inoculable than that which appears
at a later period, when there  exists an affection of the bones ; the
number of pustules  is then very limited;  they are to be found
principally on the extremities, the legs; they are very large,  and

  *  Gazette Medicate, Oct.  6, 1849. We are also indebted to M. Diday for the pub-
lication of the most conclusive fact concerning the  inoculation of chancre in the
brute, a fact denied by M. Ricord.
  f  Dr. Skae successfully inoculated four out of thirty-six  cases of mucous tuber-
cles.—Northern Journal of Medicine, April 1844, or Cormack's Lond.andEd Month-
ly Journal, July 1844, p.  620.  M. Sperino (op. cit. p. 5<r_!),fiH, rs to other suc-
cessful inoculations of secondary accidents not alluded to % our  author •  they
were made by Mil. Sigmund, of Vienna, and Gamberino and Galligo, of Italy —• 
INTRODUCTION.
53
their thick scab, in falling, leaves a deep ulcer.  Thus, the condi-
tions  required for the inoculation of the secondary affections being
almost completely unknown, and these affections which are inocu-
lable, being themselves rare, the experiments on the subject, un-
like those on chancre, being also of recent date, the success obtain-
ed in the one case forms no criterion by which we may judge of
that in the other.
  I am satisfied that certain no d -syphilitic affections, which are re-
garded  as not  admitting of inoculation, would become so, could
we  but  seize on the right  moment when they contain inoculable
matter.   Thus, at present, when attempts have been made to inoc-
ulate chancre,  the ichorous discharge from the ulcer has been
used, or the detritus of the cancerous mass.  But are these really
the parte inoculable ?  Is it not rather the cancer-cell at a certain
period, whilst yet recent, that  should be employed ?   The success
obtained by Langenbeck, leads me to believe that that is  the ele-
ment required.   This experimenter took fresh cells from a  cancer
yet warm, removed from the humerus, and introducnd these  cells
into the blood vessels of a  dog.  Cancerous tumors in the lungs
were the result.
  * To return to the consecutive syphilitic affection, I would re-
mark, that in  France,  inoculation has succeeded  only after the
method adopted for that of chancre, that is, with the lancet as used
in vaccination. We know that the manner of applying the agent may
exercise a great influence upon its effects.  I have  already shown,
that for the inoculation of the brute with chancre, the ordinary
proceeding is insufficient, since M. Auzias was obliged to resort to
another  already described.  Aside even from the  inoculation of
syphilis, substances arc found which remain inert after the ordinary
method of inoculation, and yet which produce  very marked re-
sults when applied in another manner.   Tartar emetic ointment
is one of these; I have tried to inoculate it without success; while
by  frictions I have succeeded in producing pustules.  The mucous
tubercle which is so readily communicated by prolonged and repeat-
ed coition and by suckling, is not inoculable by a simple puncture of
the lancet; but if a blister be previously applied, and if we dress the
denuded dermis with charpie steeped in the pus of the pustule, in
fine, if  we adopt the method of Wallace, as M. Boulay has done,
as I have done, then the inoculation will succeed.  It is also prob-
able,  that a simple puncture  of the lancet  dipped  in syphilitic   /
blood, would not  produce  positive results.  But if, as has been  /
done by Waller (de  Prague), we scarify the  skin,  if with  a  par-
ticular instrument we  introduce infected blood into each trifling
incision, and if the whole is covered with the same  blood, we shall
have strong reasons to expect  the same success which Waller ob-
tained.   Besides the  arguments which I have mentioned and op-
posed, others have been raised less and less scientific, in propor-
tion as my adversaries have lost ground.  At first, the cases left

  *  Smidt JahrbuShar; i. xxv., quoted in the Encyclopedic Anatomique, t.  ix. p.
279.          f 
54                     INTRODUCTION.
something still to h» desired on the score of authenticity; the diag-
noses of the inoculated affection had not  been made;  instead of
taking matter from a secondary disease, it  had been taken from a
chancre;  then followed insinuations against the credulity, the dis-
honestv of the  observers, &c.   In  all desperate causes  the same
course' is  adopted   With regard to the experimenters, I will cite
the names of Wallace and Waller, who were at the head of an ex-
tensive venereal service; MM. Bouley and Richet, who  experi-
mented at the Lourcine, and M. Cazenave,  the author of a Treatise
on the syphilida, whose experiments  were made at the hospital
St. Louis.   The names of the pupils in Paris who reported these
cases, are  MM.  Pellagot, Schneph,  Lafargue, Piberct, Rossen, Co-
det, Dubreuil, and Dumenil, all of whom are distinguished internes.
Now  I entreat those who  are investigating this subject, and who
are desirous of coming to some conclusion, to peruse these reports,
together with those of the internes mentioned, and of my confreres, all
of which show the transmissibility of syphilis otherwise than by the
pus of chancre, (these cases  are particularly noticed in the chapters
on mucous tubercles, the syphilida, and exostosis;) then let them
examine those presented by the opponents of this doctrine, which
may be found  in  the Treatise of M. Ricord.  Having duly con-
sidered the arguments offered by both parties, they may then ob-
tain a satisfactory decision.   They will be surprised at two circum-
stances in the work just quoted, first, the small number of the ex-
periments,  their want of connection, and the absence of all details;
second, the limited time after the experiments that the patients re-
mained under observation.   Constant allusion is made to the very
numerous negative experiments, as was the case with those relating
to the inoculation of animals.  Now go to  their sources,  and see
what number they can offer!   Of*course we refer  to authentic
sources, to books and writings, not  to  private conversations.   M.
Velpeau has exposed the value of the facts brought forward in op-
position, in a discourse which must long be regarded as a remarkable
specimen of annihilating criticism ; they have been reduced to the
character of simple assertions, in some instances of no importance
whatever.  Waller has likewise noticed  the brief period during
which the subjects inoculated with  secondary accidents were
watched; and the incubation being occasionally quite prolonged, as
in the instances/ reported by Wallace and the physician of Prague,
M. Ricord may have regarded as  failures some really successful
inoculations.  In this case, he would  not  be the first who has un-
consciously succeeded.   I  am certain  that this has happened to
another experimenter with whom I am acquainted.   It may have
been observed, that when I alluded to the fact of incubation after
the inoculation of secondary  accidents, I did not speak in  decided
terms, for  it may be absent, or rather a small pustule may at first
be developed, which miscarries, and yet some time afterwards the
genuine pustule may appear.   In this case, the first pustule seems
to be but traumatic, whilst the other is a specific effect.  Further,
since I started  this question of the transmissibility of the second-
ary accidents, M. Ricord has not seriously examined the subject, 
INTRODUCTION.                         55
 and he has even rejected the facts brought forward without an ex-
 amination.  At  this, however, I should  not  feel wounded,  since
 he has been guilty of  the same conduct towards his own pupils
 and friends.   In the discussion on tubercular affections of the testis,
 M.  Malgaigne  proclaimed  in full tribune,  that M. Ricord  com-
 menced by rejecting the  observations of  his brethren, and that he
 treated  in the  same manner those of  his  pupils made under his
 own eyes.   Even those made by himself have shared the same fate,
 when opposed to his theories.*   If  M. Ricord  thus treats obser-
 vations relating  to  tubercular affections of  the testis, what would
 he   not do  with  those which endanger the safety of his system!
 Examine the discourses and writings of M. Ricord in reply to the
 arguments and facts adduced not only by myself, but by every
 orator in the Academy, his answer is always the same; it is always
 what we call petitio principii; for supposing that to be demonstrated
 which is precisely the point in question, and his opinion upon this
 point  being unchangeable,  he responds  by the  question, that is,
 hy  his opinion.   The whole, in fine, may thus be briefly expressed;
 chancre alone is inoculable.   Now this  is the point in dispute, and
 the  contrary we  aim by facts to prove.  This  has long  been a fa-
 vorite method of reasoning with  M. Ricord, but with no bad inten-
 tions.  It is thus noticed  in the Thesis of M. Helot, formerly an
 interne of the Mpital du Midi :

   Our  author has clearly demonstrated that secondary accidents  are transmiss-
 ible, yet as important medicodegal questions not unfrequently arise in con-
 nection with this subject, it may be satisfactory to the young practitioner to know
 that this doctrine is defended by the  following  eminent British  and American
 authorities, viz., Sir Astley Cooper, Lectures on Surgery, by Tyrrel, Am. ed., p. 497 ;
 Mr. Liston, Elements of Surgery, by Dr. Gross, p. 206 ; Mr. Colles, On Venereal, p.
 263; Mr. Wallace On Venereal, p. 335; "Sir. Hey, Med.  Chir. Transactions, vol. 7th,
 1830, p. 541 ;  Jesse Foot, On Venereal, p. 40'2; Herbert Mayo, On Syphilis, pp.
 122, 123; Sir Benjamin  Brodie, Lecture in Lond.  Lancet, Feb.  1844, p. 677; Mr.
 Babington,  Notes to Hunter, Am. ed., p. 321; Mr.  Lawrence, Lectures on Surgery,
 Lond. MedMrazetle, March, 1830,  pp. 80t>, 807 ; Mr. Porter,  Lectures  on Syphilis,
 Dub. Med. Press, Feb. 17th, 1847, pp. 99; Mr. Whitehead, Illustrations of Trans-
 mitted  Syphilis;  Samuel A. Lane, Lectures on Syphilis, Lond. Lancet, May 28th,
 1842, p. 294;  Mr. Bacot, On Syphilis, p. 252;  Mr. Carmichael, Clin. Lectures on
, Vcn. Diseases, p. 51 ; Langston Parker, Modern Treatment of Syphilitic Diseases, 2d
 ed., p. 169;  Mr. Egan, On Syphilitic Diseases, pp. 293, 294;  Erasmus Wilson, On
 Syphilis, p. 36;  Geo. McLellan, Principles and Practice of Surgery, pp. 250, 251;
 Dr. N'eligan, Dub. Quart. Journal of Medicine, Feb. 1853, p. 119;  Dr. Campbell,
 North.  Journal of Medicine, 1844,  or Cormack's Journal, Sept.  1844, p. 773; Dr.
 John Rose Cormaek, Lond. and Ed. Monthly Journal of Medical Science, Sept. 1844,
 p. 778 ; Evanson and Maunsell, On Diseases of Children, Am. ed., p. 350; Dr. James
 Stewart, On Diseases of Children, 4th ed., p. 468 ; Dr. John Watson, United  States
 Med. and Surg. Journal, vol.  2d, p. 103; Dr. H. D. Bulkley, On Syphilis in Infants,
 New York Journal of Medicine and Surgery, Oct. 1840.    We  might add to the list,
 but surely it is unnecessary.  During our recent visit to Dublin, we were person-
 ally  assured hy Messrs. Cusack, Adams, Fleming and Wilmot, that they entertain
 no doubts of the correctness of the doctrine  here advocated, and we know that
  * Take the orator's own words.   It should be recollected that M. Malgaigne is
the friend of M. Ricord, and that it is from the journal of a friend that they are
copied.  " M. Ricord, possessed of a theatre of observation vast as could be wished,
began by rejecting the observations of others ; then adopting a certain theory, he
disregards those of his  pupils made under his own eyes, in his own service, and
finally, I must say it, he takes no heed of his own, when they conflict with his own
preconceived views." Vid. VUnion Medicate, Aug. 30, 1851. 
56                VLDAL ON  VENEREAL  DISEASES.
 among our own countrymen, this view of the subject is inculcated in the lecturea
 of Profs. Mott, Mussey, and Parker.   Indeed, it is not difficult to find, even  in the
 works of the most prominent  opponents of this  doctrine, viz. Messrs. Ricord and
 Acton, positive proof in its support.   As such, we regard Case XV. (God. Eulalie)
 in M. Ricord's Treatise, 4th Am.  ed., p. 2'H, and that of the child infected by the
 cavalry officer, mentioned in his Letters,  xiii. p. 105.  Again, in  his Notes to Hun-
 ter, 2d ed., p. 776, he fully admits the transmissibility of the secondary accidents
 in the following language: " There exists a great number of incontestable cases of
 Byphilis transmitted from the nursling to the nurse, and vice versa."  Further proof
 may be found in the work of  Mr. Acton, 2d Am. ed., p. 420. We  refer to the re-
 port of the case of the infected foetus, which contaminated its mother.
  Can a husband, who has  suffered from syphilis, but who is apparently sound,
 communicate consecutive accidents to his wife, which accidents, in the latter, shall
 not be preceded by  any form  of primary sore?  It was the opinion of Mr. Colles
 (op. cit. p. 263), that " a newly-married man, who is himself free from every appear-
 ance of syphilis and every other disease, shall yet infect his wife in such a man-
 ner, that secondary symptoms shall  appear in  her a  few months after marriage,
 and these not be  preceded by any primary symptoms, or by any discharge what-
 ever from the genitals."  Mr. Carmichael (Clin. Lect., p. 50,  51) states that he has
 met with instances of young married women above suspicion, who were affected
 with constitutional symptoms,  yet who, on the minutest inquiry, I could not learn
 ever had any primary venereal affection.  But their husbands, though equally
 free from primary, at the time of their marriage, had on them secondary symptoms
 in the form of eruptions  or ulceration of  the throat.  A case  of the latter kind
 came  under our own care a few years since.  The individual  married in spite of our
 remonstrances, and  about two or three months afterwards, his wife had a similar
 eruption on her lower extremities.  We here insert the details of two very interest-
 ing cases, for which we are indebted  to Mr. Langston Parker:
  "Case I.—A gentleman contracted a superficial primary sore, which healed
 without  leaving  a  mark  or  induration behind it.   Being apparently in  good
 health, he married.   Three or four months after his marriage, he perceived on hia
 body  numerous red, smooth, elevated, scaly blotches; very shortly his  wife broke
 out with an eruption of a 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  irritation in the genito-urinary organs.
 I examined  them both frequently and carefully, and  I am  positive the wife had
 never suffered from sore, excoriation or discharge. t
  " Case II.—A gentleman, who had suffered both from primary and secondary
 syphilis, married,  after having been  free from all  symptoms for twelve months;
 soon after this he  bad another eruption and sore throat; his wife became affected
 with the same eruption, excavated ulcers of the tonsils, and was prematurely de-
 livered 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 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 primary disease, and never  had suffered from the least irritation in the
 parts."
  Mr. Porter remarks (Lect. cit, p. 100), that the cases  which have come under his
 observation, have  led him to  the conclusion, " that the semen of a diseased man
 deposited in the vagina of a healthy woman will, by being  absorbed, contaminate
 that woman, without the necessary occurrence of a  chancre, or  any other sore
 secreting matter on either the man or the woman."   Prof. Willard Parker has fur-
nished us with the particulars of three cases in support of this doctrine, and others
of a similar  nature may be found in the paper of Dr.  John Watson, to which we
have referred.
  Now, if the doctrine here broached be  true, and if it also be true,  as is main-
tained by Messrs.  Ricord, Cazenave, and Erasmus Wilson, that the syphilitic tem-
perament or diathesis, when once formed, may last ten, fifteen, and  twenty years,
or, indeed, never be eradicated, when can a man with safety many, who has had
constitutional  syphilis, but who is free from every external manifestation of the
 disease ?  Will  it do to give him " a clean bill of health," after a " six months'
quarantine," as proposed by Mr. Acton (op. cit., p. 416), or  after that  which has
lasted from  "two to five years," as  advised by Mr. Wilson (op.  cit., p. 49H__
n n  tj                                                            *    ' 
A  TREATISE  ON  VENEREAL  DISEASES.
                        PART I.

         PRIMITIVE VENEREAL DISEASE.


  In the announcement of the classification which I have adopted,
I have already explained what I understand by the terms primitive
venereal disease.  It may arise simply from  irritation, or, from a
specific cause, hence may follow affections non-specific; or specific,
virulent.  Thus, the lesions discussed in our first division may be
regarded as simple local inflammations; certain instances of blen-
norrhagia are of this class.  But, as the syphilitic virus is the most
common cause, these affections are, generally, neither simple  nor
local; if, for example, chancre should possess this  character,  it
would no longer be a chancre, that  is, a specific ulceration, but
simply a suppurating wound.
  After the accidents, which, by all, are  regarded  as primitive,
will be found discussed in this division those which by others are
called consecutive, hence  the despair  of the nosologists, who pre-
tend to be strictly logical, and of the syphilographers, who profess
to be governed by  absolute laws;  among  these diseases are the
mucous tubercles.  I have  assigned them a place  between  the
primitive and consecutive accidents, to show  that when caused by a
specific  virus  the disease is the  same, and that the facts which
relate to it belong to both.  A more arbitrary course might sepa-
rate them;  but it  should  be understood  that the  arrangement
here adopted is but provisory and artificial, to assist the  compre-
hension of junior minds.
  Most  of the diseases of this first division are of an  acute nature,
and assume a more or less inflammatory form.   Besides the symp-
toms  which may be attributed to the virus, others  more direct,
more immediate, of an inflammatory character, manifest themselves.
Indeed,  if the testicles, the  prostate gland, the articulations,  the
eves, the lyhiphatie,  ganglia, become involved through sympathy
or metastasis, it is under  the form of a phlegmasia.   The practi-
tioner is therefore most frequently required to treat  an inflamma-
tion ; and to subdue  that which threatens he  should promptly direct
all of his attention,  all his means, without  reference  to its specific
cause.   First of all, the effects must be combated.  Antiphlogistics
must then occupy a prominent place' in this division.   They seem, 
68             VIDAL ON  VENEREAL DISEASES.
     indeed, ultimatelv  to decide everything.  The  advocates  of the
     doctrine of the non-existence of a specific virus  have seized upon
     this circumstance, and taking the exception for the rule, the tem-
     porary for the permanent, have proclaimed the constant success of
     simple treatment, such as antiphlogistics, emollients, hygiene, and
     that, consequently, venereal affections do not depend upon a specific
     virus.   It is true that simple treatment is sometimes sufficient, since
     nature alone is occasionally adequate to the purpose, especially in
     those cases which are not virulent; the error lies in the generaliza-
     tions from these results, and particularly in the conclusions drawn
     of the nature of the disease from the means by which it has been
     cured; they cannot be specific, because they  have been  cured by
     a non-specific treatment!  The whole science  of medicine properly
 ,.   interpreted, protests against this error, which would deny the vij/f
J    medicatrix natures, the greatest and most brilliant fact in pathologi-
     cal physiology

                            CHAPTER I.

                           BLENNORRHAGIA.

       From the time of Swediaur, the term  blennorrhagia  has been
     applied to the inflammation of certain mucous membranes, which
     generally follows impure connection, and the characteristic of which
     consists  in a more or less abundant  secretion  of  mucus  mixed
     with pus, (muco-pus.)  • This disease has also been called gonorrhoea,
     which denotes a discharge  of semen, and it has been known like-
     wise under  the name of  chaudepisse, derived from the burning
     sensation which the patient suffers in urinating.   These terms,
     like others which  I purposely omit, express only  a symptom of
     the disease that may be wanting, in which case they would mean
     nothing; thus the  seminal flux is an hypothesis; the burning
     sensation may be entirely absent.  The word  blennorrhagia itself is
     far from being without  reproach, for the discharge is not  always
     of the same nature; for example, in the commencement it may be
     mucus, then it  may be mucus  mixed with  pus; finally, it may
     consist of pus alone.  Still worse would it be if there were actually
     a dry blennorrhagia.
       Seat.—The ordinary seat of blennorrhagia in the male  is the
     urethra, sometimes it affects the mucous lining of the prepuce and
     the glans penis; in the female, it occupies the vulva, vagina, ure-
     thra, and the uterus; in both sexes, the oculo-palpebral mucous
     lining, that of the anus, and lower part of the  rectum.   The buccal
     blennorrhagia is excessively rare, and it is probable that that of
     the  nose is but an imaginary disease.  In certain regions, when
     the  skin suffers a kind of mucous  transformation, blennorrhagic
     discharges may be observed, as, for example, in the genito-crural
     fold, at the  internal face of the thighs, and the umbilical  region.
     Several of the  parts mentioned may be simultaneously affected
     with blennorrhagia: in the male, blennorrhagia of the  glans, of
     the prepuce, and of the urethra, may simultaneously exist; in the 
BLENNORRHAGIA.                     59
female, the entire vulva, the vagina, urethra, the neck and body
of the uterus, may at the same time be affected.
   Causes.—Blennorrhagia  is  most  frequently observed  at  that
period of fife during which the functions of the genital organs are
most exercised, viz. adult age.   It has, however, been noticed at a
very early age, particularly in little girls of a lymphatic tempera-
ment, which temperament  is also favorable to its development in
the adult.
   Women are  more frequently affected than men, and communi-
cate the disease with greater facility.
   All climates  have been observed  to be favorable to its develop-
ment.  Among the causes of the disease have been ranked certain
aliments and exciting drinks;  for  example,  salted food,  spices,
asparagus, truffles, strong liquors, coffee,  beer, may really promote
the  action of the direct cause.  The excessive use of beer alone
has  been accused  of producing a  blennorrhagia.  Is  there  any
foundation for this belief?   I am well convinced that this beverage
will exasperate, and even rekindle  an urethritis of long standing
which has scarcely disappeared, but more than  this I have  not
observed.   Further, beer exerts but little influence on  other than
urethral blennorrhagias.
   Gout, rheumatism, dartrous,  and scrofulous vices   have been
noted among the causes of blennorrhagia.  It  is  certain that  the
existence of a rheumatic, or of a dartrous affection in a patient, may
modify the progress of the disease:  thus, we see rheumatic patients
affected with blennorrhagia, in whom, during a rheumatic paroxysm,
the discharge  ceases, and yet upon  the subsidence of the former,
the  latter  reappears;  on the  other  hand, there are patients who
notice the appearance of a discharge at each access of their rheu-
matic attack.  Patients afflicted with dartrous affections have been
observed, whose discharges, like the cutaneous disease, assume a
chronic character;  in such  cases it becomes of a serous nature, and
small in quantity; the secreting surface is affected  with a trouble-
Bome itching,  and the urethral  affection is cured by remedies
addressed only to the cutaneous disease.  Scrofula  renders a blen-
norrhagia chronic, and the discharge in these cases readily assumes
a gleety character.. This is all that  can be said of  the part which
the  above morbid conditions play in producing or modifying the
characters of a blennorrhagia;  beyond this all is hypothesis.*

  * Mr. Henry James Johnson, Ou the Genito-Urinary Organs, part i. p. 37, after
alluding to the influence of gout or scrofula in  predisposing to blennorrhagia,
observes: "but, I am mistaken if those peculiar states of system do not, occasion-
ally,  produce the complaint without the interposition ot any obvious exciting
cause."  He then gives the details of two cases which support  the above view of
the subject.  As to the influence of gout in producing a blennorrhagic discharge,
we have no doubts whatever.  About four years since we treated a  patient some
seventy years of aire, who was the victim of gout, and during one of his attacks he was
6eized with a most copious urethral discharge.  We know, positively, that this dis-
charge depended  upon no other cause than the gout.  Dr. John Watson, of this
city,  informs me that two cases of the kind have come under his observation.
  Numerous  and serious medico-legal questions may arise  in  connection with the
subject of urethral and vaginal discharges, both in children and the adult.   The
reader may find, both in the works of Beck and Taylor, on Medical Jurisprudence, 
60
VLDAL ON VENEREAL DISEASES.
  The direct causes are either physical, chemical, or pathological:
thus, a calculus passing through the urethra, the introduction of a
sound, an ammoniacal injection  (Swediaur), all of these agents
may give rise to a muco-purulent secretion.   Coitus too  often  re-
 eated, or performed with organs of disproportionate size, mastur-
 ation, menstrual blood, the ichorous discharge  from a cancer, the
lochia, and  especially the fluor albus, are so many causes which
have  been  accused of  producing blennorrhagia, and which,  of
course, are particularly furnished by the female.
  Virulent pus, that which is the medium of the syphilitic virus,
is, in my opinion, the most frequent and powerful cause of  blen-
norrhagia.  Those who deny that specific pus  can give rise to a
virulent  blennorrhagia, have  nevertheless supposed that it may act
upon the mucous membranes like any simple irritant; those who
are unwilling to admit the power of the virus to produce a primi-
tive syphilitic blennorrhagia, have acknowledged that it may give
rise to the same disease, but  of the consecutive form.   Syphilitic
virus is therefore entitled to  a prominent place in the etiology of
blennorrhagia, a fact which  should be  borne  in mind when we
eome to  the treatment  of the disease.
  A general view of the causes mentioned shows that they act di-
rectly  upon the mucous surfaces, or  indirectly after they  have
passed through the system.   Thus, the syphilitic virus should have
this double action,  and the  rheumatic diathesis can act but indi-
rectly.   It  is evident  that blennorrhagia, from an indirect cause,
cannot be of a simple nature, and that among the cases which pro-
ceed from a direct  cause, there are few whose action is limited to
the production of an inflammation.   Such is the fact only where
the disease has been caused by foreign bodies, excessive indulgence
in coitus, masturbation, menstrual secretion, and  the fluor  albus
which has accidentally  become a  little acrid.
  Whatever may be the nature of the blennorrhagia, certain  pecu-
liarities of the discharge, of its organic vital conditions, affect its con-
tagious properties. Thus, the predominance of pus in the secretion is
favorable to contagion; in proportion as mucus predominates, that
is, as the disease is less acute, the less are the chances of contagion.
But there can  be no doubt ttyat very  trifling discharges,  drops,

several  interesting and  instructive cases recorded, from which he may learn the
great difficulty which occasionally attends the diagnosis between the virulent and
non-virulent discharges.  We can only refer to some of the principal sources of
information upon these questions.   Rayer, On Diseases of the Skin, Translated by
Dr.  Willis, London, 1835, p. 765.  Also Memoir by the same author, " sur les injlam.
non-virdes  mernb. muq. des org. de la general, des Enfans," Paris, 1821.  Capuron,
Med. Leg.  des Accouche;nens, p. 41.  Mr. Kesteven, Lond. Med. Ga?.., vol. xlvii. p. :;72.
British Amer.  Journal, May  1848, p. 19.   Dr. John Rose Cormaek; Observations on
Gonorrhoea and Syphilis, with reference to Forensic Medicine, dc, in Lond. and Edin-
burgh Monthly Journal, Sept. 1844, p. 753.  Sir Astley Cooper, Lectures on Surgery.
Benjamin  Bell, On Venereal, vol. i.  p. 416. Dr. Underwood, Diseases of Children.
Mr. Moses, Lond. Lancet, Dec. 1835, p. 443.  Frederick C. Skey, Lectures on Vene-
real Disease, Lond Med  Gazette, vol. xxiv. pp. 439, 440. Wm. Lawrence, On Pecu-
liar Affection of the Genitals in Female Children, Lond. Med. Gazette, Aug. 21 1830
p. 828.  Mr. Egan, On Syphilitic Diseases, p. 130.                          ' 
BLENNORRHAGIA.                    (ft
which are regarded as of no consequence, may communicate very
severe and sometimes very virulent attacks.
   There are individuals so constituted that they may with impu-
nity expose themselves to the risk of contagion.  There exists be-
tween the parts brought into contact during coitus a certain sym-
pathy of action, an adaptation of form and volume which  singu-
larly favors or prevents the development of blennorrhagia: thus, a
man shall live for many years with a woman who has a discharge
from the vagina, and yet shall himself escape;  habit has created a
kind of harmony in the vitality, the form, and the volume  of the
organs which produces this immunity; but let the habits  of the
woman become changed, let her have  a new lover, and the latter
shall perhaps contract a blennorrhagia  at every menstrual period.
Facts of this nature have been observed by every practitioner who
is consulted by patients affected with venereal disease.  Fallopius,
a writer of the  XVIth century,  remarked that certain  infected
women communicated nothing to their husbands with whom they
had no sexual pleasure, but gave disease to their lovers who grati-
fied their desires.
   Certain conditions of vitality may then promote contagion, and
it is an established fact that blennorrhagia is almost always com-
municated  by coitus.  But blennorrhagic pus, which is simply de-
posited upon a mucous surface, may produce the same  effect; the
experiments of the  students mentioned by Benjamin Bell  prove
this fact.  It has been assertedjhat pus which has been swallowed
and ahsorbexLJ 'Ljfoe^stoTnaclv soTdirects itself to the genitaforgans
as to determine a blennorrhagia.   The proof of this is still wanting.
   Nature.—In discussing the question  of the nature of the  syphi-
litic virus, I have  anticipated  the difficulties which would arise
when we come to study the etiology of blennorrhagic discharges.
1 have stated that Hunter believed that  these discharges recognized
the same cause as chancre, and that this cause was the syphilitic
virus,  the effects of which differ according to the surfaces to  which
it is applied.  But, as the vagina, according to  Hunter,  is a secret-
ing surface, and as upon the mucous lining of this canal true chan-
cres have been observed,  the theory of the English surgeon is thus
strongly compromised.
   I  have  noticed the opinion of Benjamin Bell, who admits two
morbid elements,  the one blennorrhagic,  the other  chancrous.
Finally, I have mentioned the opinion which views blemiorhagia 1 "
as dependent upon an inflammation caused simply by an irritation, .
the effects of which are local, and never resemble  those produced
by a morbid poison.   AVhen the  latter effects have been observed,
then it was owing to the carelessness of the observer, or indeed he
was  ignorant of the proper method of investigation,  or he  knew
not how to manage; he could not have discovered a chancre hidden
under a narrow prepuce, in a fold of the vagina, or upon the neck
of the uterus, or in the canal of the urethra.  The observer could
not, or knew not how to detect  anything but the discharge, and
taking this  symptom  for the disease itself, he  has  placed on his
list, under the head of diagnosis, blennorrhagia, when it should have 
62
VIDAL ON  VENEREAL DISEASES.
been chancre.  It must at once be admitted that errors of this
kind have been largely committed,  especially at a time when the
hint- had not been given, and before they possessed the means of
investigation which we now enjoy.  But Hernandez  had already
inaugurated the chancre larve; Hunter dwelt at length upon those
cases in which a chancre may escape detection, and our contempo-
raries, at the head of whom must be placed  M. Ricord, for twenty
years have spoken of these errors and their causes, and have taught
the method of avoiding them.  The  speculum, in fine,  has rendered
the argument drawn from the imperfection  in observation, much
less  forcible  than it was before.   With regard to ignorance and
want of skill, these are daily disappearing,  and there  are practi-
tioners who from their position and reputation as honest and saga-
cious observers, put to naught this argument as well as another
too often employed in desperate cases.  These practitioners believe
that there really exist  syphilitic discharges which have no connec-
tion with chancre, which has  always been absent at  every period
of the blennorrhagia; further still, the syphilitic  nature of these
discharges  has been shown by the appearance of secondary acci-
dents, by the general  manifestations of poisoning.   No objection
can be seriously urged against similar facts observed in the female
where the urethra remains  sound, without any discharge ;  for the
Vulva, vagina, the neck of the uterus, the anus may here be direct-
ly explored,  but when it concerns a urethral blennorrhagia in the
male, the chancre larve renews all its claims.  This has been sup-
posed even when the pus from the urethra could not be inoculated.
Thus then, in order to combat a pretended supposition, that is to
say, the non-existence of chancre in virulent blennorrhagia,  a sup-
position has been employed, an established principle has been vio-
lated, a chancre in the urethra has been supposed when syphilitic
accidents have supervened, and all this because it is pretended, that
chancre alone can produce these accidents.   Now this is the point
in question.  I myself, do not admit the existence of chancre be-
yond the navicular fossa.  I am  aware of what has  been written
concerning the deep-seated urethral chancre; some  pathological
specimens even of which have appeared satisfactory to  those who
exhibited them.   But I must confess,  after  a very careful exami-
nation of that regarded the most important  in proving the exist-
ence of a profound urethral chancre, I am convinced  that it was a
case not of syphilitic,  but of tubercular ulceration, which existed
at the same tune in the form of cavities in the prostate gland, in
the testicle and in other organs of  the  same patient.  I observe
that some  excellent surgeons partake of this same  doubt*  M.

  * In his Communication to the Academy of Medicine, Oct. 12, 1852, (De la Sy-
philization, Ac, p. 367,) M. Velpeau thus remarks: " The specimens presented by
M. Ricord as  examples of chancre, are far from being incontestable. In one of
them, I recognize that of a tubercular young man, having large  cavities in the
prostatic portion of the urethra, and I see no indication that chancre had existed
there; the other is that of an old man, almost equally obscure.  I saw these spe-
cimens when first exhibited to the Academy,  but they were far from satisfying me
of the existence of chancre."^ The report of these cases in the Treatise of M. Ricord
(4th Am. ed. pp. 126, 127), is exceedingly meagre and unsatisfactory; compared 
BLENNORRHAGIA.
63
Baumes cannot understand how the pus of a chancre can traverse
the great extent of the urethra without leaving  any trace on its
passage; in  fine, without producing ulceration but at one point
of this canal.  M. Chomel remarks, with his accustomed modera-
tion :  " It is only an exceptional case where the presence of a
chancre in the urethra has been demonstrated or rather presumed."*
  But admit, for a moment, the existence of chancre deep in the
urethra, provided that it is rare, and exceptional, and that we have
the candor to acknowledge.  Now compare the frequency of  ure-
thral chancres with the number of consecutive syphilitic accidents
which have been seen to follow urethral discharges, and  the enor-
mous number of the  latter compared with the former cases,  will
at once be apparent.   Physicians who devote  special attention to
the diseases of the skin, as, for example,  MM. Cazenave, Martins,
Legendre, will tell you that blennorrhagia produces as  many cu-
taneous affections as  chancre.  Now, deduct  some cases of blen-
norrhagia which you may carry to the column of urethral chancres
(if you admit their existence), there will  remain a  considerable
number of eruptions  which can be  attributed only to  blennor-
rhagia. This truth has been proclaimed before the whole Academy
of Medicine, particularly by men who have long been observers,
and who have been committed to no particular theory in syphil-
ography, such as MM. Moreau, J. Cloquet, Velpeau, P. Dubois, &c.
  Now, admit still further, that every specific syphilitic discharge
is but a symptom of chancre.   There will still,  however, always
remain a  form of inflammation of the mucous membranes, a sero-
purulent discharge,—in fine, a blennorrhagia, which by its progress,
its duration, its accidents, its complications, can never be referred
to an inflammation like that produced by simple  irritants, by for-
eign substances, by ammoniacal injections, or that which Swediaur
produced  upon himself.   These simple  inflammations are  not
communicated  with the same characters, from one individual to
another;  they  are not followed by the accidents of metastasis,
such as  blennorrhagic ophthalmia, or blennorrhagic  arthritis;
they do not continue  a year as did the blennorrhagia which  that
student gave himself, by applying between the prepuce and the
glans, pledgets dipped in gonorrheal matter, f   All these effects,

with that in his Notes to Hunter (pp. 799, 803), it will be found to differ in several
particulars, and in our humble opinion,  the chapter (p. 147) on ulceration of the
bladder in the excellent Treatise on the  Urinary Organs by our countryman, Prof.
Gross, or that on Scrofulous Prostate in the work of Mr. John Adams on the Anat-
omy and Diseases of the Prostate gland, pp. 117, 125, afford a far more correct  solu-
tion of the true nature of  these cases.  The  ulceration in these cases was of very
great extent, involving the urethra, bladder and prostate; yet when  we find M.
Ricord, in 1851, (Letters, viii. pp. 59, 60,) inculcating the doctrine, that the urethral
chancre is never very extensive, and that when we find an  abundant discharge (as
existed in these cases), we  may conclude that it is something more than the pro-
ducts of a chancre, we Jire astonished that he does not even allude to these very
remarkable exceptions. At any rate, the fact that his diagnosis in these cases is
questioned by such men as MM. Velpeau, Vidal, and Prof. Gross, (as we learn from
a recent letter from the latter gentleman,) is sufficient to render them far from be-
ing, as is asserted by M. Ricord, "incontestable."—G. C. B.
  * Abeille Medicale, Jan. 1851.   Lecon clinique de M. Chomel.
  f B. BelL on Venereal, t ii. p. 492. 
64               VLDAL ON VENEREAL DISEASES.
which are  not denied by  my opponents, proceed from  a  single
cause, which does not simply irritate the mucous membrane, but
which penetrates the  system.  Now this cause we may call a vice,
or virus; we may say, that it is not syphilitic, that it is gonorrheal.
We come then to the conclusion of  Benjamin  Bell, and admit a
double virus, or more properly speaking, we apply two names to
the  same virus, which really  requires much less expense of the
imagination, much less research, much less time, since it is already
made*   M. Baumes  also  admits  a double virus, that of chancre,
and that of blennorrhagia  ; the action of the latter, in his opinion,
is not confined to that of irritation, it is absorbed, and then it does
terminate in the production of primitive accidents, such  as bubo,
ophthalmia, arthritis, but it gives rise to such symptoms as are de-
scribed in the following  remarkable passage: "I can affirm," said
Mr. Baumes, " that during the past three years  alone, I have seen
at the hospice de VAntiquaille, exclusive of  my practice  in the city,
five cases of simple  blennorrhagia, where I was certain that there
was no chancre in the  urethra, which cases were  followed after
some  time,  by constitutional symptoms,  such   as  well-marked
rounded ulcers on  the tonsils; mucous  tubercles at the commissures of
the lips, about the anus, and on the scrotum ; syphilitic ecthyma ; fur-
furaceous, squamous, and papular eruptions, &c, &c. In two of these
cases, on the seventh or eighth day from the commencement of the
blennorrhagia, I inoculated with muco-pus, by three punctures on
each thigh, withaut any result."!  M. Baumes then admits, that

  * For further proof of the existence of a blennorrhagic  virus, which virus pro-
duces ulceration of buboes, arthritis,  opthalmia, sore throat and papular eruptions
—the reader may consult Mr. Carmichael(CTm. Lectures, pp. 2041); Mr. South (Ed
of Chelius, vol. i. Am. ed. p. 188); Erasmus Wilson (on Syphilis, p. 53); Mr. Bacot
(Treatise, p. 126;) Langston Parker (Mod. Treat, of Syph. Diseases, pp. 32, 43); Mr.
Egan (on Syph. Diseases, pp. 17,  18, 21, 59, 60); Mr. Wallace (on Venereal, p. 264);
Henry I. Johnson (on Gonorrhoea, Ac, p. 23);  M. Ricord (Notes to Hunter, pp. 59,
60; also Treatise, Am. ed. pp. 70, 284), in both of which he insists upon the fre-
quent connection between blennorrhagia and  ulceration.  Even Mr. Acton, (2d
Am. ed. oiTncJise, p. 222,)states that "we are compelled to admit that in gonor-
rhea the system is so modified as to become affected by rheumatism;" again, at
page 36, he says, that we should not be deterred from attempting to cure gonor-
rhea rapidly by the fear of driving the disease into the system, for, "it will rush
in fast enough.'  And yet, in view of the  above fact, Messrs. Ricord,  Acton and
Bransby Cooper persist  in proclaiming  that blennorrhagia is a non-virulent, non-
specific disease!  But, asks the former, (Lett.  v. p. 37), is it not true that in the
immense majority of cases, blennorrhagia is not followed by  syphilitic infection?
Very true, and in this respect, it  resembles  the superficial  primary chancre.
" There are chancres," says the same high  authority, " and perhaps these constitute
the greater number, which do not infect the system."  (Lett, xxvui. p.  207).  The
testimony of Mr. Acton is to the  same effect; at p. 264 of his  Treatise, (Am. ed.) he
observes,  "that in simple, uncomplicated chancres, secondary symptoms occur in
such feeble proportions that they should not enter into our calculations." Again,
blennorrhagic  matter, applied to the lining membrane of  the eye-lid, contrary to
the assertion of M. Ricord (Treatise, Am. ed. p. 67), does sometimes  produce chan-
cres (ulceration) of the palpebral lining, which is followed by peri-auricular bu-
boes.  For proof, as furnished by Dr.  Mairion  of the Military Hospital at Louvain,
Mr. Wilde  and  Dr. Egan of Dublin, see the Treatise of the latter gentleman, pp!
114, 115.  These facts viewed  in connection with those which we shall presently
adduce in favor of its inoculability, and its mode of propagation, we believe suffi-
cient to entitle blennorrhagia to be regarded as a specific disease, independent  of
the existence of chancre larve.—G. C. B.
  f T. i. p. 233. 
BLENNORRHAGIA.
65
urethral discharges may be produced: 1. By a chancre;  2. By a
virus, which is not chancrous, but which gives rise to the accidents
already  mentioned; 3.  By an  irritation  or  inflammation  which
produces but sympathetic effects.  M. Ricord is of the opinion that
M. Baumes has arrived  at these conclusions from conciliatory mo-
tives.   For my own part,  I believe that M.  Baume's has, by a long
and  directly opposite  method to M. Ricord, formed  the opinion,
that there are  urethral discharges without any chancre, which are
virulent, and capable of giving  rise to consecutive syphilitic acci-
dents ;  only, these accidents may be less  frequent, less profound.
But there are chancres which frequenly do not produce  consecu-
tive  accidents, and the  latter are not  always profound.   Experi-
ment, besides, here steps  in  with  unanswerable  arguments;  for
Hunter proved that the  pus of chancre and that of blennorrhagia
might produce both chancre and blennorrhagia.*   When I reach

  * Mr. Carmichael claims Cases xiv. p.  108; ix. p. 101; xx. p. 113, and xv. p. 109;
in the Treatise on Inoculation (4th Am. ed.) by M. Ricord, as proof that the matter
of blennorrhagia like chancre is inoculable.   To  the above, we would add Case lxi.
p. 185. In this case the matter was taken from a bubo  following blennorrhagia, and
the pustules produced are called false pustules.  If with the report of this case, the
reader will peruse M. Ricord's account of the characteristic pustule, (Lett, xviii. p.
142), and that of the false pustule at page 146 of the same Letter, we think that he
will hesitate before he accepts the pointed pustules  with slight induration, pro-
duced by this inoculation, for pseudo-pustules.  The latter, we are distinctly told,
(Lett,  cit.) never lasts longer than from five to six days, yet the pustules in this case
lasted thirteen days.  That they healed without treatment is surely no evidence
that they were not syphilitic, for this is a test on  which, we believe, neither M.
Ricord nor any modern authority relies.  In his Treatise, (p. 255,) he states that
"the  primary specific ulcer may often heal without treatment," and  Mr. Acton
(op. cit. p. 255) assures us  " thpt  some syphilitic sores heal in twenty hours."  In-
deed, this spontaneous healing of chancre was known even to Abernethy,(pp. 48, 9.) •
In the report of the above case, it is mentioned that  the pustules did not assume
the appearance of specific ulcers.  Now, what is the appearance of a specific ulcer.
In another part of this work, we have  already shown that an absolute diagnosis
cannot be formed from the physical characters of an ulcer, a fact admitted even by
M. Ricord himself.  Though in his Letters, (xviii. p 138,) he informs us, that in true
inoculation, the dermis is completely bored, as if with a punch, in the same Letter,
(p. 141,)  he states, that the primary ulcer does not always destroy the entire thick-
ness of the skin or mucous membrane.   Indeed, this distinguished syphilographer
has at length been compelled  to admit that, after all,  there is no characteristic pus-
tule.   In his inoculations on M. Laval—that martyr to syphilization—M. Ricord in-
sisted that the little ecthymatous pustules which he produced, and which speedily
disappeared without ulceration or suppuration, were genuine chancres, only, of a
particular form (seidement avec une forma particulicrc).   For proof of this assertion,
Bee the Communication of M. Depaul to the Academy of Medicine, July 27, 1852,
(De la Syphilization, <fcc. p. 54,) and that of M. Ricord  himself, (op. cit. p. 67.)  But,
is it reasonable to suppose that a virus, which, when applied as  in the ordinary
modes of propagation, produces effects so diversified,  should on  artificial inocula-
tion produce the same invariable results ?  The  numerous experiments of Mr.
Egan, of  Dublin, and M. Sperino, of Turin, if further proof be wanting, conclusive-
ly settle  this question.  Mr. Egan (op.  cit.  p. 27) observes: " in some of the cases
to which I allude, the only effect produced (on  inoculation), was slight inflamma-
tion, which in the course of a few days subsided; in  others, the inflammation ran
to a higher pitch, and terminated in an unhealthy phlegmonous abscess; while, in
a third, no visible effect was at all discernible.  These remarks apply more parti-
cularly to the first class of primary ulcer" (the superficial).  It will be  remem-
bered that the matter used in these experiments, was taken from ulcers which were
followed by constitutional infection.  On this subject, the reader may also consult
the Treatise by M. Sperino, "on Syphilization,"p. 94.   At p. 501, he informs us that
the pus of the so-called false pustules  has been proved by his experiments to be
improbable.   There » at present (August  9, 1853), in the New York Hospital, a 
66               VIDAL ON VENEREAL DISEASES.
 the subject of balanitis, I will prove that the pus secreted  by the
 glans and the prepuce, which is not ulcerated nor even excoriated,
 may produce chancres.  Now, in this case,  even the pretext of tho
 chancre larve cannot be invoked, for it is one of external blennor-
 rhagia ;  the whole surface  furnishing  the humor may be directly
 explored.  Thus the existence of virulent blennorrhagia is proved
 by the writings  of  those  opposed to the doctrine, and this from
 the simple circumstance, that it is a fact.
   Incubation.—Incubation, like  that  of chancre,  has here been
 admitted  and denied.   The period  of incubation  is generally
 exaggerated by patients :  thus, it is not uncommon to hear  them
 speak of eight, and fifteen days elapsing between the suspected
 coitus and the first appearance of their blennorrhagia; they have
 even gone as high as fifty days.    The majority of patients, having
 suffered nothing at  first, and  the discharge being but trifling and
 colorless,  they mistake  the starting point  of their disease.  We
 should,  therefore, in  general, mistrust  the computation  of most
 patients.  But there are those who  begin immediately after their
 suspected coitus, to  watch the most trifling phenomena which ap-
 pears on the genital organs;  and among these observers are found
 not only men of the world capable of noting these phenomena, but
 even experienced physicians.  Now, these persons have noticed a
.real  incubation; that is, twenty-four  hours and three days have
 passed without  anything  being  discovered,  absolutely  nothing;
 after this interval, a sensation of pricking, of  itching,  followed by
 a more copious  secretion of mucous, which afterwards becomes
 troublesome, indicates that they have contracted the disease.  This
 has been  observed not only in urethral blennorrhagias, but also  in
' those of the prepuce and glans,  which are directly  open to our
 observation.  It must be admitted, however, that certain  cases  of
 blennorrhagia, especially those which follow sexual intemperance,
 are said to create, even on the first day, a modification in the sen-
 sibility of the parts;  and that on the second, the discharge appears.
 Most generally the  truly inflammatory phenomena are not estab-

 patient, named Hugo Kiel. He is 18 years of age.  On the 6th of June, eight days
 after exposure, he first felt a burning sensation at the meatus.  This was followed
 in a day or two by a discharge, which soon became profuse.   He  is positive that
 he has never suffered pain except when urinating.  A bubo appeared on the right
 side two days after the commencement of the discharge.  In the course of a week
 this was opened, and the matter successfully inoculated three weeks from the first
 attack.  At present, we can detect no  roughness within the urethra, though  we
 have  examined most carefully with a bougie, nor can we detect  any induration
 along the track of the canal.  The patient assures us that he has never been able
 to detect the slightest hardness, or any unnatural feeling.  Is this a chancre larve ?
 As such it is regarded by the talented surgeon (Dr. Van Buren)  who  performed
 the inoculation, and who has charge of  the patient.  The only proof, however, of
 the existence of  a concealed chancre in this case, is the fact, that inoculation pro-
 duced positive results.  Believing with M. Ricord, that chancre alone is inoculable,
 the successful inoculation is to him proof positive of the existence of a chancre
 larve.  The fact being now incontestably established, that secondary accidents,
 and blennorrhagia, may produce  positive results on inoculation, (for further proof
 of the latter, see Thesis  of M. Barthole, 1845.) with all due  respect to the opinion
 of the above-named surgeon, in the instance of Hugh Kiel, we can, after the most
 diligent search, discover nothing more than an ordinary case of blennorrhagia.—i
 G. C. B.                                                       6 
BLENNORRHAGIA.
67
lished until the fifth day, at which period pus predominates over
the mucus.
  Symptoms.—I have already stated that in the commencement
there is a modification of sensibility, which is most frequently in-
creased as are the functions of the organ, especially its normal se-
cretion.  In the second stage, there is real pain and dryness of the
mucous membrane, which is but of short duration, and soon gives
place to a morbid secretion.   This secretion is a mixture of pus
and mucus, muco-pus.  At first of a white color,  it assumes a yel-
low shade, and after  awhile a deeper color.  As the discharge be-
comes more abundant, the muco-pus is turned to a greenish color.
This is owing to the presence of some blood-globules which by
their increased numbers give  to  the discharge a reddish aspect.
These shades are particularly observed in cases where the discharge
is of a sanious sero-sanguineous character.   But in general the color
depends upon the mixture of pus with the mucus.   In the acute
stage of the disease the matter  discharged has an odor which gene-
rally resembles that of decayed codfish;  sometimes, even in the
urethral discharges of the male, it has  a faint sickish smell like
that of leucorrhcea.   It is very true that the odor may be rendered
remarkably  strong by a neglect of cleanliness.  But this alone
does not give rise to  it, nor decide its character.   Thus, when we
find a subject with a  large number of mucous pustules on the geni-
tal organs, we perceive an infectious odor, which, however, is not
the same as that exhaled by a  patient affected with blennorrhagia,
even when both subjects are  guilty of the same want of cleanli-
ness.  I do not agree with those who so much despise the odor in
trying to distinguish the  different kinds of blennorrhagia.  I have
observed urethral discharges in the male of a sour and nauseous
smell like that of the fluor albus of the woman with whom he had
had connection.
   Progress.—Sometimes  at the commencement  of an attack of
blennorrhagia, we find general disturbance of the system, such as
chills and febrile reaction.  It often begins without any premoni-
tory symptoms, and proceeds to a chronic state, or what is less fre-
quent, to a rapid and perfect  cure.  This  termination is often ob-
served in  those forms of  the disease which are, so to  speak, exter-
nal, like that of the prepuce and the vulva.  But, when the disease
is more deeply seated, when irritating humors are  brought  into
contact with  the inflamed surfaces, as happens to the urethra so
often traversed by the urine, then  there is less hope for a speedy
termination.   Sometimes, especially in those who have been often
affected, it puts on a chronic form from the beginning, and then
the tenacity of the discharge is indirect proportion to the number
of attacks which the  patient has suffered.
   The decline of a blennorrhagia is particularly marked by the
predominance of mucus  over  the pus, by the separation of these
two elements of the  blennorrhagic discharge.  Some globules of
pus, so to speak, are found wandering in the mucus, or the stain
upon the linen is of a grayish color with a point at the centre  of a
deeper tinge: finally the linen is no longer marked.  The duration 
68              VLDAL ON VENEREAL DISEASES.
of blennorrhagia, where it is somewhat severe, varies from four to
six weeks, from six months to a year.   There are few exceptional
cases where the discharge is permanent, but in such cases there is
reason to suspect the existence of a stricture, an absence of hygiene,
an imprudence in the diet, which incessantly renews or rekindles
the  discharge.  M.  Cazenave  believes that  when these relapses
occur, it is owing to the  existence in the first place of a virulent
blennorrhagia, which  has left the urethra susceptible to the least
irritation, and there it is that non-specific causes produce discharges
with the greatest facility.
  Diagnosis.—The diagnosis of blennorrhagia brings us to the con-
sideration of the chancre larve.   In the female, by the proper  ap-
plication of the speculum, we may discover ulcerations on the neck
of the uterus, the walls of the vagina, or learn whether the disease
be  simply one of blennorrhagic  inflammation.   In the  male, the
difficulties are great in the way of diagnosing a chancre deep in
the  urethra*  Some syphilographers who admit the existence of
this chancre, are satisfied when with a  catheter they detect a
roughness at the seat of ulceration; but a thickening, or a fold of
the mucous membrane may give rise to the same sensation.  Then
comes inoculation: now nothing can be more unfaithful  than this
latter means, since those  who admit the urethral chancre maintain
that it is inoculable only at a certain stage of the disease, and  be-
cause the matter withdrawn by the lancet may be furnished by the
portion of the canal which is in front of  the chancre, where the
inflammation is  supposed  to  be of  a simple character.  In this
manner may be  explained the  fact, that M. Bigot, in the service
of M. Puche, inoculated with urethral pus sixty-eight times with-
out success.  These difficulties besides have been admitted by those
with whom urethral chancre plays so important a part in the pro-
duction of virulent discharges.   As I  do not believe in the deep-
seated chancre, and  admit  only that of the  meatus and the  fossa
navicularis, my mind is  less prepossessed with the difficulties of
diagnosis.
  It is difficult to distinguish simple blennorrhagia, that which is
but a catarrhal inflammation from virulent blennorrhagia.  How-
ever, if we can establish  a true incubation, if the discharge has a
tendency to become chronic, we  have reason to suspect a specific
discharge; if, on the contrary, it has followed excessive  sexual in-
dulgence, if its progress  be rapid and  the interval brief between
the coitus and the attack, if the termination be sudden and rapid,

  * The best speculum for the  male urethra with which we are acquainted, is that
devised by Mr. Avery of the Charing Cross Hospital, London.  It consists of a coni-
cal metallic tube, into the  outer funneflfehaped extremity of which  the light is
thrown from a reflector fastened to the forehead of the  surgeon, through which is
an orifice sufficiently large to  admit the light to reach the eye of the examiner.
Through the politeness of this  skilful surgeon, we have had opportunities of ex-
ploring the seat of strictures, and could not but admire the distinctness with which
the interior of the urethral canal was brought into view. Still as we have already
shown on the authority of M. Ricord, the physical characters, even of  the external
primary ulcer are so diversified, that from them alone we cannot pronounce upon
its nature, and though we may succeed in exposing an urethral ulceration our di-
agnosis is not yet fully established.—G. C. B.. 
BLENNORRHAGIA
69
we have strong grounds for deciding in favor of a simple blennor-
rhagia.   At a later period, if accidents supervene, the diagnosis is
then completely established.
   Prognosis.—The prognosis depends upon the seat of the blen-
norrhagia, the  age of the patient, the  temperament, the intensity,
and the duration of the disease.  In  urethral blennorrhagias we
have to dread the occurrence of strictures, affections of the bladder,
of the kidneys, and in the male, the prostate gland.  In advanced
age the latter accidents are most  frequent:  at an earlier period of
life orchitis is oftener observed.  The more protracted the disea.se,
the more have we to fear the production of strictures.  Previous
attacks are favorable to new contagions, and renders the treatment
less successful; but the patient  suffers less in proportion to the fre-
quency with which he has been affected.   The nature of blennor-
rhagia modifies the prognosis: there is a vast difference between
the gravity of that which is simply inflammatory, and that which
is virulent
   Pathological Anatomy.—The  lesions  of tissue  observed in cases
of blennorrhagia  must vary according to the seat of the disease;
these will be particularly examined when we  treat of urethral
blennorrhagia in  the male.  I may observe, in a general manner,
that the mucous  membranes have been found of a deep red color,
and thickened by plastic infiltrations of the subjacent cellular tissue,
and by abscesses.  Ulcerations have been  observed, even simple
ulcerations, the reparation of which by inodular tissue may give
rise to stricture, if a canal be the seat of the disease.  The same re-
sult may be  produced  by the  reparation of the loss of substance
caused by the passage of the pus through the urethra which was
formed around this canal.
   Accidents.—These depend upon the seat of the disease; they will
be made known when we come to treat of particular forms of blen-
norrhagia, especially that of the  male urethra, described in the
next chapter.
   Treatment.—This, in  the first place, should be prophylactic.  I
do not  believe that we are ever under the necessity of practising
coitus under  circumstances where we have reason  to  apprehend
contagion, and still less when we have reason to suspect that we
are sufficiently diseased to communicate a blennorhagia.  Mediate
coitus has been recommended  where there is reason to fear conta-
gion ; it certainly is  a means of prevention, but  not an infallible
one.*  The coi'tus attended with the  least risk is  that which is
quickly performed, is not often repeated, and which is complete,
as the ejaculation may carry away  the contagious matter which
might have entered the urethra.  For the same reason  it is of ad-
vantage to urinate immediately after the  act; the latter, however,
should not lead  one to dispense with thorough ablutions with
some mild astringent  lotion.  Those who have  suffered, if their

  * The intermediate consists of a small sac  made from ea;cum of a  sheep.  This
discovery, which  by its utility deserves  the gratitude of the public, gave to the
unfortunate Englishman who left to it his  name, such an unenviable notoriety,
that he was obliged to assume another. 
70
VTDAL ON VENEREAL DISEASES.
memory serve  them, will admit that a surprise, carelessness, too
much confidence in the person with whom they had intercourse,
prolonged coitus, a false shame in asking for the means of ablution,
were among the circumstances which led to their misfortune.
   As in the case of chancre, some advise in this  disease, the abor-
tive method of treatment.   This can be proper  only at the com-
mencement of the disease, before inflammation appears; in fine, at
the very outset of the malady.   Now, the interval  between  the
suspected coitus and the first appearance of the inflammation is
not always  the same, for sometimes it occurs in twenty-four hours
from the application of the  cause, whilst in other instances seven
days have passed before it becomes well marked: then, the means
could no longer be abortive, but on the contrary would tend to
aggravate the  inflammation, to prolong  its duration, and to  pro-
duce serious consequences.   I shall never forget the case of a man
whose absent wife was expected in a very short time after he dis-
covered that he had contracted a blennorrhagia.   He applied to
me for a sure method of at once arresting the disease.  As I could
not  promise this, he consulted another practictioner who advised
a caustic injection into the urethra, which produced a most severe
and painful inflammation of the canal and of the bladder.  I was
requested to treat  this  patient, who was confined in his bed for a
month, during which time the most energetic antiphlogistic treat-
ment was required.*
   Could we be  consulted at the very moment of contagion, when
the virus is producing its first effects, and were  there a characteris-
tic symptom of this period in blennorrhagia, we should act at least
rationally in trying to  destroy  the  cause at the part affected, as
well as its effect, which must then be local and very limited.  But
this is very seldom possible.   Besides, it is necessary that the point

  * Mr. Langston Parker, in a letter to the writer, dated May 31st, 1853, thus ex-
presses his opinion of the abortive treatment in blennorrhagia:
  " When a patient seeks advice before the inflammatory  symptoms 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 and any pain in micturi-
tion, and 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
favorable circumstances it will not always succeed."
  In addition to the above extract from the manuscript copy of the third edition
of his valuable work on  the "Modern Treatment of Syphilitic Diseases," now in
preparation, which he has had the kindness to furnish me, he observes, " but under-
stand, I never employ the nitrate  of silver in stronger solutions than from 2 to 5
grains in 8 ounces  of water. I have seen death result in one case from a stronger solu-
lon.  For the details of another fatal case, from the nitrate of silver, see the work al-
ready quoted of Mr. H. J. Johnson, p. 59. We think that it may be safely asserted that
the majority of the London and Dublin surgeons are opposed to the abortive treat-
ment, except under the circumstances mentioned by our author, with whom as will
be observed, M. Parker so strongly coincides,  During our recent visit to Dublin
Mr. Adams, of the Richmond Hospital, assured us that it was not a favorite method
in that city, and  that in Dublin it is called the " abominable" treatment'  We
have tried the chloride of  zinc, as proposed by Mr. Lloyd, of  St. Bartholomew's
Hospital, London  (London Lancet, Dec. 1850), and though at first much pleased
with its effect, have been taught by further experience, that in some of our sup-
posed cures, we had produced only a temporary suppression of the discharge  We
Btill prefer this substance to the nitrate of silver, as we are satisfied that it causes
less pain.—G. C. B. 
BLENNORRHAGIA,
71
of the mucous membrane affected should be discovered, before one
application can be really topical, direct and limited to the lesion;
this may be done, in affections of the glans, the prepuce, and, un-
der certain circumstances, of the vulva; but  the  most common
form of blennorrhagia, the urethral, does not  admit of an appli-
cation so methodical, so direct; we should have reason, therefore,
to apprehend  an  extension of the  inflammation from the applica-
tion of an irritant to the sound portion of the mucous membrane.
  At one time the  sulphate of zinc was much employed;  at pres-
ent, however,  preference is given to the nitrate of  silver.  Car-
michael was the first in England, as was M. Debeney in France,
to highly extol this method to which I shall again refer.
  Besides, it should be well known that the  pretension to cut short
a blennorrhagia is an old one, and that the abortive treatment was
long since  tried, judged, and condemned.  Indeed, Charles Musi-
tan professed to cure a gonorrhea in three days by injections.  If
we employ them when the purulent discharge first appears, it
is at once  arrested.  If they be used before the discharge has
appeared, whilst  the parts suffer from  an  extraordinary itching,
the disease is prevented.  Astruc, who quotes Musitan, has already
remarked that unfortunately for the debauchee, both reason and
experience demonstrated the falsify of this method, and that it is
possible in place  of  preventing a gonorrhea sometimes to operate
when  no  disease exists.*  Finally, Astruc very justly remarks,
that physicians are seldom consulted whilst gonorrheas are forming,       »
and still less before they have appeared.?   This passage from As-
truc is very remarkable.
   For my own part, when there is but a suspicion of congestion,
 or when the inflammation has commenced, I recommend, distinctly,
 rest of the organs, bodily repose,  abstinence from food and drink
 which can render the  urine irritating, or  excite  or inflame the
 genito-urinary mucous membrane; then follow  emollients, baths,
 diluent drinks, a diet not too severe, and most powerful  antiphlo-
 gistics when the inflammation is really established.  If the patient
 is young, vigorous, and the inflammation very active, very painful,
  I at once abstract blood and thus greatly promote resolution, and a
 decided resolution.   I have never found that antiphlogistics, even
  when used for a length of time, produce the chronic state to which
  blennorrhagic discharges too often tend.  The contrary I have very
  often observed; I have seen, indeed, that the cases which most readily
  become permanent, are those in which the abortive treatment has
  been tried, and in which violent means have been employed. When
  the symptoms of a decline are apparent, and the violence of the
  inflammation is less marked, I have recourse to anti-blennorrhagics,
  to a combination of cubebs and copaiba.   In the last place, and
  when the inflammation is  extinguished, if the discharge persists,
  I  resort to injections.  With regard to the order in which injec-
  tions should  be used, I am entirely of Swediaur's  opinion.  I pre-
  fer astringent to caustic injections, and when I wish to produce
* T. iii. p. 86.
f T. iii. p. 87 
72              VLDAL ON VENEREAL DISEASES.

the effects of the latter, I prefer the solid nitrate of silver, which is
more easily managed than the solution of the same salt.  I believe
that it is of great advantage in the treatment of blennorrhagia, to
isolate, as much as possible, the inflamed surfaces;  thus, in bala-
nitis, in vulvitis, and in a  certain stage of vagnitis, we may with
lint, or charpie, or wadding, produce this  isolation.   But  such is
not the case with urethritis; the  tents and foreign bodies which
we suffer to remain in the urethra, can only exasperate the inflam-
mation.   The  same  effect would be  produced by  plugging  the
vagina, in females in whom it is narrow, and whilst the inflamma-
tion is at its height.  The details of the treatment will be particu-
larly exposed in the following  chapter.
         CHAPTER  II.

BLENNORRHAGIA  IN  THE MALE.
                        SECTION  I.

             BLENNORRHAGIA OF  THE URETHRA.

  Causes.—There are certain predispositions to urethral  blennor-
rhagia in  the  male  which  may be  called organic;  thus,  its
development may be promoted by the unusual size of the penis,
a large meatus urinarius,  and hypospadias.   These  conditions
favor the  introduction of muco-pus in the urethra.  This is par-
ticularly the case with hypospadias, which prolongs, so to speak,
the meatus towards the scrotum,  enlarges the opening of the
urethra, and brings the  mucous  membrane in contact with that
part of the vagina in which  the humors are collected.  These
etiological  notions should  prevent  us from taking any  steps  by
which the meatus shall be increased in size.
   In discussing  the  etiology of blennorrrhagia in  general, I
endeavored to  appreciate the influence of age, temperament, ali-
ments and certain antecedent pathological conditions.   I have
stated that the direct causes were physical, chemical, or patholo-
gical.  Thus, the passage of a calculus through the urethra, the
introduction of a catheter, an irritating injection, may all produce
a muco-purulent secretion.  Too frequent connection, or  that per-
formed  with organs of disproportionate size, masturbation, men-
strual blood, cancerous ichor, the  lochia, the product of a uterine
or vaginal catarrh, are anions the causes which have been accused
of giving rise to blennorrhagia.
   I designedly repeat, that specific pus, the pus containing syphi-
litic virus, is, in my  opinion, the most  frequent and powerful 
              BLENNORRHAGIA OF THE URETHRA.           73

cause of blennorrhagia.   Those authors who have denied that this
virulent matter may produce a syphilitic blennorrhagia, have  ad-
mitted that it may act as an irritant to the mucous membrane, and
at the same time that they have denied to it the power of produc-
ing a primitive syphilitic blennorrhagia, they have acknowledged
that it may give rise to this disease, but under a secondary form.
This virus therefore deserves a prominent place among the  causes
of the disease, and this fact should not be forgotten when we come
to its treatment.  Indeed, to render it complete, after anti-blennor-
rhagics, we should adopt the treatment of chancre, distinctly under-
standing that blennorrhagia should be regarded as a specific disease.
   Seat.—Attempts  have been  made to mark  the point  of  the
urethra affected in the form of blennorrhagia under consideration.
According to my observation, it is found most frequently  at  the
commencement of  the  canal.   Thus, Stoll fixed upon that point
of the canal which corresponds to the fra)num.  Desault  speaks
of the fossa navicularis.  In the two criminals dissected by Hun-
ter,  the urethra  was somewhat more  than ordinarily  injected,
especially towards  the  glans.  Feu Cullerier also mentions  the
fossa navicularis,  and  lastly,  ^T"Th. Boyer,  having made  the
autopsy of a subject connected with blennorrhagia, noticed a red-
ness at the anterior part of the canal.  Swediaur maintained that
in all cases, the disease is seated  in the fossa navicularis ; accord-
ing to him, when the inflammation extends to a greater depth, it
is owing  to  improper  treatment, the sudden suppression  of  the
discharge, or to some internal cause.
   The  appendages of the  urethra  have also been designated as
being the  scat of the disease in question.  Thus Astruc speaks of
the  vesiculaa  seminales, the prostate,  Cowper's glands,  and  the
lacunae of the urethra.  William Rondelet believed that in cases
of virulent gonorrhea,  the disease  was particuly seated  m  the
prostate gland.  M. A.  Severin points  out the kind of lesion of
this gland; it is an abscess.  It is known that before the time of
Morgagni, the majority  of writers admitted the existence of ulcer-
ations which secrete the purulent matter, which, in their opinion,
could not be produced  except by a mucous membrane in a solu-
tion of continuity.   The idea of locating  the disease in one  of the
glands  annexed to the urethra, was suggested by the abundance
of the discharge.  Whatever may be its seat, the anterior part of
the  urethra  is really  that which  is first and most  frequently
affected.  At  this  point, as Benjamin Bell remarked, blennor-
rhagia in its first stage is seated, from which, by extension, it may
invade other points of the urethra, and  extend not only to Cow-
per's glands, the prostate, the vesicuke seminales, the  bladder, and
even reach the kidneys.  Blennorrhagia has, therefore, really  in-
volved  all the different parte mentioned by authors.  But these
are exceptional cases, complications and accidents. Thus, certain
inflammations of the prostate  gland and bladder, are only com-
plications of urethral blennorrhagia; such is also the case when the
tissues surrounding the  urethra become inflamed and  suppurate,
producing abscesses which are called peri-urethral. 
74             VIDAL ON VENEREAL DISEASES.
  Symptoms and Progress.—Blennorrhagia appears in from one to
three days after the  suspected  coitus.   " I have observed," says
Cullerier^ the uncle, " what  is extraordinary, the discharge  com-
mence the next day, and I have  seen  it, in two instances, first
show itself not until a month afterwards."  Cullerier, the nephew,
and M. Ratier, refer to an instance  in which the  disease did not
appear until five months .afterwards coitus.  The following is the
report of it, given by these authors :  " There is, at present, in the
Hopital des Veneriens,  a man aged fifty-eight years, of a good con-
stitution, accustomed  to  the enjoyment of  excellent health, and
who never had the venereal  disease.  One day, together with four
other individuals who did  not  suffer, he had  connection with a
woman.  Five months afterwards, a blennorrhagia appeared.  It
lasted  fifteen days, when the  discharge ceased,  and he became
affected with mucous tubercules about the anus,  for which  he
required my services.   Whence  these morbid phenomena ?  For
eight years previously, this patient had  had no connection with a
female, nor had he after  that above mentioned."*  For myself, I
can only say, that this case is unique.
  Generally the discharge is not  the first symptom which appears:
some patients experience at first a peculiar  kind of itching in the
anterior part of the urethra, and a feeling of weight in the  peri-
neum ; others have an uneasy feeling in the groins; some complain
of general indisposition,  and of chills;  cases have been observed
which have all  the symptoms  of blennorrhagia, minus the dis-
charge, constituting, as it were,  a dry blennorrhagia, which  ordi-
narily is but a stage  of  true blennorrhagia. Sometimes,'on the
contrary,  the  discharge  precedes  all the other  symptoms; 'the
patient  perceives stains  upon his linen, and yet  he has suffered
nothing.
  But, in  the majority  of  cases,  the following  is the order of
events: the patient feels an itching sensation  at the commence-
ment of the urethra, which  increases, and soon becomes changed
to pain, particularly at the moment of urinating; there follows a
discharge  of a thready, slightly-troubled humor, which dries upon
the linen.  Astruc  observes:  " The  first oozing from the ure-
thra is attended with a pleasant sensation,  and glues  together
the lips of the meatus."*   This humor looks like nasal mucus.
When it becomes dry, the first  jet of urine breaking the mucous
scab (which is soon formed again), produces  acute pain.   But the
lips  of  the meatus become swollen, and of a redder color; the
pain in urinating increases, and as  the urine traverses the urethra,
it gives rise to a burning sensation ;  hence the  popular name of
chaudepisse, that of arsure, and internal burning of the penis, long
ago employed.  In proportion  as the disease becomes more severe,
the pain seems to extend more and more towards the neck of the
bladder; it may be produced by pressing along  the course of the
canal; the sensibility  and tumefaction of  the walls of the urethra
* Dictionnaire de Medecine et de Chirurgie Pratiques.
\ Astruc, t. iii. p. 2. 
BLENNORRHAGIA OF THE URETHRA.            75
are found gradually to extend towards the posterior part, and the
matter discharged comes daily from a more distant point.  These
symptoms showing  that urethritis is fairly established, are gener-
ally observed about "the fifth day.   Whilst passing urine, the pain
is most violent; it is felt strongly in the perineum, and is increased
when the patient crosses his legs, and during defecation, particu-
larly if he be affected with hemorrhoids.   The emission of semen
is also painful; when the inflammation extends beyond the mem-
braneous portion of the urethra at the  moment of ejaculation, a
lacerating pain is felt.  The semen issues, foaming as if overflow-
ing, and this  occurs shortly after the contraction of the muscles
of the perineum.  The  erections  are painful and frequent in pro-
portion to the abstinence of the patient.   The pain  is accounted
for, by the passage of the urine over an inflamed mucous surface,
by the  inflammation  itself, and the obstruction arising from the
tumefaction of the urethra and the ejaculatory ducts, a tumefaction
which impedes the emission both of semen and of urine.
   The stream of the urine is modified ;  sometimes it is bifurcated,
and it is always  diminished in volume.  If the inflammation has
reached the prostate, a complete retention may follow.
   The ingredients and the color of the discharge vary ; it consists
of a mixture of pus and mucus, or, as it is now called, muco-pus.
At first, it is of a whitish tinge, and of the consistence of cream ;
then  it becomes yellow, and afterwards  green; it has a bloody
tinge in very acute  cases.   Astruc remarks that the discharge is
of a greenish yellow color, such as we observe in the  last stages
of pneumonia.  The  blood may even flow in the form of a ure-
thral hemorrhage.
   During the progress of the disease, the prepuce and the  glands
become more or less  swollen ; the summit of the latter resembles
a cherry nearly ripe.  The tissues subjacent to the mucous  mem-
brane of the urethra, become likewise swollen. The  little glan-
dular bodies in which terminate the ducts of Morgagni, Cowper's
glands, and  the prostate itself, are all sometimes inflamed;  they
rarely  suppurate, particularly the  latter gland.  The canal feels
knotty.   The abscesses which form here  and there open within
the  urethra, or  externally, this last termination becoming more
frequent as we approach the glans.  On the sides of  the frenum,
two small collections sometimes  form, which always open exter-
nally.  Cases do occur in which  the  inflammation extends over
the whole urinary apparatus.
   Erections  occur  during the progress of a blennorrhagia.   But
when the latter is severe, and the patient is very nervous, these
erections may  become  very frequent,  painful, and obstinate.
Then occurs that  symptom to which has been applied the name
of chordee.   It is often very troublesome  when the  patient  is in
bed.   During an attack of chordee, the penis is hard, very sensitive,
sometimes even painful.   It preserves its natural shape, or it  be-
comes  curved;  in  the  majority  of cases  it  is bent downwards,
sometimes to one  side, and rarely upwards.  Astruc has noticed
this last curvature; Benjamin Bell twice observed it; I have my- 
76              VIDAL ON VENEREAL DISEASES.
self seen it.   Chordee may occur  at any period of blennorrhagia;
but it is  found most frequently when the inflammation is com-
pletely established, in the second stage of Benjamin Bell.   It has
been seen to remain  even after the subsidence of all inflammatory
symptoms.
  Hunter recognized two varieties of chordee, one inflammatory,
the other spasmodic.   In the first, the inflammation is not limited
to the mucous  membrane and the little glands, but it affects the
reticular tissue of the urethra, into  which coagulable _ lymph  is
effused;  these cells become adherent, the walls lose  their pliancy,
and  the canal, no longer able to follow the cavernous bodies  in
their  development,  assumes  the  office  of a cord, by  which the
curve is maintained ; and hence  the curvature of the penis.  The
spasmodic chordee is  but a nervous  phenomena; it appears and
disappears, but at no regular intervals.
  Is there a  dry blennorrhagia?   According to  Swediaur, the
inflammation of the urethra sometimes becomes so intense, that its
internal surface  and the orifices of the  glands which border upon
it, yield no secretion, as occasionally occurs in inflammation of the
mucous  membranes of the nose  and lungs.   In a severe catarrh,
all discharge is  arrested. This Fabre  denies.  He maintains, on
the contrary, that the  inflammation in these cases is not severe.
A very small number of carefully-observed cases have been re-
corded,  establishing the absence of the  discharge with all the
other symptoms of  blennorrhagia.  I have really observed cases
of urethritis without  any morbid secretion.   Cullerier and M.
Ratier report a case which is perhaps the most authentic on record.
But, in my opinion,  this form of  urethritis is never dry through-
out the disease ; the discharge is  wanting either at the commence-
ment or towards the end.  It was at the latter period that it became
dry in the instance mentioned by Cullerier.*
  The duration  of the principal symptoms  of blennorrhagia varies
from ten, fifteen, and even to twenty days; when it begins to sub-
side ;  then the patient suffers pain only during the passage  of the
urine, the erections are less frequent, and the matter discharged is
less in  quantity.  Besides it turns yellow, then of a dirty white
color;  it puts on, in fine, the characters of mucus, which denotes
the most fortunate termination of the disease.  But, when after
the cessation of the principal symptoms,  the  matter discharged
does not assume this consistence, this  particular clast**^wiJbiaJ*»
characterizes mucus;  when,  on the contrary, the drops  easily
separate, like those of milk, somewhat thickened, we have reason
to apprehend a chronic state.   Then  the discharge  sometimes
assumes  an intermittent character;  it ceases, still to reappear;  it
is, as is commonly said, a relapse.  It consists sometimes of a single

  * Dr. Beadle reported to the New York Medical and Surgical Society, March 7 th,
1840, the case of a young man, who was under his care twice within the year, for
an affection of the  urethra resembling gonorrhoea in  all its symptoms, except
"there was not the slightest discharge."   This patient had impure-connection forty-
eight hours before his attack, and he was cured, in both instances, by an injection
of Nit. Arg. and mucilaginous drinks.  Vide N. Y. Journ. of Medicine and Suraeru
Oct 1840, p.435.—G.C.B.                                      J  J' 
BLENNORRHAGIA OF THE URETHRA            77
 drop, which is seen in the morning, if the glans be pressed  before
 urinating.   The least imprudence in diet, coitus, &c, produces a
 return of the discharge.   Occasionally, however, connection with
 a healthy woman causes it for a long time to disappear.  In these
 different states,  pain  properly speaking  does not exist, the dis-
 charge seems entirely passive, nothing indicates the least irritation
 of the urethra;  the canal  may be said to have contracted  a habit
 of an abnormal secretion, which requires no inflammatory conges-
 tion to produce it.   This is the blennorrhagia of Swediaur, which
 I have partly described.  Generally, then, the urine does affect the
 canal,'and the proper  relations between the properties of this fluid
/and the sensibility of the urethra, would seem  no longer to exist.
    Diagnosis—Here the question of the chancre larve again presents
 itself; I have already discussed it in speaking of blennorrhagia in
 general.   [In the  text, the  author  here repeats the observations
 made at  p. 62, which we have taken the liberty to omit.—G. C. B.]
 Chancre at  the commencement of the urethra is distinguished from
 blennorrhagia by the induration, tumefaction, and pain under the
 glans.  In separating the lips of the meatus, the ulcerated surface
 may sometimes be detected.   The discharge from the urethra is
 small in quantity;  it is badly assimilated pus,  rather serous than
 mucous, and generally there is a bubo more or less marked.*
    Like all other forms of blennorrhagia, it is difficult to distinguish
 the  simple  urethral blennorrhagia, that which is but a catarrhal
 inflammation, from that which is virulent.  But still, when in this
 case we  can establish a real incubation, when the discharge has a
 tendency to become chronic,  we have reason to suspect a specific
 disease; on the contrary, where it follows excessive coitus, when
 its progress is rapid, the attack almost immediate after exposure,
 if the termination is sudden, rapid, there are strong presumptions
 in favor of a simple blennorrhagia.  If, at a later period, syphilitic
 accidents supervene, our diagnosis is rendered certain.
    Pnxjnosis.—Urethral blennorrhagia is more liable to be followed
 by stricture, affections of the bladder, kidneys, and in the male, of
 the prostate gland.  At an advanced age the latter accidents are
 most frequent.   Orchitis is the most common of all the accidents.
    Pathological Anatomy.—As the opportunity seldom  occurs of
 making  the  autopsy  of a  subject affected  with blennorrhagia,
 anatomy, on this point, has but little to offer.f
    Aajd^d^—l have already spoken of chordee and peri-urethral (
 a1wS?f^Tlie other accidents  in part mentioned under the head
 of prognosis, will be examined separately when we come to con-
 sider the consequences of blennorrhagia.
    Treatment.—In speaking of blennorrhagia in general, I have

   * Mr. Henry James Johnson observes (op, cit. pp. 19, 20), that the pain in  mak-
 ing water  is not  so decidedly referred to the navicular fossa, or the orifice, as in
 blennorrhagia. The induration in question, he adds, is found from an inch to an
 inch and a half from the orifice,  is circular, yet flattish, about the size of a three
  1>enny piece, or less—tender to the touch—and gives to the finger just the  same
  mpression as is conveyed on pinching up an indurated syphilitic sore upon the
 lurface.—G. C. B.
   f Vid. p. 69, for remarks here repeated in the text—G. C. B. 
78              VIDAL ON VEXEREAL DISEASES.
indicated the basis of our treatment;  I noAV proceed to enter into
the details  and the methods particularly adapted to the urethral
blennorrhagia.
  1. Abortive Mrthod and Infections.—The  abortive method here
offers the greatest pretensions; 1.  It proposes rapidly to extinguish
the inflammation, and thus to prevent the accidents of the disease.
2.  To  neutralize the virus and  to  destroy it in situ.  I have
expressed my opinion of this method in my general remarks  on
blennorrhagia.   I have stated that it would be rational at the very
onset of the disease, before inflammation  is really established, and
at the  moment of inoculation.  Now, the surgeon very seldom is
consulted at this stage of the disease.  It is only at this period that
M. Ricord proposes this method;  it is therefore applicable only in
very exceptional cases.   M. Debeney generalizes it and resorts to
it in all stages  of the disease, even in blennorrhea, and according
to him, none, even of the most chronic cases, resist it when well
managed.  M. Debeney prefers caustic injections.
  A very old, very general, and almost popular reproach against
injections, is their liability to produce strictures.  To this it  has
been replied, that  stricture, in  reality, is but an inflammation of
the urethra, which has become too protracted; and that the best
method of avoiding this is to cut short the inflammation, in fine to
effect its absorption.  This reply, first made by Benjamin Bell,
would be unanswerable if we did truly subdue the inflammation,
or if we only abridged its duration.   Now, of this there is but very
little proof.   During an entire year I made use of caustic injections
in blennorrhagia, and once only did I obtain a cure which did not
require a Week's treatment.  In almost all the other cases the cure
was retarded, and in three a urethritis  very rapidly  produced a
stricture, which compelled me  to  discontinue the injections and
to substitute in their place antiphlogistics of a decided and energetic
character.  One of these patients was finally cured after a moderate
dilatation with  the yellow wax bougies;  the other two, weary of
the tedious treatment, demanded  their discharge;  six left with
blennorrheas, which I could not cure.  Among the latter, several
have probably suffered from strictures.   I  have been  told that I
employed the injections in every stage  of the disease, which is
true;  otherwise I should never have had before rtie a large number
of observations.  I am  convinced that those who would employ
the abortive method only when the inflammation is about to com-
mence, will employ it but very rarely, for the reason already given,
that we are almost always consulted too late.  What  I have said
in reference to the  prevention of inflammation, I would repeat for
that of syphilitic infection.   Still, even  for this purpose we are
almost always too  late.   I am convinced that many practitioners,
instead of treating the first stage of the disease, as" they suppose,
in  reality treat  different stages, and for this reason, their practice
differs less than they imagine from that of M. Debeney.
  Therefore I consider the abortive method liable to reproach, for
instead of cutting short the disease, it produces the opposite effect.
As to the cases of orchitis, of abscesses, of arthritic and opthalmic 
BLENNORRHAGIA OF THE URETHRA.
79
inflammations, which have been attributed to the use of caustic
injections, I believe the picture has been greatly overdrawn.  Soon
I will notice the accidents which even M. Ricord admits.  I have
already mentioned a case where a caustic injection did violently
inflame the urethra  and the bladder, so as to compromise, if not
the life of the patient, at least the peace of his friends.  Further,
this was the most severe accident which I have observed.  But the
most common accidents, and those  most  to be apprehended, are
not of  a primary but a consecutive nature; these are, I repeat it,
strictures.  It is evident that a cauterized, burnt mucous mem-
brane will undergo a solution of continuity, a kind of ulceration,
the reparation of which must always be accompanied with a dim-
inution in  the diameter and elasticity of the  canal.  What  has
deceived practitioners who believe in  the efficacy of caustic injec-
tions, is,  that there really follows,  after the pain and immediate
effects  of this method, a suppression of the discharge, a subsidence
of one  of the symptoms of the disease.  But with this suppression
we have not subdued the urethritis; it has been rendered dry only,
and this is but a transient, a temporary effect.  Now caustic injec-
tions are not  the  only means  which can thus  suppress a blen-
norrhagia;  the  same result may be obtained by the  powerful
agents  belonging  to a rational or empirical  therapeutics of the
disease.  For  example, cubebs often produce this effect,  and I
have suppressed the discharge in more  than  one instance by the
application of leeches to the perineum.   But in  the majority of
cases the discharge returns, and these relapses should be noted and
acknowledged if we would advance science.
   In my general remarks on blennorrhagia, I have already shown
that the  pretensions of this  abortive treatment  are very old.  I
have quoted the critical remarks of Astruc.  Behold the formula
of  Musitan,  which  according to the pretensions of the  above
named author, was to  cure  instantaneously:  " Take of plantain
water eight ounces, in which dissolve some sweet  mercury reduced
to a very fine powder;  agitate them together, and with an ivory
syringe inject an ounce of this fluid lukewarm,  into  the urethra
three times in a  day."
   M. Debeney, in a case which he has denominated, Blennorrhagia
with irritation of die neck of the bladder, employed the following
formula:

                     $. Nit. Argent.  3i.
                        Aq. distill.    £i.

According  to  M. Debeney the surgeon must himself administer
the injection ;  having first washed out the canal so that the muco-
purulent matter may not impede its direct action upon the mucous
membrane; this wash  should consist of a solution of nitrate of
silver about one-thirtieth of the ordinary strength; and should be
allowed soon to escape.   Immediately after this another injection
is made which should be retained in the canal for a minute, if we
would  produce a decided impression.  The fluid enters the canal 
80              VEOAL ON VENEREAL DISEASES.
    more deeply by pressing with the fingers  towards the root of the
    penis.
       The following  is M. Ricord's formula, and his  manner of pro-
    ceeding :*

                       I£. Nit. Argent, grs xv.
                          Aq. distill.   l'\.

    The patient sits upon the edge of a chair; the penis is put slight-
    ly upon the stretch, and the extremity of the syringe is introduced
    within the canal.   The lips of the meatus should be so pressed as
    closely to embrace the canula.  The injection must be sudden;  in
    this manner we take the mucous membrane by surprise, otherwise
    the urethra would close  upon itself and oppose the further pro-
    gress of the fluid;  one half of that contained in the syringe  is
    sufficient to moisten the whole canal.  The  patient should be in-
    formed  of the  sensations which he will be likely to  experience,
    lest he attribute to the progress of the disease what is but the tran-
    sient effects of the treatment.  This injection produces severe pain,
    the discharge is augmented, a serous, sero-sanguinolent or bloody
    exhalation,  appears, and this is soon followed  by phlegmonous
    pus  forming a swelling in the urethra.  The first emission of
    urine is extremely  painful, the pains  being  most  intense in  that
    portion of the urethra corresponding to the glans; the stream of
    urine may  assume every variety  of form observed in  cases of
    stricture.  These  pains may be mitigated, if the patient will urin-
    ate with  the penis immersed in cold water, and if he will refrain
    from  making any efforts.  These accidents subside in the course
    of twenty-four hours  ; if the bloody exhalation  and suppuration
    continue, the injections should not  be repeated until they disap-
    pear.
      In certain patients blennorrhagia ceases suddenly after the dis-
    charge of some globules,  the cure is preceded by the discharge of
    a kind of thready mucus which is of short duration.  Sometimes
    a greenish muco-purulent matter appears;  in this case we may ex-
    pect that the blennorrhagia will continue.
      If the  abortive  treatment fail, we  find on the third day that the
    characteristics of the disease are reproduced;  sometimes, however,
    it is not till  after  a  longer  interval, some five or six days for ex-
    ample, that the discharge re-appears.  These are the cases in which
    a complete cure has been supposed to have been obtained, but in
    which there  really has been but a suppression of one element of
    the disease,  viz. the muco-purulent discharge.   The careful ob-
    server who will follow these patients, and closely question them,
    will learn that  there  remain in the urethra modifications in its
,   sensibility, unusual heat, especially at the moment of the emission
    of urine; sometimes there is a real pain, or an itching sensation
    with a disposition  to urinate frequently.  The circumstances show
    clearly, in fine, that a  urethritis remains, that there is a dry blen-
* M. Debeney claims this formula. 
BLENNORRHAGIA OF THE URETHRA.            81
norrhagia which will  soon exhibit  all the characters of a  true
blennorrhagia.
   When the discharge reappears the injection should be repeated,
if it has not forfeited the confidence both of the practitioner and
patient.  M. Ricord admits that the injection of nitrate of silver
according to the formula  which he has so long employed, may
produce fainting, hemorrhage  and retention  of urine.   Add to
these, the pain experienced at the moment of injection,  and the
inconveniences of the method are already manifest.
   It should not be forgotten that the abortive method of M. Ri-
cord does not  consist exclusively of injections of greater or less
violence, but that in addition to them, he recommends the use of
balsams, of  which we  shall soon speak.  Now,  as these balsams
are given in heavy  doses, as  they are very powerful, and may of
themselves  speedily cure blennorrhagia, we can comprehend how
those who have confounded in the same  statistics the results of
M. Ricord's  practice with the facts  of M. Debeney, have furnished
a very decided proof of their ignorance of the  most common rules
of true medical statistics.
   What I have stated in relation to M. Ricord's practice, has been
based upon  his lectures reported in the Gazette des Hopitaux.  Now,
I find  in his Notes  to  the  second edition of Hunter,* that he ad-
mits the inconveniences to which we have alluded, and that he
has almost entirely renounced the use of injections.  At  present,
M. Ricord prefers the following formula :

                 $. Aq. Ros        gvi.
                    Sulph Zinc.
                    Acet. Plumb, afi grs. xv.

M. Venot has tried injections of chloroform; he has published in
stances of cure resembling those which we have cited as being fa-
vorable to the employment of very strong injections of nitrate of
silver.  It is in the commencement, a period in which the practi-
tioner seldom sees a patient, that chloroform is recommended.
   2. Balsams.—We now come to the consideration of the balsams,
at the head of which must stand copaiba.  This is an oleo-resinous
substance which is  obtained from  an American tree, growing in
the Antilles, which tree has also been  elsewhere cultivated.  M.
Guibourt prefers, for internal use, the copaiba of Cayenne.  It may
be administered in doses from ten drops to two ounces in a day.
Pure and in the liquid form, the copaiba has a  prompt and power-
ful action.   But the disgust, the retching  and vomitings which it
produces,  have compelled  practitioners  to employ some  correct-
ives, or adjuvants, in order that  it  may be tolerated by the  stom-
ach.   Combined with magnesia, it has been rendered solid  so as to
be made into pills.   It has also been inclosed in capsules.   The
pills when very hard are difficult of digestion, and are sometimes
passed entire by stool.  The same objection applies to the capsules.
* P. 157.
    6 
82
VIDAL ON VENEREAL DISEASES.
Besides in this form, it is difficult to give very large doses of co-
paiba, at least to increase considerably the number of pills and
capsules without disturbing the stomach.  In the form of potion
it is  more sure, but even then it still requires correctives ; these
I will specify by formulae.   The most celebrated  is that  of Cho-
part:

                 r). Copaiba.
                    Alcohol, rect.
                    Syr. Bals. Tola
                    Aq. Month, pip.
                    Aq. Flcur. orang. aa  § ii.
                    Alcohol, Acet.       3 ii.

With all of these corrections, however, there are some  patients
who cannot tolerate  the use of copaiba, even when thus adminis-
tered.  Yet I have seen those who  could take it without repug-
nance ; one of these was almost a gourmand.  The above potion
is given in  doses of a tablespoonful, from two to six times in a day.
  At the  hopital du Gros  Caillou  the following formula of M.
Gimelle is much esteemed:

                    $ • Copaib.       3 iii.
                       Cubeb.       3 ii.
                       Vin. Aromat. § iv.

This is to be taken in a single dose, having previously shaken the
bottle strongly.  The aromatic wine is intended to prevent vomit-
ing.
  Copaiba  has also been given by enemas, according to the follow-
ing formula:

                  r>. Copaiba,         3 v.
                     Ov. Vitel.        3 i.
                     Ext. Op. (gummy), gr. i.
                     Aq.              | viss.

Before using the injection of copaiba, a simple lavement should be
administered, so as to empty the rectum.
  I have been accustomed to combine copaiba with cubebs in the
following manner:

               $. Copaiba,    1 part.
                  Cubebs,     2 parts
                  Ess. Menth. q. s. ft. Electuary.

This forms an electuary, of which about half an  ounce is to be
taken in the course of a day.  A bolus is made of this by the
patient  himself, and covered  with  unleavened  bread.  He  is
generally cured after having used about four ounces of the above
electuary, it being distinctly understood that he has been suitably
prepared by the means which I shall presently indicate.
  Some practitioners begin with small doses of copaiba, which
they gradually increase, without, however, ever reaching a very 
BLENNORRHAGIA OF TnE URETHRA
83
strong dose.  This mode of administration is less efficacious and
more likely to disturb the digestive organs.
  Patients who have taken copaiba are attacked first by an intense
thirst, the throat becomes dry, and they drink abundantly.  Ac-
cording to M. Ricord, they must not indulge in drink, that they
may pass urine  less frequently, and this, as it were, will be ren-
dered more balsamic, more impregnated with the principles which
it derives from the blood.  Copaiba also  produces other effects.
Sometimes  it acts upon the stomach in such a manner as to pro-
voke vomiting by the disgust which it occasions.   These vomitings
now and then occur at a later period, and proceed from another
modification of the stomach, being then rather the effect  of an
irritation of the ventricle.  More frequently the intestinal  canal
suffers,  active purgation  being  produced.  Both  vomiting and
 urging are sometimes present, in fine symptoms of cholera mor-
 us.  Sometimes, on the contrary, there  is  constipation.  It may
happen, and this is most fortunate, that the bowels are not unusu-
ally free.  In all these cases the blennorrhagia may be suppressed
even rapidly, but this result, it must be admitted, is more frequent
and most complete when the digestive organs have well tolerated
the copaiba.
  Attempts have been made to explain the modus operandi of this
substance.  The majority of the French school attribute the cure
to a displacement of an irritation from the urethra to the intestinal
canal.   The Italian school recognizes in copaiba neither an irritant
nor a  specific,  but an  antiphlogistic hyposthcfiisant;  instead of 7i.__
accelerating and strengthening the pulse, as is generally supposed,
copaiba, on the contrary, diminishes both its force and frequency.
According to M. Ricord, there is an element of the copaiba which
enters the  blood, reaches the kidneys, which  then  secrete  urine
having medicinal properties which produce a beneficial effect upon
the lining membrane of the urethra.
   This question is of but little consequence, but it is of importance
to remember  that  copaiba is  the most  powerful of anti-blen-
norrhagics.  If it is not often employed it is because it is antipathic
to most patients, in whom it produces an unconquerable disgust.
   There is an accident which I have not yet mentioned, and which
may deceive the young practitioner; it is the affection of the skin.
This is sometimes an erythema, a variety of roseola, or an urticaria.
These effects of copaiba are more frequently observed in the spring
and autumn.   In the majority of cases, this  eruption, which varies
in different individuals, is of a simple character and soon disap-
pears ; however, as it is proved that it does not promote the cure
of the disease, but that it rather tends to aggravate it, the copaiba
must then be discontinued and the patient  allowed repose, during
which he may take  some acidulated  drinks preparatory to sub-
mitting to  the  use of some other anti-blennorrhagics.   Copaiba,
combined with cubebs, according to  the formula  which I shall
presently mention, very rarely produces this eruption on the skin.
Let us  examine this  substance, cubebs, for a  moment.  It is  a
variety of pepper reduced into powder, having somewhat the odor
 
84
VLDAL ON VENEREAL DISEASES.
of copaiba.   It has a hot, pungent, and slightly bitter taste.  As I
have already stated, I often combine this powder with copaiba so
as to form an electuary.   It has  also been used both in the form
of an extract and infusion.  The powder, however,  is that which
is most generally employed.  A dose of from 2£ to  5 drachms is
given twice  a day.   M. Puche sometimes gives as  much  as  2£
ounces in a day.
  Cubebs does not disturb the stomach nor inspire disgust like
copaiba, it produces vomiting less  frequently, and  especially, it
does not purge.   Indeed it often gives rise to constipation.  Some-
times the  stomach is swollen ; the appetite' becomes keen, and nu-
trition most  active; rarely does it produce cutaneous disease like
that from the use of copaiba.  The powder is placed in half a glass
of an infusion of lime-tree and orange peel,  or it is  enveloped in
bread, or capsules, or coated with sugar in the form of saccharated
capsules.
  M. Puche's treatment.—The following is his practice in cases of
acute blennorrhagia.   His prescriptions which  I here insert, are
copied from  his  own  writings.   M. Puche never administers co-
paiba before the twentieth or twenty-eighth day from the commence-
ment of the discharge.

                  GUMMY SYRUP OF COPAIBA.

                 fy.  Copaiba pur.     | ii.
                    Gum. Arab.      § ss.
                     Aq.             § iss.
                     Ess. Menth. pip.  itixxxii.
                     Syr. Sacch.      | xiiss.

Dose from  1 to li and 2 ounces of this emulsion in a day.

                 BALSAMIC GELATINOUS BOLUS.
                $. Copaiba.
                   Terebinth. Inspiss. aa.  3 iss.
                   Cubebs,              3" iii.

  Dissolve the  turpentine over a hot-water bath, and then incorporate with
it the copaiba and cubebs ; divide this mass into 100 boluses, which cover
with gelatine.  Dose from 12 to 24 in a day.   Two to be taken at once,
at regular intervals.

  M. Puche administers cubebs according to the following method •

                      POWDERED CUBEBS.

               Take 1st day, 2£ drachms for a dose.
                 "  2d    "  5    «     in 2 doses.
                 "  3d    "   1  ounce   in 3  "
                 "  4th   "   li ounces  in 4  "
                 "  5th   "   1|  «     in 5  «
                 "  6th   «  2    "     in 6  "
                 "  7th   "  2i  «     in 7  « 
BLENNORRHAGIA OF THE URETHRA.            35
  If the medicine arrest the discharge, says M. Puche, I diminish
the dose in the following proportion:

               Take  8th day, 2i ounces in 7 dosea
                 "    9th  "  2    "   in 6   "
                 "   10th  "  1|   "   in 5   "
                 «   mh  "  li   "   in 4   "
                 "   12th  "  I    "   in 3   "
                 "   13th  »  5 drachms in 2   "
                 "   14th  "  2i    "   in 1 dose.

   These doses are  to be taken in a well-sugared lemonade at regular in-
tervals, between meals.

  When the disease is of more than two months standing, and has
become chronic. M. Puche employs the following injections:

                    $.  Nit. Argent, grs.li
                        Aq. disk     § iii.

   An injection every morning and evening for five days*

                     IJ,. Nit. Argent,  grs. iii.
                        Aq. dist.     | xii.

   An injection morning and evening for five other days.

   M. Puche adds: after these injections have  been used for six
days, the  patient is  to  take no medicine for the next five days.
Very frequently the discharge is entirely suspended; but whetner
it does or  does not continue, it is prudent to give the cubebs in 2£
drachm doses for eight days.
   Author's Treatment.—The following is my method of treating
blennorrhagia.   I always commence with  antiphlogistics, the ac-
tivity of which is proportioned to the  duration and severity of the
disease.  Thus, in the majority of  cases,  I recommend in the first
place  the  use of baths, a  soothing tisane, and quietude.  If  the
patient is  strong and plethoric, and the disease severe and painful,
accompanied with frequent  erections, to  the  above I add the ab-
straction of blood; this is generally effected by the application of
twenty leeches to the perineum. It sometimes happens that these
means, aided by a mild regimen, are sufficient, that is to say, in
about eight days after  their use, the  blennorrhagia  subsides.   If
the discharge continues, I  have recourse to indirect anti-blennor-
rhagics, to copaiba or cubebs, but more frequently to a combi-
nation of  the two in the form of the electuary of which I have al-
ready given the formula.  In conjunction with repose, the baths
alone, or  leeches, this  anti-blennorrhagic produces a very speedy
and powerful effect; very rarely  does  it effect the  neck of the
  * It will be noticed that this corresponds to the injection which I employ after
the use of balsams. 
86
VIDAL ON VENEREAL DISEASES.
bladder in the manner which is observed when antiphlogistics have
not been previously employed, and when it gives rise to frequent
dispositions to  urinate, to high  colored  and sometimes bloody
urine, or by a more or less decided dysury.
  I never resort at once to injections.   I employ them only when
the antiphlogistics, the indirect anti-blennorrhagics, have failed to
arrest entirely the discharge.  Then, only, do I make use of in-
jections, and these not of caustic  but an  astringent nature.  The
following is my favorite formula; it is old, not very scientific, but
excellent in a practical point of view:
        •
                   ]J. Aq. Eos.       § v.
                      Acet. Plumb.
                      Sulph. Zinc, aa grs. viii.

  Shake the vial.   At least two, sometimes four injections in tlie day.

  When I  employ the nitrate of silver, it is generally as an as-
tringent, and then I prefer the following formula:

                   J},. Aq. Ross.     1 viss.
                       Nit. Argent, gr. i

When we wish to produce a caustic effect, it is better to use the
nitrate in a solid state.  This may be done with a straight porte
causiique for the anterior portion of the urethra, and with the
curved  porte caustique of M. Lallemand for the membranous and
prostatic portions.  We should resort to this means only in the
chronic state, when we have reason to suspect that the disease has
become seated on a limited extent of the urethra.
  A long and extensive experience, both in hospital and private
practice, with the method of treatment which I have recommended,
authorizes me to declare that  its results are more certain and even
more rapid than those obtained by methods which make preten-
sions to much more speedy cures.  It is easy to perceive, that  in
any case it has  neither the inconveniences nor the dangers of that
which is called the abortive treatment.
  There is  one phenomenon quite intolerable to the patient, and
to which I have alluded in the symptomatology of the disease, viz.
chordee,  an inflexible condition of the urethra which  does not
permit it to follow the cavernous body during an erection.   Even
here, in the majority of cases, the  first and best means, is the ap-
plication of leeches to the perineum.   Next come the sedatives,
properly so-called, such as opium, camphor and hyoscyamus.  The
first named are often thus combined :

                 ]J. Camph.
                    Ext. Opii. aa gr. viii.
                    Ov. Vitel.    3 i.
                    Aq.         | v.
For an enema. 
BLENNORRHAGIA OF THE URETHRA.
87
  The following pills are generally preferred:

               IJ,. Camph.    gr. ii. to grs. 6.
                  Ext. Opii.  gr. \ to gr. i.
                  Mucilag.   q. s.

  One, two or three pills a day, commencing in the afternoon.

  Thirty or forty drops of laudanum may also  be administered
when the patient retires, or when the  first erections occur.
  Cold applications to the genital organs, to the feet, a walk upon
the cold  marble slabs have  sometimes succeeded.   The patient
jumps out of bed, and by walking with naked feet upon the floor,
is  sometimes relieved.  But  it occasionally happens, that, when
the patient  returns to bed, and becomes warm again, the erections
are stronger than before.
  The hyoscyamus niger was sometimes successfully administered
by  Benjamin Bell, even when  opium had failed.  This English
surgeon gave from one to eight grains of the extract, three times
in a day; eight grains being administered  after the patient had
become accustomed to this medicine for some weeks.* But if the
patient  suffered from  chordee during all this  time, I  think it
would have been better to have resorted to some other means.
  A number of topical applications have also been employed.  I
once succeeded in relieving a chordee with very painful erections,
by  means of mercurial  ointment applied along the track  of the
urethra in front of the scrotum.   After the employment of fric-
tions, a thick layer of the ointment was left upon the penis.   Com-
presses dipped in equal  parts  of cold  water and laudanum may be
applied  so as to cover the penis, scrotum and perineum.  Brandy,
camphorated oil, bran and water, have been used in the same man-
ner.  When there is  nothing more than an erection, or a  spasm
by which a  superficial urethritis is complicated, these means  may
succeed.   But when the chordee depends upon an inflammation
which involves the tissues covered with mucous  membrane, when
plastic lymph is already effused in the cellular tissue, the antispas-
modics and sedatives above mentioned will fail, we must then re-
sort to antiphlogistics, to local and sometimes to general bloodlet-
ting, particularly if the patient be young, vigorous, and plethoric.
Benjamin Bell has proposed,  as have other writers, to depress the
penis, and  to bind it to one of the thighs.   It has been  recently
recommended to pull upon the prepuce, to press on its extremity,
so  as to comp'ress the  glans  and penis by its  sheath.   These
means, which may have succeeded where the erections have  not
been very painful, would not only prove ineffectual but might ag-
gravate a case of really inflammatory and painful chordee.
  Ilygeine  must be recommended.  Thus, the quantity of  drinks
taken should be diminished, and those used should not be of an
exciting character.  The patient should be advised to cover him-
self lightly on retiring, and to apply cold lotions to the penis.
* VoL i. p. 246. 
88              VLDAL ON VENEREAL  DISEASES.
      Consequences of Blennorrhagia.—The consequences of blennor-
    rhagia are numerous, as an urethritis may in its course involve the
    whole genito-urinary apparatus.  I must, however, here confine
    my remarks to those which are closely allied  to the  primary dis-
    ease,  the others being discussed in every treatise on surgery ; thus,
    strictures of the urethra, chronic affections of the prostate gland,
    affections of the seminal ducts, could not be embraced in this work,
    without  disproportionately increasing its bulk.   But I will treat
    of blennorrhcea, hemorrhage, and  of pains and perverted sensa-
    tions  in the urethra;  I will afterwards consider the subject of or-
V  chitis, prostatites, cystitis,  nephritis,  arthritis, and  blennorrhagic
    ophthalmia, accidents sometimes of  a very serious  nature,  and
    which we should endeavor to prevent, which we must often com-
    bat, and the study of which cannot  be separated from the affection
    of the urethra.
     Blennorrhcea.—According to Swediaur, blennorrhcea is a passive
    discharge, (fluxus  passivius,)  whilst blennorrhagia is an active, in-
    flammatory discharge (fluxus activus).  In accepting Swediaur's
    definition, because it is generally admitted, I cannot receive it, at
    least  in the majority of cases, in the sense in which it  is used in
    English  syphilography.   Because,  in my opinion, blennorrhcea,
    that is to  say, the discharge which is generally the result of blen-
L^norrhagia, more mucous in its character and less abundant in quan-
•^tity, which ceases but to re-appear;  in fine, that discharge which is
    called a gleet, military gout^ is but a chronic inflammation of the
    urethra with or without a complication of an analogous  inflamma-
    tion of its appendages.  I have already remarked that this opinion
    should not be  received in the most absolute sense, for there may
    be gleety discharges without a previous blennorhagia, that  is with-
    out an active discharge.  I would not therefore deny the existence
    of a passive discharge, or at least of one which is entirely indepen-
    dent of an actual urethritis or one already extinct.
     It is difficult to name the precise period at which blennorrhagia
    ceases, and  a  blennorrhcea begins.   Some authors  maintain  that
    the discharge is no longer blennorrhagic but a gleet, when it ceases
    to be  contagious, others regard it as a gleet when it is  no longer
    troublesome, when  the discharge is transparent, and viscous  like
    mucus.   But it is well-known how difficult it is to establish con-
    tagion from an urethral discharge, and as regards its transparency
    and mucous character, this may change from day to day ;  indeed
    a gleet which to day may be transparent,  and mucous to-morrow,
   may be opaque and more or less purulent, and all this may come
   from the least imprudence in regimen.   But an examination of the
   causes of blennorrhcea will lead to a better idea of its nature.
     Causes.—The principal and most  frequent cause of a gleet is the
   persistence in a chronic form of the urethritis which caused the
   blennorrhagia.   For, according  to my views, blennorrhcea  is
    chiefly a chronic blennorrhagia.  Indeed, when after forty or fifty
   days the blennorrhagia does not cease, we have reason  to  appre-
   hend  that it will become chronic.   Then, if the patient be care-
   fully examined, as well as the circumstances by which  he  is sur- 
BLENNORRHAGIA OF THE URETHRA.            89
rounded, it  will be found that he is of the lymphatic or bilious
temperament; or that he has a strumous, rheumatic, dartrous, or
a syphilitic diathesis.
  According to M.  Cazenave, syphilis plays an  important part in
the etiology of blennorrhcea.  In his opinion, every Slight discharge
which  becomes permanent, is due to a morbid  disposition left by
the virus which first affected the urethra;  blennorrhcea, in fine, is
but the remnant of a virulent blennorrhagia imperfectly cured.
If no  particular diathesis or  vice exist, it will be found  that the
patient has not submitted to hygienic rules; during the treatment,
and the decline of the  blennorrhagia,  he has  not observed the
necessary  repose,  and has indulged in  improper aliments  and
drinks, and sexual intercourse, or masturbation.  Among my city
patients, the  discharge is maintained by  the presence  of a  com-
panion, near which the patient cannot remain without excitement;
and in hospital practice, I have had opportunities of knowing that
the very youngest of those affected with  an obstinate discharge
were inclined to masturbation.
  In the etiology of this disease,  we must not  omit the influence
of the absence of  all treatment, or  of improper treatment.  In
speaking of the therapeutics  of blennorrhagia,  I have  designated
as a cause of chronic urethritis the so-called abortive  treatment,
because it is that which most frequently fails, and which has the
strongest tendency  to render the disease protracted.
  If we take a general view of the causes, we find  that they are
of two kinds, the  one pertaining to  diathesis,  the  other irritant,
excitant.  The first gives a chronic and specific character to the
disease, rendering it exceedingly rebellious  to treatment;  these
are, therefore, complicated cases,  for to the inflammatory element
there has been added the rheumatic, the dartrous, the strumous, or
syphilitic.   The obstacles in the way of treatment may  already be
anticipated,  obstacles which will render it  especially difficult when
they depend upon a complication with a peculiar diathesis.  Thus,
there are patients with dispositions to catarrh, to discharges with-
out provocation, from the ears, nose, and eyes, which, once affected
with blennorrhagia, never get rid of the  disease.  These  are the
patients who may have a primary or  non-consecutive gleet (d'em-
blk), that is to-say,  a blennorrhcea which  has not  been preceded
by a blennorrhagia. A neglect of hygiene is chiefly the  exciting
cause.  The patient devotes himself too much to his occupations,
is guilty of luxurious indulgences, and makes not a proper selec-
tion of his aliments.
   Seat and Anatomical Characters.—I have already shown that the
part first involved in blennorrhagia was the commencement of the
urethra, in the vicinity of the glans.   The most common  seat of
blennorrhcea, on  the contrary, is towards the end of the urethra,
in the region of  the prostate.   M. Baumes is very explicit  upon
this point.   However, blennorrhcea has been observed, in which
the disease was less profoundly seated; there  are some cases, even,
in which the seat  is the same as that of an incipient blennorrhagia;
indeed, it happens that an urethritis becomes chronic in the  same 
90
VIDAL ON VENEREAL DISEASES.
situation in which it has been primarily acute. .Of this I am cer-
tain, for by the application of  the  nitrate of silver to the fossa
navicularis, I have  removed the most obstinate cases of blennor-
rhcea.  When the latter is symptomatic of stricture, it is generally
towards the curve of the urethra that we find the most important
lesion, viz. a thickening or induration of the sub-mucous cellular
tissue.   Sometimes it is difficult to decide upon the seat, the ana-
tomical  characters of blennorrhcea; in these cases, there is that
disposition to mucous discharges of which I have spoken in treat-
ing of the causes of the disease:  the mucous membrane  of the
urethra may here preserve its natural appearance, like that of the
nose, which  presents  nothing abnormal, even in a state of well-
marked hyper-secretion.
   Symptoms.—The discharge in gleet is  not always  constant;
sometimes there  is  a kind  of intermission: it thus happens that
the meatus  urinarius is  always moist, that  the  linen in contact
with it is always more or less stained, or that the discharge appears
more particularly at certain periods ; this  may be in the morning,
after slight  exercise, or a repast.   In some  cases,  it is only by
pressing  the  urethra  from behind  forward, that the discharge is
brought  in this direction; this is the case when it is deep seated
in the canal.   Then  it is thick, viscous, and small in quantity;
being carried  away from time  to time by the  urine, it is rarely
observed  at the  meatus, or  if here perceived,  it  is only in the
morning, when no urine has been passed during the night.   If its
seat be  the  fossa navicularis, we  may in a manner produce  the
discharge at pleasure; we have but to press upon the glans, which
is then  often  very sensitive to this pressure.   It is a little en-
gorged ;  one or both  lips of the meatus are sometimes of a violet
color; and in separating the lips, the urethra appears of a violet
red. If the seat of the discharge be more  deeply situated, the lat-
ter may be perceived without resorting to pressure, but for  this a
certain quantity of the discharge is necessary.   Thus the quantity,
consistence, viscosity of the humor,  the more or less frequent  dis-
charge of the urine, may exert  an influence upon the  manner in
which blennorrhcea presents itself to the observer.  In   every
case, the different positions of the penis must, more or less, favor
the appearance at the meatus of the gleety discharge.
  The humor may be entirely transparent and viscid, as described
by Benjamin Bell, when it is supposed to be no longer contagious,
it may be of grayish or milky white color; and the pus is more or
less combined, or more or less separated from the mucus.   The
stains on the patient's linen are generally of  a pale yellow color;
sometimes scarcely visible;  they  are of a grayish white  color;
generally the central point  is more deeply colored, the rest being
very clear.  Sometimes the stained Yifef has a sickly, sourish odor.
Hunter maintained, that when the globules of pus, instead of float-
ing in the serum,  are suspended in a thready mucus, the discharge
is no longer  contagious.  M. Baumes  is less confident; according
to the physician of Lyons,  When the  discharge is simply mucus
transparent, limpid, without color, thready, and glairy, it then less 
BLENNORRHAGIA OF THE URETHRA
91
frequently possesses contagious properties, but even with these
characters, when  it would seem to be deprived  of all purulent
globules, the discharge may still be contagious; the only difference
being that contagion  under these circumstances is  less frequent.
Blennorrhcea,. in  general,  is not painful; the  sensibility of the
urethra, however, is not normal; the patient complains of itching
in the canal towards the perineum,  or there is a feeling of weight
or vermicular sensation extending from the urethra to the rectum,
which the patient refers chiefly to the latter situation.  Sometimes,
indeed,  it is on account of this annoyance, and not for any affection
of the urethra, that we are consulted.   Most generally he is of the
opinion that he is troubled with ascarides in the rectum.   I repeat
it, that in blennorrhcea there is an absence of pain, properly speak-
ing ; and when, as the result of excesses, it is present, it is felt in
the vicinity of the gland, at the  moment when the urine reaches
the fossa navicularis, or when the last drops are voided.   In such
cases chronic inflammation exists in the anterior part of the canal.
The same pains may exist when the urethra is inflamed at a greater
depth, which  is the most  common seat of the lesion in cases of
long standing.   Then, in addition  to pain, there is a frequent dis-
position to urinate;  the urine contains  more or less of deposit, and
there are symptoms  of inflammation of the neck of the bladder.
  Diagnosis.—The diagnosis of blennorrhcea is generally not diffi-
cult.  The only difficulty is in distinguishing cases  in which  the
discharge is from those in which it is not contagious.  What may
most confidently be  asserted is, that when the discharge is entirely
mucous, free from pus, contagion is least to be apprehended; but
it is a more dangerous doctrine that when  the discharge is of the
above character, that for a long time it could not  have been  con-
tagious.  It is evident that many very obstinate cases of gleet, in
which the discharge is  thin and milky, and  sometimes even colored,
in all its shades and degrees of consistence, are entirely innocent,
and that females have  escaped after  intercourse with those affected
with every kind of  gleety discharge.   But notwithstanding these
facts, which are very  numerous, exceptions have  been  observed,
which have given rise  to much domestic unhappiness.  I know of
two cases of contagion from gleet;  the disease was considered as
of no consequence,  and marriage, under  the  circumstances, was
permitted; separations were the result.  One of the infected women
gave birth to a child, which succumbed in three months,  covered
with pustules.  Thus  the greatest  uncertainty attends our means
of distinguishing a contagious from a non-contagious case of gleet,
and the  practitioner should always inform the patient affected with
it, who  consults him upon the subject of matrimony, that the dis-
ease is contagious.*

  * The judicious advice here given by our  author accords, we believe, with the
sentiments of the majority of the  most experienced  British and American practi-
tioners.   Wc have, however, nowhere seen this  common sense view of the subject
more happily expressed,  than by Mr. Skey, in his Lecture on Gonorrhoea, in the
Lond Med. Gazette, June 1839, p. 448.  "Applications are  frequently made for the
purpose of ascertaining at what period of the disease it ceases to be communicable.
I  iivomiiH<nd you to be most cautious how you commit yourselves on this head, by 
92              VIDAL ON VENEREAL DISEASES.
  Prognosis.—Blennorrhcea, being in the greater number of cases
a chronic urethritis, the seat of which is  in the deeper portion of
the canal, where the  openings of the seminal canals touch  the
prostate gland and neck of the bladder, we can understand how,
from  any excitement  or irritating cause, this inflammation may
extend to the vesiculaB seminales, the bladder,  and the prostate
gland.  Thus, it is not unusual to observe disturbance of the func-
tions of the vesiculae seminalis, such as nocturnal or diurnal emis-
sions, the consequence of the inflammation which has been propa-
gated from its first seat, the urethra, to the adjoining parts.   More
than one vesical catarrh has been caused by  an aggravated blen-
norrhcea.   Prostatic engorgements are often thus produced; a fact
which is incontestable in the adult.   In old men it may proceed,
as is well known, from spontaneous hypertrophy, without previous
inflammation of the urethra.  But to maintain, as does M. Mercier,
that urethritis has no connection with this hypertrophy, is more
than is warranted by the facts of the case.  I believe, on the con-
trary, that in the prostatic  engorgements of old  men urethritis
plays an important part.   If, in our inquiries into the history of
the case, it is not found, it is  sometimes owing to the fact that it
occurred before, or at a forgetful age, or that the patient is un-
willing to admit certain details.  The prognosis in blennorrhcea is
therefore serious, as regards the connection of a female with a man
thus affected, and the health and constitution of the children which
may spring from such connection, and as regards the patient who
is himself diseased.
  I have already alluded to the dangers of an urethritis when it
becomes extensive;  it is to  be dreaded  even when it is concen-
trated on a limited space;  for then strictures  may result from  the
engorgement and condensation of the sub-mucous cellular tissue.
  A gleet, even when'there are no apprehensions of contagion, and
when it does not interfere with the functions of the genito-urinary
apparatus, may exert a deplorable influence on the spirits of  the
patient.   It seems difficult to comprehend how the appearance of
a single drop of discharge,  in the day,  at the  meatus urinarius can
so affect the mind of the  patient.  Those who have often been
consulted  by persons affected with venereal disease,  know  the
despair which is felt by certain patients,  and  must possess letters
written  by them, in  terms most melancholy.  Others, again,  are
perfectly indifferent to this disease;  such are  the most dangerous
as regards the female sex.
  Treatment.—In the treatment of this disease we should take into
consideration all the  causes which have been enumerated as con-
cerned in  its production.  But our practice should be chiefly based
upon the  idea which I have  constantly endeavored to keep in

which, in case of failure, you render yourselves morally responsible for whatever
consequences may ensue.   In truth we know nothing about it.  What is communi-
cable to one person is incommunicable to another;  and so long as we have no cer-
tain evidence by which to draw the line, it is better to  adopt  the alternative of
declining an opinion altogether, or of leaning to the side of good morals, by declaring
that, so long as discharge exists, there  is no exemption from the liability to com-
municate it"—G. C. B. 
BLENNORRHAGIA OF THE URETHRA
93
view, viz. that we have to contend with an urethritis.   Every
practitioner acquainted with this fact, may calculate upon success
much more frequently, and  much more confidently than can he
who is  impressed with an opposite  opinion.   Thus, for  my own
part, the  basis of my treatment of blennorrhcea is identical with
that of blennorrhagia.   In both affections it is the urethritis which
I combat.  Especially do I  conform to this doctrine when blen-
norrhagia has not been treated,  or, in cases where  it has been
improperly treated, if antiphlogistics have  not been employed in
the first place, if hygienic rules have  not been observed during  the
treatment, and if the disease has not  been improved.   In cases
where these  measures have  been employed, and  these rules  ob-
served, I  do not insist upon the use of antiphlogistics, but  resort to
direct astringents, to derivations, in fine to the means which  are
generally used to  combat a  blennorrhoea, not as  a symptom of
inflammation, but as a disease essentially catarrhal.
  This is not the place to prescribe the rules of treatment  adapted
to every constitution, to every diatheses.  I will only remark, that
when we  have reason to suspect the rheumatic diatheses, a change
of climate, a dry and warm residence, the vapor bath, aloetics,  are
calculated to produce beneficial results.  It is particularly in  pa-
tients of this class, that we observe cases of blennorrhcea cured by
horse-back exercise, the excitement of the chase, or a voyage to a
warm climate, especially where a suppressed perspiration has been
made to reappear,  or a new one established.   If the strumous dia-
theses is suspected, we must  resort to the preparations of iodine.
In  this category should be classed the patients who are cured by
salt bathing,  a  remedy so  highly  extolled by Hunter.    When
blennorrhagia is  complicated with a dartrous vice, and runs into an
obstinate blennorrhoea, saline purgatives should be repeatedly em-
ployed, an irritating regimen avoided, and all diffusible stimulants,
without, however, prescribing tonics properly so called. When blen-
norrhcea  exists in a patient affected with eczema, or who  has  the
mucous  temperament of which I have  spoken, I have recourse to
the internal  administration of ferruginous preparations: as for  ex-
ample, the pills of valette, or the saccharated ferruginous pills made
according to my own formula.  Each of these contains about one
grain of  the  lactate of iron.  At first, I give  three in a day, and
the patient may take  as many as six  or  eight  in a day if  the
stomach tolerate, and if there be not obstinate constipation.*  De-

  * With Mr. Skey (Lect. cit p. 443), we  are  satisfied that in many cases of gleet
it is necessary to raise the standard of the circulation, and nervous power, by re-
suming ordinary diet and ordinary stimuli.  " If," says this surgeon, " you treat a
person habitually prone to large libations of drink, by entire desistence from his
ordinary and necessary stimulus, he will have a protracted gleet; and this prin-
ciple holds  in all cases, cateris paribus, in which the depletion,  whether positive or
negative, has been needlessly persisted in ; therefore, the first consideration applies
to constitutional treatment which  is, at least, equally important to local.  I re-
cently had  a man under my care, who, when in health, took per diem about one
gallon of porter, in addition to an occasional glass of gin.   He had been the subject
of gleet for ten months, for which he had employed the usual catalogue of local
remedies.   I desired him to leave the gleet to take its own course, and  resume his 
94              VIDAL ON VENEREAL DISEASES.

rivatives, such as blisters, cauteries applied at a greater or less dis-
tance from the urethra, should be preferred  in cases complicated
with the rheumatic or dartrous vice.   Benjamin Bell greatly ex-
tols  the efficacy of blisters applied to the  perineum.   Recently
this practice has been revived, even in the acute etages of an ure-
thritis.  In blennorrhagia they can be applied along the track of
the urethra, in front of the scrotum.   But as they have been used
in conjunction with, or immediately after certain injections, it  is
difficult to decide upon their agency in effecting a  cure.  They
should  always be regarded as means to be  employed after others
which are less painful and attended with less  inconvenience.  J£
there be reason to suppose that blennorrhcea is a primary syphil-
itic accident which has become protracted, or  that it is a consecutive
accident, the general treatment  for syphilis should be  pursued.
Both the direct  and indirect anti-blennorrhagics must necessarily
be employed in  the management of blennorrhcea; as for example,
cubebs and copaiba.  If the disease is the result of a marked blen-
noragia, that is to say, one which could not be cured, either from
wrong or improperly-directed treatment, then after the application
of leeches to the perineum, and along the course of the antiscrotal
portion of the urethra, a combination of copaiba and cubebs in the
form of the electuary already mentioned,  may be  administered.
But  a blennorrhoea cannot be removed  like blennorrhagia, and
these means continued for a  length of time in the doses specified
may singularly disturb the digestive organs;  in such a case the
dose must be diminished,  or the medicine  must  be for a time sus-
pended, or turpentine substituted, of which the patient may take
one drachm in the day.  If the stomach is still intolerant, we must
resort to injections.  An  immense variety of these have been em-
ployed.  Here I recapitulate the formulas which I have used  in
blennorrhagia: sometimes I inject 5 ounces of water with  8 grains
of the sulphate of zinc and acetate of lead; sometimes.I employ
the nitrate of silver in the strength of 2 grains to 3 ounces of
water.
  Injections should be more frequently  repeated here  than  in
blennorrhagia.  In  certain obstinate cases, we  inject not  only
twice, or four times, but  even more  frequently during  the day.
My success in more than one case has been owing to the use of
astringent injections thus repeated.  I prefer, therefore, the  injec-
tions of the sulphate of zinc and  the  acetate of lead.  Sometimes
I have used cold water alone.  We may also employ the follow-
ing formula of Benjamin Bell:

                   $. Sulph Zinc, § ss.
                      Eau. dist.    | viii.

usual drink.  He perfectly recovered in  a week, and  has had no return of the
discharge."
  Mr. Henry L Johnson (op. cit. p. 103), after alluding to the fact that gleet is
often cured by the most inconsistent treatment, remarks, that after all, these cases
resolve themselves into the following formula:—that gleet, being a morbid action
in the part slight* in itself, but sustained by habit maH be cured by any thing
which excites a new action, and so breaks that habit.—G. C. B. 
BLENNORRHAGIA OF THE URETHRA.
95
Or this:

          ]$.  Sulph. Alum, et Petass. grs. xv. to xxx.
              Eau. dist.             | ii-

Vinous  solutions of vegetable  astringent have been much  em-
ployed,  according to the following formulas:

                  $.  Vin. (heavy red)  § ii.
                      Tannin pur.     gr. i.

                      Vin. (heavy red), § ii.
                      Quinquin, rub.    3 i.

  Macerate for 48 hours.

  It has  also been proposed to act by injections upon the cause,
the diathesis which protracts the blennorrhcea.  In supposed scro-
fulous cases, M. Ricord  has experimented with injections of the
iodide of iron (one grain to the ounce); then he has increased the
strength to 18 grains  to  the ounce.  Certain patients with a thick
discharge, have been cured  in four or five days.  In others, these
means have rekindled the acute stage;  instead of a muco-purulent,
there has been a discharge of bloody serum, and when  the injec-
tions have been discontinued, the blennorrhcea has been  removed.
Other patients have been irritated, and not cured.  It is very pro-
bable that these iodurated injections have acted simply as irritants,
and not as specifics against  a diathesis (antidiathc'siques).
   The mildest injections may so irritate the canal as to oblige the
practitioner to suspend  them for awhile, and to resume their use
after an interval of some days.   If the irritation should reappear,
and especially if in a severe form, injection must be proscribed, or
at least the formula which has excited it.
   It often  happens,  when a preliminary  treatment  has been
adopted,  and the injection well selected,  that the  discharge  is
lessened, in which case  we should continue its  use until it has
completely ceased.  Even after this occurs, as  many as ten have
been employed, at intervals of from two to three days.   Some-
times, without  augmenting  the urethral irritation, and reviving
the inflammation; the first effect of the injection is to increase the
 discharge.  Then, after  four or five  days use, they should  be sus-
pended.  If,  after this  period,  we  observe  a diminution of the
weeping, the injections should be resumed, and it is very probable
 that they will be followed by complete success.
   I have already remarked, that caustic injections have been em-
ployed not only in  the acute stage in blennorrhagia, but in the
 chronic state in  blennorrhcea.   It  then often  happens that after
the immediate  and primary effects have passed, the gleet disap-
pears.   But  be  not  deceived;  the  disease may then be only
masked; there may be a dry blennorrhagia, a urethral inflamma-
tion without secreting,  which, in subsiding, will reproduce its
effects, which have  only been  postponed; for  the cause being
renewed, that is, the irritation of the urethra being brought back 
96
VTDAL ON VENEREAL DISEASES.
to its first condition, it will give rise to the same discharge, with
the same, if not still more obstinate characters.
  I  do not proscribe  caustics iu the treatment of urethral dis-
charges, even where they depend upon an inflammatory condition,
for analogy compels me to admit their use, and clinical observa-
tion has furnished me with facts in support of this analogy :  thus,
a slight  cauterization  of  the  anterior, or deeper portion of the
urethra, is a rational practice; for then we act only on  the part
affected; in certain opthalmic inflammations, for example, we in
this manner modify the condition of the conjunctiva.  When the
part diseased in blennorrhoea  is  deep  seated, it  is  difficult to
ascertain  its  situation so  as to  attack it, and it alone.  Before
employing the porte caustique, we must explore the canal with the
ordinary sound, or bougie.  When the instrument comes  m con-
tact with the inflamed or indurated part, the patient experiences a
severe pain, and  the surgeon feels an impediment to the passage
of the sound; it  is irregular,  encounters slight  obstructions, and
an uneven surface.  I acknowledge that this exploration is not
easy; it requires long practice, but  it may be attained.  M.
Baumes, for example, constitutes it a guide to his practice.   We
must not confound the sensations mentioned, those on  the part of
the patient and the surgeon, with those produced at the moment
when the sound passes through the curve of the urethra, or when
it enters the bladder, reaching  too far into its cavity.  When once
the irregular and  sensitive point is felt by the operator,  its distance
from the  surface should be marked upon the porte caustique, and
the latter should be introduced within the urethra.  The cup con-
taining  the caustic having been protruded, it should be turned
rapidly upon its  axis, so  that it  may act upon the  circumference
of the canal.   The caustic is then withdrawn  into the  sound, and
the latter is immediately  removed.  After this trifling operation,
a bath should be directed, and should be repeated at intervals of
two, three, or four days, according to the effect produced.
  Sometimes bougies are employed, which have been coated with
an ointment more or less irritating, or sedative ; thus, an ointment
of the nitrate of silver (1 grain of the nitrate to 1 drachm of lard),
or of camphor, may be used.   Now and then I have been success-
ful with the following:

                  $.  Ungt.  Hydrarg , 1 part.
                       Ext. Bellad.    2 parts.

Occasionally the  mercurial ointment, or \\ie  mercurial cerate, is
relied upon alone.  The naked bougie has also been employed; in
this case, it acts as a physical  agent, modifying the sensibility of
the urethra, and  tanning, as it were, the mucous membrane, and
thus changing ite mode of secretion.  Sometimes I have adopted
this practice with the greatest advantage;  this was especially the
case in two instances, where  the patients in the higher ranks of
society suffered so much from  mental despondency as to consider
life as a burden.  I generally  use the yellow  wax bougie.  Blis- 
BLENNORRHAGIA OF THE URETHRA
97
ters  to  the  perineum, and the use of bougies, were regarded by
Benjamin Bell as our most efficacious means of treatment.   This
practitioner insists upon  the employment, and prescribes rules for
the use, of the bougie.  According to him, we  should select very
soft bougies, which will slightly stimulate the parte, without excit-
ing an inflammation;  they are often extremely useful, not only in
thus stimulating the weakened parts, but  supporting them  by
their volume and their  form;  they are  attended with less risk
than injections,  even when they stimulate beyond our expecta-
tions, for  the inflammation  thus excited is always accompanied
by a temporary  discharge, which is well  adapted to prevent  any
unpleasant consequences, which might otherwise result from their
use.   The bougie should be as large as the capacity of the urethra
will  admit.  Benjamin Bell maintains that it is particularly essen-
tial in this variety of discharge, that the bougie should be of a
large size, for it is chiefly from the volume of the instrument that
success in these cases is attained.  We generally ascertain, in the
course of a few days, whether the bougies are  likely or not to be
useful;  nevertheless, we should not expect any lasting advantage
unless  their use  be  for a long time continued. In cases of long
standing, they must  be employed for ten or  twelve weeks, and
they should not be discontinued until the cure  is complete.   It is
well, however, to observe, that when we have pursued this method
of treatment for a reasonable length of time, it should occasionally
be suspended in  order to ascertain its effects.   When bougies are
daily introduced, it is impossible to  decide whether the discharge
proceeds from'disease, or from the irritation excited by the instru-
ments ;  a bougie cannot remain for a length of time in the urethra
even of a sound person, without being covered, when it  is with-
drawn, with pus or muco-purulent matter.
   It is better to  use the bougies three or  four  times in  the day,
and  not to  leave them  in the urethra more  than ten or fifteen
minutes.  Sometimes, the discharge is not only increased by these
instruments, but a true blennorrhagia is produced, especially when
they are allowed to remain in the canal;  in such a case, their use
should be suspended; particularly, if they have given rise to  fre-
quent disposition to urinate, or to symptoms denoting an inflam-
mation of the neck of the bladder.  When  the inflammation  has
been subdued, we should notice whether the discharge has com-
pletely ceased. • If it has not, we may resort to them again, though
cautiously.  Particularly should we  guard against passing the
instrument too  deeply, a practice of which patients and young
practitioners are often gtrilty.
  A gleet which has resisted every kind of treatment, occasionally
disappears in  an unknown manner:  sexual intercourse  has pro-
duced this effect.  Finally, there  are some  cases which resist
everything, even time, and which, after having been symptomatic
of a form of inflammation of the urethra, are found at length to
be maintained by strictures, disease of the prostate or bladder, or
they are complicated with seminal emissions.  The treatment, then,
should be modified according to the complications  of the case.
                             7 
98
VLDAL ON VENEREAL DISEASES.
                        STRICTURE.

  As we are at present concerned with stricture only as one of
the consequences of blennorrhagia, we shall not dwell upon other
points in ite etiology.   Frequently there exists but a single stric-
ture, though we occasionally meet with more ; thus, M. Lallemand
refers to the case of a captain Foltz, who had seven ; Collot *  met
with eight, and John Hunterf six, in a single patient.  As the lat-
ter surgeons were deprived of our present means of exploration, we
may reasonably doubt the accuracy of their diagnosis.   No autopsy
has ever revealed a large number of strictures  in a single subject.
Yet, it is well established, that in many cases, more than one exists.
M. Leroy d'Etiolles asserts that in nearly one-half of those examined,
two strictures are found, within about three lines of each other.
  Seat.—Differences of opinion have prevailed  in reference to the
seat of  strictures. This has arisen from  the  different  estimates
formed of the length of the urethra, the  result  of different modes
of measuring this canal.  As a general rule, it  may be stated,'that
the most common seat, is at the various points  of projection of
the canal, or in the vicinity of these projections, as for example, at
the seat of junction of the bulbous and  membranous  portions of
the urethra, and particularly at the commencement of the latter
portion  ; again, we find stricture occurring at the union of the lat-
ter  with the prostatic portion,  and lastly, at the  navicular fossa
and meatus. They may exist  at any of the intermediate points.
Soemmering denies the existence of stricture in the prostatic  por-
tion of the urethra;  Hunter does not dispute such an occurrence,
but remarks that it has never come under his observation.  Prof.
Lallemand is opposed to the views of Soemmering.  Of 14 cases
reported in the work of the former surgeon, allusion is made to
strictures situated at the depth of six inches  or  more  from the
meatus; now, the average length of the urethra being  from five
inches four lines to seven inches three lines, we are compelled to
admit the existence in these cases, of strictures in the prostatic
portion  of the canal.
  [The  measurement of the urethra, as made by the following
surgeons,  twenty in number,  gives an average  of 7A to 9|
inches instead of 5^ inches to 7£,  as stated by our author.
	---- In. In.			In. In.
Amussat,	7 to 8	Lallemand,	-	71 to 91
Boyer,	- 10 " 12	Lisfranc,	•	- 9 " 10
•Begin,	7i " 91	Meckel,	-	8
Belmas,	- 10 " 12	Malgaigne,	-	■ 6| " 6?
Cloquet I.	71 " 11	Mercier,	-	11 (1 M
Cloquet H.	- 9 " 11	Perreve,	.	■ 6 " 10
Civiale, -	5 " 7	Sabatier,	-	10 " 12
Ducamp,	- Ii " 91	Segalas,	-	■ 8 " 9
Guthrie,	8 " 11	Velpeau,	-	5 " 7
Gross,	- 7 " 12	Whately, -	-	- 7i "91
  Mr. Miller states in his Practical Surgery, (London ed., p. 519,)
that the ordinary site of stricture is between six and seven inches
* Traite de Voperation de la taille et des Suppressions Murine, 1762.
f Traite des Maladies veneriennes, with Notes by M. Ricord. 
STRICTURE.
99
from the orifice, in  front of the membraneous portion of the ure-
thra, which, with the estimates given above of the length of this
canal, is far more liberal than that of our author.  Indeed, accord-
ing to  the  calculation  of the  latter, Mr. Miller would make  the
prostatic portion of the urethra the ordinary seat  of stricture!
That this portion of the canal is sometimes the seat of true stricture,
is  positively asserted by M.  Ricord, (Notes to Hunter, 2d ed., p.
217,) in proof of which he refers to the case reported  and deline-
ated by Mr. Crosse, to which, he  observes, many others might be
added.  Doubtless  it does occur, though rarely, at  this point.—
G. C.  B.]                                              F
  The most common seat of stricture is a little in front of the junc-
tion of the membranous with the bulbous portion of the urethra. The
following results were obtained by Ducamp by means of his gradu-
ated instrument: In 5 out of 10 cases, the stricture was encountered
in from three and a half to four and a half inches, and to be more pre-
cise, in 4 out of 5 cases it is from four inches ten lines to five inches
seven lines, from the meatus.  It is evident that this would bring it
in the vicinity of the urethral curve, which, with the exception of the
meatus, is the narrowest portion of the urethra.  At the meatus,
strictures are not uncommon: I have seen them  produced by
chancres, which had destroyed  the frenum, or spent their ravages
on the summit of the glans.  Should the destruction by these ul-
cers have been more complete, so as to destroy a portion of the
penis, stricture occurs at the point where the urethra may have
been divided.   The meatus has likewise a tendency to become ob-
literated, when chancre produces a perforation of the inferior wall
of the urethra at the navicular fossa, by which a kind of hypos-
padias is formed.
   Form.—A stricture occasionally presents  the  appearance of a
slightly-projecting  line, over which the mucous membrane seems
only to have lost its elasticity and transparency;  sometimes, on
the contrary, the thickening of the parts  is considerable; all  the
tissues which enter into the formation of the urethra become in-
volved, thus producing a decided tendency to its obliteration.
   The extent of a  stricture may greatly differ, being from that of
the thinnest fold of the mucous membrane, to  one and a half
inches  (Lallemand,  sixth case);  ten to fourteen lines (Legalas).
and one inch,  nine  lines; or two inches, eight fines  (Hunter,
Chopart and Charles Bell.)
   The longest strictures are generally found at the spongy portion
of the  urethra.   Sometimes they are of considerable thickness,
their dimensions in other respects being not very extensive.  In
such cases a stricture may be mistaken for a fold, a valve, or some
morbid growth.
   This disposition  is particularly frequent at the commencement
of the urethra, in the vicinity of the glans;  ite direction is likewise
more perpendicular to the axis of the canal.   A case is reported
in the Gazette Medicate,  1840, in which a valve existed in the ure-
thra,  its free margin being directed  towards the bladder, thus
causing an obstruction to the passage of the urine.   The patient 
100
VIDAL ON VENEREAL DISEASES.
was sixteen  years of age, and  this growth was  supposed to be
congenital.   A stricture, which involves but a portion of the cir-
cumference of the urethra, may be situated on its  upper, lower, or
lateral walls.  The latter interfere  less with the evacuation of the
urine, because the opposite point being sound, is easily dilated;
this variety is also most liable to exist a long time undetected, for
it does not, except when excessively developed, oppose the intro-
duction of the catheter.   No instances of a perfectly longitudinal
Btricture have yet been  discovered.
  M. Amussat maintains that the urethra is never perfectly oblit-
erated ; he asserts that a communication  always exists between
the parts anterior and posterior to the obstruction.   Any inter-
ruption to this  communication, is, in his opinion, but  temporary,
and is caused by some foreign body.
  It was doubtless through inadvertence that Richerand asserted,
that of 10 cases of retention of urine, 8 are due  to an obliteration
of the urethra.*  The  truth is, that  these obliterations have fre-
quently been supposed to exist, when they were absent, or only
caused by accidental circumstances; but cases have occurred whicn
prove the possibility and actual occurrence of impermeable stric-
tures.  I admit, that the plates of Sir  Charles Bell are overdrawn,
but the case  mentioned by Chopart f is conclusive, and accords
perfectly with  the dissection made by  M. Delmas on a subject
named Juniot, who died  at the Hotel Dieu,  from an extensive in-
filtration of urine4  On this subject, the reader may likewise  con-
sult the case reported by M. Monod, and referred to by Cruveilhier
in his great  work, and which  is also noticed  in the  Annates de
Chirurgie, 1842.  I believe, that the obliteration did not take place
until a fistula was established, through which the  stream of urine
was diverted.
  [Mr. Liston once boasted that he had never been foiled in intro-
ducing a catheter with one hand, and it was not until some two or
three years  before his death that he encountered a  case at the
North London Hospital, which baffled him, and caused " the  cold
sweat to start in big drops from his forehead," (vide Lizars, on
Strictures of the Urethreo, pp. 18, 19.)   Mr.* Wm. Cadge, the pupil
and friend of Mr. L., informs  us  in the Lond. Med. Times, Nov.
9th, 1850, that this  distinguished  surgeon, in the latter years of
his  life, abandoned  his former  opinion, that there are really no
impermeable strictures.   Mr. Syme, as is well known, still adheres
to this opinion.   In the very excellent Memoir on the Treatment of
Stricture of the Urethra,  ke., by Prof. Eve, of Nashville, (Nashville
Journal of Medicine and Surgery, June  1853, p. 332,) this able sur-
geon has reported a case in which, with all his well-known skill,
he  could not pass the stricture.  After making an incision into
the perineum, he <( drilled  a hole through a hard cartilaginous
mass occupying the membraneous portion of the  urethra."  In a
note, Prof. E. refers  to  another  case, treated by Dr. Webb, of St.
       * Nos.  Chirurg. torn. iii. p. 470.
       + Traite des Maladies des voies urinaires, torn. ii. p. 823.
       \ These inaugurate, of M. Selles, 1824.  Also Soemmering, p. 17^ 
STRICTURE.
101
Louis.   In this  instance,  Dr.  W.,  after opening the perineum,
could not find the urethra;  he then cut out a cartilaginous mass
an inch in length, around which he supposed the urine must have
passed.   Prof. Eve, in  view of the above facts, very pertinently
asks, "would not this have proved an impermeable stricture, even
to Mr. Syme, of Edinburgh," and, we would add, to M.  Amussat
himself?  Impermeable strictures are distinctly recognized in  the
Treatises on the Urinary Organs, both of M. Civiale and Prof. Gross.
—G. C. B.]
  Structure.—A knowledge of the structure of a stricture is abso-
lutely essential to a just appreciation of the means proposed for its
treatment.  Laennec, in his  lectures, speaks of  bridles formed of
plastic lymph deposited upon the  lining  membrane of the urethra.
The existence of this kind of stricture is denied on the grounds,
1st, of the slight tendency of mucous membranes to form plastic
lymph;  2, the impossibility of the condensation of this lymph,
owing to the frequent passage  of  the urine, by which it  must ne-
cessarily be removed.   But one well-authenticated case is sufficient
to destroy the force of  these objections.  Admit that the mucous
membranes do not often secrete this lymph, still instances have
occurred both in  the intestinal  canal  and  the laryngeal and
bronchial tubes.   Urine is not constantly  passing through  the
urethra; the interval of the acts is sometimes sufficiently long, to
permit the condensation of a layer of plastic lymph, which process
is often very rapid.
   Laennec deposited in the  Museum of the Faculty de Medecine,
a pathological specimen, in proof  of his  opinion: this I have not
been able to procure.   Besides, the preparation is now so old that
one could not decide whether the  stricture in this case was  formed
by a deposit of plastic lymph, or a thickening of the mucous mem-
brane  itself   The views of Laennec were admitted by Ducamp,
and  similar  opinions were  entertained  by  Morgagni,  Sharp,
Goulard, and other surgeons;  but further investigations on this
question are to be desired.
   [This question has  been  definitely settled by the researches of
that able surgeon,  Mr. Hancock,  of the Charing Cross  Hospital,
London.  His recently-published  work,  " On the Anat. and Phys.
of the Male Urethra, and the Pathology of Strictures of that  Canal,"
contains more valuable practical  information than we have ever
seen embodied in so small a compass.  We shall have occasion to
refer to this work again in noticing the subject of spasmodic stric-
ture.   In speaking of the influence of adventitious membranes in
the production  of  stricture, (p. 74,) he  remarks, that he  is con-
vinced  that  the latter depends upon the former more frequently
than  is commonly  supposed:  " To gain as much information as
possible upon this point, I have examined all the urethras I could
get.  I have examined the urethras of those who have died of other
diseases, in whom the existence of stricture had  not been sus-
pected; I have also, through the kindness of my friends, been
enabled to examine preparations taken from  those who had at
one time suffered from this malady, and who  were supposed to 
102
VTDAL ON VENEREAL DISEASES.
have been cured; I have  also been enabled to examine those
taken from patients who have  died whilst  laboring under the
complaint.   And the  result of these examinations is the convic-
tion  that  permanent  stricture from false membrane within the
canal upon-its free surface, is a common and frequent occurrence :
and I am confirmed in this view by  my friend Dr. Beith, who has
rendered me great assistance, and who from his position at Green-
wich Hospital, has had ample opportunity of studying these dis-
eases, to which he has  devoted much attention."  At pages 75-78,
Mr. Hancock has detailed  some of the autopsies which he has
made, and wrhich prove incontestably the accuracy of his opinion.
—G. C. B.]
  In the majority of cases,  the mucous membrane seems the only
part affected; its redness, consistence, and thickness are increased,
and its elasticity impaired.  When,  at an autopsy, this lesion only
is observed, we are surprised that it could have caused so serious
an obstruction to the passage of the urine; but we forget the con-
gested state of the subjacent tissues which subsides after death, nor
do we take into consideration the fact that this obstacle may have
been increased by spasm.  This is the most common form of stric-
ture ; that through which, it may be remarked, the largest bougies
are most readily passed.  It should  be remembered that the tissues
subjacent to the  mucous membrane  are increased in thickness only
by the temporary presence  of a large quantity of blood, which is
only temporary, being withdrawn at death, or which may be ex-
pelled  by well-managed  external compression.  Occasionally the
mucous membrane is  sound, and the subjacent  tissues are  alone
affected.   This does not imply that the former has not been dis-
eased ; for it is  to be supposed that it was primarily affected, the
effects  having here subsided, as in the case of certain  alterations
in the pyloric and cardiac orifices of the stomach, when these parts
suffer from organic lesions.  In proportion as the inflammation
assumes  the chronic  form it becomes more  profound,  and the
mucous membrane regains ite natural aspect, whilst the subjacent
tissues, especially  the cellular, becomes indurated and hypertro-
phied.
  Samuel Cooper was wrong  in  asserting, that when the mucous
membrane is the seat  of stricture, ite color is whiter than natural:
for the contrary is often the case, especially during the earlier
stages of the disease.  In my opinion, sufficient attention  has not
been paid to the morbid alterations  in the tissues subjacent to the
urethral  mucous membrane.   On this subject I beg the reader's
indulgence, for its investigation may lead to  important modifica-
tions in the preventive treatment of strictures.  The hypertrophy
of the subjacent tissues is a fact well established, but it is produced
in various  ways: sometimes, it would  seem that  a  deposit of
plastic lymph had taken place, in all the tissues of the part; whilst,
in other cases, these parts  seem to  be thickened only.  These are
the  strictures to which the  term fibrous has  been applied.   Cru-
veilhier believed that they  are all of this nature.   On this  point
the  reader may consult the Annates  de Chirurgie, t.  iv. p. 129. 
STRICTURE.                       103
However this may be, there is a projection into the  canal as well
as externally ; by pressing the urethra a decided induration may
be felt.  This variety  of stricture is ordinarily of considerable
length, and is most commonly found at the spongy portion of the
urethra.  To this category belongs the case reported by M.  Lalle-
mand, in which he speaks of a stricture of considerable extent,
produced by the lesion of the walls of the urethra, and even  of the
tissues of the corpus cavernosum.   After the death of the patient,
on exposing the canal longitudinally, the indurated tissues  pre-
sented the  aspect of a gun barrel split in its longest direction.  A
cartilaginous hardness has been spoken of in these cases.  Some-
times the length of these strictures is not considerable;  they then
form a band which surrounds the urethra, protruding both within
and without the canal.  There are good grounds for believing that
this kind of stricture is frequently the result of an abuse of cauter-
ization.
   Nodosities form in  the substance of the cavernous bodies, and
diminish the calibre of  the urethral canal, though the latter may
not be directly affected; sometimes  they do not in the least en-
croach upon the urethra, but project externally.*
   Instead  of becoming dilated and thickened, the cells  of the sub-
mucous  tissues may contract and even become effaced.   We then
have, necessarily, a diminution of the calibre of the canal, and the
formation  of a contracted circular stricture as if caused by  a liga-
ture ; this  is the variety to which, in my opinion, the  term stric-
 ture atrophy should be applied.   It is met with most frequently at
 the bend of the urethra.   It should be borne in mind, that inflam-
 mation,  after having invaded  the tissues, does not always  leave
 them in the same condition ; not unfrequently these tissues seem
 to enjoy a new vigor and activity; but the contrary may happen,
 and hence the  atrophy, and  the development of  that  form of
 stricture to which we have referred.  It is  not, besides, the only
 instance in  pathology where opposite effects are due to the same
 cause.
    We must likewise take into consideration the effect  of the sub-
 mucous abscesses in the  sub-mucous tissues which occur, either
 during  or after a severe attack of blennorrhagia.   Since my con-.
 nection with the Mpital ditf Midi, I have found these very common
 in young girls.  Now when these abscesses heal,  a bridle or de-
 pression remains.
    Ulcerations of the urethra which were once regarded as the sole
 cause of strictures, have since been denied a place in their etiology.
 But modern researches have shown that they are only less frequent
 than was  formerly supposed, their existence  having been  clearly
 established.  M. de Selles observes in the Thesis already quoted,
 that Dupuytren during his lectures, exhibited several examples of
 urethral ulcerations.  Some of these were superficial,  others deep
 seated,  and appeared  as if cut  out  with a punch.   They  were
  * Roche, Sanson and Lenoir, Nouv. e/em. de Path, Medico-CMrurgicale, 4th ed.
torn. iv. p. 596. 
104
VEOAL ON VENEREAL DISEASES.
generally confined to a single point of the canal, in some instances,
however, they occupied  its whole  circumference.   Around  and
beneath these ulcerations, the mucous membrane was engorged and
thickened.   These characters were particularly noticed in the cases
mentioned  in  a  note which I have received from my freind Dr.
Goyraud, of Aix.
  It is obvious that the cicatrization of these ulcers must diminish
the natural calibre of the canal, and the bridles formed resemble the
cicatrices of burns.  To this category belongs the stricture produced
by cauterization either with caustics in a solid or diluted state.
  Vegetations, which by the ancients were called carnosities, are
by no means so common as they supposed, a fact first established
by the investigations of  Brunner and Mery, and  afterwards by
those  of Benevoli,  Marini, Garengeot, Morgagni, Lafaye, Desault,
and the more careful observations of modern surgeons.  But  Gir-
tanner was wrong in asserting that these carnosities have but an
imaginary  existence,  for  they  were  observed by  Morgagni,
Hunter, Ch. Bell, Dupuytren,  and  Baillie.  I  myself have  met
with them, and  M. Mercier has  reported a remarkable case.  I
have twice seen them on the  cadever; they are generally seated
near the fossa navicularis.   Wigelin and Lobstein have observed
them behind the verumontanum.   These, in my opinion, were cases
of hypertrophy of the prostate or tumors of this gland. On this  sub-
ject Soemmering remarks : " The carnosities which I have observed
in the  lacunas were of a violet  color, hard, of the size and form of
a lentil; they adhered by a kind of pedicle to the urethral mucous
membrane; it is an easy matter to ligate or excise them when they
are not of  too large size."*   It is  evident that Soemmering here
refers  to vegetations in  the vicinity of  the meatus.  " But," he
adds,  " since these  vegetations have been found to  exist at both
extremities of the urethra, why may they not  occur  at ite middle
portion?"  He, however, never met with  an instance of the kind:
though the testimony of John  Hunter, Benjamin Bell, Andre, and
especially of Baillie, is sufficient to establish the fact of their ex-
istence.  More recently,  together with  M. Mercier, I have  seen
small vegetations along the whole course of the male urethra.  I
have  also  met with an  instance where  the  urethra was rough
throughout; it was  that of a prostitute, who was under my care at
the hopital du Midi.   These vegetations were  of a whitish color,
soft, and bled from the  most trifling  cause.   With the aid  of a
catheter, and a finger introduced  into the vagina, I detected their
existence  throughout the urethra.  This girl  was of a decidedly
lymphatic temperament, and had no other symptoms of syphilitic
disease; these vegetations  were reproduced with a wonderful facility.
Those situated most externally,  I  attacked with  narrow-bladed
scissors; the others were cauterized with the nitrate of silver, which
was introduced to a great depth.  Van Swieten refers in his Com-
mentariesf to vegetations developed at the orifice of the  urethra;

  * Traite des maladies de la vessie et de Furitre. Translated by M. Hollard, p. 167.
  f VoL v., p. 453. 
STRICTURE.
'105
these are not uncommon.  It would appear that cancerous vegeta-
tions may exist in the urethra.  M. Lallemand has  reported an
example.  But such an occurrence is  exceedingly rare in the fe-
male, especially as a primary accident.   Cancer of the  uterus may
extend so as  to  invade the vagina and even the urinary  appa-
ratus.
  Nature.—The remarks which we have made upon the causes and
pathological anatomy of stricture render any extensive observations
upon their nature unnecessary.   Thus, in the etiology, particular
notice was  given to wounds and  inflammations.   Both of  these
causes  frequently lead to the same  final result, viz.  the fibrous
condition of the parts.  Thus, the cicatrix of a  wound, and the
condensation of the sub-mucous tissue arising from a protracted
urethritis, produce the same anatomical changes, the fibrous or true
stricture.  As already stated, the inflammatory stricture is but the
commencement of the fibrous, and it may  also exist as a compli-
cation of the latter variety.
  Is there a spasmodic  stricture ?  There is  nothing in the struc-
ture of the urethra, abounding as it does in erectile  tissue, and
surrounded as it is by muscular fibres, to forbid .such an existence.
Wilson's muscle  alone may produce a constriction of the  com-
mencement  of the membraneous portion of the urethra.   Spas-
modic stricture, however, rarely exists  alone, it is generally  but a
complication.   In some cases, stricture would appear to be, at the
same time,  spasmodic,  inflammatory, and  organic. Suppose, for
example, a chronic condensation at some point of the walls of the
urethra, at which its natural calibre  is diminished; yet, the blad-
der retaining ite contractile power, the urine is freely evacuated.
Now, let the subject of this stricture indulge in excesses, either  at
the table or venery, the obstacle  to  the passage of urine is soon
increased ; its strain, which before was scarcely distorted, is now
arrested ;  but a bath, and the abstraction of blood, suffices to re-
lieve the patient.  It  is  evident, that the difficulty in this case
arises from inflammatory congestion, and not from any permanent
alteration in structure.  The same  patient is greatly excited by
some accident; he has retention of urine at once; but  it soon
disappears, after some trifling remedy, or after his mind is restored
to  its accustomed tranquillity.  We find,  therefore,  in the same
subject, three kinds of stricture;  at least, such is the case with
those who  admit this  number, but it  is obvious that  but two of
these are  permanent, the spasmodic being but a complication of
the other varieties.  For the anatomical grounds  on which this
opinion is based, the reader may consult the well-written article
oi  M. Gosselin, in the  Archives de Medccine et Annates de  la Chir-
urgie.
   [The muscularity of the urethra, a doctrine advocated by  John
Hunter, Sir Everard Home, Bauer, Wilson, Howship and  Samuel
Cooper, is, at length, positively established by the more  modern
researches of Messrs. Quekett and Hancock, of London,* and Kol-
* Op. cit. 
106             VIDAL  ON VENEREAL DISEASES.
liker, of Wurtzburgh*  But,  it is to Mr. Hancock that we are
especially indebted for pointing out the practical bearings of the
results of these investigations.  It is now clearly demonstrated,
that, as the urethra is muscular throughout its whole extent, spas-
modic contractions may occur, independently, in any part of the
canal, as well within an inch of the orifice of the urethra as at ite
membraneous portion.  Indeed, it was  a  case of the former, Mr.
H. observes, that first led him to examine the minute structure of
the parts microscopically.   We cannot too strongly recommend
the work of the latter  gentleman, to those desirous of becoming
acquainted with the true pathology of strictures.—G. C. B.]
  Symptoms.—The stream of urine  is  diminished in size, length,
and  force; its course is altered, particularly in cases of lateral
stricture; its form is flattened  like the  blade of a penknife, or
spiral  and twisted like a  gimlet, frequently it is  bifurcated, or
forked, to use the language of Ambrose Pare ;f in some cases, one
of these forked streams  projects beyond the rest, which fall upon
the patient's feet, or are scattered in all  directions;  in these cases,
it appears as if they issued from four or five small orifices in the
glans, which seem as if perforated like the spout of a water-pot.
Generally, in the normal  state, the  jet gradually diminishes in
proportion as the bladder becomes emptied, and the curve which
it describes is effaced, but in the case of stricture, this curve is, as
it were, broken, and the stream is suddenly arrested.   The blad-
der is not completely evacuated; the  desire to urinate is  soon
again urgent and irresistible ;  however, a long time is  required to
empty even a portion of the contents of the bladder.  It may be
stated, that the patient urinates longer and more frequently than
natural, and yet the bladder is never empty.  A certain quantity
remains behind the  stricture, which oozes in drops immediately
after  the patient  has finished,  as he supposes, the act.   Mental
emotions, and  changes  of temperature, modify the extent of the
resistance opposed  to the passage of the urine.   The retention of
the urine in the bladder leads to an alteration in its composition.
It becomes more ammoniacal, less  aqueous; turbid,  and sometimes
a grayish deposit takes place ;  it may  be mixed with  blood, pus,
semen,  and a  glairy tenacious mucus, which, according to Sir
Everard Home, indicates  a lesion of  the  prostate gland.   The
emission  of  semen is obstructed, as well as  of the urine.   The
slightest stricture interferes with its discharge, and  it escapes after
the erection has subsided.   Sometimes the semen, instead of reach-
ing the glans, takes a retrograde course towards the bladder.  In-
stead of a retention, we may  have an  incontinence  of semen.
Nocturnal pollutions are common in patients  affected with stric-
tures.   The semen escapes, also, during a semi-erection, or during
the act of defecation, without the consciousness of the  patient;
but sometimes he experiences severe  pain after an  emission, as  if
a needle were thrust into the  perineum.  This occurs particularly
* Mikroskopische Anatomie, dkc.
f (Euvres Completes.  Paris, 1840.  VoL ii., p. 565. 
STRICTURE.                       107
where the stricture is seated in the prostatic portion of the urethra.
M. Dezemeris was present at the autopsy of a young man who
had suffered  from repeated nocturnal pollutions; in this case, ul-
cerations existed at the orifices of the seminal ducts.
  Besides the urine and sperm, the urethra gives exit to the liquor
prostaticus.   This fluid is sometimes secreted in abundance, par-
ticularly where the gland is irritated by the presence of a stricture
in its vicinity; but its emission is  prevented  only by very exten-
sive stricture; then it is carried away with the urine, or falls back
into the bladder.   With a stricture, there almost always exists  a
gleety discharge, more or less copious.   This  discharge generally
proceeds from a point of ,the urethra, immediately behind the
stricture,  and is  observed more  especially in the morning.  In
some instances, instead o/ being muco-purulent, this fluid is of a
serous character, and is more or less limpid.   When the stricture
is of great extent, this matter, like the  semen, is carried into the
bladder, to pass off only with the urine ; in the latter we now find
a deposit.  When  the  stricture  is  of long standing, and  when
there is reason to believe that it is extensive, if we do not find
this discharge from the  meatus, we may suspect that it escapes
from the other extremity of the urethra, or has accumulated in a
pouch formed behind the obstruction.   The lining membrane of
the pouch in  these cases assumes a villous aspect, and is preter-
naturally reddened  and thickened; for it is  constantly irritated,
either by this prostatic fluid, or by the urine, which no longer re-
mains in ite natural  reservoir.
   [In patients disposed to the formation of calcareous matter, the
latter is apt to accumulate in the  pouches or dilations which form
behind the seat of obstruction.   A few  years since, we removed a
large stone from the membraneous portion of the urethra, the ob-
stacle to the passage of urine in this case having been caused by
a congenital narrowing of the  meatus,  which, indeed, was nearly
obliterated.—G. C. B.]
   Whatever may be the seat of the stricture,  whenever pain  is
felt it is generally in the vicinity of the meatus; however, when
this pain is sympathetic, it indicates some lesion near the neck of
the bladder.  It is  then also felt in the perineum, about the anus
and rectum, or there is a more or less uncomfortable sensation of
weight  in these regions, especially when the  prostate gland  is
affected.  If the stricture be seated in front of the bulb, pain is felt
along the scrotum and penis; the projection formed by the obstruc-
tion may be readily felt, particularly when it is caused by indurated
nuclei in the cellular tissue of the urethra, corpus spongiosum, or
corpora cavernosa.  These pains extend towards the testicles and
the hypogastric region, following the course of the ureters and the
vasa deferentia, whence they are reflected to the  glands from which
they started.
   The efforts made by the patient  to  expel the urine affect the
intestinal canal; faeces are passed involuntarily; the inner coat of the
rectum becomes prolapsed; the small intestines, with certain other
abdominal viscera, are  displaced,  and at length we find disorder 
108            VTDAL ON VENEREAL DISEASES.
of the organs of circulation.   Fever is established, and this is often
of an intermittent type.  This arises from the more or less exten-
sive irritation of the urinary organs, but more especially from the
greater or less absorption *of urine, which occurs whenever its
evacuation is prevented, or it may occur from  an inflammation of
the veins surrounding the neck of the bladder.
  Innervation is often seriously modified by  the  existence of a
stricture, particularly when it is of long standing.  The patient
becomes exceedingly irascible, is constantly exaggerating his dan-
gers, and not unfrequently becomes a complete hypochondriac.
  Nothing can exceed the sufferings which the patient, in some of
the graver forms of stricture, experiences.  There is strangury and
complete retention of urine.   Desperate  efforts are made to void
the urine, he becomes agitated and is sei^d with despair;  his face
is flushed; his eyes protrude; he cries aloud  for aid;  he seizes a
chair or a table; stamps his feet; he squats, for he is in constant
apprehension that the faeces will escape, and escape they do. At
this crisis hernia may form, hemoptysis occur, or  pulmonary em-
physema be produced.  The spectacle is heartrending; but unut-
terable is the joy of the patient at the moment of his  deliverance.
His gratitude is expressed in glowing terms.
  Diagnosis.—This is not always easy, though of the highest im-
portance in a practical point of view.  Notwithstanding the numer-
ous researches that have been made, and the ingenious  methods
devised for the purpose, the diagnosis is sometimes difficult.   Occa-
sionally, as already stated, a stricture exists and the patient remains
ignorant of the fact, in consequence of the little suffering to which
it gives rise.   (Desault, Lallemand).   When the stricture is seated
beyond the bulb  no tumor can be felt  along the urethra; the
stream of urine is not materially altered; and the patient's attention
is directed  solely  to  the  constant gleety discharge.  In some
instances this discharge ceases for a time, and it is only long after-
wards, when age has enfeebled the  bladder, or when the stricture
itself has become more extensive, that the jet of urine is so modified
as to leave no doubts as to the  existence of an obstruction in the
urethra.   But a retention of urine may arise from other causes; as
for example, a foreign body without, or within the bladder, an
enlarged prostate, a tumor  in the vicinity, &c, &c. It is easy to
distinguish these tumors from true stricture.  An enlarged prostate
may have nearly the same antecedents as a stricture, but the former
most generally occurs in persons upwards of fifty years of age, and
is not often  accompanied  with a discharge,  whilst the latter is
seldom absent in  stricture.  Again, in  the  case  of an  enlarged
prostate,  with the aid of a finger passed into the rectum, even  a
large catheter may almost  always be introduced,  and  the  enlarge-
ment of the gland be thus detected.   In the case of stricture some
resistance is felt at first, then a gentle shock against the instrument
indicates that an obstacle has been encountered.   But we must b'e
careful not to confound the kind of valve near  the bulb with a true
stricture, for it frequently gives rise to the same  sensation  as the
latter.  There are several other points in the urethra  at which an 
STRICTURE.                       109
instrument may be arrested, unless great  care be taken to follow
the natural axis of the canal, but by withdrawing the instrument
a little, depressing its handle gently, and delicate manipulations of
this kind, the obstacle, depending  upon this cause, may generally
be surmounted.   Wax bougies are almost exclusively used by M.
Civiale, both for  the  purpose  of obtaining an  impression  of  the
form of  a stricture, and as an agent of  dilatation.  Should  the
stricture  be complicated with  inflammation, this instrument may
be firmly held at some point of the urethra  anterior to the stricture,
and during its  detention become so softened and distorted as to
render it useless for the objects intended.   Ducamp was also accus
tomed, before proceeding  to  cauterization, to introduce a wax
bougie, peculiarly modified, for the same purpose, and he boasted
that, from  the knowledge thus obtained, of the form, extent, and
other conditions of the  stricture, he could treat it with the same
precision  as if it were  fully exposed to view.   Sir Charles Bell
proposed the use of metallic bougies, with a bulbous extremity,
but their inflexible  nature  rendered their  introduction sometimes
painful.   M. Leroy d'EtioUes,  to  remove this  objection to their
use, recommended that they should be made of gum elastic.  These
bougies have  an olive-shaped  extremity, more or less elongated,
by which their introduction, in some cases, is much facilitated.
  [Profs.  Syme and Gross  attach but little value to the impress-
ions obtained  by the wax bougies.  The former denounces it as
a " preposterous" procedure, and says that it can result only in
the deception  either of  the practitioner or patient.   Mr. Guthrie
considers that, for examining  the urethra, a conical solid  silver
sound  is  the best instrument  (op. cit. p. 69).   It should be of a
size, he observes, not more than two-thirds of that of the meatus.
Mr. Miller (Practical Surgery, p. 522,) states that a metallic  instru-
ment is  quite capable of fulfilling all ordinary indications  in this
way.   Sir Benjamin  Brodie  asserts that  the best instrument for
diagnosis is the plaster bougie " of full size, and large enough to
fill the urethra" (op. cit, p. 23).  He objects to the use of conical
bougies,  which he thinks  are liable to extend  forcibly the orifice
of the urethra, and to  excite  inflammation.   Prof. Gross recom-
mends a common silver catheter, of moderate size, and a little coni-
cal at its extremity.   Almost every surgeon has his peculiar mode
of exploring the seat of a stricture, and  doubtless, in his  hands, it
is the best.  No matter what the method adopted, in some cases
an accurate diagnosis is impossible.—G.  C. B.]
  Treatment.—We must never lose sight  of the fact, that inflamma-
tion  is not only the most  common cause, but may be one  of  the
complications of stricture.  This knowledge will lead us to be gen-
tle in our manipulations, and to resort at  once  to the use of anti-
phlogistics, whenever the latter  may  be indicated.   In  some
instances,  they  may obviate  the  necessity  of resorting  to  the
operations commonly employed in the treatment of strictures, all
of which may be comprised under the heads of  dilatation, cauteri-
zation, and incision.
  Dilatation.—This is generally attempted by  means of bougies. 
110
VEOAL ON VENEREAL DISEASES.
The time during which they are permitted  to remain, varies  with
different practitioners.  Thus,  until recently, this period varied
from two to fifteen hours.  The interval of 'their use also  differs.
With some,  this may be  three  days, with others they are  used
every day.  With MM. Civiale and Pasquier, I  prefer to leave
them in the urethra not longer than five minutes, and to prolong
the sitting at the same time, gradually increasing the size of the
instrument.  This may be called  temporary, gradual dilatation.
But more  recently, mention  has been made, on the authority of
M. Lallemand,* of a rapid 'dilatation.  M.  Pirondi, who has  ably
described and advocated this method, has  not been guilty of the
exaggerations of  M. A. T.  Chretien, f who  proposes sudden, forced
dilatation.  The enormities of M. Mayer, in my opinion, can find
but few imitators.  His principle, that the narrower the orifice of the
stricture, the larger should  be the instrument employed, must  disgust
every sensible mind.   His  bougies  consist  of six in number, vary-
ing from two  to four and a half lines  in diameter.   When the
instrument has reached  the seat of stricture, he hesitates not to
press with force:  various movements are given to the instrument,
as  from left to  right, from before backwards,  and  in a spiral
direction.
  [For all the objections to this method, we must refer the reader
to our author's Treatise de  Pathologie Externe, &c, 3d ed., vol. V.,
pp. Ill, 116.—G. C. B.]
  My treatment  is based  upon the following principles: gradual
and gentle dilatation, at first with conical wax bougies, like those
so  successfully employed  by M. Civiale; in recent  cases, and
where the stricture is not of  a fibrous character, I rest satisfied
with  these means.  Afterwards, I may substitute for the  wax,
gum elastic bougies, but in all cases they are used  gently, and
suffered to remain but for a short time in the urethra.
  [Prof. Gross states that he  is satisfied  from ample experience
that the very best instrument  for dilating  a stricture is the  com-
mon silver catheter, with  a slightly conical  point.  " I have em-
ployed this instrument now in the  treatment of this  affection for
upwards of twenty years, and nothing could induce me to abandon
it.  It possesses  all the requisites that such  an instrument ought
to have, viz., lightness, firmness, and  durability, and  is incompar-
ably superior, in  every respect, to all the metallic, wax, gum-elas-
tic, ivory, and other bougies, that have ever been invented. .  .  .
My desire is  merely to recommend, in strong  and decided terms,
an  instrument which  is capable, as a general rule, of fulfilling
every indication presented in this disease, even in its worst forms,
and which, I am satisfied, is much less appreciated than it deserves
to be."   Mr. Ferguson gives  the preference to  the  bougie,  and
generally employs the plated steel rod, or a silver tube.  Mr. Syme
asserts that  the  best  instruments for dilatation are made  hollow,
of  Berlin silver,  which possesses the requisite degree of rigidity,
* Gazette Medicate, 1835.
f Bulletin Therapeutique, torn, xvi p. 288. 
STRICTURE.
Ill
takes a fine polish, and is not liable to rust. (On Strictures of the
Urethra,  p. 44.)  Sir Benjamin  Brodie  (op. cit. p. 33,) uses the
common plaster bougie, as well as those
made of solid silver.   He likewise, in  Fi^8: *».  2»    3»   4-
some cases, employs the gum  catheter,
which he allows to remain day and night.
This induces suppuration in the urethra,
after  which a large-sized instrument may
be introduced.   The wax bougie is liable
to bend upon itself, as  represented in Fig.
1st.   Fig.  2d,  Porte Empreinte,  an ex-
ploring instrument.  Figs. 3  and 4,  coni-
cal and fusiform bougies.—G. C. B.]
   I have already stated, that  an instanta-
neous dilatation has been highly extolled,
and it is proposed to banish  the practice
of permitting sounds or bougies to  remain
in the canal.*   MM. Civiale, Leroy, A.
Pasquier, approve of this method, with-
out,  however, excluding others.  For example, M.
Civiale permits the bougie to remain from two to
three minutes to half an hour; whilst M. Pasquier
never allows it to remain more than five minutes.
It is evident,  that certain strictures may be re-
moved by the employment of a  certain  number
of bougies, gradually increasing in size, which are
introduced and withdrawn one after another, or
which may be permitted to remain  for five or six
minutes; but, in my opinion, certain fibrous stric-
tures can never be cured in this manner, believing,
as I do, that the dilating agent must be allowed to
remain for a longer period in the urethra.
   [Mr. Thomas Wakeley, of the Royal Free Hospi-
tal,  and Mr.  Bernard  Holt, of the Westminster
Hospital, London, within the last three years, have
published numerous cases in the  London Lancet,
illustrating the efficacy of certain instruments in
the treatment of stricture, which they have devised
and  employed, and the object of which, like the
method of M. Benique, is, in the language of Hun-
ter,  to act " like a wedge upon inanimate matter."
Indeed, more  than thirty years ago, Mr.  Guthrie
had a dilating  instrument made by Mr. Weiss, for
this purpose.  At first, this consisted of three blades,
which were gradually separated by the action  of a
screw which turned in the handle, but the same
mechanism was afterwards applied to  a two-bladed  instrument.
(Guthrie on Urinary Organs,  Am.  Ed. 1845,  p. 76.)  At page 77,
he observes: "I thought I had now obtained an instrument which
* Vide the last article of M. Benique. 
112
VIDAL ON  VENEREAL DISEASES.
could not fail of fulfilling all my expectations, and was only disap-
pointed by finding that it did too much.  The opportunity of dilating
was in general too tempting to be resisted, and the consequence was,
that it produced irritation in so  many cases, that I was forced to
give  it  up, having  also fully satisfied myself that dilatation, to
whatever extent it  might be  carried,  could not cure the  worst
kinds of stricture."  After noticing the dilating instrument of Mr.
Arnott, consisting of softer materials, and which is dilated by means
of air or water, he adds, p. 78: "I do not now use instruments of
this kind, either from their often failing,  or being so troublesome,
whilst they place the surgeon too much in the hands of the instru-
ment maker, unless he has time and ingc-nuity to  make them him-
self, and they are after all unequal to effect a cure in the more ag-
gravated cases of disease."  At page 96, Mr. G. states that he gives
the preference to a pliable hollow gum elastic bougie, of a medium
size, perfectly smooth, and tolerably round at the point, so as to
give as little uneasiness as possible.
  The method of M. Benique, to which our  author has referred,
is regarded by Messrs. Ricord and  Acton as "pretty," but they
observe that the idea emanated rather " from  a mathematician than
a practical man."  (Acton, op. cit. p.  99.)  However true the latter
observation may be, as applied  to  M.  Benique, this  method has
recently been most highly lauded by one of our own countrymen,
who is both a mathematician and a practical man.  We refer to the
very  able paper of Prof. Eve, to which  we have already alluded.*
This paper concludes with the following propositions:
  1.  " That while dilatation  is the proper treatment for stricture
of the urethra, this  has hitherto failed  to effect a cure, because in
the ordinary mode of applying it, the seat of  the disease has not been
specially acted upon ty the dilating instrument.''1
  2.  "To cure stricture, the orifice of the urethra must be so en-
larged that the canal beyond it may be dilated to its  original size,
which we ought to recollect is about twice that of the opening lead-
ing to it.   Instead, therefore, of  being  satisfied with  introducing
bougies of two lines in diameter through a restricted portion, they
should measure four to five lines in thickness.
  3. " There  is no necessity to confine a patient to bed in treating
stricture; once an instrument has been  introduced, it has done all
it can to expand the passage and  should be withdrawn, that others
larger in size may be immediately substituted.  While  this process
ought to be cautiously and  very gradually conducted; still the
more rapidly  and freely it can be  applied,  provided no  pain is
excited, the sooner the disease will be removed.
  4. "By this method strictures maybe permanently cured in a few
days,  without suffering,  inconvenience or exposure,  to serious  conse-
quences"
  The box of M. Benique' consists of thirty-six pewter bougies, in
diameter from one and one-third to five  lines, cylindrical of the or-
dinary curve, and  flexible.  From two  or three to seven1 or eight

  *  On Treatment of Stricture of the Urethra by rapid and free Dilatation, dec., die. 
STRICTURE.
113
may be introduced at each sitting, which if no irritation be devel-
oped, may be daily repeated.  If necessary to pass the large size,
the orifice of the urethra may be enlarged with the knife.
  The trials yet made with these instruments, are not sufficient!}'
numerous,  we fear, to justify the unqualified praise of  Prof. Eve.
He has been able to furnish but two cases from his own experi-
ence,  which he  is compelled to admit are defective, especially in
regard to time, and in one of these, certainly a desperate one, dila-
tation  was successful,  only after the employment  of  the knife.
Even after the external incision in the case, nineteen days were re-
quired to pass a bougie measuring one-fourth of an inch in diameter.
Prof. E. remarks, that when this patient returned home,  so  scep-
tical were his friends  as to the relief he had experienced, that they
required ocular  demonstration, " whereupon he,  in  true Wesjern
hyperbolical language, offered to aid any water-wheel deficient in
power, if they would only let him mount a fence!"
  [Perhaps subsequent trials on a large scale, may prove that not
onl v the instruments of M. Benique', but of Messrs.  Wakeley and
Holt's modification  of Perreve's like those first issued by M.
Guthrie, are capable of " doing too much."  Mr.  Wakeley's expe-
rience, thus far, however, has been highly encouraging.   In the
dilatation of the female urethra, the vulcanized India-rubber appara-
tus of Mr.  R. E. Hodges, may be used, for a description of which,
together with those of Messrs. Wakeley and Holt, we would refer
the reader to the excellent work of  Mr.  Fergusson on Practical
Surgery (Am. Ed.), where may also be found some judicious ob-
servations  upon  the  methods of treatment to which we have here
alluded.—G. C. B.]
   Cauterization.—Surgeons of the XVth, XVIth, and XVHth cen-
turies, among wnom may be  named. A. Feri, A. Pare, Loyseau,
and F. de Ililden, resorted to cauterization to  remove  urethral
obstructions,  whioh  they  supposed to be caused by vegetations,
fungous growths,  and  carnosities  within the canal.   Hunter was
the next whose  name  stands conspicuous in connection with this
mode of treatment.   In 1822, Ducamp (Trait's des retentions oVurine)
stamped upon it a  character of certainty that caused it to take pre-
cedence over all other methods in the treatment of stricture.  There
are two kinds of cauterization, the lateral, and the direct or antero-
posterior.
  Lateral Cauterization.—This may be done with the porte-caustique
of Ducamp, or of  M. Lallemand.  The modification of the latter
instrument, however, as made by M. Segalas,  by which  the ad-
vantages of Ducamp's and that of M. Lallemand  are combined, is
preferable to either.
  Antero-posterior Cauterization.—For this purpose, Ambrose Pare*
employed coated bougies; Hunter, a porte-caustique  stylet, which
was introduced  through  a canula;  Everard  Home, an armed
bougie.  M. Leroy d'EtioUes has brought the instrument of Hunter
to perfection.  It now consists of a gum-elastic tube, with a fixed
curve, at the extremities of which are two ferrules, the external of
silver,  the vesical of  platina.   An obturator closes the orifice of
                               8 
114
VTDAL ON VENEREAL DISEASES.
 the tube, while it is passed towards the seat of stricture.   As soon
 as this is felt the obturator  is withdrawn, and  a rod substituted,
 of which the vesical end is charged with caustic, the latter, nitrate
 of silver, being contained in a platina cup.  Instead of the nitrate
 of silver, we may use the Vienna paste.  The  urethra should bo
 cleansed of all mucosities before the caustic  is applied.
  One word in reference to the comparative advantages of dilata-
 tion and cauterization.  The advantages and inconveniences of
 both have been mutually exaggerated by their respective advocates.
 Thus,  it has been  urged, that by dilating a stricture we do not
 destroy it,  on which account  it is of course liable to return.   Cau-
 terization, carried to a certain point, does, indeed, effect its destruc-
 tion ; but it cannot insure us against a relapse, and, in the opinion
 of some surgeons,  this will  assume a graver  form, an inodular
 cicatrix is  in fact produced, endowed with  considerable retractile
 power, which property may aggravate the condition of the patient.
 The application of caustic requires extreme accuracy in the diag-
 nosis of "stricture, both as to number,  seat, extent, direction, &c.
 Now this  is impossible in practice, therefore with caustic we must
 always operate in  the dark, as is the case in  the operations of
 incision and scarification, to which we shall  soon  refer.  The
 caustic or  point of the cutting instrument may  be thrust into
 sound parts, by which, instead of benefiting we  injure the patient.
 M. Lallemand and his disciples rely exclusively upon cauterization,
 rejecting dilatation altogether, a course which, in my opinion, is
 attended with serious objections.
  The question is different if by cauterization, it is proposed merely
 to modify  the vital action  of the  parts.   The slightest contact
 is then sufficient,  and of course, this superficial cauterization  must
 be free from the risk of that which  is more profound, as must be
 frequently  practised by M. Lallemand  and  his  followers.  There
 are cases, on the other hand, when the smallest sized bougie cannot
 be passed, though the patient may, after desperate efforts, succeed
 in voiding his urine.  Again, there are case where neither a bougie
 nor the urine can pass, then direct, or the antero-posterior cauteri-
 zation may be followed with the happiest results; for this purpose
the instrument of M. Leroy is admirably adapted.
  [Prof. Gross notices an objection to the instrument of M. Lalle-
mand, which is certainly of a  serious character.  He states that
from the manner in which the cup is joined to the rod, it is liable
to be broken;  and he refers to the instance of a physician in
Buffalo, who was in the habit of cauterizing  himself with this
instrument, and in which this accident proved fatal.   (Treatise, p.
 642.)   To obviate this risk, Prof. G. now employs the instrument
represented in Fig.  5; which he says is all that can be desired.  It

                            Fig. 5.

                                               HQu—UK)
r 
STRICTURE.
115
resembles a common silver catheter, straight or curved, according
to the situation of the stricture.  At its vesical extremity is  an
eyelet three-quarters of an inch in length and  two lines in width,
corresponding with the cup containing caustic, which is attached
to a rod.  The cup is partially filled with tallow, soap, or extract
of hyosciamus, and this is sprinkled with a thin  layer of the pow-
dered salt, a much better plan, he asserts, than that of melting
the caustic over a lamp.
  " To  this method and this instrument," he observes, " am I in-
debted for two of the most perfect cures I ever effected.  I should
not be  surprised if cauterization should again become a favorite
mode of treatment."
  [For  a favorable notice of this method the reader may consult the
Prortieal Observations on Strictures, ke., by Mr. Robert Wade, (Lon-
don, 1853, pp. 79,181.) See, also,the TreatiseoiProf.Gross.—G. C.B.]
  Incision.—Resection.—A variety of sheath-bladed  instruments
have been recommended by MM. Ricord, Guillon, Leroy, Amus-
sat, Stafford, and others, for the internal division of strictures, but
this method of treatment is liable to the same objections as that by
cauterization.   It  must, however, be admitted, that in cases  of
valvular growths near the meatus, and in the prostatic portion of
the urethra,  it may be advantageously employed.   Should com-*
plete  retention of urine occur we must then resort to the button-
hole incision, (boutouniere), or puncture of the bladder.
  [Sir  Benjamin Brodie  has given the particulars of a very bad
case, (op. cit. p. 41,) in which he  resorted to a modification of Mr.
Stafford's operation.   In this case, a plaster bougie  having been
passed down to the seat of the obstruction,  an opening was made
in the perineum.   The bougie was then withdrawn and an instru-
ment introduced in its place, which consisted of a straight silver
tube, closed at its extremity, except a narrow slit, through which
a small lancet could be made to project by pressing on a stilet
which projected from the handle  of the instrument.   " The round
extremities of the instrument being pressed against  the anterior
  §art of the stricture, the  lancet was  protruded and  the stricture
  ivided."  The advantages of this proceeding, he adds, consists in
the fact that the free opening in the perineum prevents all danger
from infiltration of urine;  and the application of the  finger to the
posterior surface of the stricture serves as a guide for the lancet,
by which we can make an exact division  of the stricture. Mr.
Guthrie, referring to Mr. Stafford's instrument, (op. cit. p. 92,) says,
" it must always be a two-edged tool,  capable of doing much good
and much mischief."   We have often seen M. Civiale perform the
internal division of stricture with the happiest effects, and if proper
care be taken we are satisfied this operation will not often be pro-
ductive of ill consequences.—G. C. B.]
  Button-hole Incision  (Boutouniere).—A  staff or catheter  having
been passed as far as the  seat of  stricture, is held by an  assistant.
The surgeon makes an incision along the raphe, and  seeks for the
membranous portion of the urethra;  by freely incising ite inferior
wall, he reaches the staff which the  assistant withdraws a little. 
116            VLDAL ON VENEREAL DISEASES.
Figs. 7,  8.
       (I
Whilst searching for the continuation of the canal he directs the
patient to urinate.  A grooved staff or stilet  is then introduced
into  the urethra, which serves as a guide in prolonging the incis-
               ion  beyond  the  seat of  stricture.
     Fig. 6.     j^  catheter   is  then  introduced,
               which is allowed to remain, and the
               edges of the wound are brought to-
               gether.
                  [Mr.  Fergusson says that he has
               been  much pleased with the instru-
               ment represented in Fig. 6, in treat-
               ing slight strictures within an inch or
               two of the glans, or even  deeper
               than an ordinary bistoury can  reach.
               Figs. 7 and 8  is an ingenious instru-
               ment, manufactured by Frenau, com-
               bining blades both for the lateral and
               antero-posterior  incisions.  Fig.  7
               represent for  lateral incision,  Fig. 8
               for antero-posterior.—G. C. B.]
                 In my opinion, this operation is not
               justly appreciated. Its difficulties and
               dangers have been exaggerated, and
               I believe that it will become more
               general in proportion as surgeons be-
come better acquainted with the anatomy of the parts,
for then, if the staff fail to reach the point at which we
propose to operate, we shall know where to find it.  In
such a case a knowledge of anatomy is our best  guide.
The  stricture, in these cases, is almost always  seated
at the commencement of the membranous portion, and
this is the point where the  opening should be made;
now, it is not very difficult to find the bulb of the
urethra, nor to follow the course of the raphe, as in
the incision for lithotomy.  Guided by anatomy alone,
the surgeon cuts down upon an artery,—why should
he not, in the same manner, cut for the membranous
portion of the urethra, the position of which is far less
liable to change than that of an artery ?  If the mor-
bid alterations of the part have produced such a change
it is an advantage to the operator, for this alteration
is a dilatation, which renders  this  part of the  canal
more easy to be found and opened.  There can  be no
comparison between the dangers of this operation and
that of forced catheterism, or puncture of the bladder.
It is limited to the perineum, remote from the deeper
fascia, and consequently from the peritoneum. Strictly
speaking, it does not affect the pelvic cavity, but only
its walls.   This operation places the male urethra in a
condition similar to that of the female: the catheter has but a short
distance to pass to reach the bladder, and if the prostate gland be 
STRICTURE.
117
  not affected, this is readily accomplished.  A staff, sound, or bougie,
  may also be passed through the stricture from behind forwards,
  to meet another introduced at the meatus.   In the  majority  of
  cases, these instruments may be brought into contact, and may
  afford as valuable information as to the extent and the thickness
, of the stricture, as well as of other matters required to guide us  in
  our treatment.
    [In 1849, Mr.  Syme of Edinburgh, published a  work on stric-
  tures of the urethra, &c, in which he attempts to prove (p. 58)
  that:
    1st. " The division of a stricture by external incision,  is suffi-
  cient for the complete, remedy of the disease, in its most inveterate
  and obstinate form.
    2d.  " That,  in cases of less obstinacy,  but still requiring the
  frequent use  of  bougies, division  is  preferable to dilatation,  as
  affording relief more speedily, permanently, and safely."
    Mr. Syme claims as the peculiarity of his operation,  that instead
  of simply passing a staff, sound, or catheter down to the seat  of
  stricture, a grooved staff is passed through the stricture before the
  incision is attempted, there being, in his opinion, no such thing  as
  an impermeable stricture  (p. 57).   Of course, where  this can be
  done, the operation must be greatly facilitated and rendered more
  free from danger.   Thus  performed, he states, it  is " completely
  effectual."  From the cases reported in the volume to which we
  have referred (p. 13), it would  appear that  Mr. Syme performed
  his  first operation  about the year 1838.  Since that period, we
  believe that he has operated in upwards of  sixty cases without a
  fatal result.   He asserts that, if " correctly performed," the opera-
  tion is perfectly  safe.  Now, fatal cases  have occurred to Messrs.
  Bransby Cooper, Cock, Gay, Coulson, Mackenzie,  and Fergusson.
  These  deaths occurred from phlebitis, hemorrhage,  urinary infiltra-
  tion, &c., &c.   In other instances, patients have had a very narrow
  escape.  Now, we  think that few will be disposed to attribute the
  fatal results which occurred in the practice  of the above-named
  surgeons to their  inability to perform the operation  " correctly."
  There  can be no question, that even in the most skilful hands, it
  is not devoid of danger.   The suffering, which the patients have
  long endured, on whom this operation  is performed  as a dernier
  resort, doubtless increases  its hazards.  If surgeons would resort
  to it at an earlier period of the disease, instead of aggravating the
  condition of the patient, by fruitless efforts at dilatation, where
  dilatation is  impossible, we believe that the operation would pre-
  vent much distress, and, in many cases, prepare the patient for a
  radical cure  by the  very means  which were before ineffectual.
  Mr.  Fergusson recommends that it should not be  practised indis-
  criminately;  and as he speaks  impartially, and from experience,
  we  cordially  commend the remarks on this subject in the last edi-
  tion of his Practical Surgery, to those who propose to perform the
  operation.  Professor Mussey informs us that, in a case in which
  he  not long since resorted to it, he was much pleased with the
  results. 
118
VEOAL ON VENEREAL DISEASES.
  [In the text, our author has spoken of the simplicity and safety
of the old  operation—the button-hole incision, in cases of imper-
meable stricture.  Mr. Fergusson states, in his Practical Surgery,
that he has had two fatal cases in his own practice from this pro-
ceeding,  and Sir Benjamin Brodie (On Urinary Organs,  2d Am.
ed., p. 40),  alluding to an operation performed by himself, which .
consisted in laying open the whole of the contracted portion of the
urethra, speaks of the difficulties connected with these operations;
and the testimony of Professor Gross,  who performed it some thir-
teen years  ago (op. cit.), is to the same  effect.  The operation to
which we now refer for impermeable stricture, and which has been
performed and recommended by Collet, Petit, Wiseman, Bertrandi,
Arnott, Shaw, Desault, Hunter, Cooper, and others, seems to have
been  almost universally mistaken for that claimed by Professor
Syme, the peculiarity of which, as already stated, consists in cut-
ting down upon  a small grooved staff passed through the stricture.
For a more complete account of the present state of the question,
see Report  of the proceedings of the Royal Medical and Chirurgi-
cal Society,  April, 1853,  in the American Journal of die Medical
Sciences,  July, 1853,  p. 226.  M. Ricord, in  noticing Mr. Syme's
operation (Notes  to Hunter, 2d ed., p. 259), merely states, that' the
cases  reported would seem encouraging, but M. Civiale, as we were
personally  assured by him,  never resorts to it-; the old operation,
however, he informed us, he frequently performs.   The Irish sur-
geons are  decidedly  opposed to  it.  During our recent  visit to
Dublin, Mr. Porter, the president  of the College of Surgeons, de-
clared to us, that he would venture to assert that it never had been
performed  in that city, and that it never would be !—G. C. B.]
   [Urinary Abscesses.—Infiltration of Urine.—Under the head of
blennorrhagia our author briefly referred to peri-urethral abscesses,
which form during the existence of that disease.   Among the con-
sequences of stricture, we have likewise to note the development
of abscesses, produced by the constant distention and irritation of  '
the parte behind the  seat of obstruction.  In obstinate cases the
continual straining of the patient is very likely to terminate in this
manner.  Ulceration  may likewise ensue, and the urine be gradu-
ally infiltrated into the adjacent loose cellular tissue.  It forces its
way  slowly  in  some instances, in consequence of the adhesive
inflammation which  its presence excites; in other cases, from a
rupture of the urethra, a sudden  and extensive  infiltration may
take place, which shall result in the sloughing of portions of the
urethra,  or the  entire canal, together with  the glans penis and
scrotum.  The peculiar arrangement of the perineal fascial, causes
the direction of the effused urine to vary according to  its seat.
Fig. 9 shows the tumefaction of the scrotum and perineum from
infiltration of urine.  If it  occur  in  the  membranous  portion it
passes under the sheath of the levator ani, laying bare the rectum;
if at the bulbous portion, it encroaches upon the deep-seated fascia
of the perineum, and is arrested in its course opposite the  anus,
from  which point it may extend so as to involve the circumference
of the penis, the scrotum^ escaping entirely, (Malgaigne.)  It may 
 
�167373100 
URETHRORRHAGIA
119
also reach towards the groin and abdomen, infiltrating the cellular
texture of all the coverings of these parts.  Mr. Shaw, in his Notes
to the work of Sir Charles Bell, on Diseases of the Urethra, (3d
Lond.  ed., p. 244,) has related  an  extraordinary example of the
extent of the infiltration and suppuration which sometimes occurs.
In this case there  was sloughing not only of the coverings of the
penis and scrotum, but of the loins and abdomen, as far  as the um-
bilicus, and in a downward direction as far as  the  knee!  and yet
this patient finally recovered!   At page 267, Sir Charles Bell has
reported a case which proved fatal from  delay; the swelling was
on the left side of the pubes,  and was mistaken for a hernia.
When the urine is effused into the corpus spongiosum, and limited
to this body, the penis  may assume a semi-erect appearance,  as in
the case described  by Mr. Earle, in the Lond. Med. Gazette, vol. ix.
p. 736.  In the same journal, p. 213, he relates a case where the ure-
thra gave way about an inch from  the external orifice;  the under
surface became enormously swollen, and a pouch or kind of second
bladder was formed, which it was necessary to  empty whenever
the bladder was evacuated.   It will be seen in Fig. 10, (from Sir
Charles Bell,) that  notwithstanding the numerous external fistulous
openings, there is but one communicating directly with the urethra.
   [Treatment.—When no communication exists between the abscess
and the urethra it must be opened in the same  manner  as when
seated near the rectum.   If confined behind the deep-seated fascia
the  only indication of its existence may be a slight degree of ful-
ness and deep-seated hardness in the perineum.  The matter having
been reached by the point of  the bistoury, the opening may be
enlarged by  directing the instrument downwards and outwards, as
in the operation for  lithotomy.   In many of these cases no time is
to be lost; a free  exit must be given to the matter or the  most
serious consequences may follow.   The fistulous openings result-
ing from these abscesses, of course, can be cured only after the
stricture has been removed. When extensive sloughing of the parts
 covering the urethra has taken place,  and the granulating process
 is insufficient for their reparation, recourse must be had to plastic
 surgery,  on which subject the works of Mr. Earle, Sir Astley
 Cooper, Delpech,  Dieffenbach, and Messrs. Ricord and Jobert may
 be consulted.  The latter surgeon in particular has devoted especial
 attention to these  operations, and in his splendid volume on Plastic
 Surgery the practitioner may find every desirable  information.—
 G. 0. B.]

                    URETHRORRHAGIA

   Symptoms.—Nothing is more common than  the  discharge of
 a small quantity of blood by the urethra.  It is not, strictly speak-
 ing, an accident, but only a symptom, which I have noticed under
the head  of  urethritis.  Sometimes, however, it happens  that the
 quantity  discharged is sufficient to constitute a true  accident, a
hemorrhage.  Thus we occasionally find that the blood flows in a
 full stream, unmixed with urine or with a muco-purulent matter, 
120            VTDAL ON VENEREAL DISEASES.
and without any effort to urinate on the part of the patient.  This
hemorrhage may last for an hour,  and weaken the patient to a
surprising extent.  Generally the discharge is not so abundant,
and it is rare that a glass of blood is lost.  In every instance the
patient experiences relief, or a temporary improvement after this
discharge.  Severe cases occur in paroxysms, which are sometimes
excited by a walk, by imprudence, and occasionally occur without
any evident cause, even while the patient remains in the horizontal
position and is submitting to anti-heinorrhagic treatment.   If the
hemorrhage be considerable, and often repeated, the relief of which
I have  spoken,  is  followed  by syncopes  and a  prostration  of
strength which scarcely permits the  patient to raise his eyelid.
  Causes.—Attempts have been made to  establish the etiology of
urethrorrhagia.   Among the causes  assigned are severe inflamma-
tion, wounds, rupture of certain vessels, a hemorrhagic diathesis,
and finally, a change in the mode  of action of the cause  which
ordinarily gives rise to blennorrhagia.  I believe that the etiology
of this affection may be regarded under  all these aspects, and we
should not be exclusive in our views.   Thus it is evident, that in
very severe cases of blennorrhagia, with the muco-purulent matter,
mingled or separate, some drops of blood  may be discharged which
have oozed from  the inflamed surfaces.   There is a manifest solu-
tion of continuity in the vessels in cases of rupture of the cord by
a blow of the fist, by  coitus or masturbation, which  certain indi-
viduals  practice during a blennorrhagia  even wnen most severe,
either to gratify their passions or to cure the disease.   In these cases
the hemorrhage may be very abundant; it is of a bright red color
and jets like arterial blood.   These  are the instances in which the
discharge is followed  by  so much relief;  it also  hastens the sub-
sidence of the inflammatory symptoms; but it  is the harbinger of
troublesome days to the patient, for  at the point where the urethra
was ruptured, an inodular stricture, the worst of all strictures, may
after awhile be formed.   I am not aware that an urethrorrhagia,
the result of an  hemorrhagic diathesis, has been really observed,
but such a case is not impossible.  An  instance of which has come
under my own notice, and of which M. de Castelneau has published
the details in the Annates de la-syphilis et des maladies de lapeau,
would seem to belong to this category; but the patient had suffered
only from some trifling attacks of nasal hemorrhage, and there was
nothing either in the antecedents or  in what followed, to prove the
existence of this diathesis.  In this  case the hemorrhage occurred
in paroxysms, which  sometimes lasted for  an  hour.   After each
attack the patient was so debilitated that he could not raise his
arm.  This example of an urethrorrhagia so grave in character, I
believe to be unique.  There was this  remarkable fact  in connec-
tion with it, that during  its continuance, as well as the intervals
between these attacks, the muco-purulent discharge was suppressed,
and it did not return until the urethrorrhagia was completely cured.
It was for this reason  that M. de Castelneau conceived the' idea of
a change in the modus operandi of the cause; as it sometimes pro-
duced a blennorrhagia, sometimes urethrorrhagia.  This hypothesis, 
URETHRORRHAGIA.
121
which  has been ably sustained by M. de Castelneau, is, however,
after all but an hypothesis.
  Diagnosis.—Hemorrhage from the urethra may be easily distin-
guished from that of the Madder.  In  the first case, the blood is
not mixed with urine, and flows spontaneously;  in the other, it is
at the moment of, or immediately after  micturition that it appears,
and is  always more or less mingled with urine.   Very often, when
a blennorrhagia is severe  and deep seated, involving  the  neck of
the bladder, with the last drops of urine may be noticed a clot of
blood.   In these cases  the patient experiences  severe pain when
the stream of urine is voided, and vesical  tenesmus.   Sometimes
the blood comes both from the urethra and the bladder;  we see,
indeed, as has been already mentioned, patients discharging blood
mingled with muco-purulent matter, in the intervals of micturition,
as well as during the act.
  Prognosis.—Urethrorrhagia  is not serious in itself, but it gener-
ally indicates the existence of an intense urethritis, and may give
rise to unpleasant consequences, especially if there be a rupture at
any point in the urethra.
   [Mr. South states, in his edition of Chelius (vol. i. p. 178, Am.
ed.), that  he once saw an instance of  enormous extravasation of
blood,  from the rupture of some vessel  in the penis  during  the
act of coition;  the penis and perineum  were greatly distended,
there was a severe pain in voiding urine, the evacuation of which
required the use of the catheter. In the  course of two or three
days extravasation of urine ensued, and the bladder was punctured
through the rectum.  Sloughing in  the perineum and groins oc-
curred, and the patient had a very tedious recovery.—G. C. B.]
   Life is not compromised by the loss  of blood  alone, and, in the
most severe cases, the  treatment consists simply in repose, and a
milk whey diet, which  suffices to arrest the hemorrhage.   In the
case already mentioned, after the hemorrhage had ceased, the ap*
petite  was keen, and the patient soon begged to be discharged from
the hospital.
   Treatment.—This  should be based on  the cause  of the hem-
orrhage, and the quantity of blood  lost.   Generally, repose, diet,
slightly acidulated or demulcent drinks, are sufficient to arrest the
discharge, when  it arises from  excessive inflammation or a rup-
ture of the urethra.  If the patient be young, plethoric, and the
urethritis subacute, to repose I add blood-letting, or what is better,
the application of fifteen or twenty leeches to the perineum.  Some
practitioners, with Hunter,  have employed copaiba.   I have  no
faith in its efficacy, and am  of the opinion that, in certain cases,
this medicine might produce  an injurious  effect, by irritating the
neck of the bladder, and thus, to the hemorrhage from the urethra,
add a  bloody discharge from the bladder, which is an unfortunate
complication.
   When the quantity of blood lost threatens the life of the patient,
the remedies  to be  first employed, are  refrigerants  along  the
urethra, the scrotum, and the perineum.   Sometimes alone they
do not suffice to arrest the discharge; in  such a case, Benjamin 
122
VIDAL ON VENEREAL DISEASES.
Bell recommends compression of the  urethra:  it may be made
from without inwards, or vice  versa, or in both directions at the
same time.  We may, indeed,  by seizing the antiscrotal portion of
the urethra between  two fingers, employ compression sufficiently
long to arrest the hemorrhage, or with a truss we may compress
the urethra in the perineum.   The compression  in  front of the
scrotum  may be effected by the application of little bands  sur-
rounding  and  compressing the whole penis.   Should this  be
judged insufficient, we may resort to the use of bougies, or sounds
which are to be introduced into the urethra; if of large size, they
may of themselves arrest the hemorrhage.   If in spite of these
means it continues, we join to the  excentric, concentric compress-
ion ; we  apply narrow bands  circularly around the  penis, or the
perineal truss, according to the depth from which the blood pro-
ceeds.  But, I must  declare, that  I have never had occasion to
resort to these mechanical means.  I repeat, therefore, that in the
great majority of cases, repose and soothing applications are  still
the best and the most speedily effectual means.  Further, in mak-
ing the two kinds of compression mentioned, we may often obtain
a contrary effect to that which is desired.   It is well understood,
that when we have  to treat a hemorrhage from rupture of the
urethra, after its cessation, and that of the urethitis, with which it
is complicated, we must dilate the urethra with bougies, in order
to prevent the formation of strictures.
                    URETHRAL  PAINS.

  Symptoms.—All the symptoms of blennorrhagia may disappear,
with the exception of the pain : this not only continues, but may
become exasperated, and constitute the only disease.   It may be
seated in any part of the urethra which has been inflamed, from
the fossa navicularis to the neck of the bladder, but more fre-
quently it is situated in the vicinity of the glans.  This pain is
sometimes of a shooting character; it is constant, though occasion-
ally exacerbated, and puts  on the form of neuralgia; it  may be,
though rarely, intermittent, and the attacks occur at irregular in-
tervals.  The actual severity of  the pain can be generally but
little known to the practitioner, for this accident  occurs chiefly in
nervous subjects, who are sometimes more or less hypochondriacal,
and who always exaggerate their sufferings.   Occasionally the
pain is reflected from the bladder towards the anus and the rectum,
and there is a feeling of weight in the testicles.
  Causes.—It is  evident  that urethral  pain is more likely to be
observed as one of the consequences of a blennorrhagia which has
been imperfectly or improperly  treated.
  A neglect of hygiene  is also an actual cause  of this accident.
Very  excitable nervous subjects are those who suffer most  from
blennhorrhagia;  but it must  be acknowledged that,  in certain
cases, neither age, nor temperament, nor the intensity of the in-
flammation, nor a neglect of hygiene, nor errors in treatment, can 
URETHRAL  PAINS.
123
be accused.   I have * treated a patient who has  been strict in his
observance of hygienic rules, very precise in submitting to  me-
thodical treatment, and who was not of the nervous temperament:
he suffered equally from urethral pains after the cessation of the
discharge, and this pain resisted every plan of treatment.
  Treatment.—For a long  period, antispasmodics, narcotics, and
blisters have been  employed.  John Hunter highly extolled the
latter remedy, which he applied to the perineum.  To these have
been added,  cold injections of opium and perineal frictions with a
pommade of laudanum.  Hunter speaks of injection, of a slightly
irritating character, which  are to be employed from time to time;
thus, we may use eight grains of corrosive sublimate to eight ounces
of water.  When these injections.have produced a good effect, it
has been but temporary.   Bougies have also been employed, as
well as sounds smeared with some  particular  ointment, or caustic.
Thus, by the introduction of a large yellow wax bougie, I  have
sometimes diminished the irritability of the urethra.   The bougie
as it were toughens the mucous membrane of the urethra ; it seems
to act like the bit in the mouth of the horse, of the presence of
which after  awhile  the  mouth becomes unconscious.   By means
of the bougie belladonna ointment has been introduced.   Finally,
the urethra has been cauterized after the method and with the in-
strument of Lallemand.
  I have seen all  these methods fail in the most skilful hands,
and in cases which have been permanently cured by very simple
means, viz. compression of the penis.
  Author's Treatment.—Compression.—I have observed that patients
suffering from urethral pains, either as the result of blennorrhagia,
or from certain morbid conditions of the neck of the bladder, often
compress the penis  with their fingers, and they have declared that
in this way they obtain true relief.  Again, I had  observed, as
have other surgeons, that calculous patients  compress the glans,
that they stretch the penis, and thus strive to ease their anguish.
From this I conceived the idea of employing constant compression.
This I effect by the methodical application round the penis of little
bands of diachylon plaster, as follows: each little band should not
be more than 4 lines in width: its  length should be  sufficient to
encircle the penis, so as to  permit the ends to  lap each other under
the urethra.   The dressing is thus rendered  more solid, and the
urethral compression  more  certain.  The bands should overlap
each other, the second covering a third of the first, and so on with
the rest.  The compression should be very decided, but not carried
to an extent sufficient to prevent the patient from urinating. These
bands should be allowed  to remain as long as possible  until the
pains  have  ceased  at least for three days.  We should not fail to
renew them, as the}' may  become deranged, and fail to effect the
object for which they were applied.  This method of treatment is
chiefly successful when the pain does not  extend beyond the limits
of the antiscrotal portion of the urethra.  When it is seated in the
perineum, there is less chance of causing  it to disappear.  In such
cases,  it sometimes becomes permanent; generally it happens that 
124             VIDAL ON VENEREAL DISEASES.
it is only moderated, but occasionally it enti'rely disappears.  We
may know in advance, if compression will succeed, by making the
patient  attempt it with his fingers; if a momentary relief is ex-
perienced, we have strong grounds for anticipating complete success.
  I should remark, in conclusion, that the pain may be caused by
the remnants  of an inflammation,  in  which case,  leeching will
be preferable to compression.  In the Annales d" la syphilis et des
maladies de lapeau, moreover, maybe found facts recorded, which
favor the practice here recommended.*


    PERVERTED SENSATIONS IN THE URETHRA.—ABSENCE OF
                          SENSATIONS.

  Symptoms.—Instead of an exaltation of sensibility in the urethra
which amounts to a pain, certain aberrations of this sensibility may
be manifested  as the  result of blennorrhagia, which  Benjamin
Bell and M. Lagneau have denominated extraordinary sensations of
the urethra.  These sensations are also referred to  the bladder, and
in some instances to the testicles.   Thus, after the cure of a blen-
norrhagia and the cessation of  the  true accidents of this disease,
there sometimes remains a modification of the normal sensibility of
certain  parts of the  genito-urinary apparatus.  According to M.
Lagneau,  it  is  a continual titillation, a pricking sensation  of the
urethra, the vesiculae seminales, the neck and even the body of
the bladder.   There is also a  kind of undulatory movement of
the testicles (Benjamin Bell).  Sometimes the  symptoms resemble
those of stone in the bladder.  These abnormal sensations are oc-
casionally felt not only in the genital, but in  the pubic and^ hy-
pogastric  regions, and upper part  of the thighs; sometimes the
stomach itself, and the intestines become involved.  It is not im-
probable that in certain cases, these morbid feelings proceed from
the stomach, particularly in hypochondriacal patients.
  Instead of an increased or perverted sensibility, it may be com-
pletely wanting at some point of the urethra.  Thus, after certain
cases of blennorrhagia, there may be  an entire absence of the
voluptuous feeling, which coincides with the ejaculation of semen.
What is  quite remarkable is,  that the patient  may  indulge in
sexual intercourse as  usual, and the erections may be complete,
but the ejaculatory act is unattended by the least pleasure, and
the completion of coition is only made known by the cessation of
the erection.
  [We have recently  been consulted  in relation to a case of this
kind.  If the patient indulge in a second connection shortly after
the first, the ejaculatory act is then accompanied with a slight sen-
sation of pleasure.—G. C. B.]
  This  condition  has been observed  without any appreciable
lesion of the urethra, as well as with an indurated and  thickened
state of the walls of this canal.  M. de Castelneau has published an
interesting case which belongs to this last variety.  The patient
* T. ii. p. 135. 
         PERVERTED  SENSATIONS IN THE URETHRA, &c.      125

was cured by the application of leeches to the perineum, another
fact corroborating the views which I have always professed, and
which have guided my practice since I have* been connected with
so vast a theatre of observation.
  Attempts have been made to cure these abnormal sensations by
means of yellow wax bougies, blisters to the perineum, hypogas-
trium, and the internal surface of the thighs.  Success has by no
means always followed this mode of treatment.
   Causes.—Females are sometimes,  though very rarely, affected
with these perverted sensations, and  when they do  occur, it is
generally owing to the fact, that there still remains a certain de-
gree of irritation in the neck of the uterus, from the extension of
the blennorrhagia to  this  organ.  In such cases, there are most
frequently venal and  vesical difficulties, together with tenesmus,
which greatly annoy the patient.   These abnormal  sensations oc-
cur in both sexes, after every form of blennorrhagia, the mild and
the severe, after attacks supposed to be syphilitic, as well as those
which have been regarded as simply catarrhal.  M. Lagneau  is
said to have observed these cases in men who have  had what has
been called a dry blennorrhagia.
  Patients who have suffered from  these  perverted  sensations,
firmly believe that the disease has been  but imperfectly treated;
they are impressed with the idea, that a syphilitic virus still lurks
in their system,  and  they dread its effects; they incessantly de-
mand to be radically  treated, and  especially by mercury or some
other powerful  remedy.
   Treatment.—There  can  be no  doubt  that antispasmodics and
narcotics, used  either  internally or applied to the  surface of the
perineum, together with very small doses of the pil. hydrarg.  to
satisfy the imagination, sometimes produce beneficial effects.  But
still more frequently antiphlogistics are indicated ;  for instead of
a simply nervous state, there is, in reality, an urethral inflamma-
tion with sympathetic phenomena.    Therefore,  these abnormal
sensations, either of the urethra,  testicles, or other parts of the
genital  sphere, cannot be made to disappear, until this inflamma-
tion has been removed.  I still repeat what I have stated in speak-
ing of blennorrhcea: those who  regard these  morbid phenomena
as the effects of a more or less protracted inflammation of the ure-
thra (and, I will here  add, of the prostate), will meet with greatest
success in their treatment, since they will employ antiphlogistics.
In these cases,  I have not only applied leeches to the perineum,
but  have bled from the arm, for,  as is well known, the condition
in question is sometimes met with in young and vigorous subjects.
When it is really a nervous affection, blisters succeed well, and are
of greater efficacy than electricity.  I should add, besides,  that
since the diagnosis of strictures and  prostatic engorgements has
become more perfect, fewer cases of extraordinary sensations of
the urethra have been, observed; these phenomena are much more
frequently and justly  attributed to organic affections of the genito-
urinary apparatus.
   [Mr.  Acton has devoted a chapter to the subject of Monomania 
126
VIDAL ON VENEREAL DISEASES.
Syphilitica, or Syphiliphobia, a form of disease to which, he asserts,
the medical profession is particularly liable ! (2d Am. ed. p. 401.)
He states, that instead  of simulating certain  affections,  or com-
plaining  of sensations  for the  purpose of misleading the practi-
tioner, the  syphilophobist describes only what by an exhalation
of nervous sensibility he fully  believes he sees or  feels.  Like
hysteria,  syphiliphobia  assumes every  form of venereal  disease
found  or described in  books.   He observes that these cases are
very numerous in London, and we think that in our own  large
cities, those who see many cases of venereal affections, must have
met  with instances of  the kind.  We  doubt, however, whether
they could corroborate  the assertion,  that it prevails particularly
among the medical profession.  In confirmation of  Mr. Acton s
statement, that these patients are very  apt to lodge complaints
against the testes, we subjoin the following case :  Some few years
since, we were summoned  hastily,  at  midnight, to  a patient's
chamber.   No sooner had we entered, than he presented his scro-
tum, and directing  our attention in turn to each of his testicles,
with a doleful  countenance,  exclaimed,  " Here,  doctor, is Susan,
and here is Mary ; cut them out!"  With much difficulty we per-
suaded him to defer the operation until morning!   We tried, in
this  case, as Mr. Acton  directs,  "moral treatment,  very  little
physic, and much exercise," to no  purpose, and it was not until
he became  greatly emaciated, that some  "Father  Confessor" (the
patient being a Catholic)  effected what  we had  failed to  accom-
plish, viz. his restoration to health.—G. C. B.]
               BLENNORRHAGIC  ORCHITIS.

  The history of inflammation of the testicles has recently made
unquestionable progress.  Of this we may be readily convinced if
we  go no  further back than to the time of Dupuytren.  For ex-
ample, this surgeon asserts, in his Lemons, that when the epididy-
mis is affected, the swelling is  not as large as when the  whole
parenchyma of the testis is involved.   The fact is precisely the
contrary.   Boyer is still less  advanced than  Dupuytren.  Sir
Astley Cooper had more correct views; but the  true  progress in
the history of  this affection did not  commence  with him.   The
truth  of these  remarks  will be obvious in the exposition of the
additions to our knowledge on the subject, which I am about to
attempt.
  Causes.—Although orchitis is an accident of frequent  occur-
rence, it is not an inevitable sequence of a  blennorrhagia.  Other
causes are  required for  its  production.  Unfortunately these are
not well determined.  Nevertheless, it is  certain, that this compli-
cation of blennorrhagia  occurs most  frequently in patients who
have been guilty of imprudence of various kinds during the exist-
ence of the discharge,  and who,  among  other excesses,  have
indulged in sexual intercourse.   Some there are,  who, though not
guilty of the latter act, do not completely avoid  excitement of an 
BLENNORRHAGIC ORCHITIS.               1£7
analogous nature.   When obstinate cases of orchitis are encoun-
tered, when the inflammation passes from one testicle to the other,
or when the disease reappears, these facts should  not be forgotten.
  Improper treatment, or that which has been neglected, may cer-
tainly exert an influence on the development of orchitis.   Injec-
tions have been much accused.  Doubtless an irritating fluid may
give rise to  an orchitis, since the simple introduction of a bougie
will, in  some  instances, produce the  same  effect.  Howrever, it
must be acknowledged, that  orchitis  is not the accident most to
be dreaded from the use of injections.  One circumstance which
has  led  to  such a  suspicion, is the fact, that they  are generally
employed in the last stages of blennorrhagia,  a period most favor-
able to the development of orchitis, as I shall hereafter establish.
  It should also be known, that this accident may occur, and not
unfrequently,  under hygienic conditions  least favorable to the
development of inflammation;  for example,  whilst the patient
observes complete  repose, and is under the influence of proper
treatment, not  by irritants, injections, and  the  resins, but of that
which is most antiphlogistic and soothing.   At the  present time,
there is  in  my service a very robust patient, who has had three
attacks  of  orchitis, attended,  with violent pains.   This patient
strictly maintained  the horizontal position, observed a mild  regi-
men, and was  guilty of no imprudence.  Cases of  orchitis have
been seen to follow a hot bath, taken with every precaution.
  The intensity of  the urethral inflammation  seems to have no
influence in the production of this disease.  Of 37 patients, inter-
rogated by M.  de Castelneau, for the purpose of ascertaining this
fact, 31  had suffered moderately at the commencement  of their
blennorrhagia,  6  had experienced  acute pains, and  one of these
6 had had  hemorrhage  from  the urethra  so severe  as  almost to
produce syncope.   In this individual, orchitis appeared whilst he
was confined to  his bed, and  while he was in a state of anemia
from excessive loss of blood.
  Can a di-y blennorrhagia give rise  to this  disease ?   I prefer
thus to  propose  the question.   During the stage  of urethritis,
which is marked by an absence of the discharge, can orchitis oc-
cur ?  I reply  in the affirmative, for I possess  facts  in corrobora-
tion of such an answer.
  Certain seasons of the year, certain conditions of the atmosphere,
favor the development of orchitis.  Thus, I have  occasionally ob-
served,  after sudden changes of temperature, the number of cases
to increase, so as to appear almost like an epidemic.
  Generally, orchitis manifests itself after the first, second, and
even the sixth week of  a blennorrhagia.  When treating of ure-
thral blennorrhagia in the male, I stated, that  in the majority of
cases, the affection was seated, primarily, in the fossa navicularis
and the anterior portion  of  the urethra.    Thence, at  different
periods   of the disease, the inflammation gradually  or suddenly
reached the other portions of the canal.   Orchitis does not gener-
ally occur, until the inflammation  has extended  to  the prostatic
portion  of the canal.   When it does not appear until after the 
128             VLDAL ON VENEREAL  DISEASES.
cessation of the discharge, and, as we have observed, at the end
of eight days in one case, of fifteen in another, we have reason  to
suspect the existence of an irritation  in the region of the prostate,
or the neck of the bladder.  We then find that the patients have no
longer a discharge, that they suffer somewhat in urinating, having
ardor urinae.  As it is possible, on the other hand, for an inflam-
mation to commence in the  region  of the prostate, or, at  least,
speedily to reach that part, it is  easy to explain cases of orchitis
which are met with either at  the commencement, shortly after,  or
even before the appearance  of a gonorrhoea.  Orchitis exists al-
ways with an urethritis, whether the discharge, the ordinary phe-
nomenon of this inflammation, be present or absent.
  Age seems to exert no very marked influence in the production
of this disease, though it may be observed that it is less frequent
at an advanced age.  Orchitis, involving the parenchyma of the
testis, appears to  be more frequent in persons about eighteen  or
twenty years of age, who are affected with blennorrhagia;  while
in those more  advanced, that is, from thirty-five, forty-five, and
fifty j^ears,  vesical  and prostatic affections are more frequent.
However,  there is now (March 5th, 1852) in my service, at the
Hopital du Midi, two patients, aged thirty years, who have paren-
chymatous orchitis.
  Orchitis may exist on both sides, but it is rare that both testicles
are simultaneously affected;  generally but one  is involved, and
when the  other becomes  inflamed, it  is  after resolution has com-
menced in the one first attacked. It is rare, but sometimes occurs,
that orchitis passes rapidly from one testicle  to  another, without
leaving traces of its first invasion.   When one alone is affected, it
is generally the left, and  it is  on this side that the inflammation
begins when it  involves both  testicles.  This may be explained by
the fact that the blood is more easily returned from the right than
the left testis.   The epididymis is the part which is  the first and
most frequently affected ;  in this part,  also, the inflammation con-
tinues for  the greatest length of time.   It is said that the discharge
is sometimes suppressed when orchitis appears, or that, very fre-
quently, its quantity is  suddenly diminished.  As a general rule
it would be more correct to say, that during orchitis  there is but a
trifling discharge, and this for a good reason, viz., that the affec-
tion occurs in the last stages of blennorrhcea, when the discharge is
of course  small in quantity.   The diminution or. suppression  of
the discharge has therefore preceded  the  invasion of the orchitis,
at least such is the fact  in  the majority of cases.   It would  be
wrong, however, to deny the influence of orchitis in diminishing
or suppressing the discharge, for when  the  inflammation of the
testis subsides, we generally  observe  its return.   It  may happen
that both the urethritis  and the orchitis  cease at the  same time.
Examine,  on this point,  the statistics of MM. Gaussail, Aubry,
and de Castelneau.   Of 187 cases, in  161  the discharge diminished
suddenly  on the  appearance of the orchitis, and in nine it was
totally suppressed; of fifteen which  remained stationary, thirteen
occurred to M. Aubry, who noticed  that  in all of the latter the 
BLENNORRHAGIC ORCHITIS.
129
blennorrhoea was of long  standing, and the discharge small in
quantity.
  Pathology.—A variety of opinions have been entertained as to
the manner in which blenorrhagic inflammation invades the testis.
It has been attributed to sympathy, to extension, and to metastasis.
The doctrine of extension, or propagation, along a continuous sur-
face, is that which is now most generally admitted:  the inflamma-
tion extends from the urethra to the ductus ejaculatorius, from the
latter to the vesiculae seminales, thence to the vas  deferens, from
which it reaches the epididymis.  M. Velpeau adopts this opinion,
and has given the following account of the affection :
  " It would seem  that  the  induration  and swelling  of the  vas
deferens must always precede that of the epididymis, if the inflam-
mation always extends  from the urethra  to  the  testis;   such,
indeed, is  often the case.  The  epididymis, in  certain patients,
reaches to the inguinal canal  and even to the iliac fossa.  It is in-
durated, painful, equal in size to a large quill, and sometimes even
to  the little  finger, and it may readily be  mistaken for the  vas
deferens.   But it must be confessed, on the  other hand, that this
indurated cord is not a constant symptom; that very often, indeed,
the vas deferens and the whole spermatic cord are perfectly natural
to the touch,  insensible, and entirely normal, from the testis to  the
pelvis.  If we carefully inquire into the early history of the case,
we learn that pain,  or uneasiness, is felt in the perineum, neck of
the bladder, iliac fossa  and  inguinal canal, before it is perceived in
the testis.  After all, may not an inflammation  be developed in
the testicles nearly  in the same manner as in the lymphatic glands,
that is, by the retrocession or by the continuous progression of
irritating  particles  from point to point, from the urethra  to  the
epididymis, without seriously involving the  canal through which
such particles  are conveyed?  Moreover, the inflammation itself
may be limited to the mucous surface of the vas deferens, whence
it sometimes  reacts  upon the  whole thickness of the canal, so that
the absence  of swelling, induration,  sensibility,  or even pain at
this part, may as readily be comprehended as where the opposite
condition obtains.  This is analogous to what is  admitted, and
daily observed in  every' kind  of canal, and especially in  the
lymphatic vessels."
   M. de  Castelneau, who  has written a remarkable article  on
orchitis, and  which  is  published  in the Annates des maladies de la
pea a, defends the doctrine  of a metastasis ; but, according to him,
it is not the matter  of blennorrhagia which  is transported,  but, if
we may so speak, the cause.  I confess, for my own part, without
denying the production of  orchitis by extension of inflammation,
such as we sometimes observe to follow the passage of a bougie, or
a sound into  the urethra, I am strongly inclined to admit this doc-
trine of metastasis, in a certain number of cases, for  blennorrhagia
is one of the diseases best adapted to this kind of displacement.
"Why is it that, in general, but one testicle is involved ?  The  ori-
fices of the  ejaculatory canals are in close proximity, and both
should be liable to  the same  influences.   Why is it, also, that in
                                9 
130
VTDAL ON VENEREAL DISEASES.
certain instances, orchitis passes rapidly from one side to the other,
without  leaving behind any trace of its  existence on the side
abandoned by the disease ?  And why do cases occur in which
the vas deferens does not become swollen until  after the epidi-
dymis?             •
   I believe, likewise, that inflammation of the prostate is some-
times metastatic. Let me explain myself:  I believe in the possi-
bility of an affection of the neck of the bladder and the prostate,
in cases  of blennorrhagia, where the disease is seated in the ante-
rior portion of the canal, and where  it has passed over the rest of
the canal to invade the gland and the neck of the bladder.  It may
happen even that the last-named parte shall be passed, and that
the body of the bladder and the kidneys shall be attacked with
blennorrhagic inflammation, while the intermediate tissues between
the starting point and the organ last affected  shall escape.  Still
farther, the articulations may become involved, as is well  known,
and surely no one in this case will pretend that the inflammation
has extended along the continuous tissue of the skeleton to reach
these parts.  It  is  said that these facts favor the doctrine of sym-
pathy as  well as of metastasis, but this is a mere dispute for words
alone. What I wish distinctly to establish is, that the doctrine
which admits orchitis from extension of the inflammation from the
urethra, is insufficient and incomplete.
   Symptoms, Progress and Termination.—Before any change is per-
ceived in the testis we  sometimes observe a  febrile state, chills,
restlessness, nervous phenomena, and  even syncope.  Generally,
there is at first a sensation of weight in the scrotum, which causes
the patient to apply his hands to the testicles, or to make use of
a suspensary bandage; sometimes pains in the loins are among the
first  symptoms: it follows a line extending from the kidneys  to
the scrotum.  Some cases, indeed,  commence with  pains  in the
perineum, and a frequent desire to urinate, as in inflammation of
the neck of the bladder.   Frequently, there  is at  first a pain  in
the groin,  and  inguinal canal on the side affected, which pain
may be very severe.  Sometimes it extends towards the antcro-
superior  spine of the ileum, and is soon felt in the testicle, itself.
The application of cold, the weight of the testicle  whilst standing,
walking,  and particularly the jarring of the body, exasperate the
pain and cause it to be reflected towards the corresponding kidney,
rarely towards both.   The heat and sensibility are greatly in-
creased in the testis and epididymis, but not to the same extent in
each.   The  sensibility often exists in an almost equal degree, and
it  is very rare that the  pain is specially concentrated in the cord,
and when such is the case, it is always, or almost always, in its in-
ferior part.  If the pain be sometimes very acute, this is not of
long  duration ;  having  reached its maximum point, towards the
third, fourth, or  fifth day, it generally begins to moderate, and  in
forty-eight  hours more  becomes supportable.   After it has once
moderated, its further decrease  is very slow, sometimes  requiring
three weeks before it entirely disappears   This pain is always in-
creased by pressure.  In the last stages of orchitis, it is only when 
BLENNORRHAGIC ORCHITI&
131
the testicle is touched, that it is felt. Sometimes the testicle has been
observed to  be evidently swollen before any pain is experienced.
  The tumefaction begins occasionally in the cord, but more fre-
quently in the epididymis; it  rapidly increases  and reaches its
height in the course of three, four, or five days.   So speedy is the
development of the tumor, that its progress  cannot be followed.
The  swelling reaches from the  size of a hen's egg to that of the
patient's wrist, or it  may  become still larger.  It is composed of
all the parts which enter into the composition of the scrotum, but
especially of the epididymis.  In two or three days after the com-
mencement of a severe orchitis, the tumor forms a homogeneous
mass, of almost equal hardness  throughout.   The scrotum on the
affected side is tense, shining, adherent to the subjacent  parts and
of a  red color, the deepest shade being on the external surface of
the inflamed testicle, whence it extends, though faded, to  the sound
testicle.   At this period it is difficult to determine the precise seat
of the tumefaction, for it is exceedingly sensitive to the touch; but
after two or three days, the mass being somewhat diminished, be-
comes separated into two parts,  the one more  anterior is  the testis,
the other, posterior and superior, is the epididymis, which overlaps
the  other to a considerable extent.   Sometimes owing to vicious
conformation, which is  not rare,  the  epididymis  may be situated
anteriorly.  It is then in this direction that we observe the  hardest
portion of the tumor.   We know that the induration and tumefac-
tion  are sometimes remarked over a more or less extensive portion
of the vas deferens, but not in every case.   The testis is generally
but little augmented in volume, and its consistence is not changed:
the swelling of the epididymis, however, is on the contrary much
more decided.  When there is a more or less marked effusion into
the cavity of the tunica vaginalis, we may feel the fluctuation and
assure ourselves of the existence of a fluid; seldom is it sufficiently
abundant to give rise to a transparency.
   Resolution commences  in the testicle, when the latter has been
affected ;  it regains its natural  feel towards the fifth or sixth day.
The  rest of the tumor  soon begins to subside, but resolution is
here much slower in its progress,  and in the majority of cases, it is
not  complete until from  the fifteenth to  the thirtieth day; very
frequently it is prolonged for a greater length of time.  Resolution
in the cord  succeeds that of the testis, after whieh follows that of
the  epididymis, which is  the last in order, and which  sooner or
later occurs.  The resolution in the epididymis differs from that
in the other parte, not only by its slow progress, but by the nature
of that  progress.   In the testis and the cord, resolution is perfectly
regular in ite progress;  in the epididymis,  on the contrary, at first
its course is rapid, and the anterior part of the organ is  that in
which it begins; when the tumor has diminished one-half in size,
ite further diminution is very slow, and at the posterior and inferior
part of the  scrotum may now be felt a very  hard nucleus, which
is very slow to disappear.  These nuclei have doubtless been the
means of causing authors  to assert that an enlargement of  the epi-
didymis often lasts during life. 
132
VLDAL ON VENEREAL DISEASES.
   Should there be an effusion in the tunica vaginalis, the fluid is
generally absorbed during the resolution of the other parts.
   The spermatic secretion during the existence of orchitis has been
but imperfectly studied.  M. Lagneau has mentioned a case show-
ing that  a  patient affected with a swelled testicle of two months'
duration, had had, during an amorous dream, a pollution mixed
with streaks of blood.
   The fever  accompanying orchitis is generally slight;  it exists
only when the disease is at its height, and in cases where the local
symptoms present a certain degree of intensity.   M. Marc d'Espine
in 24 cases of orchitis, found 17 in which fever existed at the com-
mencement, and 2 in which it  happened during a relapse, but in
which it was absent during the primary affection.  M. de Castel-
neau  has observed fever only in  11  out of  37  patients, a result
which differs materially from that obtained by the observer above
mentioned.  -But it must be remarked that patients present them-
selves to us at a time when the general symptoms  have disappeared,
supposing of course  that they had existed.  Their own statement
then  is our only source of information.  Now, as all patients  are
not equally intelligent, I required,  says M. de Castelneau, as symp-
toms  of fever, a want of appetite and a decided heat of the skin.
   Sometimes there are pains in the loins, and in the extremity cor-
responding to the side of the diseased testicle, with headache, nau-
sea and vomiting.  The renal pains as well as those in the inferior
extremity, are explained by the nervous connections of the testicle
with  these parts and occasionally by a true complication on  the
part of the kidneys, when the pain reaches to such a height.
   Varieties.—The description of orchitis which I have given, is of
modern  origin.   The  recent progress of science  and  my own
researches  have enabled me to fix the-seat of inflammation in
different parts of the testicle, and to  establish varieties  based on
this special seat.   I know what arguments may be opposed to this
localization.  It is evident, that if it be objected that one  tissue of
the testis cannot be affected without involving  another, this is a
reasonable  objection,  and applies  not  only to this, but  to every
case which comes under the observation of the pathologist;  thus,
when attempts are made to establish varieties of ocular inflamma-
tion according to the structures involved, we meet with the  same
objection.  But as regards the testicle,  if it be maintained that by
the term epididymitis we are to understand that  the epididymis is
more  particularly inflamed, and if by conjunctivitis we are to  un-
derstand that the  conjunctiva is more particularly inflamed, after
these  explanations no further argument is required.   Here, then,
the testicle being composed of three parte,  the epididymis,  the
tunica vaginalis, and the  glandular parenchyma, I shall  establish
three  varieties corresponding to these different parts.
   1. Epididymitis.—This is the most common variety.   It is evi-
dent,  that if the starting point in every case  of blennorrhagic
orchitis is the urethra, if the cause be conveyed through the  vas
deferens, it should be more or less arrested by the convolutions of
this canal, that is, by the epididymis.  Sometimes this part of  the 
BLENNORRHAGIC ORCHITIS.
133
testicle is affected, while the vas deferens remains sound, and then
follows what is observed in certain cases of adenitis, the result of
inoculation;  we see, indeed,  the gland affected by the virus or
irritating cause, yet the vessel wtyich transported this virus appa-
rently preserves its complete integrity.  It is thus, that we have
inflammation of the epididymis from metastasis, or if it please, from
sympathy.
  The swelling belonging to  this variety is the most voluminous
and irregular.  The epididymis, when not well supported, becomes
compressed and flattened on its sides; it undergoes the most rapid
changes, at least in' the acute stage.   When, from the anomaly to
which I have already alluded, the epididymis is situated in front,
the length of the tumor appears to be increased; it is  almost
cylindrical.
  Epididymitis is less painful than the two other varieties which I
shall presently describe.
  What I have asserted in reference to the size of the tumor, where
it is formed by the epididymis, may perhaps surprise the  readers
of the Lerons Or ales of Dupuytren, who, as already stated, main-
tains exaetly the opposite opinion.   On this point daily experience
completely refutes the opinion of Dupuytren,  and if any would
judge for themselves, they have only  to visit my wards at the
Midi, or attend some of our  public consultations.  Moreover, we
can comprehend how an inflammation which invades an organ like
the epididymis, a dilatable body, should easily expand the  tissues,
while the substance of the testis, enclosed by a sclerous tunic much
more unyielding than that of the epididymis, cannot expand  beyond
a certain point.
  The inflammation which  makes  such  rapid progress  in the
epididymis leaves behind, nevertheless, indurated nuclei, the com-
plete resolution" of which  is  in  general very slow.  The  seat of
these small tumors  is the part  of the epididymis called the tail.
These chronic  inflammations, limited to small foci, are therefore
but inflammations primarily acute, but which have become chronic.
It happens also that these nuclei have a character primarily chronic,
but  then they proceed from some  vice, and it is generally the
tuberculous  or syphilitic which gives  rise to their formation or
which protracts their existence.  Tubercle especially is  a frequent
cause of chronic inflammation of the epididymis.  Indeed, if it has
not been preceded by blennorrhagia, and particularly if the tumor
is very irregular  and occupies but  one  side,  no matter what the
temperament or strength of the patient, tubercle is to be  suspected.
   Varicocele is one of the effects of epididymitis,  especially when
the latter occurs on the left side, where a predisposition  naturally
exists to varices of the scrotum.
  In connection with epididymitis are observed very considerable
engorgements of the vas deferens and the parts which surround it
to fill up the inguinal canal.  In these cases we sometimes find
that the aponeuroses yield with difficulty to the swelling, thus
causing a true strangulation, attended with many of the symptoms
of strangulated hernia, such  as pains in the abdomen, anorexia, 
134
VTDAL ON VENEREAL DISEASES.
vomiting, and a tumor, the long axis of which follows the track
of the inguinal canal, ke.,  ke.   It  may be distinguished from
strangulated hernia by the antecedent circumstances, and the fact
of the engorgement of the epididymis.  When  the cord becomes
similarly engorged it gives rise to symptoms of peritonitis.
  2. Vaginalitis.—Inflammation  of the tunica vaginalis does not
exist in every case when there is found more or less fluid in its
cavity; if such were  the case this variety of orchitis would cer-
tainly be most common, and it would almost always co-exist with
epididymitis.  We know, moreover, that M. Rochoux has asserted
that this fluid nearly always exists, as it is maintained again that
epididymitis  is always present, for which reason it  is proposed to
call every case of blennorrhagic orchitis, vaginalitis or epididymitis.
But it is evident that the serous  effusion generally constitutes but
an epiphenomenon; ordinarily there is, in  the tunica vaginalis, a
certain quantity of serum exhaled, because there is an engorgement
of the vessels of the testicle.  Indeed, when one of its principal
parts  is affected, especially the epididymis, it gives rise to dropsy
of the tunica vaginalis, in the same manner as do certain abdominal
tumors to ascites.   This effusion is, properly speaking, passive;
the opening of the tunica vaginalis gives  exit to a limpid lemon-
colored serum, but produces no perceptible effect on the progress
of the orchitis.  Sometimes,  on the other hand, every circumstance
goes to prove the existence of a true inflammation of the tunica
vaginalis.  The pain  is  sharp and constant; the tumor decidedly
tense; there  is neither  fluctuation nor  transparency, and  if the
serous cavity be punctured  with a lancet, the fluid evacuated is
slightly muddy, of a reddish color, and very hot.   After this oper-
ation the pain is speedily relieved.  The fluid is often reproduced,
when it  more nearly resembles  that contained in chronic hydro-
cele.  I have sometimes seen, after this trifling proceeding, the
testicle become swollen,  occupy the place of the fluid, and a paren-
chymatous orchitis rapidly succeed to a vaginalitis.
  If varicocele sometimes follows an  inflammation of the epididy-
mis, hydrocele is rather one of the consequences of inflammation
of the tunica vaginalis.  If we closely interrogate persons affected
with hydrocele, we shall find a great number admitting that they
had an acute affection of the testis, which is but a vaginalitis.   This
variety of orchitis  has undoubtedly existed when we meet with a
multilocular hydrocele.   The swelling from vaginalitis is smooth
and even, more or less globular, it extends much farther forwards
than in the other varieties, and does not retain marks of pressure
upon it as does the swelling from epididymitis.
  2. Parenchymatous  Orchitis.—I have thought  proper  to apply
this name to the inflammation which affects more particularly the
parenchyma of the testis, and the substance contained in its firmest
and most immediate envelope,  the  tunica  albuginea.  This va-
riety I have remarked  chiefly among the youngest subjects af-
fected with blennorrhagia, about eighteen or twenty years of a°-e.
I have also observed it in persons not far from thirty years.  Very
seldom,  indeed,  is this  variety  a primary affection.   In these 
BLENNORRHAGIC  ORCHITIS.
135
rare cases the patients present certain symptoms which I will pre-
sently describe, and  there is no serum contained in the cavity of
the tunica vaginalis, as I  have proved by incision, of which  I
shall speak hereafter. Much more frequently, the parenchymatous
orchitis has been preceded  by an epididymitis.  Sometimes it fol-
lows a vaginalitis; as I have already observed, I have emptied the
cavity of the tunica vaginalis of the serum which it contained,
and the next day I have seen the testicle become so tumefied as to
fill the vacuum produced by the evacuation of the fluid.
   The swelling in  parenchymatous orchitis is less voluminous than
in the other varieties.   Where it coincides with a vaginalitis and
an epididymitis it forms a part of the  general swelling, though
less than that produced by the epididymitis,  but more than that
by the vaginalitis.  The swelling resembles, though in an exagger-
ated form, that of the testicle; the mass is tense, and of an ovoid
shape.   Anteriorly  it projects more considerably than does that
of epididymitis,  but  less abrupt than vaginalitis when the effusion
in the latter affection is small in quantity, for, when in vaginalitis
there is but a thin layer of fluid, the swelling remains of an ovoid
form.   In the variety under consideration, the part of the tumor
which belongs to the epididymis  is with difficulty distinguished
from that which belongs to the testicle itself;  all is one indurated
and confused mass, covered by skin more or less red, and cellular
tissue which is sbmetimes cedematous.  The testicle is retracted
towards the abdomen.
   This  is the most  painful variety; it is attended with pains and
cramps, which extend  towards the groin,  the iliac fossa, the kid-
ney,  and the inferior extremity of the corresponding side. Vom-
iting and very decided symptomatic fever are present; and  it
gives rise to reactions  the most severe.  This is explained by the
seat of the inflammation;  the tissue affected  being enveloped in
 a fibrous sac which  resists  its expansion, and which thus gives rise
 to a true strangulation.  We can therefore understand the havoc
 caused  by this  inflammation when  it is severe.   It produces not
 only suppuration, but mortification of a portion of the testicle it-
 self, which is the  more or less completely discharged.
    Treatment.—In  the  treatment of orchitis  a great variety of
 methods have been adopted, and in my opinion without  benefit.
 Local and general blood-letting have been employed, together with
 sedatives, purgatives,  balsams, revulsives, all kinds of cold  and
 hot topical applications, mercurial ointment, cataplasms, cotton,
 terra sigillata, vesicatories, compression, and, last of all, chloro-
 form.
    I  am completely satisfied of the inefficacy, the impotence of
 these means in  a curative  point of view.   Let me explain myself.
 I believe that the common blennorrhagic orchitis, that is, epididy-
 mitis with more or  less effusion into the cavity of the tunica vagi-
 nalis, and a little irritation  of the testicle, will pursue its course,
 in spite of any or all the means above mentioned.  From this it
 must not be inferred that  I  am opposed to all treatment in all cir-
 cumstances of orchitis, in all its forms, for there are cases which 
136
VIDAL ON VENEREAL DISEASES.
compel the practitioner to act temporarily, if for no other purpose
than to mitigate the sufferings of the patient.
  1. Blood-letting.—Sedatives.—It is certain  that  in some very
plethoric or nervous subjects, antiphlogistics and sedatives can-
not cure orchitis, nor  abridge the duration of this inflammation,
but can only moderate certain  symptoms.  For example, a very
high fever  has more than once  been lessened by general blood-
letting, and the pain subdued at least for a time, by leeches, cata-
plasms, of laudanum,  aided by repose.
  2. Mercurial Ointment.—The mercurial ointment, applied not by
frictions, but  in very thick layers, as in cases of peritonitis, and
certain aithritic inflammations, may relieve the pain, and that too
speedily.   But  if the mercury  be  continued  under this form, a
very unpleasant salivation  may sometimes be produced.  I am
convinced that in certain young subjects, the  ointment  thus em-
ployed may prevent vaginalitis and parenchymatous orchitis.
  3. Purgatives.—I believe that the repeated use of mild purgatives
may promote the dispersion of some of the indurated nuclei of the
epididymis, and that  in the  acute stages it is often  necessary to
remove the constipation.  But, I repeat it, the ordinary  course of
an orchitis  is not abridged by any of these means.
  4. Compression.—This is of difficult application ; the little bands
which  are  used become  easily loosened, and  from the  irregular
form of the tumor, they act  more on certain points  than others.
Besides, pressure  cannot be borne  in severe cases, where the in-
flammation runs  high, and when the latter involves the tunica
vaginalis, and especially the parenchymatous structure, as it does
in certain cases of epididymitis; by compressing the tumor  under
such circumstances, we may produce symptoms  of strangulation.
The suffering excited, in some  instances, by handling the tumor
for the purpose of examination, enables us to form some idea  of
that which the patient must endure from the application of com-
pression.
  [Our author, though differing in his estimate of compression
from some of the highest authorities, among whom may be named
Messrs. Ricord, Acton, South, Langston  Parker, and Egan,  is yet
far more moderate in  his condemnation  of this method (Frieke's
of Hamburgh) than is Mr. Henry James  Johnson.  At  page 212
of his " Treatise on Diseases of the  Genito- Urinary Apparatus,"  he
remarks, that from the torture he has seen patients undergo who
have submitted to it, he "is inclined to compare it to the process
of the Buccaneers of the Spanish Main, who slung their  prisoners
to the yard-arm by the testicles, until they had confessed where their
dollars were concealed. H the inflammation is acute, it is a piece of
ridiculous cruelty; if mild it is disproportionately painful, trouble-
some to manage, apt to lacerate or excoriate the skin, and not a
little treacherous." _ We think that the  majority of practitioners
who have  tried this plan, will agree with  Mr. Johnson  in his re-
marks  on the difficulties in its application, and the accidents to
which, from ite exceedingly great liability to become deranged, it
is apt to give rise.   Even M.  Ricord cautions us to be attentive to 
BLENNORRHAGIC ORCHITIS.              137
these  matters, if we would avoid unpleasant consequences.  At
page 177, of his 2d ed. of Hunter, he describes the conditions to
which this treatment is applicable.   When the spermatic cord is
not too  much engorged, and  the cellular tissue of the scrotum is
not the seat of a phlegmonous inflammation, when there is no ten-
dency to suppuration or abscess formed, when the inflammation
has been subdued by antiphlogistics, and when,  if complicated
with  hydrocele, the cavity of the  tunica vaginalis has been emp-
tied, that he considers Frieke's method superior to any other plan
of treatment.   If in the course of half an hour or an hour after its
application the patient experiences no relief, but an aggravation
of his sufferings, he directs that it should be at once removed, and
mercurial ointment  with  fomentations  or emollient cataplasms
substituted.   Mr. Langston Parker, p. 73, 2d. ed., states that  he
has repeatedly employed Frieke's  method from the very com-
mencement of the  disease with the most complete success, and
Mr. Egan, p.  104, of his excellent treatise, states that  he does  not
remember to have witnessed a case in which its employment was
not followed by speedy and permanent  relief,  and  Mr.  Acton
thinks it has superseded the thousand and one remedies formerly
employed (2d Amer. ed. p. 144).  From what we  have seen of it,
we would  advise  the young practitioner, before resorting to it,
to bear in mind the indications mentioned  by  M.  Ricord, and
the objections  urged against it  by Mr.  Johnson and our  au-
thor.— G. C. B.]
   5.  Chloroform.—This substance, when topically applied, produces
at first severe pain, and I have had an opportunity of seeing a
partial peritonitis from the employment of chloroform according
to the method of M. Bouisson, who has highly extolled  this plan
of treatment.
   6.  Puncture of the  Tunica Vaginalis.—M. Velpeau.—If  it be true
that the treatment ordinarily  pursued does not retard the progress
of orchitis ; if leeching and compression  are incapable of promot-
ing resolution, operative medicine, properly speaking, may put an
end to the accidents, or abridge the duration of the disease.  When
there is actually'a vaginalitis, and a subacute hydrocele is formed,
the puncture of the tunica vaginalis as  first practised by M. Vel-
peau, may favor resolution and promptly relieve the pain.   This
puncture is  made with  a lancet or sharp pointed  bistoury; it
should be half an inch in extent.  As soon as the instrument has
  Eenetrated the serous cavity, a demi-rotatory movement should
  e given it, by which the borders of the little wound will be sepa-
rated, and the discharge of the fluid facilitated.   The lancet should
not be withdrawn until the fluid has been completely evacuated,
that the lips  of the  wound through the  integuments and serous
membrane may preserve their parallelism, and the  issue of the
liquid be not prevented.
   7.  Incision of the  Testis.—Author's Method.—In cases of paren-
chymatous orchitis, puncture of the tunica vaginalis is not suffi-
cient;, the inflammation is then accompanied by strangulation, for
the organ affected is surrounded by a very dense fibrous sheath. 
138
VTDAL ON VENEREAL DISEASES.
This is the variety of orchitis which I remove by an  incision of
the testicle.  I puncture  the  tunica albuginea with  a lancet or
sharp-pointed bistoury, the opening being little more than half an
inch in extent.   This operation is attended with no more pain
than that of puncturing the tunica vaginalis.  Its safety is estab-
lished beyond a doubt.   I have operated on more than 400 pa-
tients in private practice, and at the Ilpital du Midi.   My internes
have often performed it in the night, during an exacerbation.  It
has never  been followed by the least accident, and generally, in
half an hour or an hour, the patient is greatly relieved.   He sleeps
the whole of the following night, and sometimes the following day.
I have adopted this plan of treatment when  other energetic meas-
ures have  failed.   The result has been the same :  relief prompt
and decided.  But this trifling operation is not only sedative, it is
antiphlogistic, a powerful resolvent, and a certain preventive of
suppuration, and the consequent disintegration of the testicle ; for
after  the  puncture,  the tumor is rapidly dispersed.   The  great
number of these operations which I have practised may give rise
to an impression that I have performed it in other varieties than
the parenchymatous orchitis, in which suppuration is not of fre-
quent occurrence.   Indeed, when I became satisfied of the inocu-
ous character of these punctures, I extended their employment to
cases of epididymitis with swelling of the testicle, acute pain, and
more or less sympathetic disturbance.   In these cases, also, I have
relieved the pain, removed the symptoms, and expedited the cure.
For example, in  one instance, by some anomaly, the epididymis
was carried forwards and downwards.  Inflammation  in this  part
produced a tumor, which I mistook for a swelled testicle.  I there-
fore cut  the  epididymis, by which proceeding the pain was re-
lieved,  the sympathetic  disturbance  removed,  and resolution
greatly promoted.  These punctures, then,  are useful not in the
treatment of parenchymatous  orchitis only,  as I at first proposed
and practised ; they are beneficial not in the treatment of vaginal-
itis only, as M. Velpeau has often proved ; but they may also pro-
mote the resolution of an epididymitis, and prevent the accidents
which this inflammation might produce.
   To this operation objections  have  been  made; it is supposed
that by it, a large incision is  made in the organ, and great fears
have been expressed for the safety of the tubuli seminiferi, which
must be wounded and obliterated, whence must follow atrophy of
the testicle, impotence, and  sterility!  Now the fibrous  envelope
of the testicle is divided to the extent of little more than half an
inch in length, and less than half in depth.   With every precau-
tion, some of the tubuli seminiferi may be reached, but is it possi-
ble for the obliteration of  a few of these innumerable  ducts to
produce atrophy of the testicle, and to render the patient impotent ?
As to the production of atrophy, I can  speak from great experi-
ence, for all of my patients have been strictly watched in reference
to this matter, and that too for a long  time after the operation;
and in no instance has the testicle become  diminished in size or
consistence.  There is no reason to apprehend impotence or ster- 
BLENNORRHAGIC PROSTATITIS.
139
ility, for even though but one other testicle remains, it is difficult
to comprehend how the obliteration of some of the tubes of one
testicle  should destroy the functions of the  other.  In certain
tubercular affections  of the testicles, both of these organs are
partly destroyed,  and yet the patient is  not  generally rendered
impotent.  Further, if we  wish to obliterate  a great number of
these tubes, the best method is to permit the inflammation to pur
sue ite course, and the suppuration which follows will be sure to
effect our object.  Now, nothing but a trifling incision can arrest
the progress of an acute inflammation of the parenchyma  of the
testicle  itself.   What is most extraordinary, the two most  able
and experienced  surgeons who have opposed me in this matter,
have made the same  and the  least  important  objection to the
practice.  Since then,  one of these  same  surgeons has claimed to
be  the  inventor of  this proceeding!   M. Velpeau has remarked
that this  operation alarms both patient and practitioner.   Who
has ever been frightened at a simple puncture of the tunica vagi-
nalis ?   Patients daily  submit to it without hesitation,  for the ope-
ration is daily performed by the practitioners whom I have men-
tioned.   Now, when we are puncturing the fibrous envelope of the
testicle,  does  the  patient know whether we penetrate a few lines
more  deeply?  Practitioners, I am sure,  must derive confidence
from  the  numerous  facts which  daily occur  in favor  of this
method.

            BLENNORRHAGIC  PROSTATITIS.

  Chronic engorgements of the prostate  have in modern  times
been carefully studied.  Home, J. L. Petit, and very recently MM.
Mercier and Civiale, have  devoted  much attention to these affec-
tions  as observed in old people.  But acute prostatitis, that which
is met with in persons under fifty years of age, and which  is one
of  the  accidents of  blennorrhagia,  has been  much neglected.
Doubtless, those  authors whose attention has been directed to the
subject  of urethral blennorrhagia, must have noticed certain symp-
toms  of prostatitis; thus Benjamin Bell has briefly described its
history  upon which I  shall soon enter, but ite  complete  history
has yet to be made and detailed, and  authentic facts for the  pur-
pose are still wanting.   I will here insert the histories of three cases,
they will be of service to those who will hereafter attempt a com-
plete description  of blennorrhagic prostatitis.  The particulars of
these cases were  collected  by M. de Castelneau,  while he was my
interne at the Hopital du Midi.
  Case 1. Diot, set. 40, a market-house porter, with brown hair,
black eyes, dark  skin,  of ordinary height, muscles well developed,
entered  the Hospice du Midi, Ward 10,  No.  5, on the 6th Feb., 1843.
nis health had always been good, having  never suffered either
from syphilis nor any other malady.   On the 1st Jan. he had con-
nection  with  a widow woman, who was  not  menstruating.  He
knows  not whether she was diseased.  At  the  end of four days,
there was  a slight  discharge from the urethra unattended with 
140
VEOAL ON VENEREAL DISEASES.
 ain.   This discharge continued about the same for ten days, when
 e experienced a prickly sensation in urinating, this was soon fol-
lowed by frequent desires to urinate.  The urgency of these de-
sires increased, and became finally so irresistible that the patient
was obliged to satisfy them wherever  he might  be, under the
penalty of  passing his  urine involuntarily.  After eight days, to
these symptoms was added a greater or less difficulty of urinating,
which, since yesterday, has become converted into a complete re-
tention, and thrown the patient into a state of great anxiety.
  After his admission,  the catheter was introduced, which entered
the bladder with the greatest facility,  and without producing more
than ordinary pain, its pavilion having only been turned a little
to the left, when its beak reached  the region of the prostate.
About twenty ounces of urine were forcibly evacuated.   The
urethra is the seat of burning, pricking, shooting pains throughout
ite entire length, which are felt most severely deep in the perineum.
This pain  prevents the  patient from sitting,  and causes him to
groan  continually.  An  examination per rectum, detects  a tumor
with a squared surface,  so to speak, and presenting two lateral bor-
ders, nearly parallel with the direction  of the intestine, and two
other edges, the one anterior, the other posterior and perpendicular
to the first. The surface by which these borders are intersected,
may have  about two inches in extent from one side to the  other.
The angle  formed by the junction of the  right and posterior bor-
der, is much more  salient than that formed by the posterior and
left.   This salient angle, more  or less decided, exists throughout
the whole length of the tumor.   Pressure  on this tumor is insup-
portable ; to the touch it presents the same feel as a phlegmonous
tumor offering an obscure sense of fluctuation.  There is  but a
very small discharge of a sero-mucous nature from the urethra.
   The face of the patient is red, the conjunctiva  injected, the eyes
prominent; the heat of  the  skin  is increased, and  the  pulse is
about 100.  He neither eats nor sleeps.  The use of the catheter
afforded some relief.  Prescription :  orange  Tillen  tisane;  thirty
leeches and cataplasm to the perineum; diet.  Evening: the pain in
the perineum has somewhat abated, but the retention of urine is al-
ways complete.  The catheter is again  introduced with the same
facility, its handle being always a little deviated laterally when the
break arrived at the prostatic portion of the urethra.  No change of
remedies.
   Feb. 7th.—Morning: patient did not  sleep last night, and it be-
came necessary to use the catheter at  3  o'clock in the morning,
which instrument has always been very readily  introduced.   The
tumor when examined by the  rectum, presents  the same volume
as yesterday.  In other  respects the same as last  evening.  Pre-
scription :  twenty-five leeches to the perineum, followed by a cata-
plasm, two pills of opium and camphor,  camphorated lavement;
hip-bath ; other'treatment unchanged.
   8th.—The tumor  has  sensibly diminished in volume;  it is soft
and has a feeling of  fluctuation; on pressure  the  pain is about
the same, but less spontaneously; the lavement brought away one
I 
BLENNORRHAGIC PROSTATITIS.
141
stool, which caused severe pain in the tumor.  In the night the
patient was able to expel some drops of urine; nevertheless it was
necessary to use the catheter, which as before wras introduced with
perfect ease.  The urine was expelled in  jets the same as before :
slept none, countenance a little less anxious, pulse 90, and weaker.
Same prescription, but fewer leeches.
  9 th.—Scarcely any change; the patient,  however, suffers some-
what  less, but  can  pass  his  urine only in  drops.   The  tumor
seems to be diminishing in size, at least on the side of its salient
angle.   Catheterism  as before.   Pulse from  85 to 90, still very
strong; heat of skin somewhat more than natural.   Same  prescrip-
tion, ten more leeches to the perineum, and diminish the  quantity
of fluid used in the lavement.
  10th.—Marked improvement: has  passed a  glass of  liquid
at seven or eight different times, drop by  drop:  catheterism not
required during the night;  slept a little ; pain  less severe in the
urethra and perineal region, except  on pressure, when it is  still
very great.  The finger introduced into the rectum, discovers that
the angle so salient on the right side, is almost completely effaced,
and  the tumor is but little more prominent on this than on the
left side;  throughout its whole extent it has equally diminished,
and has  assumed a  softer consistence.  Heat of skin nearly nor-
mal ;  pulse of less force and from 70 to 75  ; appetite feeble.   The
urethral discharge has become somewhat opaque and a little more
abundant, but nothing passed which leads to  a  suspicion of the
opening of an abscess in the urinary passages.  Heat of skin nor-
mal ; pulse  more feeble and 70; appetite  good.   Catheterism  is
practised this morning with the ordinary facility.  Tillen's tisane,
cataplasm on the perineum, prolonged hip-bath  ; broth twice.
   11th.—More  than two  glasses of  urine  passed  without the
aid of  the catheter, and almost entirely drop by drop;  at times
only  when the patient makes a powerful effort, the urine  issued in
a very fine stream, which ceased almost immediately.  The cathe-
ter was used only once last evening.  The tumor examined per
rectum continues to diminish in size, especially, at its angles which
are more and more effaced.  Pain even on pressure slight.  Sleep
has  been interrupted  only by  the constant frequent desire to uri-
nate.  Appetite very sharp, pulse and heat  natural.  Same  pre-
scription, with the addition of soup twice.
   From this time  the patient continued uninterruptedly to im-
prove, and urinated with more facility.  February 18th, the urine
is passed almost without pain, though more frequently  than na-
tural.  February 26th, urine is  passed  without  difficulty.   The
tumor  steadily diminishes,  and is quite insensible  to  pressure.
When the patient left there was no unnatural projection in the
rectum.  The urethral discharge diminished  in proportion  to the
increase of inflammation of the prostate.   February 28th,  it  is
almost as copious as before the supervention of the above-named
accidents.   From this period to the 11th March, 1 drachm of tur-
pentine  was daily  used without benefit; then cubebs were em-
ployed in increased doses, even as high as 5 drachms daily.  On 
142
VIDAL ON VENEREAL DISEASES.
the second day of its administration, the discharge had perceptibly
decreased.  On the sixth it had completely disappeared.   The use
of this medicine was continued until the patient  left, and the dis-
charge did not  return, although, for five days before he left, he
had spent part of the time in the garden.  His food has been grad-
ually  increased to its natural quantity, and yet his digestion has
not been disturbed.  In fine, the patient left the  hospital on the
3d April in perfect health.
   I know of no more complete or conclusive case on record.
Here  we see  a prostatitis following close on  to a blennorrhagia.
The disposition  to  urinate was constant, the retention of urine
complete.  The pain  in  the  perineum  was  so  severe that the
patient was unable to sit.  The prostate was considerably enlarged.
During  the prostatitis  there was but a mere weeping  from the
urethra.   The catheter was introduced with ease; it was turned
from its course laterally, showing that one lobe of the prostate was
larger than the  other, a fact which was proved by examining with
the finger introduced into the rectum.  The subsidence of the dis-
ease was coincident with the reappearance of the urethral discharge.
The resolution of the tumor formed by the prostate was complete,
proving that it depended solely on  an  acute inflammation.  The
application of leeches succeeded perfectly.
   Case 2d.—Collat, aet. 27, printer, was admitted July 8th, 1844:
constitution robust; for some years had been subject to rheumat-
ism.  About three weeks since, four days  after an impure connec-
tion, this  man was  attacked with blennorrhagia.  The discharge
became  speedily white, thick, very copious, but the pain was not
severe in urinating.  On the 6th July, there was scarcely any pain
whatever.   That evening he  indulged  excessively in alcoholic
drinks ; the next day  he could not urinate.  In this  condition he
passed Sunday, the 7th July, and on Monday morning he sought
relief.
   July  8th. The face is  pale and anxious;  pulse  feeble; body
bent forward, hypogastrium tense and  painful;  frequent disposi-
tion to urinate,  impossible to be satisfied;  a sense of weight in the
perineum, tenesmus in the lower part of rectum.  The dulness in
the hypogastrium extended to the umbilical region.   Nearly two
and a half quarts of urine were drawn off by the  catheter  (the
patient haying passed  none in forty hours);  the instrument was
easily introduced, its passage through the prostatic  region alone
having been attended  with pain, but the surgeon encountered no
obstacle.  A rectal examination detected a marked enlargement of
the prostate.   Buttermilk;  twenty leeches  to the perineum; a
soothing lavement;  diet; and the introduction of the catheter three
times  in twenty-four hours.
   9th. The leeches drew but little blood; treatment not changed ;
a hip  bath ordered.  Faeces more freely passed, but at the time of
their evacuation, the patient experiences pain  and decided vesical
tenesmus.  The catheter used three times.
   10th.  Improvement;  less frequent disposition to urinate;  and
the patient passes only some tablespoonfuls of urine; size  of the 
BLENNORRHAGIC PROSTATITIS.
143
prostate diminished.  Buttermilk; twenty leeches to the perineum;
catheter used twice in the twenty-four hours.
  11th. Much blood discharged by the last leeching;  great im-
provement ;  the prostate reduced nearly to its natural size.  Gen-
eral bathing; catheter still used twice.
  12th. Patient has passed without the  catheter, during the night,
at different times, nearly a pint of urine. Prolonged general bath-
ing ; catheter used once during the evening.
  13th. The "examination, per rectum, shows that the prostate is
not enlarged.   The catheter  is no longer required.  Indeed, he
passes his urine well, after considerable intervals, and  in a con-
tinuous stream.  The blennorrhagia has reassumed an acute char-
acter, the discharge is white, thick, but  unattended with pain.
  20th. Tisane of fir-tree buds, and powdered cubebs.   The  dis-
charge gradually disappeared, and the  patient left cured on the
31st July.
  In this case, the blennorrhagia  was  already of long standing.
It should be remarked, that the  exciting cause was the excessive
indulgence in alcoholic drinks, which was almost immediately fol-
lowed by prostatitis, since on the next  day the retention of urine
was  complete.
  Case 3d.  B. aet. 30; admitted 10th  June, 1844.   Constitution
not  very robust; temperament lymphatic;  usual health  good.
About  eight months  since this  man contracted a blennorrhagia.
No regular  treatment was followed,  having been interrupted by
excesses of every kind.  Each relapse was  followed by acute
symptoms, which diminished of themselves whenever the patient
conducted himself properly,  and observed repose.   On the 9th
June, this man drank immoderately of spirituous liquors, indulged
repeatedly in sexual intercourse; in the night found  it  impossible
to urinate, and on  Monday morning was  in the same condition.
He then  sought  advice.  His state was as follows: countenance
pale  and anxious; skin cold; pulse feeble; his body was bent
forward as  if by some irresistible force.  The bladder was dis-
tended by a large quantity of urine;  there were sharp pains in the
lower part of the belly, and a sense  of weight in the  perineum,
neither pain nor tenesmus in the lower part  of the rectum.  A
rectal examination detected  a very  decided enlargement of the
prostate, which is hot, but little painful, except on strong pressure.
The catheter was used as soon as  the  patient was admitted.  At
least three and a half pints of urine were withdrawn.  The instru-
ment was introduced without difficulty, yet  on passing the pros-
tate region it excited an abnormal sensation.   Milk-whey ; twenty
leeches to the perineum; diet.  In  two hours the vesical tenes-
mus  was as strong as in  the morning.   Catheter  used at two
o'clock, at six o'clock in the afternoon,  and at eleven o'clock in the
evening.*
  June 11th.  No change ; bladder still distended; patient unable
to expel the  least drop of urine; no  effect from treatment; no
blood drawn by the leeches.   General bathing; twenty leeches to
the perineum; diet.  Catheter used four times; during the even- 
144
VIDAL ON VENEREAL DISEASES.
ing leeches again applied, the first not having taken:  six only drew
blood ; thus, of sixty leeches, only six were of any use.
  12th. No change;  same  prescription.  Leech bites  now dis-
charge freely;  and an improvement is manifest; at 11 o'clock in
the evening the finger passed into the  rectum detects  a decided
diminution in the size of the prostate; catheter, however, had still
to be used four times.   During the night, by great efforts,  the
patient succeeded in passing about half a glass of urine at different
times.
  13th. This morning the bladder  is still distended,  but the hypo-
gastric pain is less.  The patient craves food.  No fever.  Milk-
whey ; prolonged general bathing; soothing lavement;  and some
broth were ordered.  Catheter used only three times in twenty-four
hours.
  14th. Patient begins to urinate himself.   Prostate still diminish-
ing in size, having nearly regained its natural dimensions; catheter
still required twice a day, morning and evening, until the 16th
June.  Mdk-whey, twenty leeches to the perineum;  soup twice.
Improvement  continues.  On the 17th, enlargement of prostate
gone;  and patient passes his urine naturally.
  When the patient was  admitted there was but a  slight weeping
of serum from the urethra;  now the discharge reassumes its acute
form.  The right epididymis is swollen.  Ordered rest in bed;
cataplasms over the swelling; light nourishment.  June 30th, tisane
of fir-tree buds, powdered cubebs five drachms.  Patient left cured
on the 10th July.
  In this case, too, the prostatitis  was caused by the  immoderate
indulgence in alcoholic drinks, and by other excesses.  The  en-
larged gland was  hot, but less painful than in the other examples.
The reappearance of the urethral discharge coincided with  the
subsidence of the  prostatitis.
  In all three of these  instances we  observe that the disease
occurred in persons upwards of thirty  years of age.   As in  the
case of orchitis, it is not the severer forms  of blennorrhagia which
produce it.  In the three cases cited the discharge was slight,  the
exciting cause, excessive indulgence in alcoholic drinks,  and a
complete retention of urine followed, which might have led to the
suspicion of obstruction in the urethra,  or even a paralysis of  the
bladder.  The catheter, nevertheless, was  readily introduced, and
the urine passed in jets through the instrument.  It should, how-
ever, be  remarked, that the passage of  the catheter through  the
prostatic portion of the canal, was attended with pain.   The cure
always coincided  with an increase of the discharge.   If we adopt
Benjamin Bell's divisions of blennorrhagia we  should say that it
had passed into the second or third degree.
  How shall we explain the retention of urine and the facility with
which the catheter was introduced in the  case of a prostatitis ?   We
know that the gland may be enlarged throughout its whole extent,
or that this enlargement may be confined to one of ite lobes.  In
the latter case  the middle lobe is most frequently affected.  When
the patient would void his urine this enlarged lobe presses against 
BLENNORRHAGIC PROSTATITIS.
145
the commencement of the urethra and obstructs the passage of the
urine.   The latter, in trying to pass, by its pressure  against this
lobe, produces a kind of valve, which 'the catheter, on the contrary,
easily thruste aside.  The same occurs when one of the lateral
lobes alone becomes enlarged;  the  tumor may cause the urethra
to deviate towards the  opposite side; it still acts as a valve; in
this case the  catheter passes readily into the bladder and rectifies
the prostatic  portion of the canal.   Once in the bladder we feel
that this  instrument is turned to  one side, as in the case first
reported.
   In an old man we might suspect a paralysis of the bladder; but
what happens  then ?  The catheter  reaches this organ, but  the
urine drivels away, while in the three cases just detailed it issued
in a strong and continuous stream.
   In  the  three cases observed by us, the patients complained of
anal and vesical tenesmus, and of sharp pains during defecation;
the examination per  rectum detected a tumor corresponding to the
situation of the prostate, in one (the first) case it presented a feeling
as if it had been squared.  Except in one case this examination was
very painful, the  tumor was hot, and had the  elastic feel of an
inflamed testicle.   The  pain was increased by sitting, walking, or
crossing the  legs.  In one case the patient's body was  strongly
bent forwards and could not be straightened.
   [Mr. John Adams, of the London Hospital, in his recently-pub-
lished work  on the Anatomy and Diseases of the Prostate Gland,
states that a swollen state of the hemorrhoidal veins, forming
external piles, frequently accompanies this distressing disease, and
that these are attended with painful itching sensations around the
anus and weight in  the perineum,  materially increased when  the
patient  is  in the  erect  position.   He also confirms our author's
remarks, that prostatitis may occur in the chronic as well as in the
acute stage of blennorrhagia, and that the patient is liable to it on
exposure to  cold and wet, or  any other exciting cause,  though a
gleet only remains.  He states that one of the most severe cases
he ever saw occurred in a patient twenty-seven years  of  age, who
had only a slight gleety discharge.  In this case, as well  as in
those reported by our author, " there was no difficulty in the intro-
duction of a moderate-sized silver catheter," though the  retention
of urine was complete.  After perusing Mr. Adams' report of this
case, our author's explanation of the facility in which the catheter
is introduced in prostatis, seems, to us, quite satisfactory.   The
remarks of Mr.  Adams  on this  disease are worthy of careful
study.—G. C. B.]
   The treatment in all was the same; the repeated application of
leeches  in large  numbers  to the perineum, which caused a sub-
sidence of the symptoms, as already mentioned.  With the removal
of the prostatitis we have seen  the return of the blennorrhagia.
   I have  already stated  that Benjamin  Bell had  imperfectly;
sketched the history of blennorrhagic prostatitis.  He established
the fact, that it may  set  in gradually or become at once developed,
that is, bv the extension of the urethritis, when the latter is already
                               10 
146
VEOAL ON VENEREAL DISEASES.
of long or very recent standing.  He asserts, what is possible, that
the prostatitis may occur suddenly when the commencement of the
urethra is inflamed, without requiring an affection of the interme-
diate points of the canal; in which case there is a kind of metastasis.
Benjamin Bell, with reason, extolled the use of lavements,  con-
sisting of:

                    I£. Tinct. Opii. v\xxx
                       Amidon.    § ii.
                       Aq.       q. s.

  Inject gently into the rectum.   An excellent method of relieving the
vesical pains and tenesmus.

  According to Bell, it is  better to promote than to suppress the
discharge, that  is, to diminish  the inflammation by degrees.  For
this purpose he placed great dependence on bloodletting.   He pre-
scribed astringent or emollient injections, which was wrong,  inas-
much as nothing, in acute prostatitis, can be more injurious  than
the introduction of liquids into the urethra.
              BLENNORRHAGIC  CYSTITIS.

   There are two different methods of treating blennorrhagia, which
in my opinion are equally dangerous; viz.  that which attacks it
violently at the onset, and that which consists in an  almost com-
plete inaction.  Both of these plans may lead to a  chronic dis-
charge, and the extension or displacement of  the disease.   Thus,
it is remarkable, that all the probable cases  of nephritis are more
or less connected with blennorrhagia; it is remarkable, I say, that
all of these  patients had taken Chopart's potion, or some  other
resinous anti-blennorrhagic.   Inflammation of the neck of  the
bladder, or of the bladder itself, is not rare,  after the  use of these
means.   But by inaction the same result may follow.  Thus, the
following case was  furnished by a subject  affected with a very
mild form of blennorrhagia, which  became  transferred from  the
urethra to the bladder, and  this, too,  while  the patient observed
complete repose, submitted to regimen,  and guarded against  ex-
cesses of every kind, as well as the sudden  changes  of tempera-
ture.  I shall confine myself to a description of this case, as  the
cystitis, which most commonly arises from .the gradual extension
.of the urethral inflammation, is analagous to all the cases of cys-
titis which have been described in  standard works.   This case,
moreover, is especially interesting in a practical point of view ; it
is a remarkable  example of success obtained by cauterizing the
perineum.
   Case 4th.—G. aet. 30, quarryman by  occupation  from the  age
of fifteen ; born at Montigny, but resided in Paris since six  years
old;  of  high stature, strong limbs,  ruddy  complexion, hair and
beard black and  copious, of vigorous aspect.   G. always enjoyed
good health;  has been accustomed to drink much wine, but little 
BLENNORRHAGIC CYSTITC&
147
brandy;  was never addicted to masturbation ;  never  had sexual
intercourse before the age of twenty, and until 1840 had always
indulged in it with great moderation; during the past two years,
however, he  has carried  it to excess.   His  labor was difficult,
though he never descended into the  mines.   About the 20th of
May, 1842, the patient, who had never suffered from the venereal
disease, had connection with a prostitute, the result of which was
a discharge.  At the  commencement the pain in urinating was
very severe; the matter discharged was of a whitish color, not
thick, but  abundant in quantity.  He suffered from frequent and
painful erections.  G. did not submit to any treatment; he stated
that he had followed regimen alone, but continued to work until
the 26th of May.  Then  the pain became more  severe, and the
glans and prepuce  swollen.  The patient confined himself to his
bed until the 2d of June.   On the 3d he came from Montrogue to
Paris, and obtained a bed in my service.
   At this time the prepuce was  swollen, red cedematous, and
crossed the glans, which was itself enlarged; the whole covering
of the penis was infiltrated with  serum.  A  whitish matter was
discharged through the opening of the prepuce, and the pain was
very severe.  Ordered local emollient baths, to be prolonged and
repeated three times a day; emollient injections between the pre-
puce and glans; rest in bed; an allowance of food,  and general
bathing.
   Under  the influence  of these means the external symptoms
 rapidly improved.   On  the  15th  June there remained but slight
 oedema at the inferior part of the prepuce,  which yielded in the
 course  of a few days to compression made with narrow straps  of
 diachylon plaster.
   June  25th.—There exists only an urethral discharge, thin, and
 small in quantity ; pain however whilst urinating, and after urin-
 ating is very severe.  Patient refers the maximum of pain towards
 the meatus urinarius.  He observes the same regimen.
    30th.—Patient has been allowed three portions of food, but the
 pains have increased, and  a little blood  is voided  with the urine,
 which in other respects is  quite limpid; he urinates six or seven
 times in the twenty-four hours.  No change in the discharge ; two
 portions ; confinement in bed; three purgations to remove an ob-
 stinate  constipation, to which, moreover, the patient is  accus-
 tomed.
    July 6th.—Discharge the same, and at each attempt to urinate
 little clote of blood are passed;  the urine is still mixed with some
 shreds  of blood; the pain is the same  whilst voiding urine and
 for some time after the act, when the patient becomes tranquil.
    14th.—Urine is no longer mixed with blood ; the discharge is
 much less, but the patient is compelled to urinate more frequently,
 being  warned  by a severe pain the perineum.   This pain is  not
 increased by the passage of the urine, but it lasts for a quarter of
 an hour after the water has passed.  One  portion;  two  of milk;
 whey for drink, and patient to remain quiet.
    20th.—For several days the  patient has urinated almost every 
148             VEOAL ON VENEREAL DISEASES.
hour.  When the desire is felt he experiences a sharp, overwhelm-
ing pain behind the penis;  if the desire be resisted, the pain ex-
tends to both groins, and  compels him to urinate.  During the act
it is felt at the root of the penis.   Another pain exists  in the hy-
pogastric region, at a point which corresponds  to the situation of
the bladder.  The discharge is very slight; the quantity of urine
is not increased.  The urine, which for eight days has been per-
fectly limpid, now deposits a thick layer of greenish mucus, resem-
bling jelly, thready, and  adhering to the bottom of  the  vessel.
The pains are  very severe, and the  disposition  to urinate  most
frequent towards evening.   At the same time there is some febrile
excitement.  Ordered to continue regimen; twenty-five leeches to
the perineum, and the bath.
  28th.—The leeches have  been applied  the second  time.   The
pains are  greatly diminished, and the patient has  not urinated
more than fifteen times since yesterday morning.  Last evening
did not feel the lassitude and febrile excitement which had existed
for  some  days, but the deposits in the urine are still the  same.
Patient still suffers in the  hypogastric region.   Ordered inspissated
turpentine one drachm; continue the baths.
  Aug. 3d.'—The discharge is  very slight, almost without color;
deposit in urine less abundant, less viscous, and not of so green a
color.  The pains continue severe; patient urinates fifteen times
in the twenty-four hours; urine slightly increased  in quantity.
Dose of turpentine increased to two drachms;  perineum cauterized
with Vienna paste; milk-whey ; two portions.
  12th.—The eschar has separated, and a  pea  is inserted.   Tur-
pentine to be continued in two-drachm doses;  urine becomes more
and more transparent,  only a slight  deposit of a whitish color re-
maining in the  bottom of the vessel; this deposit is but slightly
adhesive, and the color of the urine is changed  to  citron.  The
pain which warns the patient of  the  necessity for urinating is still
very severe behind the penis; it continues during the  passage of
the  urine, but ceases immediately after it  is evacuated.  Patient
urinates twelve times in the twenty-four hours; lie asks for food;
double allowance; three times the quantity of milk; continue the
turpentine.
  25th.—The discharge has ceased, but from time to time there is
a very slight  weeping.   The urine is voided without pain, and
has been limpid for some days.  The dispositions to  urinate are
less frequent, and manifest themselves by  less urgent desires; be-
sides,  it is now at the root of the scrotum, and  not  behind the
pubes nor in the groins.   Continue the cautery; omit the turpen-
tine ; treble the allowance.
  Sept. 3d.—Patient has  eaten four times, and sits up every day.
He urinates not  more than five or  six times in twenty-four hours,
and this without difficulty or pain.  He can resist for hours the
disposition to void his urine, without inconvenience.  Urine is
clear; and there is no discharge  from the urethra.   The improve-
ment is constantly progressive.
  10th. G. is perfectly cured, and obtains  his discharge. 
BLENNORRHAGIC NEPHRITIS.
149
  I recommend to practitioners the application of the  cautery to
the perineum, a plan of treatment which I often adopt in obstinate
cases of cystitis.  Sometimes I substitute for it the seton, which I
pass through a  fold of the skin in the same region.   For example,
in Ward No. 11 of my service, was a  patient troubled  with an
affection of the  bladder, which had resisted every possible indirect
means, and two applications of the cautery,  but which yielded to a
seton inserted in the perineum.
              BLENNORRHAGIC  NEPHRITIS.

   The attention of the profession begins to be seriously directed
to the study of inflammations of the kidneys, in  their connection
with ehronic affections of the urethra, the prostate, and bladder.
These cases of nephritis moreover are very frequent, for most of
the diseases of the genito-urinary apparatus whieh precede that of
the kidneys, being attended with, more or less complete retention
of urine, it is reasonable to suppose that the too prolonged sojourn
of the urine should become a new cause of aggravating and of
extending  the inflammation  already existing, which passes from
the bladder to the ureters, and is thence oftea transmitted to the
kidneys.   M. Rayer reports a case,* showing the existence of in-
flammation in its most extensive  form.  The patient was first
attacked with blennorrhagia,  then followed stricture with infiltra-
tion of urine, and abscesses; to these  succeeded  pains in the hy-
pogastric regions,  about the kidneys, frequent  dispositions to uri-
nate, purulent urine, numbness in the lower extremities.  Finally,
the death  of the  patient afforded an opportunity of establishing
the anatomical lesions of every part of the genito-urinary appara-
tus.   But when these lesions  occurred slowly, as we find recorded
in the books, as M. Rayer remarks, it may be suspected that some
other inflammation is added to the effects of the blennorrhagic in-
flammation, which, besides, for some time, has singularly ehano-ed
its characters.   For example, in  the ease reported by M. Rayer,
this practitioner observes, that the symptoms of nephritis appeared
seven years  after the  blennorrhagia, and the nephritis was calcu-
lous.   M. Rayer has recorded no ease  which scientifically estab-
lishes what  I  call blennorrhagic nephritis; in  other words, that
inflammation which in its nature may be compared to orchitis.
   Benjamin Bell, in his extensive treatise on Gonorrhoea Virulenta,
is very brief on the connections of this affection with  nephritis.
He observes in one passage :f " The kidneys become  sometimes
affected  through nervous  sympathy, or  in consequence of the
extension  of inflammation along the ureters."  We have, then,
two kinds of blennorrhagic nephritis, which may be  compared to
blennorrhagic orchitis.   This opinion of Benjamin Bell is worthy
of note, as  it has some bearing on the case reported in the LXIId.
letter of Morgagni.  It  is that  of a chevalier, set. 46, who had

                  * Traite des Maladies des Reins, t iii.
                  f VoL L, p. 41. 
150
VTDAL ON VENEREAL DISEASES.
three attacks of blennorrhagia, followed by accidents, the  seat of
which was always referred to the  bladder, which organ was sup-
posed to  be seriously affected; now  behold what  the autopsy
revealed:  " The kidneys were  smaller than  natural; their form
was extraordinary; and presented at  various points externally
several protuberances.   The dissection  of these brought  into view
a sanious humor,  which had an open passage to the calices.  But
in the bladder, which, by several scientific men, was unanimously
supposed to be the seat of the principal disease, nothing of conse-
quence was found, except a slight erosion about the orifices of the
ureters.
  In this  case, the blennorrhagic inflammation had  leaped over
the bladder and  seized upon  the  kidney, which was found in a
state of  suppuration.  In reading this  case, we cannot but regret
the absence of details, in reference to the condition of  the urethra
and the  prostate.
  The connections of blennorrhagia with nephritis are  very remote
in the reports which I have been able to find in  different works;
a long time has always intervened between the two inflammations.
There have always been several attacks of blennorrhagia, and the
appearance of the nephritis is of a date very distant from that  of
the last  blennorrhagia, which is considered  as its  cause.  I insert
in this place the particulars of a case which occurred in my service,
and which establishes, in a manner  much more precise, the inti-
macy of the relations existing between blennorrhagia and  nephritis.
  Case.—P. Theophile, aet. 23, painter, born  at St. Brieux; pale
oomplexion, black hair,  middling height, statue lean, limbs small,
muscles imperfectly developed, health  generally good.  P., how-
ever,  was easily fatigued.  Having lived  in Paris for the last five
years, during  this time was guilty of  excesses with females, not
so much for the last two as the three preceding years.  In other
respects, his conduct had  been good,  At the age of  17, he con-
tracted a blennorrhagia  from his  first  connection with  a female.
From the commencement he suffered severe pain in urinating, the
discharge was of a greenish color, and  abundant in quantity, and
there was redness about the mouth of the urethra.  He adopted a
severe regimen, and made use of tisanes for a month; then  he
took  Chopart's potion, and the  discharge entirely ceased.  One
month afterwards, P. contracted a new discharge,  which was less
painful  than the  preceding, and which was cured nearly in the
same manner.   At this period he came  to Paris, where he resided
for two  years without being affected by the venereal disease.
  About two years since he had a third  attack of blennorrhagia.
The latter was not of an acute form ;  indeed, there was but trifling
pain, no redness, the discharge of a  white  color, rather thin, and
small in quantity.   The patient submitted at first  to  regimen,
without adopting any active treatment.   After some weeks, there
was nothing but a weeping from the urethra, which appeared prin-
cipally in the morning, and which increased at intervals,, attended
with an itching sensation in the urethra.   P.  resumed his  habits,
still had connection with females, &c., ke.  About the 10th  of Sep- 
BLENNORRHAGIC PHRENITIS.
151
tember last, matters  being  in this condition, P. experienced pain
in urinating, and still greater pain during an erection.  The dis-
charge became thicker and more abundant.  Was this  a new
blennorrhagia that the patient had contracted, or was it an aggra-
vation of  the  old attack?  At any rate,  it lasted for  twenty
days, with  the same characters as at first, when the patient, for a
whole night, indulged excessively in wine and brandy.  The next
day the discharge became thicker, of a greenish color, and slightly
tinged with blood; the emission of urine was accompanied with a
smarting sensation towards the glans.  Soon a more acute pain
was felt behind the pubis, which was exasperated by the accumu-
lation of urine, and the efforts to expel  it.   The disposition to
urinate was not more frequent than usual, but the desire was more
urgent; sleep was good, and uninterrupted during the night.  He
remained in this condition for about two weeks.  P. continued the
use of the  baths;  he pretended to observe a proper regimen, yet
he ate large quantities.  lie took long walks in the evening, made
use of copaiva,  and purged himself repeatedly.  The  pain  behind
the root of the penis rapidly diminished, the  discharge completely
ceased, and he had  only a slight and shifting pain in the pelvis,
which was not  increased in urinating.
   During the night of the 15th Oct. he was disturbed by chills,
and was soon seized with a sharp, fixed, deep-seated and lancinat-
ing pain, on a level with the left kidney.  He was restless during
the whole  night, but was somewhat better in the morning.  The
pain became greatly aggravated every evening; it  was always re-
ferred to the situation of the left kidney, and was perfectly limited
to this region.   His  nights continued to become worse and worse;
the pain which increased daily, became so severe as to extort cries
from the patient.  His only relief was obtained  by lying  on the
side affected, and by taking large doses of  the syrup of  opium.
He remained in bed, and took only a little broth,  for, to  use his
own language,  " I had fever."  A physician in town recommended
the application of a cataplasm to the painful part,  and expressed
the opinion that he would soon be relieved.
   P.  came under my care, Oct.  27th, 1842. During the whole day
he was affected with tremors, which  he attributed to the  change
from his hot chamber to a colder temperature.  Pain very severe
in the region of the  left kidney, fixed and confined to this space.
Urine copious,  voided naturally and without pain,  and at healthy
intervals it is of a high color, slightly bloody, and deposits a thick,
whitish purulent layer, which does not adhere to the sides of the
vessel.  No pain  in the hypogastric  region; a feeling of weight
and uneasiness along the course of the spermatic cord and  the left
testicle.  Ordered Jour cups to be applied to the painful region;
milk-whey for drink, and a milk nourishment.
   Oct.  31st. The cups drew  considerable  blood;  the fever is
somewhat abated,  the tremors and agitation has disappeared, pain
is less, but the urine remains purulent.   Deposit large, but hypo-
gavstric region  free from pain.   Appetite not impaired.   Apply
twent}- leeches to the anus;  continue the whey; milk nourishment. 
152
VTDAL ON VENEREAL DISEASES.
   Nov. 1st. General condition improved; the fever and nervous
irritation have ceased.   Urine always voided at natural intervals;
renal pain still continues.   Apply three cups to the painful part.
   3d. Not only the lancinating but the fixed pain, which existed
before the application of the last cups, has disappeared.   Urine is
still a little cloudy, but the deposit has nearly ceased.
   8th. Continues to improve;  no pain in kidney ;  no fever.   The
discharge has not reappeared,  and  there is no pain in the region
of the bladder; general condition perfect.   Allow a little chicken.
   11th.  Pain has not returned ;  pulse and appetite are good ; no
agitation ; urine limpid; patient convalescent.
   I  repeat that this case is remarkable, as showing the  intimate
connexion between blennorrhagia and nephritis.   The reader will
not fail to note the following  circumstances: 1st.  The extraordi-
nary quantity of purulent matter found at the bottom of the ves-
sel.  2.  The absence of pain in the hypogastric region.   3d.  The
power which the patient had of retaining his urine, the same as in
perfect health.   The two  last-named circumstances go  to prove
that the  bladder remained unaffected during the existence of the
nephritis, for when the cavity of this organ is inflamed  the urine
cannot be long  retained, and  great expulsive efforts are made to
discharge it; thence the continual tenesmus; again, pain is felt in
the region of the bladder.  In  this patient none of these symptoms
were experienced.   Was it  owing to a sudden  metastasis of the
blennorrhagia?  Had  it, as it were, leaped over the bladder, as
we see it pass from one testicle to the other, without involving
the intermediate points?   It  is true that  after  the night of de-
bauchery already mentioned, there had been a severe exasperation
of the urethritis and  the  cystitis.   But during  the development
of the nephritis, the  bladder remained unaffected, and yet the
urine was  decidedly purulent.  The patient suffered no vesical
tenesmus; the disposition to urinate was no more frequent than in
a state of health.   To many of my readers the question  may sug-
gest  itself whether the more serious inflammation may not  have
obscured the lesser one, and the cystitis been thus masked by the
nephritis, thus affording some grounds for the observation made
by Valsalva after the autopsy of Chevalier detailed in the letter of
Morgagni, to which we have already alluded.   " Valsalva thought
that  this dissection was calculated to make us cautious when called
to treat affections which are referred to the urinary organs, be-
cause very frequently, even when we exercise the greatest  care,
we may  commit  an error in  diagnosis  as  was the  fact in  this
case."*  Thus, in the  instance to which Valsalva refers,  they ex-
pected to find traces of a cystitis, but they were wanting.   In my
patient I might indeed have committed the opposite error.   That
which should console  me is the success which I attribute to the
two applications  of the cups in the region of the  kidney, the part
supposed to be affected, and to  the use of leeches in large numbers
about the anus.  These local  depletions were quite copious, and
* Letter, xlii. § 3. 
BLENNORRHAGIC OPHTHALMIA
153
accorded with my wishes, notwithstanding the apparent debility
of the subject, his pallid countenance and slender figure.  Practi-
tioners know that in severe inflammations of the urinary organs,
the abstraction of blood is indicated, and the more deeply the or-
gan affected is situated, the more frequent and copious should this
depletion be made.  Whilst writing this, a patient is admitted un-
der my care, who had been treated by my predecessor, M. Cul-
lerier.   This patient was  affected  with a blennorrhagia, and M.
Cullerier gave him three doses of powdered cubebs which he took
at once.  The discharge was suddenly suppressed, and he suffered
acute pain in the region of the kidneys. The numerous cicatrices
of incisions made by  the  scarifier,  satisfies me that the  above
symptoms were  followed  by important morbid phenomena, and
for which M. Cullerier had the cups applied.*
            BLENNORRHAGIC OPHTHALMIA.

  This form of ophthalmia, one  of the  most serious accidents of
blennorrhagia, which is so frequent, and which gives rise to theoret-
ical and practical questions of the highest importance, is neverthe-
less passed over in silence by Hunter!
   Causes.—It necessarily depends on a blennorrhagia.  Its devel-
opment has been  differently explained:  metastasis, inoculation,
general infection and sympathy  have all in turn been accused.
Saint-Yves was among the first to defend the doctrine of a metas-
tasis, a doctrine which emanated from the absolute reign of humor-
ism.   Under  that of exclusive  solidism this doctrine was com-
pletely abandoned.  This was an error.   Sanson, who denied the
doctrine of a metastasis,  is said to have frequently observed this
affection, and  the  urethral discharge was never  suppressed when
the eye became involved. Further still, this ophthalmia has been
observed in subjects who never had a blennorrhagia, but who had
been brought  in contact with persons  so affected; they  washed
their eyes with a sponge  wet with the blennorrhagic discharge, or
they had used a collyrium of the urine of persons affected with the
disease.  These facts favor the idea of a contagion.  But facts do
not warrant us in asserting that this ophthalmia is always thus pro-
duced.  For my own part, without denying the doctrine of conta-
gion, I am a decided advocate of that of metastasis.  The  follow-
ing are my reasons:—1st. For almost all the cases observed in my
wards at the JPpitaldu Midi, this ophthalmia has co-existed with a
blennorrhagic  arthritis:   now, this  arthritis  was certainly not
caused by contagion, but, without doubt, by a transfer of the irri-
tation or humor.   Why should this not be the case in blennorrha-
gic ophthalmia ?  2d. The number of these  ophthalmias bears a
very small proportion relatively to the  number of eases of blen-
norrhagia, and of  individuals who are careless  of their persons.
3d. Besides, when  the  fingers are brought into contact with the
* Extrait des Annates de la Chirurgie, t. vi. 
154
VTDAL ON VENEREAL DISEASES.
eyes, the latter are covered by the eyelids, and the conjunctiva is
not directly touched; for,  to  do this, it  would  be necessary  to
depress the lower eye-lid, as the lids close instinctively, and we
know that it is on the internal surface of the lids that this form of
ophthalmia  commences—in other words,  at  a point least liable
to be  contaminated  by  contact with the fingers.   4th.  This
ophthalmia  occurs  during the decline  of a  blennorrhagia, at a
period of the disease when the contagious  properties of the muco-
pus is diminished.  5th. Why is it that the discharge of blennor-
rhagia inoculates the eyes, whilst the pus from a chancre never
inoculates ?   Indeed, patients may be daily seen at the Ilnpital du
Midi with chancres in full suppuration, and buboes, the discharges
of which soil all  their garments, who are very negligent in  their
persons, and constantly applying their hands to their face, and yet
they have never  contracted purulent ophthalmia, even when the
pus from the chancre on the penis would inoculate the smallest
leech-bite, the scrotum,  the perineum, and the unabraded  skin.
6th.  The patients whom I  have seen affected with  blennorrhagic
ophthalmia were precisely those who best  understood the import-
ance of care and cleanliness under the circumstances in which they
were placed.  I will even add, that some of these patients were
suffering from a  second attack of blennorrhagia, which, like the
first, was followed by a  purulent  ophthalmia.  They were, at the
time, duly warned of the danger of applying their fingers to their
eyes, and yet they became inoculated!
  The doctrine which attributes an important part in the produc-
tion of these ophthalmias to sympathy, has found  many advocates
among the solidists.  Sanson, without being absolute, adopted this
opinion,  and presented, in their strongest light, the arguments and
facte in its support.  He maintained, that the sympathy between
the mucous  membrane of the urethra and that of the eye, is proved
by the feeling of smarting in  the latter organ, and the impaired
vision  which  follows every protracted irritation of the  genital
organs.  "It is  known, strictly speaking," says  Sanson, "that a
current of cold air, under these circumstances, coming in  contact
with the conjunctiva, may determine an irritation, which, in a
sound  individual, would become purely catarrhal,  and which, in a
person affected with blennorrhagia, may take a more serious  char-
acter.  However," continues this surgeon, with much reason,  "this
explanation does  not fully satisfy the mind.  All that is positively
known on this subject, is, that in the individuals in  question, con-
junctivitis may assume certain forms which it does not in others."
  Sanson's opinion may be reconciled with that  to which  I am
myself inclined.  I believe that, in the majority of cases, the pur-
ulent ophthalmia, which, after an attack of  blennorrhagia, follows a
certain course, is an accident which is  analagous  to the arthritis
which  occurs under the  same circumstances.   The  blennorrhagic
virus is transported by the blood or otherwise, and it is not to the
topical action of the muco-pus of the urethra that  this unfortunate
occurrence,  called blennorrhagic  ophthalmia, is to  be attributed.
However, that atmospheric influences should be taken into consid- 
BLENNORRHAGIC OPHTHALMIA.
155
eration, that the patient would have escaped an attack of ophthal-
mia if he had not been exposed to a current of cold air, is possi-
ble, as  it is  probable that of those affected with  blennorrhagic
arthritis, some would not have suffered had  they guarded against
atmospheric changes. This influence of a general cause allies the
blennorrhagic to the Egyptian ophthalmia, to that of infants, in
the production of which atmospheric influences exert so important
a part.  But  it should likewise  be known, that  blennorrhagic
ophthalmia sometimes occurs under hygienic circumstances most
favorable to the healthy exercise of the functions of the eye, where
we are unable to trace the  slightest cause, as is sometimes the
case with blennorrhagic orchitis and arthritis.
  Symptoms.—The redness is here more decided than in any other
variety of ophthalmia; it  is  a scarlet of the deepest dye, from
which it changes to a brownish red.  The tumefaction also attains
ite maximum.  Chemosis exists in its worst form ; the excessively
tergid mucous lining of the eye-lids constitutes a hernia, and there
is a kind of acute ectropion,  which separates the celiary margins
of the lids.  According to M. Desmarres, the hernia of the lining
membrane is sometimes strangulated by the orbicularis palpebra-
rum ;  this skilful occulist  then compares it to the rectum stran-
gulated by the sphincter ani.   The swelling involves even the skin
of the eye-lids ; which  are so tumefied as to give to the orbit the
aspect  which is pathognomonic  to those practitioners who are
familiar with this form of ophthalmia.  The superior falls over the
inferior lid,  and the two  are, as it were, imbricated.   The dis-
charge, always copious  in the specific forms of ophthalmia, is still
more  abundant in this.  It  is said that it comes principally from
the upper lid;  it is, indeed, especially along its  free border, that
we see the secretion escape.  This fact authorizes us in believing
that  the Meibomian glands  play an important part in its produc-
tion.   This discharge is at  first bloody  and thin, it afterwards
becomes thick and  greenish, and perfectly resembles that of blen-
norrhagia ; it stains the linen in the same manner; at last it becomes
white and of a creamy  consistence; and its contact excoriates the
skin  of the cheeks.  The pain is very severe, extensive,  and burn-
ing, it is felt on the forehead when  it is dull and heavy.   It is
throbbing, and extends to  the temporal and occipital regions.
   With such a chemosis, and  so severe an inflammation of the eye,
we should naturally expect that the retina must suffer;  and there
would be a well-marked photophobia; it  is, indeed, very.decided,
but as a general rule it soon ceases; it is always a bad omen when
it disappears very suddenly,  for the effusions have taken place in
the interior of the eye,  which have impaired the sensibility of the
retina.
   We find that in these eases, all the physical and physiological,
the objective and subjective, symptoms of  ophthalmia  are mani-
fested in their highest  degree. Such is sometimes the case with
the general reaction; thus, the patient is greatly agitated; there is
sleeplessness, delirium and stupor; the pulse is full, the tongue
furred; everything in fine is  indicative of cerebral disturbance and 
156
VIDAL ON VENEREAL DISEASES.
of real danger.   However, I have observed several cases of this
form of ophthalmia, where  the eyes have been lost, and yet there
was no general disturbance of the system.
  Progress.—It may be of frightful rapidity.  Here a timid practi-
tioner, slow in deliberation,  and slow in execution, will often find
himself  taken unawares,  for six hours may suffice to prepare the
way for the destruction of the eye, and to seriously compromise
the whole system.  Sometimes the disease is seen to progress more
slowly, but it is not less serious;  thus, instead of destroying the
organ in a few hours it may occupy ten or twelve days.
  In some instances its progress is quite insidious;  for example,
it may commence in a very mild manner, and preserve this charac-
ter for  some days;  then, suddenly  it reaches  its maximum  of
intensity, and the eye will inevitably  be  lost.  It  may happen
also, that the ophthalmia appears in  this moderate form, and the
eye, though abandoned to itself, may escape uninjured; yet it may
show itself suddenly in the other eye and this be lost forever.
  Terminations.—A complete, entire resolution is rare.   The result
is often  a destruction of the eye.  It  is true, that  in a great num-
ber of cases, but one eye  is destroyed.  It is evacuated in several
different manners; sometimes it is by a  sloughing of the cornea,
which is said to arise from the strangulation, from the inflamma-
tion which  has interrupted the circulation  between the conjunctiva
and the transparent  cornea;  or,  the eye  may  be discharged by
ulcerations, which commence on the surface of the cornea, become
excavated,  and extended thus, giving vent to the humors of the
eye.   One  of the most serious affections following purulent oph-
thalmia  is  staphyloma.   An hypopion, amaurosis, cataract, ectro-
 ion, and prolapse of the iris, may all follow this terrible ophthalmia.
 have seen vegetations also after this disease; they were attached
to the conjunctiva precisely in the same manner as those which are
observed on the prepuce.
  Prognosis.—This is grave, when the ophthalmia has not  been
vigorously  attacked in the commencement; even  then we should
always be guarded in the opinion we express respecting the result
of the disease.
  Treatment.—Here general and local treatment, direct and indirect
antiphlogistics, cauterization,  all, so  to speak, should  be at  once
employed, the same day, if at its onset the disease puts on a serious
aspect.  Thus, I have commenced by phlebotomy in the foot, or,
if the saphena does not bleed  well, I  take blood from the arm; I
apply leeches continually to the temples, and then I administer an
emeto-cathartic.  Beware how time is lost in using liquid  or semi-
liquid collyriums,  or insufflations of calomel and sugar; on  all
these  means, invariably unsuccessful, no reliance is longer placed.
The cures  attributed to their employment  are very questionable.
Dupuytren, who so much lauded and used these insufflations, never
obtained the least success.   Those  who  visited  the  Hotel  Dieu
during the  lifetime of this celebrated surgeon, know what import-
ance to attach to the practice  under consideration.   Further, we
need but peruse the  cases  detailed by Sanson in his article  on 
BLENNORRHAGIC OPHTHALMIA
157
Ophthalmia.  This  surgeon, having unsuccessfully tried all the
methods of treatment, resolved on resorting to a violent, but accord-
ing to him, efficacious plan.   He destroyed the part, the morbid
secretion of which produces such disastrous effects upon the cornea.
" I excised all the ocular conjunctiva and cauterized with nitrate
of silver all the palpebral conjunctiva which was too adherent to
be removed.   I am so convinced  of the efficacy of this eradication
over every other method of treatment, that should I meet with a
oase in which the swelling of the lids was such as to render their
separation impossible, I would not hesitate to divide the external
commissure to facilitate their separation and the application of this
method."
   This excision being sometimes impracticable without the debride-
ment of which Sanson speaks,  and this operation be attended  with
real inconveniences, cauterization, with the nitrate of silver, has
been  employed.  A blunt-ended cylinder of this  salt has been
carried around the circumference of the cornea, with the precaution
of avoiding the centre  of this membrane, lest  it be disorganized.
The caustic will also act upon the lining membrane of the lids, and
especially the superior, which is the greatest source of the discharge.
The whole  interior of  the lids then assumes a dark gray tint, a
large  quantity of pure blood is immediately lost, and a dirty red-
dish-brown water is discharged in a deluge.   A smarting, burning
sensation is  immediately felt;  the suffering is so severe that the
patient would fall in frightful  spasms, if immediate recourse  were
not had to the constant affusion of cold water between the lids and
over the whole fronto-palpebral region.
   After the excision and cauterization, M. Rognett gives tartar-
emetic  in  large doses  (twelve grs.  to six oz. of water); and, ac-
cording to his reports, an  amendment always takes  place.  The
next day he substitutes for the application of simple water that of
d'eau blanche strongly charged (one oz. acet. plumb, to four oz. of
water).   It is seldom that it is necessary  to repeat  the  cauteriza-
tion.   Of course every particular observed  in a decided case  of
conjunctivitis must also be regarded in that  under consideration.
If the patient cannot bear the  tartar  emetic in large doses, M.  Rog-
netta employs  some other contra-stimulant, such as the  extract of
belladonna, from six to eight grs. in the  day; a pill containing one
gr. every two hours, with a small quantity (three grs.) of calomel;
the acetate of lead, from twenty to thirty grs. in the day; a pill of
two grs. every two hours;  the extract of hyoscyamus in quantities
from  fifteen to twenty grs. in the day, &c. All these remedies in
large doses act like tartar emetic ;  in other words, they diminish ex-
citement ;  and, what is extraordinary, these enormous doses, which
in a state of health would poison the person taking them in the
case  of a  grave inflammatory affection, produce only the  same
effects as would the copious abstraction of blood.  Those who are
acquainted with  the  valuable experiments of Rasori  and  Gia-
comini  on  the true effects of these remedies,  will not be surprised
at the formulas above mentioned.
   Tyrrel, believing that the sloughing of the cornea in cases of 
158             VIDAL ON VENEREAL DISEASES.
 urulent opthalmia, arises from the strangulation of this membrane,
 as proposed a kind of debridement of the conjunctiva which forms
the chemosis.  Adopting the principal of multiplied debridements,
he incises the conjunctiva around the cornea, from which point he
carries his incisions outward so  as to make four radiating wounds,
directly in  the spaces intermediate  to the recti muscles.  Accord-
ing to'Tyrrel,  we thus avoid the principle nutrient vessels  of the
cornea.  This multiplied incision is to be  preferred to general ex-
cision, by which we remove all  of these vessels and endanger the
vitality of the cornea.  Tyrrel pretends to have cured all his pa-
tients by this operation.  I believe  that in the majority of cases,
it would be exceedingly difficult to  make these incisions as he
directs,  and especially to make  them precisely in the spaces in-
dicated.
  For my  own part, I at  first resort  to one or more general ab-
stractions of blood, with local depletion, according  to the consti-
tution and age  of the patient; immediately afterwards I admin-
ister  an emetic, and then  cauterize the  ocular conjunctiva, the
whole being done the same day.   On  the following, prescribe a
cathartic, which is to be repeated every  second day.
              BLENNORRHAGIC  ARTHRITIS.

  During the progress of blennorrhagia, it is quite common to
observe this accident, and yet, up to the time of Swediaur, authors
passed it in silence.  Swediaur himself does not devote more than
a page and a half to its consideration.  It is probable that this
affection was at that time regarded as ordinary rheumatism, which
was merely coincident with the blennorrhagia.   But as it has been
proved that certain patients never suffer  except when  affected
■with blennorrhagia, the connection between the two diseases has
been established, and a blenn/Drrhagic arthritis or rheumatism has
been admitted and described.
  Causes.—A blennorrhagic urethritis is regarded as  the specific
cause of the disease in question.  Doctors Jarjavay and Foucart
admit that balano-posthitis may,  like urethritis, give rise to it, but
this must be an exception to the  general rule.
  Men are more frequently affected than women.   Almost all
the subjects which I have treated have been emaciated, pale and
debilitated, and about thirty years of age; several have had re-
lapses on a second attack of blennorrhagia.
  Cold and violent exercise  may exert an influence in the pro-
duction of this disease;  and they may then be regarded  as occa-
sional causes.
  Great importance has been attached  to the  suppression of the
discharge, and then ite development has been attributed to a me-
tastasis.  The direct and indirect anti-blennorrhagics have then
been accused.   But the discharge sometimes ceases without any
treatment, and yet this arthritis has been seen  to occur during the
mildest treatment, the most  perfect rest, and while the patient is 
BLENNORRHAGIC ARTHRITIS.
159
observing a strict hygeine.   I will add that the discharge is not
always suppressed when the arthritis appears;  it is often slight,
for the reason that the  articular affection is generally observed
during the decline of a blennorrhagia, when it has already existed
several weeks or months.  It never occurs during the first week
of the latter disease.   On this account, however, we should not
deny the influence of the arthritis on the quantity of the discharge,
nor a metastasis, for there can be no doubt, that after the arthritis
is cured, the discharge often becomes more abundant than during
the existence of the articular disease.   As regards the metastasis,
without wishing to enter here into the  discussions  to which this
doctrine has given rise, I will remark, that by this term I do not
understand a displacement, a conveyance of the humor of a blen-
norrhagia itself, out the  displacement of the cause  of this humor.
Thus, in the arthritis in question, it is not the muco-pus  from the
urethra which is carried to the articulations, but the cause which
produces it, the blennorrhagic cause which invades  this  same ar-
ticulation.
   Dr. Foucart, who has  written  an excellent work on blennor-
rhagic arthritis, has  given the following summary of propositions
on the connection of the arthritis with the discharge :
   " 1. When  the discharge has been  suppressed before the ap-
pearance of the arthritis, the latter then depends either  on a  me-
tastasis, or the cause which gave rise to the suppression.
   2. When the discharge still continues, and the development of
the  rheumatism is determined by an occasional appreciable cause;
such as cold, contusions, excessive fatigue, the blennorrhagic dis-
charge then acts only as a predisposing cause.
   3. When, in fine, the discharge exists, and there  is no other ap-
preciable determining cause  of  the arthritis than  the blennor-
rhagia.
   4. Sometimes, in the  two cases last mentioned, the suppression
of the discharge is consecutive to the development of the rheuma-
tism, the latter being very severe.  It does not then depend upon
a metastasis, but simply a revulsion produced  by a more intense
inflammation  in the part secondarily,  than in that which is prima-
rily affected.*
   Seat.—Swediaur noticed the fact that the knee is the articulation
most frequently affected.   True,  he  mentions the  calcaneum, by
which term he probably intended the  ankle joint.   (I  know not
why M. Gilbert persists in using this term.) Generally it is really the
knee joint, and a single knee, that is affected.   M. I.  Cloquet thinks
that in women, he has more frequently observed the disease in the
coxo-femoral articulation, an opinion which has not been corrobo-
rated by any other author.   Further, we find this form of arthritis
involving all the joints, several being  simultaneously or consecu-
tively affected.   There is  in my wards at the Hopital du Midi,  a
young man affected with an arthritis in the articulation of the first
phalanx of the  index finger with the corresponding metacarpal
* Foucart, Gazette des Hopitaux, 1846, p. 192. 
160
VIDAL ON VENEREAL DISEASES.
bone, and very near to this patient, is another in which the disease
is seated in the wrist-joint.  M. Reynard, surgeon in chief of the
Marine, has treated a student in whom all the  joints, both of the
upper  and lower extremities,  were successively involved.*  But
when several of the joints are attacked, there is always one in par-
ticular which remains the longest affected, and which becomes the
seat of serious accidents, leading sometimes to other changes, by
which  the  arthritis becomes transformed into a white swelling.
Sometimes it happens even that only a pain more or less deeply seated
is felt in the other articulations, the movements of which are some-
times impaired.
  Symptoms.—Generally the pain and swelling are the first symp-
toms which manifest themselves.   Sometimes, however, these are
preceded by chills and fever, and by vague wandering pains.  The
pain is less severe than in the other varieties of acute arthritis, such
as the ordinary rheumatic, the traumatic, or that caused by the
penetration of a tubercle  in the articulation.   [Some two years
since we treated a patient affected with blennorrhagic rheumatism
in the ankle joint, and the pain was more severe than ever occurred
in any form of articular disease which has come under our obser-
vation.—G. C. B.]   The movements of the joint  are impeded, or
rendered even impossible; like  pressure with the fingers motion
increases the  pain, but to a less extent than in the form of arthritis
which  I shall mention.  The swelling  is  sudden  and  sometimes
considerable.  We may perceive that this tumefaction does not de-
pend upon an enlargement of  the bone, nor a swelling of  the soft
parts surrounding it.  It  arises from an effusion within the joint,
an hydarthrosis, which may easily be  detected, when  the knee is
the joint affected.   The patella, indeed, is  raised and separated
from the femur and the tibia; it is movable and as it were float-
ing.  On the sides of this little  bone, instead of two depressions,
are two more or less marked elevations.  If we press upon one,
we depress it, but raise the other ; we may press the fluid from
one to the other side, we may in fine produce fluctuation.
  The color of the skin remains  generally unchanged,  and  its
temperature is natural.  The absence of the  external characters of
inflammation, at the outset of the disease, is a fact so constant, that
when  the  opposite occurs, we should carefully examine  to see  if
indeed it is a blennorrhagic arthritis, or if some complication has
not given an acute character to an affection  at first subacute.  At
a later period, as  the articular affection.progresses, it is character-
ized by really inflammatory phenomena.  The swelling  is  more
tense, the skin hotter and more highly colored, and the vascularity
around the joint is increased as in acute rheumatism.  The urethral
discharge then ordinarily undergoes a  marked diminution, a cir-
cumstance which does not occur, when the disease remains in a
state of hydarthrosis.
  As we generally find that the blennorrhagic arthritis commences
without any previous fever, we  also frequently observe apyrexia
* Traite pratique des maladies veneriennes, p. 204. 
BLENNORRHAGIC ARTHRITIS.
161
throughout the whole progress of the  disease.  But fever may
supervene, though it existed not at the commencement.   In every
instance, even when the inflammation is most decided, the febrile
excitement bears no comparison with the  intensity of the rheu-
matism.
  The disease at the beginning having some  characteristics  of
chronic affections, we need not be astonished to see it protracted
for months at least,  by one of its elements—the effusion into the
synovial cavity.   But in ordinary, uncomplicated cases, and under
the influence of well-directed treatment,  the affection subsides in
from three to six weeks.  It is not uncommon for a certain quantity
of the effused fluid to remain in the synovial  cavity. We sometimes
see the disease pass  from one joint to the other, or give way to a
blennorrhagic  ophthalmia.   It is much more rare to observe puru-
lent synovitis, but the fact of its occasional occurrence is unques-
tionable, a circumstance not observed in ordinary rheumatism, in
which, indeed, we know that more than one pathologist will not admit
the occurrence of suppuration. But, even in blennorrhagic arthritis,
under particular circumstances, some complication may aggravate
the in flanimation until it reaches the stage of suppuration. Moreover,
I had an opportunity of witnessing this accident while attached to
the Lourcine.  The  patient had been guilty of no imprudence, he
was quiet, and had submitted to no injurious  treatment, yet  he
was attacked with an inflammation of the knee which terminated
in abscesses which I was obliged to open.   He had in fact a white
swelling, which I had the good fortune to cure, but at the expense
of a complete  anchylosis.
   Diagnosis.—We must not confound with blennorrhagic arthritis,
the rheumatic pains which a patient suffers while laboring under
syphilis. The  latter are intermittent, nocturnal, and are aggravated
by the warmth of a bed ; they are relieved by, and even  disappear
under, the influence of cold, and of motion, and are not increased
by pressure.  As in blennorrhagic arthritis, several joints may be
involved, and as ordinary rheumatism may like it assume a chronic
form; the disease in question is liable to be confounded with the
rheumatism which  merely coincides with, but  has no dependence
on, a blennorrhagia. What I have stated concerning the suppress-
ion  or the diminution of the discharge when the joints become
affected, does not corroborate the opinion  of those who pretend
from this  circumstance to form an opinion of the nature of the
disease.  The discharge, indeed, may not be changed by the oc-
currence of the urethritis,  as it occurs most frequently at  a pe-
riod when the former is so slight, that the articulations become
involved.              '
   Thus, there are cases in which the diagnosis  is difficult, a fact,
however, of  no great  importance  in  a therapeutical  point of
view.
   In the majority  of cases, in which the disease is well marked,
the  diagnosis is  easily established.  For example, if during the
progress or decline  of a blennorrhagia, we observe an affection of
a  single joint, supervening  suddenly, and  without any apparent
                             11 
162
VIDAL ON VENEREAL DISEASES.
cause,  especially if it be  seated  in the knee joint, if there is
neither severe pain, discoloration, nor heat of the  skin, and  if
there is no fever, we may affirm that the disease is a blennorrhagic
arthritis;  we may be still more certain, if during a previous
attack  of blennorrhagia, the patient suffered from the same acci-
dent.
   Treatment.—Those who believe in the general idea of metastatis,
have recommended the re-establishment of the discharge.   For
this  purpose they have irritated the urethra with  bougies,  and
have even inoculated it with muco-pus borrowed from another
patient.  In the Bibliotheque medicaid* a case is recorded by Dr.
i van, which seems favorable to this practice, not yet,  as it deserves
to be, abandoned.
   Swediaur applied his treatment directly to the articulation, and
made use of only mild, diluent drinks internally.  His local treat-
ment consisted of frictions with ammoniacal  liniment, and espe-
cially with an ointment into the composition of which entered the
gum-resin ammoniacum, dissolved in the vinegar of squills.
   My own treatment consists  in the  application of  from twenty
to thirty leeches over the skin nearest to the synovial membrane.
The patient  must be feeble, indeed, if I abstain from their use in
the onset of the disease, for I have observed that the cure is much
more rapid and complete, when blood has been abstracted.   The
indications for blood-letting are much more positive when the dis-
ease assumes the decidedly inflammatory form, especially when
there is reason to apprehend suppuration ; in such a case general
should precede the local abstraction of blood.  Afterwards, I ap-
ply a large camphorated blister; this is not kept constantly open,
but  is  renewed when we wish for a length of time  to maintain
counter-irritation.  If fluid still remains in the articulation, if the
swelling continues, which  is very frequently  the case, I employ
compression  by means  of narrow imbricated bands of plaster.
Sometimes I have applied the dextrine immovable apparatus as in
cases of fracture.   The patient is then not completely condemned
to preserve absolute repose.  Constipation should  be obviated by
saline purgatives, the nitrate (sulphate) of magnesia, or Seidlitz
water.   M. Ricord gives daily from two to four drachms of nitrate
of potass, and from one to two drachms of tincture of colchicum
in a tisane of borage.  I  seldom use  liniments or pommades.
However, in a case where the synovial membrane was actively in-
flamed, I gave wonderful relief by the application of large quan-
tities of mercurial ointment.  In such a case the ointment should
be extensively applied as it sometimes is in the treatment of peri-
tonitis.   But if we continue its application for a length of time,
salivation occurs, which is occasionally a serious annoyance.
  M. Velpeau employs the mercurial ointment,  but in a milder
form, and combines it with a  little extract of opium.  The same
surgeon  also administers an alterative powder, according to the
following formula:
*T. adi.p. 116. 
BALANO-PREPUTTAL BLENNORRHAGIA.
163
                       3. Calomel, grs. 5.
                          Ipecac.   "   8.
                          Rhei,     "  12.

  Divide in six powders.   Give from two to six in the day.   The object
is not to excite vomiting, but to maintain a state of constant nausea.

  When the articular inflammation has yielded, and the effusion
is nearly absorbed, we generally  find that the discharge from the
urethra reappears; then only do I resort to the use of antiblen-
norrhagics.   I believe that they are entirely useless at any other
period of the disease; that is, when it truly exists,  and their use is
not unattended with inconveniences.
                        SECTION  LT.

        BALANO-PREPUTIAL BLENNORRHAGIA.

  This is also called bastard chaudepisse, or external blennorrhagia,
(Desruelles); and balano-posthitis.  It consists in a kind of inflam-
mation of the prepuce and glans, with or without erosions.  When
the disease is confined to  the mucous membrane covering the
glans, it constitutes balanitis;  if the'prepuce alone is involved, it
is then  called posthitis*   This disease, which  possesses much
interest in  a practical point  of view, has been much neglected  by
almost  every syphilographer.  Astruc and Hunter  form excep-
tions  to these remarks; yet  their account of it was very incom-
plete.   MM.  Desruelles (Trade des maladies veneriennes)  and de
Castelneau (Annates des maladies de lapeau et  de  la syphilis, t. ii.)
have carefully studied this affection in ite different forms, and their
writings may be  perused with profit.
  External blennorrhagia is of frequent occurrence, it being found
in about one of  every  thirty admitted into the  venereal wards.
This  number should be still  higher, and should exceed that of
urethral blennorrhagia,  considering that the prepuce and glans are
brought more directly into contact with the contagious matter and
the parts affected.
  Causes.—It is  evident that phymosis more or less decided con-
stitutes a favorable predisposition ; the importance of this condi-
tion in favoring the development of this disease, however, should
not be so exaggerated  as to deny the possibility of the existence
of it, except in  those whose prepuce  is long and narrow, for it
does occur when  the opposite  condition obtains, when the glans is
uncovered, and when the prepuce may be easily retracted.  I have
observed it in a subject on  whom I operated for phimosis by cir-
cumcision.   There  is one circumstance which has caused the ad-

  * For the sake of brevity, I shall often use the term balanitis, no matter what
the seat of the inflammation. 
164            VEOAL ON VENEREAL DISEASES.
mission in the etiology of this affection of too many cases of phi-
mosis, and that is, that no distinction is made between that which
is congenital and that which is acquired; the effect has  here  been
mistaken for the cause; thus, in the  case of a prepuce  a  little
longer than natural, a  balano-posthitis becomes developed, the
prepuce swells, becomes elongated, the mucous membrane is tur-
gid, its opening contracted; in fine, accidental phimosis is estab-
lished ;  it is now regarded as a congenital phimosis,  especially if
the patient be not questioned about the state of the parts before
the invasion of the disease.  Balano-posthitis is certainly observed
most frequently at adult age.  However, at both extremes of life
this  affection  is not very rare.  Children have  sometimes a dis-
charge from the penis, arising from  an inflammation  of the lining
membrane of the prepuce.  During my direction of the wards for
nurses  at the  Lourcine, I operated  on a nursling  affected  with
numerous adhesions between the prepuce and the glans, which led
to the  suspicion of a balanitis during  the period of intra-uterine
life.   In old men, balanitis is generally complicated with eczema-
tous eruptions.
   The syphilitic virus, directly applied, or  acting through a con-
tamination of the system, is  unquestionably the  most common
cause of balano-posthitis, whence it may  be both  primary and
consecutive.   Next to  the  venereal virus must  be  placed the
dartrous vice.   A physical  agent,  the  too frequent excitation
from masturbation, coitus, want of cleanliness, the contact of the
discharge of leucorrhcea, the menstrual fluid, cancerous ichor, all
these causes may inflame the mucous membrane of the prepuce
and the glans.  The other affections of this membrane, such as
herpes, eczema, vegetations,  and  chancres,  are often connected
with  more or less catarrhal inflammation,  and it is known, that
muco-pus,  in  issuing from  the  urethra,  may, even  on the  same
subject, give rise to a balano-posthitis.  Among the causes of this
disease, the agency of foreign  bodies must not be forgotten.  The
most common of these  are urinary calculi, and other concretions,
arising from the secretion of the mucous  follicles, which has been
allowed to accumulate within a narrow prepuce  by those who  are
negligent of their  persons.
   Symptoms and Progress.—The first symptoms of this disease are
generally observed two or three days after a suspected coitus.  At
the onset there are pruritus and heat; these are followed by  a
smarting sensation, and  finally there appears at  the preputial
opening, a certain quantity of muco-purulent matter.  If we  un-
cover the  glans, and examine the whole mucous membrane, we
find that its color  is increased, the redness being more marked on
the glans than on  the  prepuce.  Sometimes the color of a portion
only of this membrane is changed, either  on the prepuce or  the
_glans.  The epithelium often exfoliates and deliquesces,  and  the
denuded, unpolished, mucous membrane, then appears of a deeper
red  color; it is an erosion, an exulceration, or a blistered surface,
such as is frequently observed  on the neck of the uterus, and on
the  os  tincse.   The mucous  membrane itself may be destroyed, 
 
Fi<
S-

^////.,:      -/r// //trt■ /ctKt't>?/- 
BALANO-PREPUTIAL BLENNORRHAGIA
165
  and a true ulcer be  formed.   Whatever may be  the loss of sub-
  stance, it is not preceded by any vesicle or pustule.
    The two forms, the exulcerative and the ulcerative, may,occur
-  isolated  on the lining membrane of the  glans or prepuce, or con-
  iointly on both surfaces.  I have actually before me a young man
  of a lymphatic temperament, in whom the whole mucous lining
  of the  prepuce has exulcerated, whilst not even the color of that
  covering the glans is changed.  Plate 1st, Fig. 1st, represents the
  inflammation which  is limited to the prepuce.   The patient was
  28 years 06 age, a baker by  trade, and of a lymphatic tempera-
  ment   He was admitted March 1st, 1852, into Ward No. 9 Bed
  No 9   No venereal affection had  preceded the attack,   hffteen
  diys before his admission, he had connection with a female.  Eight
  days afterwards, he  discovered a tumefaction of the prepuce, and
  there was difficulty in uncovering the glans.  Pruritus, and a light
  pain, existed  at the extremity of the penis.  At the time of his
  admission  (March  1st),  I found the prepuce  slightly swollen
  There was some difficulty in exposing the glans.   The internal
  face of the prepuce is of a fine red color, and slightly turgid; it is
  excoriated, and denuded like a blistered surface ; on this reddened
  base, at different points, are whitish spots, consisting of epithelium
  slightly raised, but not  yet  detached.   The  glans  is perfectly
  sound.   Neither  pain nor itching  is felt  at this part; there is a
  slio-ht discharge between the prepuce and the glans.  No discharge
   from the  urethra;  the inguinal  glands are not enlarged.  Until
   the 4th March, the patient applied  only emollient lotions to the
   parts  affected.  It  presents the same aspect.   March 5th. Apply
   nitrate of silver lotions (three, grs. to six oz. of water); the surface
   becomes paler; no  pain, and scarcely a weeping between the  pre-
   puce and  the glans.  The lotions are continued until the 10th oi
    March, at which period the cure is complete.   The  patient asks
   for his discharge.                         . .
      I have given this case in detail, because it is one of the most
    perfect examples of the localization of an inflammation of the
    mucous  lining of the prepuce,  and as it is  one of the lightest
    forms of excoriation.  The cure, as we  have seen, was very rapid.
      Most generally we find that the excoriation occurs  both on the
    mucous  membrane of the prepuce, and the glans; and it is  par-
    ticularly  upon the latter that,it is most extensive and decided.
    The exulceration is always multiple; sometimes its limits are not
    perfectly defined, and it  is then difficult to distinguish it from a
    simple redness.  The erosions are most frequently observed upon
    the glans; they are of an  irregular shape, and have a tendency
    rather to the circular form.   Their dimensions range from two to
    six lines; when of larger size, it is owing to the fact that several
    have coalesced to form but one.  The  color of  the eroded surface
    is of a deep or  vinous red, rarely blended with gray, and more
    rarely still of a  perfectly gray  color, as is seen in  the common
    chancre.   I have already compared the erosion to a  blistered sur-
    face ;  but, whilst  in  the latter  there  is almost always a pseudo-
    membraneous formation, this is a rare occurrence in the erosion 
166            VLDAL ON VENEREAL DISEASES.
of the balano-preputial mucous membrane.  Around the erosion,
the color of the glans is of a lively red, often analogous to that in
the exulceration, and when the limits of the latter are not clearly
defined, the denuded portion may be confounded with that which
is not.   But it must be admitted, that on the glans this confusion
is more difficult than on the neck of the uterus.  If it be desired
to make a precise diagnosis, we pass a pair of forceps soaked in a
solution of nitrate of silver, which will  render the eroded surface
whiter than the polished  mucous membrane.  In the instances of
consecutive balanitis, the  parts of the glans not eroded retain their
natural color.
  The matter secreted by a balanitis is at first small in quantity,
and resembles muddy mucilage, after which it assumes  the char-
acters of muco-pus, and even of pus itself; like the urethral blen-
norrhagia, it becomes of a yellow, greenish, and  sometimes rusty
tint; it has an odor like that from spoiled fish.  This discharge is
sometimes  very abundant, and then, if the prepuce  is very nar-
row, its passage  through the preputial opening is  obstructed, it
may accumulate  in  the groove below the glands, and produce  to-
wards the base of this organ a kind of  abscess, the evacuation of
which  may require a perforation of the prepuce.  Sometimes the
quantity of matter secreted is very small;  in  chronic cases, when
we  expose the glans, we discover a thin  crust formed  over the
eroded surfaces, which falls off to make room for others.
  The  progress of  balano-preputial  blennorrhagia  is generally
rapid, and it  soon becomes healed, even when there are exulcera-
tion and superficial ulceration.   Cleanliness, the most simple topi-
cal  applications, singularly promote and hasten this happy termi-
nation, which sometimes happens in the course of four or five days.
But this does not occur when complications exist, and when the
cause cannot be removed.
  The  first case detailed  below affords an example of one of the
most simple  acute cases.  In  the second, not only the glans and
prepuce were affected, but this  had been preceded by an urethritis
which was  followed by a vegetation.  It is evident that the bala-
no-posthitis was chronic;  I regarded it as consecutive.
  G. L., set 19, shoemaker,  of lymphatic temperament, good con-
stitution, was admitted March  15th, 1852, into Ward No. 11, bed
No. 31, of the Hopital du  Midi.
  Nine months and eight days before his admission, after connec-
tion with a prostitute, he was attached with a slight urethral dis-
charge, accompanied with slight pains during the emission of urine.
This condition lasted six months.  No treatment.  At this period,
and without any apparent cause, the prepuce became swollen, red,
and painful;  the glans could no longer be uncovered.   A very-
copious discharge was formed between the prepuce and the glans.
Ordered local baths.  Regimen and tisanes for eight days.  There
was scarcely any discharge from the urethra.  The prepuce being
no longer  swollen he could expose the glans, the surfaces of both
prepuce and glans are only a little reddened.   He returned to his
accustomed habits, drinking, &c.; fifteen days  afterwards, the ure- 
BALANO-PREPUTIAL BLENNORRHAGIA.
167
thral  discharge reappeared; the prepuce became again swollen,
and there was a renewal of the phimosis.   (The patient has been
continent since the coitus before  mentioned.)   In this condition
he remained until admitted into the hospital, (March 15th.)
  15th. Some difficulty in uncovering the  glans.  The prepuce
somewhat swollen; its lining membrane red, granulated, and bleed-
ing from the slightest cause;  the color of the glans is of a bluish
gray; it presents broad layers of a slightly brownish red; these
are excoriations which bleed occasionally.   Discharge slight, thick,
and of a greenish yellow color between the prepuce and the glans;
weeping from the meatus; no pain.  On exposing the glans, in the
groove  around it, on the right side and near the frenum, is found
a vegetation of a deep red color.  The inguinal glands are more
engorged on the right than on the left side,  but  they are not pain-
ful.   The patient did not discover them; he remembers, besides,
that in his childhood he had enlarged glands in the neck.   The
cervical ganglia are now normal.  Bath.
  16th. A sketch is made of the penis; it is represented in Plate I.
Fig. 2.  The  glans is excoriated, together with the prepuce;  the
latter  being somewhat narrow forms a kind of ligature around the
base of the penis.  The redness at the base of  the excoriations is
less brilliant than that in Fig. 1; it is slightly brownish.
  17th. The prepuce, which yesterday was drawn behind the glans,
is greatly swollen.  Its surface, with that of the groove, has lost,
in consequence of their  isolation,  the  tint which they possessed
yesterday.  Prescribed lotions of nitrate of silver of the strength
mentioned in the preceding case.
  18th. The parts have assumed a brownish color; here and there
some  reddish points remained.   Discharge has increased.
  19th. Bath.  The parte appear perfectly sound.  The vegetation
is shrivelled and detached, from the effects of the application of a
powder composed of equal parts of savine and burnt alum.
  29th. No  traces of the vegetation.  Patient now takes Dupuy-
tren's pills; there is still a slight weeping from the canal.*
   Complications.—The phimosis, which is a cause of balanitis, may
become a complication, by obstructing the discharge of the matter
secreted, and  by resisting  the development of the  glans, which
occasionally gives rise to a strangulation and sloughing of the pre-
puce;  it is owing  to this complication particularly, that balano-
 osthitis becomes very painful., Again, the inflammation may not
 e confined to the mucous lining of the preputial cavity; it may
involve the glans, and the cellular membrane between the mucous
lining and the skin, and even the skin itself, causing it to assume
a phlegmonous character.  Two  sets of vessels are  distributed
between the skin and lining membranes of the prepuce; viz. veins
and lymphatics, and these become inflamed.   According to  M.
Desruelles, phlebitis is  a much more frequent   complication than
inflammation of the lymphatics.  The reverse of this is true.  But
it must be admitted, that before the investigations of this physician,
I
Case reported by M. Codet, interne du service. 
168             VLDAL ON VENEREAL DISEASES.
the  attention of observers was not so strongly fixed upon  the
inflammation of the principal veins of the penis, and of the capil-
lary veins, an inflammation which gives at once a serious character
to balano-posthitis.
   When  all these  anatomical  elements of the prepuce  become
invaded, the extremity of the penis becomes increased in  size; it
assumes the form of a club, it becomes red, and then changes to a
violet color.  If the prepuce is long,  we find it twisted at its
extremity, and narrow, and appears as if pediculated at a point cor-
responding to the glans;  it is more developed anteriorly, and there
is occasionally a hernia of the mucous membrane.   Then we may
have not only a retention of the matter secreted, but  a retention
of urine, which, however, is much more rare.  This complication
has  more than once rendered it necessary to  divide the prepuce,
notwithstanding the risk  incurred by this proceeding of inoculating
the wound.
   Blennorrhagia, chancre, and  buboes  are  often  rather  conse-
quences than true complications of  the disease.  Chancre  is more
frequently observed than blennorrhagia; bubo, resulting from  the
latter affection, is very rare, and as we shall hereafter find, it may
become virulent.  The vegetations and mucous tubercles whicn
may give rise to balanitis, are also sometimes consequences of this
affection.  (In Plate I. Fig. 2, a vegetation is represented.)   Thus,
it is common to see numerous vegetations arise from the reflexion
of the prepuce  lately occupied by an  erosion, or  blennorrhagic
inflammation.  Orchitis  has improperly been  regarded as a com-
plication or  one of the accidents  of balano-posthitis.
   Terminations.—The most frequent is resolution, or prompt  re-
covery, if the complications are removed, if the causes no longer
exist, and if the disease has not been aggravated by improper treat-
ment.   When balanitis is consecutive, the duration of the disease
is considerably  increased,  or it  may be reproduced.   When it
arises from eczema, as is  often the case in old men, it may be very
obstinate.
  Diagnosis.—When the  prepuce is  narrow, balanitis may be con-
founded with urethritis,  for both inflammations may cause  the
same matter to be secreted, the same muco-pus. But the emission
of urine is generally not modified,  or is not more frequent than
usual in balanitis; the pain is Umited to the glans;  the discharge
is as copious before as after urinating; and erections are not com-
mon.  In urethritis, the pain at length always extends  to  several
points in the urethra; those which are felt in urinating are especially
referred to the perineum;  there  is  more frequent disposition to
urinate, and by pressing the urethra from the scrotum towards the
glans, we considerably augment the quantity of matter which
escapes from the prepuce.
  Chancre of the preputial cavity may simulate balanitis, but gen-
erally it furnishes less matter than the latter, and by carefully feel-
ing, we may often detect an induration which reveals  chancrous
ulceration. When the glans can be exposed, other difficulties may
still exist.  Thus simple excoriations may be confounded with the 
BALANO-PREPUTIAL BLENNORRHAGIA
169
truly specific exulceration, the primary exulceration to which the
former are consecutive.   Simple excoriations are ordinarily less
extensive, very irregular,  and of a fine red color; their secretion
is small in quantity;  on  evaporation,  crusts and yellowish pelli-
cles are formed, and the  vicinity of the  glans is colored and  irri-
tated to  an extraordinary degree.  The  consecutive  erosions are
of a rounder form; the pellicle by which they are covered falls
off readily in the  form of scales, leaving behind a gloss of a red-
dish brown tint (syphilitic tint).  It is rare that  there are not as-
sociated  with these some of the syphilitic  eruptions.   Eczema,
also, leaves excoriations which may be confounded with those of
true balanitis, but they are preceded or followed by little vesicles;
the itching is troublesome, and the affection is often seen on other
parts of the integuments.
  Prognosis.—This may be inferred from what I have stated con-
cerning the terminations.  Like the local affection,  this  is most
benign when uncomplicated, but, even when it exists in ite mild-
est form, that which  is regarded as simply  catarrhal, it may be
the starting point of syphilitic infection.
  Nature.—The same diversity of opinion here prevails as in ref-
erence to the nature of urethral blennorrhagia.  But, as the parts
affected may here  be  directly explored, in the majority of cases,
and  as the chancre larve, cannot conceal  the  truth, the latter may
be obtained both by clinical and experimental observation.   Ex-
perience, indeed, has  shown that balanitis, in both ite forms, that
is, without and with erosions, has been followed by consecutive ac-
cidents, which  revealed the existence  of constitutional infection.
Experiments have corroborated these remarks; that is,  they have
established the fact, that  the matter secreted in a mucous balano-
posthitis may be successfully inoculated,  and that, too, when there
is no ulceration, nor the slightest erosion, or solution of continuity
in the mucous membrane.
   Clinical facts could not be denied; they, however, have been
explained in a manner different from our own.  The experimental
facts have simply been denied.   These facts,  however, occurred at
the Hopittd du Midi ;  they have been collected by an interne  with
whom I  am acquainted, and have  been  inserted in his inaugural
thesis.  Dr. Bartholi asserts  even that he has met with thirty cases
of this kind.  One of these is very remarkable; in a  case of bala-
nitis, without the  slightest exfoliation of the mucous membrane,
without  any other venereal  symptom,  an adenitis  supervened,
which was treated by numerous punctures.   Each puncture be-
came transformed  into a chancre.  Pus taken from one of these
ulcerations, and inoculated, produced what is called at the Hopital
du Midi the pustule caracteristique ; in other words, that which pre-
cedes chancre.   (The  Thesis of M. Bartholi was defended at Paris,
in 1845 ; it was on the subject of Syphilis and Scrofula.)   I have
not repeated these  experiments, because  the syphilitic nature of
balanitis, under the form which is called simple catarrhal,  I have
never doubted, since I have been able to watch for a length of time
the patients in whom it occurs. 
170
VLDAL ON VENEREAL DISEASES.
  It'is,  therefore,  demonstrated that balano-preputial  blennor-
rhagia, in its ulcerated and non-ulcerated forms,  may be conta-
gious, inoculable, and  the cause  of consecutive accidents, in the
same manner as certain urethral blennorrhagias.  There is this
difference, however, viz., that matters here  are more  easily de-
tected, since it is an external  blennorrhagia, a disease which  is
completely under our observation.  Thus, in my opinion, the his-
tory of this throws much light on the history of all other forms of
blennorrhagia.
  [Mr. Langston Parker (op. cit. p. 34,) states that in this form of
disease, he has seen eruptions, accompanied by a node on the fore-
head, loss  of the  hair,  and  other  symptoms  of constitutional
syphilis,  produced in the wife, where this species of abrasion, with
thickening, were the only symptoms in the husband.—G. C. B.]
  Treatment.—I shall here point out only the local treatment, for
the general  or  rather  the specific treatment,  will be taught when
we  come to  treat of chancres.  This special  treatment should be
adopted whenever we  are not certain that the balanitis proceeds
from a physical or simply irritating cause.
  The local  treatment may require nothing more than the observ-
ance of cleanliness, and  the interposition of fine lint between the
prepuce and the glans.  This isolating the parte affected should be
employed whenever it is possible.   Nothing  more prevents reso-
lution than  the contact and friction of one diseased  mucous sur-
face upon another.  Instead of lint, we may use charpie, or cot-
ton.  I will  soon mention with what they should be saturated.  In
the majority of cases, for simple water lotions, and local baths, we
substitute lead water, or  a  solution of the nitrate of silver. The
formula which I adopt has already been mentioned, while treating
of blennorrhagia.
                    ~fy.  Nit Argent, grs. 3.
                       Aq. pur,    | vi.   M.
  M. Baume's prefers;

                    IJ. Nit. Argent, grs. viii.
                        Aq. pur.   3 ii.

  M. Desruelles steeps the pledgets in the following solution:

                    $. Nit. Argent, gr. xv.
                        Aq.         | i.

  The glans being covered with these  pledgets,  the prepuce  is
brought over it.   Where it cannot be exposed, we must inject the
same solution between it and the prepuce.
  1. M. Ricord's treatment.—If he can uncover the glans, he applies
a crayon of  nitrate  of  silver over the entire diseased surface.  He
then covers it with fine lint, over which  he pulls down the pre-
puce.  In the next  place he makes use of fomentations by means
of compresses soaked  in Goulard's extract.   The lint is changed
twice a day, and each time, the parts are washed with a weak solu-
tion of lead. 
BALANO-PREPUTIAL BLENNORRHAGIA.
171
  When the inflammation runs high, and the disease  is compli-
cated with  natural or accidental phimosis, he employs  active an-
tiphlogistics ;  he applies leeches to the pubic region, to the genito-
crural fold  on each side, but never to the penis itself.  Local baths
composed of decoctions of marsh-mallow root,  of linseed,  with
warm milk, of nightshade, or  of poppy heads, may also be used,
with injections  between the  prepuce and glans of these  mild
narcotics.  One or two  scarifications on each side of  the  lower
part of the prepuce, when there is much oedema and but little in-
flammation.  This trifling operation must be avoided when there
is erysipelas, and leeches preferred as already indicated.
  If gangrene threaten, fomentations, with a  solution of the
gummy extract of opium, and injections of the same fluid into the
preputial cavity; internally, a  grain of opium several times in the
course of  the  twenty-four hours.   The same  narcotic is  to be
administered in lavements with eight or ten grains of camphor.
  2d. Author's treatment.—I employ injections  between  the pre-
puce and the glans, of the strength already mentioned,  and apply
a crayon of nitrate of silver, over all the parts affected if they can
be exposed.  I have never found it necessary, however, to resort
to the local abstraction of blood, nor to scarifications in  cases com-
plicated with inflammation or oedema.  From this it must not be
inferred  that I disapprove of the practice to which I have  above
alluded.  I wish merely to state my own.   When the inflamma-
tion is  very acute,  the subject  young  and plethoric,  I  prefer
bleeding from the arm; I  repeat  the general bathing,  and pre-
scribe fomentations of the decoction  of nightshade, after  which I
cover the penis with a linseed  cataplasm moistened with Goulard's
extract.
   Some practitioners very frequently incise the prepuce, when to
a congenial or accidental phimosis there is added an inflammatory
complication.    Doubtless, it is often of advantage to promote the
development of the inflammation as we may thus avoid gangrene.
But in  the preputial  cavity there  may  be a concealed  chancre
when we suspect only an inflammatory balanitis;  the wound may
thus become  inoculated, and be transformed into a large chancre,
which often becomes phagedenic.  I should more willingly  advise
incision, or better still circumcision in the case  of chronic inflam-
mation,  especially when it is possible to know that it is limited to
the glans  For example, a few days since, I operated on  a patient
in such a condition.   There was incomplete phimosis, and I could
assure myself that he had balanitis alone;  I performed circum-
cision, and applied  serre-fines; the wound was united in  thirty
hours, and the glans, which were very red and excoriated  at the
moment when it was uncovered, soon became pale; a crust formed
over the excoriation, which eight days afterwards fell off and was
not again renewed.  There can be no doubt that  in this  case the
contact  of the  lining membrane of the prepuce, with  that of the
glans, did  protract the existence of the balanitis. 
172
VLDAL  ON VENEREAL DISEASES.
                    CHAPTER III.

           BLENNORRHAGIA IN  THE  FEMALE.

  The specific inflammation which I am about to describe affects
several mucous  tissues.   The  female may therefore be affected
with several forms of blennorrhagia, but  they are too frequently
confounded to be described separately, as I did in treating of the
disease in the male.   I prefer to make but two varieties, which I
will describe under the same head.   When  the vitality of the fe-
male genital  organs  becomes affected, certain morbid secretions
take place, which have been confounded under the name  of fluor
albus, which may give rise to blennorrhagia.  The  female, there-
fore, may have  a discharge which has not been contracted from
another, as well as that which has been thus contracted;  for this
reason it  has been asserted, that  as regards blennorrhagia she gives
more than she has received.
  Seat.—Facte do not warrant us in locating the inflammation ex-
clusively in the vulva, the vagina, or the urethra.   Blennorrhagia
may affect all these parts, though it  more  frequently commences
in the vagina.   This is all that can be  positively asserted.  It
may be  limited to  one  of the localities  mentioned, or invade
several at the same time,  and extend over the entire  mucous lining
of the genital organs and urethra.
  Varieties.—I make three varieties of this disease, a division based
on the particular locality affected.  Thus we have a vulvar variety,
a vaginal, to which I will add a uterine and a urethral. In  the two
first named we  shall find analogies with balano-preputial blennor-
rhagia, analogies which did not  escape the observation of Hunter.
  1st.— Vulvar  Blennorrhagia.—The  vulva comprises, as  is well
known, the clitoris and its prepuce, the vestibule, the labiae  ma-
jora and minora, the caruncules, and what is called the vulvar
circle.  These parte  may be thought very rarely separately affect-
ed, in the majority of cases, indeed, the entire vulva being involved.
The blennorrhagia may be superficial; in other words, it is simply
erythematous, and limited to the mucous membrane; or both the
glands and tissues invested by this membrane may be invaded by
the inflammation.  Even the skin adjacent to the genital organs
may suffer, especially in females who  are very corpulent.
  Vulvar blennorrhagia  is  generally accompanied with  very
troublesome itchings, intense heat, marked redness, and tumefac-
tion.   Sometimes there are erosions as in balanitis.  In many, the
invasion of the disease is characterized by strong venereal desires.
It is rare, however, that this  kind  of nymphomania  continues
during the whole progress of the blennorrhagia.  Walking excites
the  parts, and  renders them painful; sometimes the patient suf-
fers whilst sitting; even when urethritis does not exist,  the emis-
sion of urine is painful,  especially when it is about finished, and
the last drops become diffused over the inflamed vulva. 
BLENNORRHAGIA IN  THE FEMALE.
173
  There is  often, at the same  time, an cedematous and inflam-
matory swelling, which may terminate in the obliteration  of the
vagina in  strangulation, and a kind  of paraphymosis of the
nymphse.  The urethra sometimes is even compressed, which pro-
duces  pain during the  whole time that the wine is voided, for
there is dysuria.  When the inflammation reaches this height, and
when  it involves the skin and parts adjoining the vulva, the dis-
charge is very acrid, and exhales a very fetid odor.  The glands
invested by the mucous membrane of the vulva, those in the sub-
stance of the labia, may become  inflamed.  When it was believed
that the blennorrhagic  discharge consisted entirely of semen, the
seat of the affection was placed in these glands,  which were re-
garded as  reservoirs of the sperm.  Thus we find in Astruc that
" the prostate and Cowper's glands" are considered as the seat of
blennorrhagia.   As regards the female, this author states explic-
itly that the last-named glands " are situated in the  perineum,
near the anus, and  that they open into the vulva by  two  ducts
which may be found at the entrance of the vagina, near the carun-
cula myrtiformis."*  This description  evidently  applies to. the
glandular bodies recently described by my colleague Dr. Huguier.
Now then,  these  glands may become inflamed in like manner
With the follicular  bodies which  are more or less deeply situated,
and there vulvitis  assumes a phlegmonous form;  abscesses  form,
which if not early opened, may produce  a  blind  fistula; that is,
with an opening  only  in the vulva, or it may rise to a complete
fistula, with an opening in the rectum very near the anus, as well
as  that in the vulva.  Long since I described the characters of
these  abscesses, and pointed out the consequences which might
follow.  In proportion as  vulvitis is more or less  superficial and
recent, and according to its depth  and extent, it  may produce a
discharge which  is at  first  mucous, wrhich afterwards  becomes
muco-purulent, and finally entirely purulent.  When there is sup-
puration of the glands, the pus  secreted may present all of these
characters.  If the inflammation involves the adjacent skin, there
oozes  from its surface  a humor like that produced by a blister.
The fetor is then especially intolerable.
_ Vulvitis is very frequently observed in little girls who have a   L*
somewhat lj-mphatic temperament.   It  is manifested, in the first
place,  b}r a mucous discharge, which by degrees  becomes trouble-
some ; it may be attended with an itching sensation, and occasion-
ally with acute pain. In the majority of cases this blennorrhagia
is spontaneous ; seldom is it caused by contagion.
  2d.  Vaginal-uterine Blennorrhagia.—Under this head I shall con-
sider not only the affection limited  in ite seat to  the vagina, but
that which reaches as high as the uterus.  Vaginitis is  an  exten-
sion of vulvitis, or, what is  most common, it commences  in the
vagina itself.   This canal  may  be  affected  throughout ite entire
extent, or in that portion only which lies adjacent to the vulva, or
to the  neck of the uterus.  If the disease is confined to this last-
Traite des maladies veneriennes, t. iii. p. 7. 
174            VIDAL ON  VENEREAL DISEASES.
named part, and if the discharge accumulate in this cul-de-sac, on
a superficial examination we may pronounce a female sound when,
in fact, she is  the receptacle of what  may readily infect whoever
shall have intercourse with her.  The  finger should be introduced
deeply into the vagina, its posterior  face depressed, by which a
cavity will be formed.  We then perceive the matter threading
ite way along  the  finger to  arrive at the vulva.  It is still bet-
ter, when possible,  to examine carefully with the speculum the
condition of the mucous-membrane as we withdraw  the instru-
ment.
  The inflammation may still be here only erythematous, catarrhal,
or phlegmonous, according as it is limited to  the mucous surface,
or as it involves the tegumentary covering and mucous follicles, a
complication which renders the vaginitis very intractable.    In
speaking of vulvitis, I have  not mentioned the phenomena which
occur in the genital regions, as  well as parts more remote, because
they are very rare;  but when vaginitis  exists, it is common to
hear the female complain of  a feeling of weight and uneasiness in
the groins, of  pains in the  pelvis, of general uneasiness, and of
painful lassitude.  The local pain is here less severe; some women
indeed never suffer during the  whole progress of the disease, and
coitus is attended with no disagreeable sensation;  now, as  they
are more than  ever troubled  with desire, the men with whom they
are intimate are much exposed to infection.  The same  danger
does not exist in vulvitis, for  no matter what the desires of the
female, sexual intercourse is then so painful as to be rendered
almost impossible.   If the pain in vaginitis is less, the discharge,
on the contrary, is more considerable than in vulvitis.  An inspec-
tion of the vagina shows the lining membrane redder  than in  ite
natural state;  the redness is deep and bright, and is  principally
remarked on  the vaginal  folds,  which are then unusually prom-
inent.  Sometimes the surface of the  vagina  has the  aspect of a
granulating wound; then it has received the name of papulous or
granular vaginitis.   M. Deville believes it to be peculiar to preg-
nancy ; true, it is most frequently observed in pregnant females,
but it may also occur in those who are not in this condition.
  As in the male, blennorrhagia is observed to  commence in the
fossa navicularis, traverse  the  urethra, even to its  most deeply-
seated parts, and then become chronic, and complicated, with pros-
tatic engorgement; so  in the female, it may be seen to attack first
the vulva, then pass through the vagina, and fix itself upon the
cul-de-sac, about the neck of  the uterus, which then suffers several
different  pathological  modifications.   These modifications,  by
the secretions to which they  give rise,  it may be remarked, are the
most  frequent cause of communicating blennorrhagia.   In this
chronic state, the female no  longer suffers during coitus; the dis-
ease being of long standing,  she thinks that it has passed, and the
morbid secretions are  confounded with leucOrrhoea.   The blen-
norrhagia may even extend farther; it may pass through the neck,
and involve the body of the uterus.  The discharge is then more
of a mucous  character, and issues from the vagina in thready 
BLENNORRHAGIA IN THE FEMALE.            175
masses; it has a tenacity that does not belong to it, when vagini-
tis alone exists.
  [The sterility of prostitutes is attributed, by several authorities—
as, for example, Mr. Henry J.  Johnson, op. cit. p. 340;  Mr. Egan,
op.  cit. p.  123; and Mr. Acton, op. cit. p. 200—to the  occlusion
of the uterine cavity by the  tenacious, stringy mucus, secreted by
the glands of Naboth, which so frequently exist in this class of
persons, in a state of chronic inflammation.  This viscid discharge
occurs also in connection with a granular state of the  cervix.
Young married women affected with leucorrhcea are often barren
from the same cause.—G. C. B.]
  There is reason for believing that the inflammation may reach
the ovaries even through the Fallopian tubes, as it does the testicle
through the vas deferens, at a  certain  period of urethral blennor-
rhagia in the male.   When I come to treat of the accidents, I shall
mention certain facts which would seem to authorize the admission
of a blennorrhagic ovaritis, analagous to blennorhagic orchitis.
  3. Urethral Blennorrhagia.—The symptoms are not unlike those
of urethritis in the male.  Sometimes there is a slight itching and
uneasiness, which becomes changed to a real pain, and, during the
emission of urine, it is  of a  burning character.  To  determine
absolutely that the urethra is really the seat of the pain, we intro-
duce the index finger into the vagina, turn its palmar face towards
the pubis, and press the urethra, from the  neck of the bladder to-
wards the meatus.   If urethritis exists, the band formed by the
urethra in the vagina appears increased in size;  it is more sensible,
and the pressure gives exit to  a quantity more or less considerable
of muco-pus.
  Accidents.—These are less numerous in the female than the male.
In the latter, we may have prostatitis  and  epididymitis ; blennor-
rhagic ophthalmia and arthritis are less frequently observed.  In-
flammation of the body, and especially of the neck of the bladder,
is by no means so  common as in the male.  An accident which
may be regarded as analogous  to orchitis, is ovaritis.   I have often
observed it; and it  has not escaped the attention of M. Ricord;
very recently,  M. Mercier has proved, by an  autopsy, that the
inflammation  may  invade  not  only  the   Fallopian tubes  and
ovaries, but even extend to the peritoneum, producing an  inflam-
mation of this membrane, an obliteration of the Fallopian tubes,
and thus become a cause of sterility.
  The  following are the symptoms of blennorrhagic ovaritis.
After vulvitis  and vaginitis, and the manifestation of  symptoms
showing an affection of  the uterus, pains are felt in one or both
iliac regions, and there  is pain, tension, and swelling,  with pain
on  pressure.   A symptom which M. Ricord has observed to be
constant, and to which he attaches the greatest importance, is the
following: whenever the patient lies on the side affected, the pain
diminishes, for with  the  change  in position, the dragging  on the
organ  affected is lessened, ana consequently the pain to which it
gives rise.
  [Mr. Acton  observes  (op. cit. p. 209), that if the finger be  car- 
176             VTDAL ON VENEREAL  DISEASES.
ried up the cul-de-sac of the vagina, and the patient desired to turn
upon the opposite side, pain of a most acute kind will be felt.—
G. C. B.]
  The inflammation is occasionally propagated to the uterus and
ovaries, not during the intensity of the vaginitis, but  after a cer-
tain period, as we observe orchitis in the male to occur after the
second or third week  of the blennorrhagia.   Generally, the most
perfect analogy exists between blennorrhagia ovaritis and orchitis.
A cure is almost  always obtained.   Suppuration rarely occurs.
I think, however,  that  I  have observed it  in a single instance.
The case was one of ovaritis, following an intense vaginitis which
extended to the uterus.  There was severe pain in both iliac re-
gions, which pains, however, were not sensibly increased by pres-
sure.  On examining  these regions,  after  having evacuated the
large intestines  by two  enemas,  an indurated space was felt;
there were cramps in the lower extremities.   Vomiting and pain
in the stomach manifested themselves.  The pulse was moderately
accelerated, and very soft.  Cephalagia.  Ten days  after the ap-
pearance of the  first  symptoms of ovaritis,  when  the  pains had
ceased,  when all was  tranquil', I introduced the  speculum.
Scarcely had it entered, when  there issued from the neck  of the
uterus a large quantity of well-formed pus, having a most repuls-
ive odor.  It was my opinion that this pus came from the ovaries,
having reached the uterus through the Fallopian tubes, or by some
solution of continuity in the substance of that organ.
  I insert in this place, the particulars of an important case which
has been recorded by M. Mercier.  It sheds some light upon  the
pathological anatomy of blennorrhagia, as  it exists in the female
in ite most severe  and  extensive  form.  We  find every part to
which I have alluded as the seat of blennorrhagia, affected.  There
were indeed  traces  of  vulvitis, urethritis,  vaginitis, metritis,
&c,  ke.
  "A girl, xt. 19, some weeks since, was attacked, whilst labor-
ing  under blennorrhagia, with the premonitory symptoms of ty-
phoid fever.  During this period, she was seized with  an intense
pain in the pelvis : the application of forty  leeches produced an
abatement of the pain, but the typhoid fever steadily progressed,
and  at the end of a month the patient died.  The following  ap-
pearances presented at the autopsy:
  "In the intestinal canal, there were about sixty  ulcers of vari-
ous  dimensions.   The internal surface of the labia majora were
red and turgid;  on the left, at various points were found excoria-
tions.  The nymphoe  were covered with compact granulations of
the size of a pin's head.  The bladder, which was very small, con-
tained a little purulent urine.   Its  lining  membrane  was  red,
especially in the vicinity of the ureters and the urethral orifice.
The urethra  at  ite inferior part, for about  three lines in extent,
presented a uniform, deep red tint.  Above this  point, there were
very numerous red spots.  The vagina,  for an  inch and a half
above  the vulva, was of an intensely red  color.  Ite transverse
folds were here also  unusually prominent,  especially anteriorly, 
BLENNORRHAGIA  IN  THE FEMALE.
177
where were found small compact projections, resembling  little
vegetations.   Higher up, the redness was less marked.
   " The neck of the uterus was  somewhat redder than the sur-
rounding portion of the vagina.  Its opening, which presented the
appearance of a  very broad transverse  cleft, indicated that this
woman had been a mother.  The color of the  cavity of the neck
was almost violet.  The substance of the uterus was not inflamed,
but the color of the membrane  lining its cavity, was like that of
very red wine.   The  inflammation  extended to  the  Fallopian
tubes, which were not obliterated on the side of the uterus.  The
cavities of these different parts contained a large quantity of muco-
pus ; but no ulcerations were found.
   " Throughout the whole abdominal cavity, except in the lesser
pelvis, the peritoneum was perfectly sound.  There were no per-
forations  in the  intestines.   The  surface of the  peritoneum pre-
sented nothing unusual;  but in the vesico-uterine cul-de-sac be-
tween the posterior face of the bladder and the  anterior  surface of
the uterus, existed reddish false membranes, soft,  granular, thin,
and easily detached.  In the utero-rectal cul-de-sac, the peritoneum
was likewise inflamed, of a livid color at various points, and cov-
ered with filimentous adhesions, which  extended  from  the uterus
to the rectum; the same adhesions existed on the broad  ligaments,
the ovaries, and Fallopian tubes, to such an extent as to destroy
all traces of the corpus fimbriatum of the latter  on the left side,
which was obliterated.  Notwithstanding the numerous  adhesions
which surrounded the right pavilion, its cavity still  communicated
with the peritoneum."*
   If typhoid fever had not destroyed this female, and she had
lived with the pavilion of the left Fallopian tube obliterated, the
corpus fimbriatum on the right side being in such  a condition as
to prevent the inclination  of the pavilion of this  side towards the
ovary, sterility must have been the consequence.  Besides, this is
not the first  time  that obliterations of the pavilion and  the Fallo-
pian tubes have been  found in females  affected  with the venereal
disease.   This fact was noticed even by Morgagni.  M. Mercier
has suggested that this may be  the principal cause  of sterility  in
prostitutes.
   Diagnosis.—In the  description given of the  three varieties of
this disease, I think that I have sufficiently established  the diag-
nosis so far as regards ite seat.  I have not alluded  to the acidity
of the discharge as a test of  vaginitis, nor to its  alkaline character
in other forms of blennorrhagia, nor to the existence of animalcu-
hv, because it is known that these are  far from  being constant,
and from  possessing  the  importance which has been assigned  to
them.  M. Baumes coincides in this opinion.   The diagnosis,  as
regards the knowledge of the causes and nature of  the discharge,
is very obscure, more  so in the female than the male, and this
obscurity  often proceeds particularly from the existence of leucor-
rhcea, which strongly resembles blennorrhagia in  its symptoms
* Gazette des Hopitaux, t. viii., 2d series, p. 432.
                  12 
178
VLDAL ON VENEREAL DISEASES
and  effects;  for,  like  this  disease,  it  may become contagious.
Doubtless,  by taking into cdnsideration all the circumstances con-
nected with the disease, the lapse of time after a suspected inter-
course, the previous liability of the female to become affected with
discharges, the candid confessions of those who can have no motive
to deceive, we may arrive at probabilities, though not to  absolute
certainty respecting its nature.  The seat of blennorrhagia affords
no light upon  its nature, for' that which is urethral is no more
syphilitic and contagious, than that which affects the vagina.  We
can learn nothing  from the character or color of the stains upon
the linen;  the pain, which  may be present in blennorrhagia and
absent in leucorrhcea, is a still more fallacious symptom on which
to rely,  for there are discharges, which, at a certain period, have a
remarkably indolent  character, and which are  nevertheless very
contagious and evidently syphilitic.   With M. Ricord, the seat of
blennorrhagia is sufficient to establish its etiology.  Thus, accord-
ing to his researches, urethritis in the female  should always be
the result of contagion.  If carefully interrogated, she will admit
that she has been exposed to a suspicious connection.   In cases
of vulvar  and vaginal blennorrhagia, frequently  they  will not
admit that they  have  been thus exposed.  Then M. Ricord, so
incredulous generally, credits  and admits the statement of the
female,  as I have already  remarked, that the urethral  blennor-
rhagia with which she is affected is the result of contagion, whilst
the others may be regarded rather as of spontaneous  origin.   But
statistics,  taken on a large scale,  show, that among prostitutes,
who,  of course, are most exposed  to infection, urethral  blennor-
rhagia is very rare.
   [It was the  opinion of John Hunter, that the urethra in the
female is seldom the seat of blennorrhagia, but M. Ricord (Notes to
Hunter,  2d ed., p. 261), states that the female urethra is more fre-
quently affected than  Hunter supposed.   Mr. Egan, who enjoyed
such  excellent opportunities  for observing blennorrhagia in the
female,  at the Lock Hospital, Dublin, thus expresses  his opinion:
"The urethral variety," he observes, (op.  cit. p. 121,) "is seldom
encountered as a distinct form ; neverthless, it is occasionally met
with."  Having recently had the pleasure of visiting the above
hospital, which contains 130 female patients, we  can cheerfully
join with Mr. Egan in the assertion, that there are but few institu-
tions  where greater facilities are afforded for investigating venereal
affections in that class of patients.—G. C. B.]
   This  point, doubtless, is still  involved in obscurity; but a fact
which is well  established is, that discharges may occur in the
female,  not the result of suspicious  intercourse, which,  notwith-
standing, are  very contagious.  To assert  that men who  have
contracted a blennorrhagia  from such a source, cannot communi-
cate it to another female, is, in my opinion, to proclaim an hypo-
thesis not unattended with danger.
   Prognosis.—The prognosis, viewed in reference  to the seat of
blennorrhagia,  has already been noticed in describing the three
varieties.  It is certain that superficial  vulvitis, that is, entirely 
BLENNORRHAGIA IN THE FEMALE.
179
external, admits of prompt and easy cure.   This is not the case
when it becomes phlegmonous, and when the glands become in-
volved ; I have already stated, that  abscesses may supervene,  and
fistulas, the treatment of which is  long and difficult, especially
when the latter complication exists.   Vaginitis, even when super-
ficial, is generally more difficult to cure than vulvitis; especially is
it the case, when the cellular tissue is more or less involved, when
the  whole vagina/ and  particularly  its superior  cul-de-sac  are
affected.   As regards rapidity of cure  urethritis occupies a middle
position between vulvitis and vaginitis.  Urethritis may easily be
modified by resinous substances, which are known under the name
of anti-blennorrhagics, but which exert no influence oyer the other
varieties.   Blennorrhagia is especially obstinate when it affects the
neck and body of the uterus; it then assumes a catarrhal form,
becomes complicated with engorgements which readily pass into
a chronic state.
   Treatment.—When I was  considering the subject of blennor-
rhagia in  general, I pointed  out the hygienic and  therapeutic
principles by which  we should be guided.  In treating of blen-
norrhagia in the male, I enjoined  certain precepts which have
their application here.  It remains  to constitute the special treat-
ment of blennorrhagia in the female, and to render the matter more
intelligible I  will adopt the same divisions as in describing the
disease in detail.                                    '
   1.  Vulvar Blennorrhagia.—That which is superficial, in addition
to general and local bathing, requires the use of pledgets to isolate
the inflamed surfaces.  The weak solutions of nitrate of silver,  and
of acetate of lead, which were recommended in the treatment of
balanitis, may here be beneficially employed.   These means gener-
ally suffice to  cure the local disease in the course of eight days, or
to manifestly improve it.   It must be distinctly understood that we
here speak of the superficial inflammation of the mucous membrane
alone.  But if it be of a phlegmonous character and the glands are
involved, then more active treatment is required; we must then
occasionally resort to the abstraction  of blood; bathing and the
topical use of emollient opiated applications should never be omit-
ted.  As with the deep-seated vulvitis chancres may exist  at the
commencement  of the vagina, without the  carunculse, chancres
which, by  their extent and  position,  may sometimes  escape  our
attention, we should  avoid the use of leeches, as the wounds which
they inflict about  the anus, and the genito-crural fold may easily
be inoculated.  When the female is young, robust, and somewhat
plethoric, it is better to open a vein in the arm, which practice  will
not  always arrest the progress of the inflammation, nor prevent
the  formation of pus, but will generally diminish  the  pain  and
tend greatly to limit the inflammatory focus.
   To return to  the topical applications; starch cataplasms, those
made from rice  farina are preferable  to those of flaxseed, which
when applied to the excited parte often give rise to eczema, during
the short time they may remain.
   The parts should be examined for the purpose of detecting sup- 
180            VTDAL ON  VENEREAL DISEASES.
puration.  Indeed, by early opening the abscesses, the focus of
inflammation is considerably lessened, and the cavity of the abscess
is placed in circumstances the most favorable for its obliteration;
the formation of burrowing sinuses and fistulas is thus likewise
obviated.  As a free incision is here of decided advantage when
an abscess forms  in the substance of  the labia majora, I prefer to
make the opening on the cutaneous  rather than on  the mucous
surface.  An opposite course would facilitate the  passage  of the
vaginal secretions into the cavity of the abscess, which may prevent
its closing, and thus expose  the  patient to the risk of purulent
absorption.  I have observed numerous facts which  tend  to cor-
roborate  this apprehension, and which cause me to insist  on the
importance of the precept here inculcated.
  Sometimes we are called upon too late; the abscess is  already
very extensive, and the mucous membrane detached and  attenu-
ated ; the opening by the skin can no longer prevent the spontane-
ous opening into the vagina.  We must then not be contented with
a free incision; we  must excise the detached mucous membrane,
expose the bottom of the abscess, in fine, reduce all  to one level,
and destroy the cul-de-sac which may have formed.   To effect this
object  it is necessary to excise not only the diseased mucous sur-
face but a portion of the sound tissues.
  2.  Vaginal-uterine Blennorrhagia.—In the treatment  of this affec-
tion injections are much employed.  Recently the tampon has been
added to these means.  But if the vaginitis is acute and compli-
cated, with decided inflammatory reaction, we should first resort
to antiphlogistics, direct and indirect.  We  may  commence by
taking blood from the arm; the bowels should be kept free.  De-
mulcent  drinks should be  administered; warm baths have  been
recommended, and injections, which are to  be used while the
patient is bathing; the injections may consist of a decoction of
poppy heads, to which a little starch may be added.   These decoc-
tions should be employed warm.   The  active character  of the
inflammation may  require the use  of  intra-vaginal cataplasms.
For this purpose we may inject powdered starch or ground  linseed
of a half-solid consistence.   These cataplasms cannot be employed
except where the vulvar ring is very large.  A syringe  may be
used from which the canula has been removed.
  When the inflammation  has lost ite intensity, and the reaction
has subsided, we may resort to the use of astringent injections.   I
recommend the  practitioner to commence with  the following
formula:
                    ty.  Aq.          1 xx.
                       Acet. Phimh. gr. xv.
                       Sulph. Zinc.  gr. xv.

  An injection morning and evening.

We may afterwards employ the following:

                   ]$.  Aq. Ros.     1 x.
                      Nit. Argent, gr. iiss. 
BLENNORRHAGIA IN THE FEMALE.
181
The strength of both these formulas may be gradually increased.
I sometimes advise the alternation of these injections with the con-
centrated decoction of the leaves of the walnut tree, either alone or
combined with an equal portion of tar water.  The injections are
rendered more  astringent in proportion to the chronic nature of
the discharge.  M. Ricord recommends the following formula:

               I}. Alum,           3i. to 3iL
                  Aq. Coram, (cold), fi>i.

Injections of acetate of lead should be preferred, when, to the other
symptoms of vaginitis, are superadded that of pruritus of the geni-
tal organs.  If this  does not exist, M. Ricord employs alum.  In-
jections of red wine, in which the red rose leaves have been boiled,
are still recommended in chronic blennorrhagic vaginal discharges;
or the following formula may be employed:

                   JJ,. Tannin pur.  3 iiss.
                      Aq.         ft>i.

   When we wish to use the tampon after the injection, the fluid
having come  away, with  the  speculum we  examine the deepest
parts of the canal.  Then, we introduce with  the forceps rolls of
soft charpie, or of carded cotton, until we form a perfect cylinder;
we then  have a elytroid (sheath-like) tampon.   Those who  have
followed for any length of time, the service of the Lourcine, can
appreciate all the benefits to be derived from this  practice.  This
method is attended  with its inconveniences, as it requires to be re-
newed daily, which is an  annoyance  both to  the  female and the
practitioner.   Hourmann  preferred carded cotton, M. Ricord em-
ploys dry charpie.  According to the latter, cotton is a mechanical
irritant, which even from ite fineness, somewhat irritates the parts
with which it comes in contact.  Besides, it  does not absorb the
vaginal secretion equally well with the charpie.  Charpie of lint
is to  be  preferred.  To each  roll  or  pledget of charpie a thread
should be attached  one end of which should portrude externally,
so as to facilitate its extraction.  Should the vagnitis resist these
means, we must then resort to the solid nitrate of  silver.  The
neck of the uterus having  been exposed by  the speculum, with
the caustic we whiten the whole vaginal  mucous surface, as  we
withdraw the  instrument, thus cauterizing it  completely  from
behind forwards.
   A. Intra-vaginal  Injections.—When there  exists blennorrhagia
of  the cervix  uteri,  I  employ chiefly intra-vaginal  injections or
douches.  The fluid used consists of a very concentrated decoction
of  walnut leaves at the temperature of the room, no matter what
the season of the year.  I use a large enema syringe; the bivalve
speculum is introduced, by which the cervix  is seized and well ex-
posed, the stream from the  syringe is thrown upon this part with
all the  force which can be applied to the piston.  Immediately
afterwards, a strong tampon of charpie is placed on the neck of the
uterus.   A liquid of this kind thus injected produces as it were a 
182           -VLDAL ON VENEREAL DISEASES.
kind of compression on the neck of the uterus, and diminishes in
temperature;  it acts beneficially also, by its astringent qualities;
sometimes singular phenomena are developed.   The cervix is ob-
served to grow pale and to decrease in size; and it seems to con-
tract.   These phenomena  do not always occur, particularly that
pertaining to its color:  sometimes, however, I have seen the color
increased during the injection.   It has also happened, that when
the uterus is relieved of the mucosities in ite neck, at the moment
that the injection strikes the latter part, new collectionsof  mucus
have been brought away,  showing the retraction of which  I have
spoken, and perhaps even a kind of contraction of the womb.
  The female seldom  experiences pain at the moment of  the in-
jection.  After she has returned to her bed, she sometimes  suffers
from colicky pains, especially about the hypogastric and iliac re-
gions.   I have observed, that these pains are frequently felt about
the time that  the  cure commences, and instead of being to me a
source of anxiety,  I regard them as a good omen.
  The following is worthy of  note:  when these  injections were
first employed, the number of  cases in which colicky pains were
felt was much more considerable than at the present day, notwith-
standing they consisted of the same liquid, and that the same pro- t
ceeding, the  same method of  administration was  adopted.   This
cannot be explained by the fact that females have now become ac-
customed to these  injections, for persons daily submit to them for
the first time.   Perhaps it would be more correct to say that the
disposition of the  uterine cavity (I'esprit  de la salle) had become
accustomed to their use.  I shall again advert to this circumstance.
  These douches have  frequently expedited in  an extraordinary
manner, the cure of certain  engorgements of long standing, and
have  speedily produced  the cicatrization of the  most  obstinate
ulcerations.  I saw at the Lourcine a woman set. forty;  there was
a granular ulceration of the cervix uteri of some eight or ten  lines
in extent  in each  direction, two or three injections reduced  their
diameter one-half.  These injections  have besides an advantage
which no  one can dispute ;  they free the vagina and neck of the
uterus from their mucosities and secretions which are more or less
acrid, and which may exert a greater influence in perpetuating or
even producing certain ulcerations than is generally supposed.'
The  application of a tampon of charpie  around the  neck of the
uterus, isolates the latter and thus promotes its cicatrization.  The
stream of the  liquid injected, moreover, determines a momentary
compression, which compression favors the resolution of  all en-
gorgements.
  These injections are employed twice a week;  they must not be
used during the menstrual period, nor during for two days  before
or after this period.   Pregnancy precludes  their employment;
they should not be resorted to under four months from the time
of labor or miscarriage.  When the cervix is very red and  turgid,
leeches applied to  the  arms, hip-baths, and general bathing,  com-
plete the treatment.  During the days that the above injections are
not used, the woman may continue  her occupation, using  herself 
BLENNORRHAGIA IN THE FEMALE.
183
the astringent injections whilst lying in the horizontal position
with the pelvis raised as much as possible.
  B.  Tntra-utcrine Injections.—The object of these is  to  introduce
the medicated liquid not only into the neck but also into the cavity
of the uterus.  They are  therefore  employed when  the blennor-
rhagic affection has extended to the womb, and when  it has as-
sumed a chronic form, and has become  a kind of uterine catarrh.
These injections  at first encountered  strong opposition  in the
lecture room and in the journals; then the question of priority was
raised, showing at  once their real  success.   I was  compelled to
disavow my claims  to the invention  of this method;  I claimed the_
merit only >»f retaining  it on the therapeutic^ and! even desig-
nated several contemporary inventors of it, all  for  the sake of
peace, but in vain !   More recently, I devised a much more simple
plan to settle the question of priority;  I think that I  have dis-
covered that it is of Greek origin.   I have availed myself of the
historical  knowledge and politeness of M. Daremberg, who has
proved, by the most authentic quotations, that the women of ancient
Greece were injected. But whenever  reference has been made to the
employment of injections by the Greeks, it has been  asserted that
they were limited to the vulva and the vagina. To this I called M.
Daremberg's attention; he has referred to me a very learned note on
this historical point;  showing conclusivelythat Greek surgery, which,
as is well known, was very bold, attacked even the uterine cavity, and
that, in fact, intra-uterine injections  were actually employed.
   The first objection to  their use is the risk of peritonitis to which-
they expose the patient.  Those who  urge  this must  of course
suppose that they pass from the cavity of the uterus to that of the
peritoneum;  the  intra-uterine become  therefore intra-abdominal
injections; the peritoneum becomes inflamed.  I cannot notice all
the various assertions that have been made on this topic,  nor all
the petty  declamations to which it has given rise.   I shall dwell
only upon that which is of importance,  and will commence by ap-
pealing to experimental facts.   I have instituted three  series of
experiments on the cadaver, to ascertain whether fluids injected
into the cavity of  the uterus, can reach the Fallopian tubes, and
through them the peritoneum, and how it can thus happen:
   1st. Forced injections ; 2d, copious injections ; 3d, moderate in-
jections.   1st.  To administer the forced injections, such  a syringe
was employed as is used in  our  amphitheatres to  inject the ar-
teries ;  the canula  having been introduced within the  neck, the
latter was bound by a ligature around  the  tube  so  as  to render
impossible the return of the fluid injected.  The piston was pushed
with all the strength of a young and vigorous man.
   These forced and prolonged injections were made  on uteri de-
tached from the body, and which were not in the puerperal  state,
but belonging to women who had borne children. The result was
that the liquid penetrated first the uterine vessels, and when  these
were emptied very slowly, it  passes  into the  Fallopian tubes, and
reaches their peritoneal  extremity.   The first series of experiments
proved the extreme difficult}'- of penetrating  into the tubes, even 
184
VIDAL ON VENEREAL DISEASES.
when great force was employed;  it proved the possibility of thus
injecting the uterine veins.   Such are the difficulties in causing
the liquid to penetrate the Fallopian tubes, that if the cervix uteri
be attached to the canula of the syringe by the ordinary proceed-
ing, the injected fluid returns between the canula and the eervix.
To avoid this reflux, it is necessary to pass, with a curved needle,
a thread through the mouth of  the  uterus, so as to embrace  a
thinner layer of the cervix, which is then brought more closely in
contact with the canula of the syringe.
  I need not here dwell upon all  the results obtained by this first
series  of experiments, pertaining as they do not only to the ques-
tion of therapeutics  of which I treat, but also to that of the func-
tions of the uterus, the history of its diseases, and of general thera-
peutics.
  2d.  In the second series  of experiments, with the copious in-
jections, a canula was introduced into the cervix having the dia-
meter  of a female  sound;  the cervix was  not fastened  to  the
canula, and the injections were continued for  a long time.   Now
the liquid was returned, passing between the instrument and the
neck;  sometimes it  reached, but  slowly, the  Fallopian tubes ; oc-
casionally it penetrated the uterine vessels.
  This series  furnished the  greatest  variety  of results, as might
have been anticipated from the structure  of  the uterus, its modi-
fications by age, and the functions which it performs.  Thus, if we
inject  the uterus of a female  who has never borne children, we
find the cervix uteri very small  in diameter;  it is  filled  by the
canula, and the fluid injected is returned into the vagina with more
difficulty than when the same operation is performed on that of
one who has been the mother of several children, and in whom the
diameter of the uterine neck is greatly increased.  The diameters
of the orifices of the Fallopian tubes must also present marked dif-
ferences arising from their greater or less permeability in different
women.     :
  The size of the canula  must therefore vary according to  the
state of the cervix;  a large quantity of liquids should not be in-
jected, and the injection should not be prolonged.  The two  fol-
lowing points should be  particularly noted;  the liquid does  not
penetrate (if it does penetrate) the Fallopian tubes, except when  a
large quantity is used, and when the pressure on the piston  has
been long continued.   In  every instance  it requires a long time to
reach the Fallopian tubes.
  3d. In the moderate injections which constituted the third series
of experiments, a syringe was selected such as is used for injecting
the urethra;  only five drachms  were  thrown into the womb.
When pressed with no  greater force than  that  ordinarily em-
ployed in injecting the external auditory canal, the  fluid did  not
reach the FaHopian tubes, but always returned into the vagina,
passing between  the  canula and cervix.   We need  not be very
strong vitaliste to understand that the passage of a liquid  into
canals  like the Fallopian tubes is still more impossible in the liv-
ing than in the dead  body. 
BLENNORRHAGIA IN THE FEMALE.           185
    Now, from a little reflection upon these experiments, and the
  unhappy results which have been attributed to them, we come to
  the  conclusion, that  if these unpleasant effects ever did  follow,
  copious and forced injections must have been employed, and that
  had the contrary practice been  pursued, the results  would  have
  been different.  Those who preceded me used for their intra-uterine
  injections a clyster or a hydrocele syringe.  Now, I maintain, that
  even with  such instruments, strictly speaking no accidents oc-
  curred.   I have been told that M. Recamier washed the interior
  of the uterus with water without the least hesitation;  and my con-
  frere, Dr. Cardeilhac, assures me that he has passed and re-passed
  pints of  sulphurous  water  into the uterus of one of his patients.
  He thus cured a purulent uterine catarrh, which had resisted many
  medications directed by respectable practitioners.
    We are taught by experiment that it  is extremely difficult to
  penetrate the Fallopian tubes by injecting the uterus of a cadaver.
  In taking precaution to guard against such an  accident in the liv-
  ing body, it would be most unfortunate  to produce the contrary
  result, as it would be truly extraordinary if these tubes are  more
  permeable in the living than in the dead female.
    The  following is the method of proceeding : the bivalve specu-
  lum is first to be introduced, and the cervix rectified if  any devia-
  tion  exist.  A silver or glass canula is then introduced within the
  neck, its  diameter being fully one-third less than  that  of  the or-
  dinary female sound.  It is well to have still  smaller canulas for
  females who have not borne children, and for maidens with  narrow
  necks of the uterus.  The importance of this precaution has been
  understood since I first made known my proceeding, a  precaution
  which  I have observed since  my first experiments on  the living
  subject.  I desire thus to facilitate the return of the liquid injected.
    A small syringe, containing five drachms of liquid, is fitted to the
m canula, and the fluid is injected suddenly by a single effort.   I for-
  merly used a decoction of walnut leaves, and a solution containing
  iodide  of potassium, and of iodine.  I now employ, most gener-
  ally, one and half grains of nitrate of silver in  about three ounces
  of water.  The strength may be increased ; only one drachm is to
  be injected at a single sitting.
    The quantity of liquid is so small, it is injected so suddenly, and
  with an instrument the extremity of which plays  in the neck of
  the uterus, that we can perceive the impossibility of the smallest
  portion of it  reaching the Fallopian tubes. What is to be appre-
  hended is, that it may reach the uterine  cavity.  There are  cases
  in which such an occurrence does take place.   It occurs when a
  douche, a preparatory injection, has not been employed  to remove
  the mucosities which collect, in the  majority of cases, in the cer-
  vix,  and which impede the introduction  of the medicated fluids
  destined  for the body of the uterus.  But when  this obstruction
  has been removed, and the cervix rectified, the injection  is easy
  and complete.  An injection may be used every morning;  seldom
  have I been compelled to resort to more than eight  during the
  whole treatment. 
186             VIDAL  ON VENEREAL DISEASES.

  In no instance should the injection  be employed unless a satis-
factory diagnosis  has been made ; it  must be borne in mind that
we  are  treating a uterine  catarrh which is protracted by a local
cause.   And as the uterus is an organ subject to great changes, as
its condition at the approach of the menstrual period, as well as
for a short time afterwards, differs from that in which it  is found
in a state of complete  repose, and especially as  its condition is
modified after an accouchement or miscarriage, the use of the in-
jections should be deferred as long as possible  after the periods
mentioned.   Prudence also demands that we carefully  examine
the state of  the other abdominal viscera.  Without these precau-
tions, certain phenomena, and even accidents, may occur, which
may be attributed to the injections, but which, in  reality, are due
only to their untimely administration.
  Especially should we avoid injections after an accouchement, when
the mouths  of the uterine veins are still widely open.   A case has
been recorded in  the journals, in  which water, impregnated with
chlorine, has been injected into a uterus  under the circumstances
just indicated; of course accidents were not long in manifesting
themselves.
  At the Lour cine, it was proposed to inject the uterus of a woman
whose previous history was unknown.  She had recently miscar-
ried.   The  accidents which  followed the injection were at first
referred to the side of the belly; they resembled the premonitory
symptoms of # peritonitis, but assumed a singularly nervous char-
acter.   The lower extremities  continued cold;  it was impossible
to warm them ; in fine, a kind of intermittent fever set in, which
I combated  with the sulphate of quinine.  This female  remained
in a painful rather than diseased state for nearly a month, but left
the Lourcine cured of her  uterine catarrh.  I advise an  examina-
tion of the  condition of the other  abdominal viscera.  If there be
any irritation of the stomach, or intestines, if digestion be difficult,
if there  be diarrhoea,  and especially if the large intestine are
affected, we certainly should abstain from  intra-uterine injections,
or we  should not resort to them until these complications have
been removed.  The following case shows the necessity of exam-
ining into the condition of the intestinal canal before  we employ
them.
  A woman, aet. 20, had long suffered from fluor albus ;  an exam-
ination with the speculum revealed a  redness of the cervix; a con-
siderable quantity of dirty mucus issued from the womb.  An in-
jection of nitrate of silver was administered; immediately after-
wards, the patient was  seized with colicky pains  and chills; she
had six stools during  the day, and  there was febrile excitement.
This woman, on being more closely questioned as to her previous
history, stated that  she was subject to  attacks of colic; that her
digestion had been impaired: all of which she had concealed from
the fear that she might be  placed on an  allowance.  This patient,
like the others, was cured after four injections—the three last hav-
ing produced no colic.   It is evident that the  colicky pains, the
diarrhoea, and trifling  accidents  which were  observed in  this 
                 BLENNORRHAGIA IN THE FEMALE.           187

  woman  after the injection, existed previously,  though in a less
  decided form.  All were exasperated by this trifling operation,
  and simple rest was sufficient for their disappearance.
    We here insert the particulars of a case which affords us another
  example of a cure, and which, at the  same time, gives us an idea
  of the 'modifications of sensibility which are  sometimes observed
  after these injections.   We shall see that this state does not pro
  perly constitute an accident, but a phenomenon which can scarcely
 ' be called  morbid.  A female, aet. twenty, who  had never born*
  children, but who was troubled with fluor albus of very long stand
  ing,  had an ulceration of the  cervix uteri  of a fungous aspect,
  about the size of a franc piece.  Douches to the cervix with cauter
  ization,  healed the ulceration.  A muco-purulent discharge' con-
  tinued from  the  os tincae.   After a  detergent  injection, one  of
  nitrate of silver was thrown into the uterus, and ten days  after-
  wards the leucorrhoea had disappeared.  In  this  case, the woman
  suffered pain immediately after the injection; she compared  them
  to those which precede the appearance of the menses ; they lasted
  during the whole day and the  night following the operation.
  Twenty-four  hours after the injection these  pains ceased without
  the use of any medicine.*
    The abdominal pains  which follow the injection are far from
  being constant.  Most generally, the women who are injected  at
  the hospitals seem indifferent to what is being done;  it happens
  that, at the moment  of the injection, the  patients complain of a
  burning sensation which  extends from the pelvis to the umbilical
  region;  it may also happen that this pain, or modified sensibility,
  is manifested in the iliac  region.  It is seldom that the pain which
  is felt at the moment of operating, even when the liquid penetrates
  the uterus, is of long duration.
    Some females, instead  of suffering  during the injection of the
# liquid, experience pains at the expiration of one or several hours;
  sometimes, however, it is sooner felt.  These pains seldom  con-
  tinue twenty-four hours after the injection; they generally sub-
  side  in about  three hours from their commencement.  But,  I
  repeat it, these colics are an  exception to the general rule; they
  occur scarcely in one  out of ten who submit to this proceeding;
  they subside spontaneously after a rest alone,  and are not abridged
  by treatment.   However, as females generally wish to have some-
  thing done, to satisfy the mind, we may prescribe some soothing
  potion.   A still better course is, by encouraging words, to inspire
  confidence and to persuade the patient that she is sure to recover.
    Should the abdominal  pain continue long after the injection, on
  questioning the patient  closely, we shall find that this pain is an
  old affair, an  ancient lesion.  A woman whom  I injected at the
  Lourcine complained for a long time of a pain in one of the iliac
  regions.   I discovered, by questioning and repeated examinations

    * M. Callant, at that time my interne, has reported other cases of the kind. The
  subjects were females who were brought to the Midi,  to make room at the St.
  Lizare for the insurgents wounded in June, 1848. 
188
VIDAL ON VENEREAL DISEASES.
with the fingers, that in this patient there was a disease  of the
ovary which had been of long standing.
  I have said sufficient on the subject of these pains which have
so greatly alarmed practitioners; they are not produced by the
irritation or inflammation of the peritoneum which had suffered
from contact with an irritating fluid ;  they are the result of uterine
spasm, and to excite, them, it is  not  always necessary to act di-
rectly on the  internal surface of the uterus, or to penetrate its
cavity.  The touch, cauterizations, douches to the  cervix, simple
vaginal injections of the most emollient nature, and those admin-
istered by the female herself, when they scarcely pass beyond the
vulvar ring, may all give rise to violent attacks of colic.  One word
further in reference to one of my critics on this  subject (an honest
man, and acquainted with the diseases of the  uterus).  This es-
teemed confrere observed formidable accidents follow a  vaginal in-
jection made by the patient herself.  Think you that this observer
wrote on the risks  that may be  apprehended from vaginal injec-
tions ? By no means; he composed a very fine article to prove from
this case, that intra-uterine injections cannot be used without danger.
  3. Urethral Blennorrhagia.—The treatment of this disease in the
female should  be similar to that pursued in the male.  Copaiba
and cupebs should here be  administered according  to the formulae
already mentioned. Thus, the electuary which I prescribe, copaiba
one part, cubebs two parts, produces in the female effects anal-
ogous  to those  obtained in the  male.  Only the dose should be
more  moderate,  as it is easier to provoke  disturbance of the di-
gestive organs;  in  them colic and diarrhoea are more  frequently
observed.
  As regards  injections, I generally recommend those of an as-
tringent character; such as the sulphate of zinc and the acetate of
lead dissolved in rose-water, or a solution of the nitrate of silver,
but of a strength to cauterize the parte.   H this effect be desired,
it would  be still better to employ the solid caustic, and the ordi-
nary crayon of the pocket-case will suffice.
  In describing  the accidents of  blennorrhagia  I have alluded to
ovaritis and local peritonitis.  When we suspect  these complica-
tions, we should  resort to the local abstraction of blood, by the ap-
plication of leeches to  the affected parts; recommend prolonged
bathing, and rub in mercurial ointment over the regions to which
the leeches have been applied.
                      CHAPTER IV.

         BLENNORRHAGIA OF  BOTH SEXES.

  The anus and the mouth have been observed to be the seat of
blennorrhagia, both in the male and female.  It is said that simi-
lar discharges have been seen in the nose,  the ears, and the infun- 
ANAL BLENNORRHAGIA
189
dibulum of the umbilicus; this would be umbilical blennorrhagia.
As I have no knowledge of these last-named varieties, I shall con-
fine my observations to those which are seated in the anus and the
mouth.
                        SECTION  I.

                ANAL BLENNORRHAGIA.

  Notwithstanding the frequency of unnatural  intercourse, anal
blennorrhagia is rare in comparison  with  the  forms which we
have already considered.  The discharges  observed in this part
are for the most part consecutive, or proceed from mucous tuber-
cles, and chancres.   In the adult female, as well as the little girl,
the muco-pus which sometimes escapes from the vulva, when the
person is in the horizontal position, bathes the margin of the anus,
and produces in this part a kind of blennorrhagia.  When the dis-
ease results from a suspicious connection,  there is  more or  less
deformity  of the anus, its folds are effaced, and it assumes a more
or less funnel-shaped form.  The lining membrane is preternat-
urally red, and it is rare that excoriations such as are observed in
balanitis are  not found.  The  surrounding skin is more or  less
heated, and exudes a moisture.  The heat  and  pain are not con-
fined to the anus, but extend to the rectum, at which part the pa-
tient feels an uncomfortable sensation of weight.  The discharge
may be  confined to the anus, the buttocks, or it may proceed from
the rectum; it is then more copious, and issues, from time to time,
in streams, when the patient goes to stool, which is frequent, or
during  our examination; occasionally it occurs during the emis-
sion of  the urine.  By the touch, we detect  an unnatural heat and
turgcscence.  M. Reynaud speaks of a speculum ani which enables
us to discover a redness of the mucous membrane which is contin-
uous and  uniform,  or confined to particular points.   In the treat-
ment of this disease, the first thing to be observed is  rest  and
cleanliness.  A tampon of charpie should  always be interposed
between the buttocks, and we should  begin  with the use of emol-
lient lotions, small  enemas of marsh-mallow, and gentle laxatives.
When the acute stage has passed, we may resort to lotions  and
injections  of the acetate of lead.  These may be followed  by the
decoction  of rhatany.   If these astringent injections do not suffice,
we whiten the margin of the anus with a  strong solution of the
nitrate of  silver, and we even inject a solution of the strength of
from a grain to a grain and a  half to eight ounces of water.  A
small glass syringe should be used like that employed for urethral
injections. The administration of copaiba and cubebs by the mouth
is now abandoned, for not only do they not produce any beneficial
effect, but excite in the lower part of the  rectum a mischievous
irritation. 
190            VLDAL ON VENEREAL DISEASES.
                        SECTION II.

                BUCCAL  BLENORRHAGIA

  The following is the substance of my knowledge on this sub-
ject.  It is copied from the work of M. Baumes.
  "A short time since," says the physician of Lyons, "a laborer
came to  consult me:  the left half of his lower lip was tumefied,
red, hot,  and painful, and there were several whitish granulations
on  its lining membrane, from which exuded a  kind of purulent
discharge.   This membrane had precisely the aspect which the
lining membrane of the neck of the uterus presents from blennor-
rhagia.   This person, who  had  been under treatment for more
than a month and a half, informed me that this affection appeared
some six or eight days after he had kissed the  vulva of a female
who,  as he  afterwards learned, was suffering from blennorrhagia.
Notwithstanding all the soothing measures which up to this time
have been employed, I have not been  able to procure more than
a trifling abatement of  this specific inflammation, evidently deter-
mined by blennorrhagic matter.*
                      CHAPTER  V.

                         CHANCRE.

  The syphilitic virus, when brought into contact, under certain
conditions, with the living tissues, produces two principal effects:
1st, a form of inflammation, which is called blennorrhagia, from
ite product; 2d, a form of ulceration, which is chancre.  I have
already traced the history of blennorrhagia;  chancre  will, form
the subject of our present investigations.   It is one of importance,
and worthy of the reader's serious attention, particularly as cer-
tain syphilographers regard chancre as the only medium by which
syphilis can be admitted into the system, as the first condition and
the sine qua non of the pox.   Hence the  doctrine, that without a
chancre, there can be no pox.  Facts and the most legitimate analogy
show  the error of this proposition.
  Seat.—Chancre in the  male generally occurs at the point of re-
flection, the cul-de-sac  of the prepuce, on ite edge, whilst in the
female, it is found external to the caruncula myrtiformes, near the
fourchette.  The cases are exceptional, where it  is observed on
the lips, the anus, the  nipple, and at  different points on the skin,
especially that adjacent to the genital organs, where it is delicate,
and has undergone a  kind of mucous transformation.  Mr. Mac-
* Baumes, t L, p. 210. 
CHANCRE.
191
Carthy, whilst one of the internes at the Hopital du Midi, collected
the statistics of chancres found in extraordinary situations.   Of
these one was observed in the nose, one on the gums, one on  the
tongue, three on the lips, two on the chin, four on the hand, two
on the scrotum, fifteen on the anus, seventeen on the urethra, and
three on the thigh.*
  Chancres are generally exposed to view, and are observed with-
out difficulty: in this  case, they are called patent, to distinguish
them from those more  deeply seated in cavities and canals, which
arc  termed concealed (larve).  We may here remark,  that  this
chancre larve has been much abused.   Its existence occasionally
problematical, mysterious, and always difficult  of detection, has
singularly  obscured the  theories  entertained on syphilis.  More-
over, there are concealed chancres which may be found, and there
are those which are never discovered ;  the latter are those which
are especially abused.
   [M.  Ricord, though he himself disavows any such claim, is erro-
neously regarded by some as the discoverer of the chancre larve.
It was distinctly noticed by  Benjamin Bell (On  Venereal, vol. 1st,
p. 22), and by Mr. Judd (On Venereal, p. 186), but for the exag-
gerated importance  first attached to this concealed chancre,  the
entire  credit is certainly due to M. Ricord.  In his Letters, v.,  pp.
34, 35, he states, that inoculation first and pathological  anatomy
afterwards, furnished him with incontestable proof of its existence,
a fact which, as we have shown, was long before  established.  We
have also attempted to appreciate the value of this  "incontestable"
proof,  and we think we have  shown, even by his own experiments,
that inoculation  cannot  be relied upon as  the  exclusive test  for
chancre, and as to his pathological evidence, the  rebutting testi-
mony  of such men as MM. Velpeau, Vidal, and  Dr. Gross, render
it far from being incontestable.   The specimens  delineated in  his
Iconographie, and repeated in his  Notes to Hunter,  we believe  are
all that pathological anatomy has yet afforded him; at least after a
diligent search throughout his various works, we  have been able
to  find no other.  Chancres at the meatus, or an inch within  the
urethra, are  not uncommon; every practitioner must have seen
numerous cases of the  kind, but the deep-seated chancre, we think,
has more frequently been presumed than proved to exist.  Thus,
Mr. Aeton has reported (op. cit. pp. 300, 301, Am. ed.) a  case of
"indurated,  urethral chancre, with secondary  symptoms."   No
mention is made of the existence  of bubo, " the necessary, inevi-
table result"  (Ricord, Lett, viii., p. 65), and " the  almost absolutely
certain result," according to Mr. Acton himself (op. cit.  p. 285),
of  indurated urethral chancre.   The  secondary symptoms,  too,
consisted of rheumatism, an inflamed  throat, and  an herpetic or
eczematous eruption, all of which circumstances render it proba-
ble  that the diagnosis made by Mr. Fichlin, of Cambridge, who
treated the case prior to Mr. Acton, for blennorrhagia, was correct
Mr. Henry J. Johnson (op. cit.) remarks: "I have  not myself wit-
These inaugurate, p. 13, et suiv. 
192
VEOAL ON VENEREAL DISEASES.
nessed more than three unequivocal cases; one at the Lock Hos-
pital, one  at St. George's, and  one in private  practice."   These
cases were presumed to be instances of urethral chancre  from the
fact that there was "a circular  yet flattish induration,"  about an
inch or an inch and a half from the orifice,  and that they were
followed by secondary symptoms, which were cured by mercury.
On almost the  next page he has reported two cases of blennor-
rhagia, followed by constitutional symptoms, and in these he does
not even  intimate his suspicion  of the existence of a concealed
chancre.  Mr. Langston Parker (op. cit. pp. 101,105), has detailed
some cases of supposed urethral chancre, but in a letter dated May
31st, 1853, with which  he has politely favored us, he observes:
" In the class of cases to which I have alluded, the existence of
the chancre has been presumed,  not  demonstrated;" and in the
same letter he  adds:  "There do  occur, from time  to time, cases
of secondary syphilis, in no way to be distinguished from those
which succeed to an ordinary chancre, which own as their origin
and source discharges from  the  urethra only, which discharges
apparently in no way differ from common gonorrhoea, and an ex-
amination of the urethra either during or after the  disappearance
of such discharges, no vestiges of contraction,  cicatrix or stricture,
or any condition incompatible with a  healthy organization, can
be detected.  Surely, if a concealed, a urethral chancre  had been
present, its  healing must have  left  some mark  behind."   Mr.
Johnson, as we have seen, based  his diagnosis upon the fact, that
the disease was cured by mercury, and that there was induration
in the canal.  Mercury, we believe, is not at  the present day  re-
garded as the test of syphilis, and induration,  in itself, is a  sign of
no importance, as  it  may arise from abscesses, which are not un-
common consequences of blennorrhagia. Although the connection
between urethral abscesses and induration is distinctly noticed  by
M. Ricord, in his Lectures (Gazette des Hopitaux, 1847, p. 473), we
find him  in his Treatise inferring from the latter symptom alone
the existence of urethral chancre, as in Case XX.,  p. 113, Am. ed.,
and others too numerous to mention.   The actual state  of the
question  has been admirably  expressed by M.  Bertherand, of
Strasburgh, in his Prize Essay on Syphilis.  " True," he  remarks,
" urethral chancres do exist, but it is no less true, that the number
of those which have been recognized on the living, or detected
after death, bears  no proportion  to  the number of cases of blen-
norrhagia which are followed by  constitutional  accidents."  Such
is the  opinion of some of the most eminent surgeons of Great
Britain, as we were personally assured on our recent visit to that
country, and such, we doubt  not, is the sentiment of the majority
of our  own most experienced practitioners.
   In adverting to the seat of chancres, we may also remark, that
while non-specific ulcerations are exceeding  common on  the cer-
vix uteri, chancres are rarely met with in this  situation.  This
fact is particularly noticed by Dr. Henry Bennett in  his excellent
work on  Inflammation of the Uterus,  3d ed., pp.  437, 451.  It is
also confirmed by  Mr. Egan (op. cit. p. 125).  He  observes, that 
CHANCRE.
193
 during his attendance at the Lock Hospital for four years, he did
 not see a single example of the Hunterian chancre on the cervix
 uteri.   What renders the testimony of Mr. Egan on this point the
 more  valuable, is  the fact,  that this hospital is exclusively for
 females.—G. C. B.]
   It will be perceived that the differences of seat and of tissue give
 rise to differences of form, of aspect, and of other peculiarities
 which I shall be particular to indicate.
   The tegumentary  surfaces to which the virus is applied may
 exist in two principal conditions:  there may be a solution of  con-
 tinuity, an  ulceration or wound, or they  may be intact.  In the
 latter case, where  the virus is applied on a surface more or less
 excited only, or where it is applied at the moment a solution of
 continuity of surface occurs, as for example, at the time of a rup-
 ture during coition, the same condition obtains as when a puncture
 is  made for  the purpose of inoculation.   It is evident that when
 there  is a solution of continuity, or when this occurs even at, the
 moment  of  inoculation, certain local phenomena  must always
 speedily become developed; these  may not appear, or if they do,
 appear at a later period, in cases where the surface of the integu-
 ments remains intact.
   Characteristics of Chancre.—To facilitate  our investigations three
v different stages or periods of chancre may be admitted; that of the
 pustule,  of ulceration, and  of  cicatrization; in other words, the
 pustule of chancre, or properly  speaking, chancre, is a suppurating
 wound.
   First Stage.—Pustule.—A distinction  should always be made,
 and especially here, between experimental inoculation and physio-
 logical inoculation, in other words, from true contagion.  Experi-
 mental inopulation will almost certainly produce the pustule;  it
 may be studied de visu.  Physiological inoculation, on the contrary,
 will rarely afford us  an opportunity of observing the pustule if it
 be observed at all.  Let us consider the first effects of experimental
 inoculation.   From the first day,  after the insertion of a small
 quantity of pus taken from a chancre, a red point is noticed where
 the puncture is made.  On the second day there is a slight eleva-
 tion, then a pimple.   Soon a demi-turbid humor, then that which
 is completely turbid, fills the little  cavity.   From the third to the
 fourth day we find a vesicle, a pustule, or  a bulla.  At first there
 is a diffused redness around the puncture; this redness  becomes
 circumscribed in proportion to the development of the pustule; an
 areola forms, furnishing us with evidence of the extent of skin
 about to be detached.  K the pustule be not  destroyed, on the
 sixth day its summit becomes flattened and is covered with a scab.
 Beneath the first scab another is seen still  larger, and other layers
 exist,  which together represent a truncated cone, surmounted by
 the first concretion.  The  surrounding tissues  then become cede-
 matous and  indurated.  If the pustule now be opened, three days
 afterwards may be seen the signs of specific ulceration of chancre,
 as  will be presently described.  Such are the  effects of experi-
 mental inoculation when the lancet has penetrated a little deeply.
                               13 
194            VLDAL ON  VENEREAL DISEASES.
 They commence at the moment of the puncture and occur without
 interruption.  Let it be observed that there  are here two things;
 a puncture or a wound, and the insertion of a virus; in other words
 a poisoning.  This double action I will here merely mention;  its
 explanation will be attempted hereafter.  So much for the experi-
 mental pustule,  which is open to our view, as it may be made to
 form under our eyes.  But observe, what is called the •pustule of
 chancre does not always present the same characters;  it exists with
 or without a depression in its centre; its contents are more or less
 turbid; in fine, it presents the characters, more or less, of ecthyma,
 but these characters are not always identical; sometimes it is even
 a pemphigoid bulla, the diameters of which  exceed those of the
 ulceration.  If there exist no pathogmonic form of eruption, neither
 is there a characteristic pustule.  The eruption, moreover, does not
 always follow the progress which I have  described.
  K the  pustule arising from experimental inoculation, performed
 in a certain manner, is most generally of easy detection, such is not
 the case  with  that from physiological inoculation, from contagion.
 I have often directed the attention of students to this fact, during
 my gratuitous consultations at the Hopital du Midi: they may pass
 years in my  wards without once  meeting a case in which the
 pustule is observed to precede a chancre.  Further, we have care-
 fully watched individuals affected with very inoculable  chancres
 on  the edge of the  prepuce, by the side of  which new chancres
 would form from day to day.  They were attentively examined
 every morning,  and the initial chancre was never seen; in every
 instance  the debut was an ulceration.  It does not follow, however,
 that ulceration is always,  absolutely always, the phenomenon first
 observed, for an abscess may precede a chancre.  Thus, the syphi-
 litic virus may be absorbed by a mucous membrane, and be carried
 to a greater or less distance from  the surface of application and
 absorption; an abscess may be there produced, and its opening by
 ulceration will be  nothing more nor less than  chancre.  Such  is
 the  condition of things in case  of primary (d'emblee) syphilitic
 buboes.   I am  aware that practitioners  have cauterized  vesicles
 and  pustules on their first appearance around the glans.   But  as
 these pimples  were not pathognomonic, and as,  according to these
 practitioners, we may confound the vesicles of acne and of herpes
 with the incipient pustule of chancre, I conclude that we cannot
 be sure that we destroy the latter by cauterization when it is prac-
 tised under the circumstances mentioned.
  I remark, in conclusion, that experimental inoculation may dis-
 tinctly produce the vesicle or pimple which  precedes chancre; that
 the form of this vesicle or pimple has nothing  characteristic, and
 that experience has always shown me the chancre already entirely
 developed.  Thus, I do not assert that chancre is always primary
 (d'emblee); I do  not  absolutely deny the  existence of the pustule
 of chancre; I assert that I have never observed it, and that those
 who suppose that they have, admit that it is difficult to distinguish
 it from certain other eruptions which are observed on  the genital
.organs, hence  I conclude that they have been mistaken. 
 
Hatr l
Fie 2
Fig 1 .^m-aiitr«(6<r da-M'tfJ(/yn-H M< >///(?/(/■ MX/ sYys/'t7/'//7a rAf/<//&> /{Ac/rZ/sr At*Aw>







        lie 3  ^#* &///-(■ ^/efeft*'W irtfufata/ii/ cxancx  i->s  ///<w. >./ ,y ,•///,
/
W.Dresex. o.c: 
CHANCRE.
195
   Second Stage.—Chancre.—This is the chancre, properly so called.
The ulcer is of a roundish form.  (Fig. 1, Plate II. represente a
follicular chancre on the glans, the circular form of which is almost
geometrical; the regularity of the chancre on the summit of the
glans is interrupted by the meatus urinarius).  Its base is irregular,
appearing as if covered with little cells, and is of a yellowish gray
color, more or less strongly marked.  Its  edges are perfectly per-
pendicular (see Fig.  1),  and more or less  indented and detached.
A violet red circle surrounds the ulcer, the breadth of which is in
proportion to the detachment.  Generally this ulceration involves
the whole  thickness of  the integuments, and the tissues immedi-
ately subjacent are  more or less indurated and tumefied.   Thus
the base is more or  less indurated,  as are the edges  of the ulcer;
the tumefaction of the latter causes them to be inverted, and the
ulcer is then of an infundi-buliform shape.  The ulcerated tissues
are not entirely exposed; but are covered by a pseudo-membranous
layer, the formation  and reproduction of  which takes place with
the greatest rapidity. This false membrane has been regarded as
the matrix, the secreting organ of the virulent pus.   Chancres are
of various dimensions, from the puncture scarcely visible with the
naked eye, to an ulceration of the diameter  or even  greater than
that of a franc piece.
   They are not generally numerous; they are two or three ; and
when  they exist in greater numbers, they  are  follicular, and
are very near to each other, either on  the glans, the prepuce  or
the vulva.  The following are the most common characters of the
regular chancre, that which is most  frequently observed.  But the
ulceration  is not always sufficiently deep to remove the whole
thickness of the integuments, and  its edges are not well defined.
Occasionally the centre  and borders of the chancre are found  to
be elevated so a<* to form a fungous projection; it is then the raised
(eleve) chancre, (ulcus elevatum.)  The circular form is not always
reproduced, and depends sometimes on the nature of the tissues
involved; thus, in the folds of the anus, we meet with the elongat-
ed form, and the circle is  more or less deformed when different
"kinds of tissue are  invaded: on the edges of the glans and the
prepuce chancre encroaches rapidly in the direction of the prepuce,
where it finds least resistance, it is then no longer circular.   When
two adjacent chancres  come in contact, they become one, which,
however, is not of a  circular form.
   At ite commencement, chancre is sometimes the seat of a pruri-
tus, which occasionally becomes very severe.  It is the only modi-
fication of sensation of  which the patient complains.   Sometimes
there is a  real pain, which may become so intense, as to prevent
the patient from sleeping, and require a modification in our treat-
ment :  this phenomenon is observed when chancres are concealed
beneath a prepuce  with a narrow orifice,  and in  phagedenic
chancres.   But the pain is most frequently slight, and in  some
cases is felt only after some irritation, as from  coition, which^may
lead to the detection  of a chancre of the existence of which the pa-
tient was before ignorant 
196             VIDAL ON VENEREAL DISEASES.
  The surface of a chancre is bathed with pus more or less sanious,
sometimes bloody, and mingled with organic detritus.  This pus
is alkaline, and contains animalculae which, however, is not a pe-
cularity of chancrous pus.  What gives  it ite specific character,
is the  syphilitic virus, which  is regarded  as the  product of  tho
false membrane covering the tissues denuded by the ulceration.
If the  chancre is seated on a mucous membrane, if it be not  ex-
posed  to the contact of the air, this pus remains in  a fluid state;
but if  seated on the skin, and exposed to the air, it concretes and
the ulcer is covered with crusts.
  Chancre is generally of slow progress; it lasts sometimes from a
month to several years, and during this long period may retain its
power  of reproduction.  M.  Ricord cites in his lectures an instance
where  the duration of the chancre was seven years.   He maintains
that chancre is never spontaneously cured in less than a week.
  Third Stage.—Cicatrization.—When a chancre is about to heal, it
passes  into  the condition of a wound, that is to say, its virulent
membrane  gives place to  an modular,  cicatrizing membrane.
Long since  I  established in my work on surgery* that the differ-
ence between an ulcer and a wound  consists in the  difference of
the membrane secreting the  humor which covers the two solutions
of  continuity.  When  this cicatrizing  membrane  appears, the
edges of the ulcer which are detached, sink, and approach the base,
to which they unite.  The inequalities of the base, the indentations
of the  borders disappear,  and  are replaced by fleshy  granulations,
resembling Ijiose in suppurating wounds.  The violet red circle is
succeeded by an areola of a  pearly gray color.   As the healing of
the ulcer progresses; its circular form becomes changed, and angu-
lar  at  several points of its  circumference, because its edges  are
drawn inwards and in an unequal manner, by the inodular mem-
brane,  which has replaced the  lardaceous layer already mentioned
in treating  of the  progress of chancre.  The cicatrix which suc-
ceeds to chancre, Hke that of every solution of continuity with loss of
substance, is shrivelled and depressed; sometimes, instead of being
depressed, it is, on the contrary, elevated, like a honey-comb.   On
the mucous membrane these marks at length completely disappear.
  Once the healing process commences, its progress is rapid,  for it
is now no longer that of a chancre but a wound.   Cicatrization is
not complete while there  remains a single  point of the grayish
base.   This point may extend, become developed, and the chancre
itself be renewed, or, to speak more  correctly, become enlarged
and  invade the cicatrized portion, and the adjacent integuments,
which were not before attacked.  But when the cicatrization has once
covered the whole solution of continuity, a return is no longer pos-
sible ;  before another chancre can appear, there must be a new in-
oculation.  This is perfectly true, and accords with the opinions of
M. Ricord.   It is well to note particularly this point in the history .
of chancre, that it may not  be forgotten when we come to decide
upon»the results of the inoculation of secondary accidents.
Vid. t. L, 3d ed., article Ulceration 
CHANCRE.
197
  Incubation.—Non-localization.—Two  important questions  here
arise, of deep interest in a doctrinal and practical point of view.
The first concerns the subject of incubation; in other  words,  it
asks, if the  syphilitic virus, when applied to  our tissues, remains
inert or in  a dormant state, during  a  certain period, to be after-
wards  aroused and to produce  effects which  are externally appa-
rent.   I believe in incubation, that is  to say, I believe that the
virus  may remain for some time a cause without effect, at least
any appreciable  effect.  Hunter admits the incubation: he adds,
even,  that the interval is longer between the application of the
virus  and its external manifestations in  chancre than in blennor-
rhagia.  M. Ricord here is opposed to Hunter; he maintains that
virulent pus, when applied to our tissues, produces an instantane-
ous action, which remains local, three, four, five and even six days;
at which period, if with caustic we destroy the ulcer, general  in-
fection is prevented.   M. Ricord invokes the aid of experiments
and confounds ite results, that is, inoculation by the lancet with
physiological inoculation,  or real contagion.   From  the puncture
made by the impregnated  lancet, and the pustule which follows,
even to the  formation and cicatrization of the chancre, he sees one
uninterrupted series  of phenomena.  But by inoculation, by the
wound made in  the skin, we create a new surface, a traumatic sur-
face which is not in the same condition as the normal surface  on
which pus  is only deposited.  The lancet produces necessarily
traumatic phenomena, which ought to manifest themseves imme-
diately, after which the manifestations of the  virus appear, so that
there is generally no  interruption in the development of the, local
effects; but these effects are not identical, they are of different na-
tures ; one is a physical lesion, the other a specific affection;  occa-
sionally we observe even  a stationary period by which the two
effects are separated.  Further still, in consequence of certain very
superficial inoculations, several days may elapse before any phe-
nomena are produced.  So much for the knowledge  derived from
experiment, when we know how to vary our  proceedings.
   The advocates of incubation appeal to analogy and to carefully-
observed facts.   Thus, the greater number of morbid poisons re-
main in the system for a certain length of time, without any evi-
dent external manifestation; they are  there  in a state  of incuba-
tion.   Why may not the syphilitic virus obey the same law ? But
facts  favor  this  opinion still more than analogy.  M. Baumes de-
clared that a certain prostitute was affected with chancre; not-
withstanding the advice of this physician, this  woman had con-
nection with an  individual who washed himself immediately.  This
person was subsequently attended by the same practitioner, who
carefully watched the progress of his  case;  it was not until the
fifth day that a chancre, preceded by a kind  of a little solid scale,
appeared on the penis.  I  am acquainted with a precisely similar
case.   A young man had  intercourse  with a  prostitute;  this
woman was famous  for her beauty.   The young man informed a
friend of his adventure.   The latter who had already obtained a
chancre from the same woman, acquainted the young  man with 
198
VIDAL ON VENEREAL DISEASES.
 the fact.  The latter, very much frightened, applied to me.  For
 four days, during which I attended him, I observed nothing.  On
 the fifth day, a chancre appeared.  Among the cases observed by
 M. de Castelneau, in which incubation preceded the development
 of the chancre, the majority of these patients were careful of their
 persons, and one of these was a confrere, who was engaged in the
 study of venereal diseases.
   Now for the other question: Is chancre entirely a local affec-
 tion, or more properly speaking, are the effects of the virus at first
 confined to the locality to which the latter is applied ?  How long
 does  it remain in this  locality?  On this subject we know no-
 thing, and experiment does not remove the uncertainty connected
 with  these questions; four, five and six days are mentioned, be-
 cause after the destruction  of a chancre at these periods, by cau-
 terization  and its  conversion into a simple wound, cicatrization
 takes place,  and the ulcer is not reproduced.   Now there are
 chancres, which, even if destroyed  at the earliest period mentioned
 in the above category,  are nevertheless reproduced in the  same
 place; of this we may be convinced by perusing the work of M.
 Ricord ; we shall there learn that this experiment has not always
 succeeded in completely destroying the effects of inoculation.  Be-
 sides, the complete disappearance of a chancre is but a part of the
 proof of the limitation of the effects of the virus;  to be absolutely
 certain that its action had not extended further, that it has not in-
 fected the system, we must watch the patient for a long time, and
 see that the accidents do not afterward occur which are called con-
 stitutional.  Now  this  counterproof,  unlike  the  clinique, experi-
 ments have not furnished.  Indeed, numerous observations prove
 that  chancres which have speedily and entirely  cicatrized,  have
 after a time been followed by secondary accidents, and the work
 of M. Reynaud of Toulon, contains the report of a ease by a phy-
 sician  who  saw on  the genital organs two  pustules which he
 thought would be followed by chancre.  These pustules he imme-
 diately  cauterized, yet secondary  accidents were not prevented,
 although after the cauterization, the patient  abstained from sex-
 ual intercourse.  This case is corroborated by the experiments
 made by M. Reynaud, Professor  at  Alfort; he inoculated the
 virus of glanders;  the puncture was first cauterized at the end of
three days, this was repeated  two days, and lastly in twelve hours
 afterwards  Now, in no instance was infection prevented.  Again,
 M. Bousquet has cauterized the vaccine pustule on its first appear-
ance, yet the subject was refractory to the influence of variola. M.
Bousquet, after a discussion on the time required in vaccination to
affect the  system,  expresses  himself as follows:  "For my own
part, convinced as I am, there is actual infection during the period
of incubation, I firmly believe that the person vaccinated has ob-
tained the  fullest influence  of the matter  a  few  hours after the
 pustules have appeared." (P. 529).  The same author again re-
marks :  " With a double object in view I have  opened pimples
a short time after their appearance.  I have then  cauterized them
deeply with caustic potash, so as to destroy the local action of the 
CHANCRE.
199
, vaccine matter.  In the next place, I have re-vaccinated these same
 children, in whom  it might be  supposed that the vaccine matter
 had not entered the system,  and no  matter what precautions I
 took, the second operation always failed."   (Bousquet,  p. 534.)
 M. Ilennequin, a  physician  who is  deservedly so  highly  es-
 teemed, gives himself but little uneasiness about the number of
 pustules; one  suffices to inspire  him with a feeling of perfect se-
 curity, and he  permits any one to  collect the vaccine matter.  " As
 soon as,  and even before the  pimple appears, the prophylactic
 effect is produced." (Bousquet, p. 540.)  Thus, in vaccination, the
 general, precedes the local action, or more properly speaking, the
 local is but the result of the general condition.  The same is true
 in the case of  the syphylitic virus: when chancre has formed, in-
 fection has already taken place.
    Admitting the localization  of chancre, what are its limits ?  Is
  is confined in its action to the ulcerated, indurated tissues, in  fine
  to the evident  anatomical lesions, or does it extend to those which,
  at least apparently, retain their normal structure?  No positive
  answer  has been  given to these questions.   But, mark  it well;
  those surgeons who at first cauterized the  pustule with the nitrate
  of silver, now resort to a more powerful caustic, one which acts
  to a greater depth, viz. the Vienna paste.  Whence the  change?
  Because the caustic first used failed  in more than one  instance.
  Moreover,  the operation of circumcision, when chancre exists,  has
  more than once furnished proof of the possible infection of tissues
  apparently sound,  and at a certain distance from the  chancre ; for
  example, I have sometimes excised almost  an  inch below chan-
  cres on  the edge  of the prepuce; I have found the skin, mucous
  membrane, and cellular tissue  entirely sound, and yet the wound
  became transformed into a vast chancre.
     [An  instance of the latter kind has recently come under  our
  own observation.    If, therefore, parts apparently sound are in-
  fected, how can we know the extent to which cauterization should
  be carried in order to insure the patient from constitutional con-
  tamination ?  M. Ricord states in his Letters (xxiv. p. 181) that
  by cauterizing twice the extent of the ulcer, he  has  always suc-
  ceeded.   From the conflicting statements  of this surgeon, how-
  ever, contained in the Letter to which we  have just referred,  and
  his Treatise (Ed. p. 221), we  are compelled to doubt this' constant
  success.   In his Treatise he speaks of his constant success with the
  nitrate  of silver;  in the above Letter he asserts that cauterization
  with the nitrate of silver almost always fails!  His own testimony
  is equally contradictory as to the influence of the extent and  du-
  ration of the ulceration upon constitutional  infection.   In his  first
  and twenty-eighth Letters, pp. 8, 208, he states that constitutional
  infection bears no  proportion to the seat, number, extent,  nor abso-
  lute duration  of a chancre; that  a small  chancre exposes equally
  with a large one to the risk of general infection,  &c.  In his twenty-
  fourth Letter, however (p. 181), he asserts that the sphere of viru-
  lent activity is in proportion  to the extent and duration of the ul-
  ceration !   In his  communication, also, to the Academy of Medi- 
200
VEOAL ON VENEREAL DISEASES.
cine, July 27th, 1852 (De la Syphilization, ke., p. 74,) he distinctly
declares that a large chancre produced a more extensive infection
than a smaller, as the extension of its borders constitutes so many
successive inoculations!—G. C. B.]
   My opinion on the subject of the incubation, and  the localiza-
tion of the effects of the syphilitic virus, may be thus expressed :
believing in the physiological absorption  of the virus; in other
words, absorption without previous ulceration at the point to which
the virus is applied, I should  be inclined to admit the doctrine of
incubation, and facts moreover show that this incubation is real.
In the localization of chancre  I  do not believe.  I do not think
that for a certain period the effects of the virus are limited to the
narrow sphere of a chancre.  I believe that a recently-developed
chancre, which already secretes a virus capable of inoculation, will
at the same time produce that which is capable of absorption.   In
certain conditions of the surface, when it is much excited, or there is
an excoriation, a wound, or puncture made for experimental inocula-
tion, local phenomena are speedily developed, which are represented
by a pustule or otherwise.  But these local  do not prevent the
general effects; they may occur simultaneously.   The physician
to whom allusion is made in  the work  of M. Reynaud, and who
witnessed the  development of the  pustules, was both inoculated
and  affected at the same time, for the destruction  of the local
effects, the pustules, did  not prevent the occurrence of constitu-
tional  accidents.  Under certain circumstances, on the  contrary,
the virus is absorbed without  producing at first a local effect, and
the latter is  produced by a reaction (contre-coup)r that is, after a
period of incubation of a portion of the virus.
   Varieties.—Thus far we have only considered the so-called regu-
lar chancre.   I have pointed out the characters by which it may
be distinguished.  I have also alluded to the  differences depend-
ing on the seat, and the  nature of the tissues affected, differences
which  may mask the ulceration, and change its form.   I now pro-
ceed to point out the varieties, the deviations of the primary ulcer,
which  are sufficiently marked  to be  separately described, and this
for the sake only of their  study.
   It is during the progress of venereal ulcerations that their most
remarkable deviations are observed, and chancres may so differ in
form as to constitute, varieties.
   1.  Phagedenic Chancre.—This is  a repetition of terms, for the
word chancre signifies a gnawing corroding affection;  but chancre
has ite conventional limits, which, once broken, go to  establish the
varieties now to be studied.   The progress of the phagedenic af-
fection  is not  always uniform, and its characters may vary, by
which  sub-varieties  are  constituted. Thus, there are  chancres,
the ravages of which  extend almost equally around the  centre,
which is their starting point;  when  cicatrization commences, it is
observed equally at all these points.  On the other hand, there are
phagedenic chancres which describe  circles and demi-circles, which
festoon a region, which have, in fine, a serpiginous progress; we then
see cicatrization going on at one point, and the ulceration at another. 
                          CHANCRE.                      201

  [The phagedenic primary ulcer has been  observed by Messrs.
Acton  and Kgan to occur in the following proportions: in ex-
amining M. Ricord's wards  for this purpose, Sept. 20th, 1847, he
found  but  5 in 112 cases of primary sores, and Mr. Egan (op. cit.
p. 49) states, that out of upwards of 300 cases of primary infection,
he met with but ten  which assumed  the  phagedenic character
from the commencement.   We are  satisfied,  that, like  hospital
gangrene, this form of ulcer is met  with much more frequently
at some seasons than at others.  Years may pass, and in the same
hospital but few cases will occur; then, of a  sudden, it shall rage
with much severity.  This was noticed by Benjamin Bell.  In his
work on the venereal, 2d vol. p. 22, he remarks that he met  with
more instances of this phagedenic chancre  than he had  seen for
several years before, and in  four of them the affection was traced
to the same  woman, a fact  tending  decidedly to corroborate the
doctrine of a plurality of poisons.   It was  formerly much more
prevalent in this country than at present.   In 1818-19,  '20, and
again in 1827-28, it prevailed to a considerable extent in Philadel-
phia (M'Clcllan's Surgery, p. 239.)—G. C. B.]
  The  two first sub-varieties which I shall  describe depend more
particularly upon gangrene,'—the first to ordinary gangrene, the
second to what is called hospital gangrene.
  a. The first sub-variety is termed gangrenous chancre.  Ulcera-
tion being in my opinion  but a form of gangrene, I regard  all
chancres as gangrenous;  but in ordinary chancre, the gangrene is
molecular, whilst in the  so-called gangrenous  chancre, there are
notable portions of tissue of  greater or less extent involved; for
example, fragments of  the prepuce, a part of the penis, &c.; it is
therefore the gangrene of  small portions (parcellaire).
  At  present I have in  my wards sftc patients affected with  gan-
grenous chancre.  This variety is more frequently observed in sub-
jects in whom congenital phimosis exists, or who, although able to
uncover the glans, have nevertheless a preternaturally elongated
prepuce.  As the glans resists the effects of gangrene more than the
prepuce, the latter becomes more particularly affected.  Generally
it is on the dorsum  of  the penis that we find the prepuce per-
forated to a greater or  less extent. The  glans sometimes escapes
by  this opening; the upper part  of the prepuce is forced down-
wards, and the penis assumes a bifid form.  Sometimes only a
small  portion of the  prepuce, connected with the frenum, is left.
Finally, the  gangrene may effect a complete circumcision, de-
stroying the whole  prepuce.   The glans  is generally invaded to a
greater or less  extent.  I  have observed  exceptional cases, in
which the  glans alone  was attacked, appearing like a little pimple
on the end of the urethra.  The prepuce remained intact.   It hap-
pens also  that the penis is sometimes completely carried away;
prepuce, glans, cavernous body, urethra, all are swept by  the gan-
grene,  which has therefore  performed a kind of amputation.   At
present there is a person in my ward (No. 9) whose penis is  de-
tached a little above the  scrotum.
  Six  subjects which have  come under my observation, had a 
202             VIDAL ON VENEREAL  DISEASES.
good constitution: they had been guilty of excessive indulgence
during hot weather.   One  had a high fever and delirium before
the gangrene was established.  During the formation of the eschar
the patient generally suffers acute pain, especially if the glans be
the part affected; the separation of the eschar is rapid, and the
wound which follows is speedily cicatrized.  I have not observed
consecutive  accidents in patients who have had gangrenous chan-
cres with considerable  loss  of substance of the prepuce, although
some of them remained two months under my care.  It is said
that gangrene is  the result of the excessive inflammation of the
tissues surrounding  the chancre, and that  this gangrene, by re-
moving the entire ulceration, prevents general infection.  But be-
fore the gangrene is developed, the virus may already have entered
the circulation, as happens in cases where  the gangrene  is pro-
duced by caustics, when the virus may penetrate the system.
   b. The  second sub-variety is called the diptheritic or pidtaceous
chancre.   It  is most frequently observed in feeble and aged sub-
jects, in children who  are  placed in unfavorable hygienic con-
ditions, and in persons debilitated by a bad regimen, or  an  im-
properly-managed mercurial treatment.
   This form of ulceration  bears the most striking  analogy to
hospital gangrene;  the chancre  is in fact  complicated with this
kind of gangrene.  The base of  the ulcer is  yellow, with points
more deeply colored, and which bleed; it is tomentose, fretted and
jagged; the  surrounding tissues  and the base are thickened and
indurated.   The  skin  is of a vinous red color, and detached, for
the destruction of the  cellular tissue  precedes that of the integu-
ments.  The skin afterwards  subsides,  becomes  perforated, and
finally suffers the fate of the cellular tissue.  The parts in which
the purulent or  rather sanjpus  matter accumulates, are those in
which the destruction is most  complete; these become distended
with organic detritus.  I have seen a pultaceous chancre of the
prepuce destroy the entire tegumentary covering of the penis even
in the scrotum.  If we attempt to wash the base of such an ulcer,
it bleeds, and we remove but the  portions of false membrane  by
which it is covered.  This kind of coating is  immediately re-
produced.
   The patient experiences hot and stinging sensations with severe
pruritus: he is, as it were, conscious of the  destruction going  on
within him.  When the nerves become  exposed by the gangrene,
then the patient  suffers all the tortures  of neuralgia.   There is a
low grade  of fever,  and an emaciation  follows which ruins the
constitution.   The patient's system  sometimes  resists until entire
regions  are made bare, as for example, the whole  inguinal region,
a part of the thigh, and sometimes of both thighs.  An aged pa-
tient, a septuagenarian, was  lately brought in a desperate state to
the Hopital du Midi, where he died from consumption, produced
by phagedenic chancres, which had destroyed the greater part of
the penis, and transformed the two inguinal regions into enormous
caverns.   The autopsy as noted by my former interne, M. Pellagot,
revealed the following: I transcribe it fully, because autopsies of 
CHANCRE.
203
this kind aie rare, and because a morbid condition of the thoracic
canal was here found, which I believe has not before been noted.
The reader will perhaps  be astonished that  the lungs were found
perfectly sound, and this too, with a very evident tubercular con-
dition of the most important portion of the Lymphatic system.
   " But a few traces of the penis, the starting point of the chancre,
were left.  In the left inguinal region was an ulceration extending
to  the femoral aponeurosis, which  had destroyed the superficial
fascia and the  ganglia without touching the vessels.  The right
inguinal  region was the seat of a vast ulceration or gangrenous
cavern, extending from Poupart's ligament, its superior boundary,
to the junction of the superior with the middle  third of the thigh.
The tissues were entirely destroyed and the  vessels were exposed.
The crural  nerve was dissected even to its origin.  The arterial
tunics were thickened but not yet  ulcerated.  Very  extensive
coagula were found in the crural vein, which was the seat of some
inflammation.   The internal saphena was destroyed  as high as its
origin.    Adherent  coagula were  here  found, which  explained
the absence of hemorrhage during life.  The  stomach  and intes-
tines  presented  nothing  abnormal,  with the exception of a slight
redness, and hardened faces in the cavity of  the latter.  Well-
organized layers of fibrin adhered to, and were interwoven with,
the columnia of the ventricles of the heart.   The cardiac muscu-
lar fibres were a little pale and discolored, but not softened. There
was a milky layer on the pericardiac surface. A slight hypostatic
engorgement of the convex border of both lungs were discovered,
but the  rest of these  organs crepitated perfectly, and  presented
neither purulent foci  nor  indurated nuclei.  Lymphatic system.
Both iliac fossa  were the seat of a peculiar ulceration.   The
cellular  tissue of  these regions, especially that of the right side,
was indurated, and studded with tumefied lymphatic ganglia of
which some were filled  with  pus.   These  numerous masses of
ganglia  surrounded the internal iliac arteries and the termination
of  the aorta;  they also embraced the thoracic  canal as  far as its
termination, reaching  even to the left  subclavian vein.   The
thoracic canal itself presented at long intervals considerable no-
dosities resembling in fbrm a stirrup (chapelef).  On incising  these
nodosities, there were found within the canal lymphatic deposits
resembling ganglia.  The greater number of these, hard at their
circumference, were soft in the centre, and had suppurated" like
those of the iliac  fossa.  The osseous system presented nothing
abnormal."
  The third sub-variety is the serpiginous  chancre.  Instead of
starting  from  a single  point hke the preceding variety, and ex-
tending  more or  less  circularly, encroaching  upon the tissues
which offer the least  resistance, the  serpiginous chancre follows
circles,  or portions of circles, more or less regular, like certain
consecutive  ulcerations,  as the serpiginous syphilida.   When
cicatrization resists ite  progress on the one part, the chancre gains
on  the other.   It may  then  be compared  to  a creeping plant.
Sometimes cicatrization begins in the centre, and the  ulceration is 
204
VIDAL ON VENEREAL DISEASES.
observed at its circumference; so that, in the middle of the ulcer,
there is  an inodular disk, which always increases in size, whilst
the borders become likewise more excavated and enlarged.
  The serpiginous  chancre most frequently coincides with  the
tubercular diathesis and the dartrous vice.  Sometimes the tuber-
cular condition is not manifested among the antecedents of the
serpiginous chancre, but only at an advanced period of the disease.
I have witnessed this peculiarity in  a patient under my care in
Ward No. 11.  Occasionally the  herpetic vice is hereditary.   In
one  subject, it  was  not  manifested  by any particular symptoms,
but became developed during the progress of the chancre, which,
together with its  form, it modified, &c.  The scorbutic vice like-
wise plays an important part in this singular variety of phagedenic
ulceration.
  In these three sub-varieties, two are clearly capable of inocula-
tion, viz., the diphtheritic and the serpiginous ;  such, however, is
not the case with the gangrenous chancre.   According to M. Ri-
cord, the latter does not  produce secondary symptoms, and is
rarely followed by buboes; and when these occur,  they subside
and disappear  even before the gangrene.  The consecutive acci-
dents of  the two other sub-varieties have not the grave character
of the chancre by which they are produced.  Everything here
depends upon the condition of the patient, of his constitution,  and
the diseases from which he is suffering at the time of his infection.
  2. Indurated  Chancre.—Induration, in other words that deposi-
tion of plastic lymph beneath and around the ulcer, which gives
to chancre its peculiarity, is an inseparable feature in this disease:
according to Babington, it even preceds the ulceration.  Accord-
ing  to this writer, all chancres  are indurated.  Thus expressed,
this proposition is admissible, and I am disposed to  accept  and
defend it.  I believe, in fact, that the specific ulceration  called
chancre is, in all cases, more or less indurated.   This opinion  has
always prevailed: to the idea of chancre,  has always been  added
that of more or less induration; thus Astruc, who gives  a sum-
mary of  the  views  entertained by every writer on  syphilis who
had preceded  him, defines  chancre a small, round, and callous
ulcer*
  With Hunter, induration is the rule.  Babington maintains that
Hunter's description applies to 49 out of 50 cases.  We give Hun-
ter's own words:  "A thickening of the part comes on, which at
first, and while of the true venereal  kind, is very circumscribed,
not diffusing itself gradually and  imperceptibly into the surround-
ing parts, but terminating rather abruptly" (p. 403, 2d ed. Ricord's
Hunter).   It is the classic induration, the  Hunterian chancre.   In
a note,  Babington adds:  " The character  of  primary venereal
infection is, essentially, induration passing afterwards into ulcera-
tion" (loc. cit. p. 409).  I should  add  that between this induration
so concisely described by Hunter, and this base which, according
to Benjamin  Bell, resembles a split dry pea, there are many de-
* Astruc, t. iii., p. 336. 
CHANCRE.                       205
 grees which, when carefully observed, go to establish the relations
 of the ordinary regular  chancre with the indurated chancre.   I
 will not, with Babington, assert that induration  precedes ulcera-
 tion ;  nor will I admit, with others, that induration is consecutive;
 I believe that  both these conditions may occur  simultaneously:
 whilst  nature affects a diuresis, it also  produces a synthesis, it
 condenses the tissues, or creates a fib^o-plastic tissue beneath and
 around the  ulceration.  One cause of deception, and the admission
 of non-indurated for the really induvatcd chancres, is that some-
 times the base alone is indurated, and the  edges  readily subside;
 or the edges alone are indurated, while the base does not present
 a marked consistence, or the inflammation which surrounds the
 chancre is sufficiently intense to conceal  the  induration.  There-
 fore, chancre is always indurated to a certain extent.  This  is the
 opinion which I profess.  The proof of it is, that  allusion is made
 to hard, hardened chancres, an expression which is diminutive of
 indurated chancres.  This truth, once understood, singularly sim-
 plifies the relations of chancre to the constitutional affections.
   The  following  are the characters of the indurated chancre, ac-
 cording to those who would at the present day recognize in  it  a
 separate form of chancre.  The induration represents a demi-
 sphere, or the base of a split pea, in the language of Benjamin Bell.
 This induration, this peculiar basis of  the ulcer, depends  upon an
 effusion of plastic lymph, and has almost  a fibro-cartilaginous con-
 sistence (vide Plate 2, Fig. 3), and a certain elasticity, which once
 observed, is  not soon forgotten.  The surrounding tissues retain
 their normal color and consistence, participating not the least in
 the chancrous induration which ceases abruptly, the boundary of
 which is a -projecting border, which  sometimes curls over under
 the corona glandis.  A perfect  specimen  of this chancre  is repre-
 sented  in the figure  already mentioned;  cicatrization  is taking
 place;  it is  not entirely round, but the cartilaginous character of
 the border is clearly recognized by the white reflection.   The sub-
ject of this  chancre was under the care of M. Puche.  A roseola
 had already  appeared at the base of the chest, in other words, the
 patient's system was completely infected.
   The indurated, chancre  secretes little matter; it is not always of
 a circular form, occasionally a portion of  its border projects and
 forms a crest.  According to M. Ricord, chancre does not become
indurated until the fifth day,  generally  not until after  the first
week.   This form of chancre is  observed more frequently in the
male than the female.  It  may be complicated with inflammation,
and even with gangrene.   When the  latter occurs, it is  central:
the inflammation appears  to have invaded the indurated portion;
it seems to  produce  strangulation, and, like all inflammations of
this kind, when left to itself, it  terminates by gangrene.  Thus
we observe eschars occurring in indurated chancre, which sooner
or later separate.  Fig. 2, plate 2, represents an indurated chancre
which has become transformed into a large  eschar, which transform-
ation was accompanied with severe pain.  It will be seen that a
portion of the glans has been removed, and the corpus cavernosuin 
206             VLDAL  ON VENEREAL DISEASES.
 exposed; further, after the separation of the eschar, cicatrization
 has commenced, and it is at this stage  that the sketch was taken.
 The patient was in Ward No. 11, of my service, at the Hopital du
 Midi.
   With the history of chancre have been connected questions still
 involved in obscurity.   By some, it  is maintained that the indur-
 ated chancre alone is  followed by syphilis, or that it is the start-
 ing point of the  constitutional disease;  others believe that it is
 principally this form of chancre which produces  the pox.  As I
 have shown that chancre  is always more or less indurated, it is
 unnecessary to refute this proposition.   Then again  it is asserted,
 that the chancre  must be  strongly indurated, to be  followed by
 consecutive accidents.  To this I reply, that these accidents have
 been known to follow chancres but moderately indurated, and the
 speedy cicatrization of those which were regarded as non-indurated.
 Moreover, those who make of the indurated chancre a separate
 variety,  admit that induration is not generally established until
 after the first week.  Now,  during this period, infection may take
 place,  and  generally it does not wait this term.  In  my opinion,
 instead of framing the question thus :  Can the  indurated chancre
 alone produce secondary accidents, or  does it produce them more
 frequently  than the other varieties of chancre ? I would rather
 ask, What connection exists between the indurated chancre and the
 constitutional disease ?  Certain it is, that the general state of the
 system modifies the form of the chancre, and wherever we find an
 action which can  be called syphilitic,  the reaction must be greater.
 For example, when chancre is obstinate,  when, from being moder-
 ately, it becomes  much indurated, and seems to constitute a separ-
 ate variety, I believe that the syphilitic virus has then for some
 time already infected the system.  The cause of the constitutional
 disease therefore exists, and the system is already infected.  This
 degree of induration proves only that  the diathesis is established:
 for the indurated  chancre is really a consecutive  accident, an  ex-
 pression of confirmed pox.   But the effect of the diathesis may be
 confined to this point;  in other words, we may have an indurated
 chancre, without any other manifestation of the general infection.
   [We are satisfied that the majority of practitioners do not coin-
 cide with the views of  M. Ricord, who would restrict  constitu-
 tional infection to the true indurated chancre.   Our own observa-
 tion has taught us the  correctness of the doctrine inculcated by
 Mr. Lane, in his valuable lectures published in the London Lancet
 for 1841-2, vol.  ii. p. 594.  He thus observes:  "The  practical
 inference I wish you to draw from these remarks is, that a mere
principle, an excoriation, a vesicle, a pustule, a minute ulcer, one
 covered with a scab or not, a  superficial ulcer, a raised ulcer, a
 deep  one, one  with or  without induration, a  spreading ulcer,
phagedenic  or sloughing, a stationary one,  a cicatrizing ulcer,
ulcers varying in form, in color, size, or  number, may contain, or
have  contained, the syphilitic  virus, and,  consequently, may be
 followed by the  secondary or constitutional disease."  Those  en-
gaged  in the study of syphilis cannot do better than to consult 
CHANCRE.                       207
these lectures by Mr. Lane, whose connection with the Lock Hos-
pital, London, and whose vast experience in the treatment  of
syphilis, render his remarks of great practical value.—Gi C. B.]
   Is it necessary to reply  to the question:  Can a patient have
several different attacks of indurated chancre ?  Is it  true  that a
chancre, becoming developed after the indurated, will  assume this
form ?   But this is a complicated question, since all chancres are
more or less indurated; or, if we would speak of a strongly-indur-
ated chancre, the expression of the syphilitic diathesis, the ques-
tion becomes involved into this:  Can a person have the pox more
than once?  Experiment has already replied to this in the affirm-
ative ; and the ease observed by M. Boully, which we have quoted,
leaves no doubt on this subject.  I shall return to this question in
treating of the consecutive venereal accidents.  The indolent bubo,
which should be the inevitable accompaniment of the indurated
chancre, will be considered in the next chapter.
   3d.  The raised chancre (ulcus elevatum).—The base of this chancre
is raised by a kind of vegetation of the form of a round or 6val
basin, of a fungous nature, and more or less raised above the skin.
These chancres occur frequently on the edge of the  prepuce ; they
furnish a sero-purulent matter,  are generally not painful, and their
borders  and base are but  little indurated.   When cicatrization
takes place, it still remains for  some time above the level of the
skin, a flattened and whitened projection,  which is  slow in  disap-
pearing ; the cicatrix, after awmile, sinks to a level with the sur-
rounding parte.  Too much importance  has been given to this
form, not only in making of it a separate variety, but as giving
rise to  a peculiar kind of constitutional disease.  Fig. 1, plate 2,
represents three raised chancres on the prepuce, and two ordinary
chancres on the glans.  The  latter are the result of  inoculation
with the matter from the former; they are therefore all produced
by the same virus ; only those  on the prepuce assume a fungous
character, on account of the yielding of the loose  cellular  tissue
of the part, which cannot occur on the glans.   The subject of these
chancres was in Ward 10, bed  No. 13.
   Now, if we reflect on the different forms of chancre, which  I
have described under the head  of variclics, we find that they are
the result of complications.   Thus, the first variety  is complicated
with gangrene; another form,  the diphtheritic, with hospital gan-
grene, whilst the indurated serpiginous variety is connected with
the tubercular diathesis.   I believe that the raised chancre depends
greatly on the locality;  it assumes this form when it is seated on
loose cellular tissue, as on the prepuce.  I believe that this is the
most important practical view of the subject, in our investigations
into the causes of the deviations in the form of chancrous ulcers.
   Diagnosis.—In the majority of cases the diagnosis of chancre is
not difficult.   The practitioner who possesses a tact for observa-
tion, need but glance at an ulcer to detect  its syphilitic nature.   I
have already described chancre with sufficient minuteness  to aid
the young practitioner  in forming a diagnosis.  A round  ulcer,
with edges perpendicular and  a little detached from  the base,  a 
208             VLDAL  ON VENEREAL DISEASES.

gray  or  yellowish base,  covered with  little cells,  induration,  a
violet-red circle" located on a part concerned in sexual intercourse,
suspicious connection: these sum up the characters and circum-
stances by which a true diagnosis may be established.   But these
elements do not always fully exist, and they are sometimes modi-
fied and defaced :  thus,  both form and color may be chaifged, and
the uleer may be  seated in an unaccustomed locality.  I ntercst,
false modesty, may lead to the concealment, or a misrepresentation
of the antecedent circumstances.  The uniform test with M. Ricord
is the matter secreted by the ulcer:  if, on  inoculation, this pus
produces a chancre, its syphilitic character is established,  and the
other elements of diagnosis are of no value.
  But, as there are  chancres, the pus of which cannot always be
inoculated, this  test  cannot always be trusted; and  these are the
chancres which present  the most difficulties, and in  the diagnosis
of which inoculation would therefore be the most useful!  Such,
indeed, are the  chancres of unnatural shape, caused by cicatrization
or eome. other  complication, such the deep-seated  chancres,  the
chancres larves, for the  diagnosis of which  inoculation should be
so important, yet these are precisely the cases in which it fails.
(See my remarks  on the nature  of blennorrhagia.)   As  to other
chancres, those which  are open to  view,  and still progressing,
unmodified by the process of cicatrization, inoculation is here use-
less ;  it is even dangerous.  Thus, in doubtful cases, when it is of
importance to decide whether an ulcer is or is not a chancre, inocu-
lation is insufficient.  The differential  diagnosis  of  chancre,  in
other words the  distinction between primitive and  consecutive
ulceration  cannot be established by inoculation,  since I have
demonstrated that both of these form's of ulceration may be inocu-
lated.  We must, therefore, in obscure cases,  have  an  especial
regard for clinical  diagnosis; we must carefully collect the antece-
dent circumstances and  inform ourselves of the commencement of
the progress of the ulceration, minutely note all the  characters of
the lesion, and pay especial attention to those furnished by the tis-
sues in which the  ulcer  is seated.  If there be an  induration, and
if the other  circumstances  are in favor, we may regard  it  as  a
syphilitic ulceration; for, in my opinion, every syphilitic ulcera-
tion is accompanied with induration.   There are  cases in which
this  is the only character on which we can fix: indeed, certain
chancres of the fossa navicularis, or concealed beneath a narrow
prepuce,  are only discovered by the touch, which detects the indu-
rated points.  True there are other kinds of ulceration which are
indurated, but then  the concomitant circumstances  are different,
their  progress is not the same, and they lack the  circumstances
that precede venereal diseases.   Thus, cancerous ulcers have a more
or less indurated base, but their entire history shows  no connection
with chancre.   Sometimes it must be acknowledged, that notwith-
standing the most minute  attention to details, and the  greatest
power of grouping them in one assemblage which shall represent
their diagnosis, the latter still remains obscure, and our doubts are
removed only by the appearance of certain consecutive accidents. 
CHANCRE.
209
The young practitioner should therefore be very cautious in an-
nouncing his opinion, especially in courte of justice.  It is import-
ant that  he be forewarned not only that observation may lead to
mistakes, but that he should also understand the errors which may
result from experiment.  He has been told that inoculation affords
a test by which we may decide in medico-legal inquiries  now, as
it  is well established that there are true chancres which  are  not
inoculable, it therefore cannot possess a positive value.   What
would be thought of a test without a positive value, and of which
the negative response is to be totally disregarded!
   Certain ulcerations are observed in the buccal cavity, which may
be regarded as syphilitic ulcerations, and here I include those which
are primary and secondary, as in a practical point of view, the
difference  is of no great importance.  Mercurial may resemble
venereal ulcerations.  When mercury affects the mouth it produces
ulcerations, the base of which is whitish, milky,  and not gray or
yellow, like the syphilitic ulceration;  in fact, they rarely exhibit
ruptured vessels.   The circumference  of mercurial  ulcerations,
instead of being like the  syphilitic, of a violet red color, is pale,
like the interior of the mouth.   These mercurial ulcerations are
found particularly within the cheeks, on the edges of the tongue,
and especially behind  the molar teeth;  they  are numerous, and
their edges are  neither indurated nor  perpendicular.   Syphilitic
ulcerations may occur  in the same situation, but they are most fre-
quently observed on the palate, the tongue, tonsils, pharynx, and
at the commissures of the lips; their edges are perpendicular; they
are indurated and few  in number, being sometimes three or more.
Besides, in the mercurial ulceration there is a peculiar odor, with
more  or less salivation, and the patient complains of a  metallio
taste.
   Complications.—In speaking of the varieties of chancre I have
asserted that in reality they depend on complications.   There are
two other complications or accidents, of sufficient  importance to be
separately described; these  are phimosis and paraphimosis.  As
buboes may occur without  a previous  chancre,  and as accidents
completely primary, I shall  treat  of them under a separate head.
   This is an appropriate place for noticing a case which I believe
to be unique.   It  is that of a chancre of the meatus urinarius,
which so narrowed this orifice as to produce a retention of urine;
a  perforation of the bladder  afterwards occurred which might have
been regarded as  a chancre, or a rupture arising from certain
alterations which  rendered  it easily broken.  The following are
the particulars, as they were carefully noted by my interne,  M.
Codet.  In connection with  the report is a sketch of the pathologi-
cal specimen.
   C. (I.), a water porter, set. 26, temperament nervo-sanguineous,
constitution  robust.  Admitted March 18th, 1852, Ward No. 10,
bed No. 12, under the care of M. Vidal.  Health always good.
He ate heartily and drank much  wine.  Three years since he had
a  chancre in the burrow of the glans near the fraenum.   After fight
treatment  it healed in the  course of three or four months.  No
                                14 
210
VIDAL ON VENEREAL DISEASES.
enlarged ganglia in the groin or in the neck.  The cicatrix of the
chancre is smooth and soft as the parts by which it is surrounded.
No consecutive  accidents.  Eighteen months ago he contracted
a blennorrhagia; during this attack there was no retention of urine.
Pain was moderate during micturition, and the latter was followed
by slight hemorrhage.  Slight pain in perineum.  Orchitis on the
right  side soon  followed;  this  was  cured  in fifteen days.  The
blennorrhagia lasted for three months.
  In  the early part of February 1852,  he had another attack of
blennorrhagia, which appeared fifteen days after a suspicious inter-
course.  The discharge was very small, and there was but  little
pain in urinating.  C. does not know whether at this time there
were enlarged ganglia.   A potion  and  injections were prescribed,
but this treatment was very imperfectly followed, and at the end
of five or six days it was abandoned, the patient resuming his usual
habits of life, drinking to excess,  and perhaps working more than
ordinarily.  He wore no suspensory bandage; the discharge was
slight, as were his sufferings.   This state of things lasted until the
14th March, 1852.
  About the 13th of March, the  patient experienced some diffi-
culty in urinating; but on the 14th he was seized with an intense
cephalagia, and violent pains in the flank.  The  urine was voided
with  difficulty, and ite emission  was accompanied with a trifling
hemorrhage.   Constant  tenesmus, anorexia, bitter taste in the
mouth,  severe thirst.   On the  15th, the desires  to  urinate were
very urgent.   Micturition more and more difficult; slight pains in
the epigastric region;  spittle tinged with bile.  This condition be-
came aggravated, and the patient  entered the hospital on the 18th
March,  1852.
   18th.—Difficulty in walking.  He arrived in a carriage, and  it
was necessary to support him, whilst he mounted into the ward;
every movement, he stated, increased his suffering, which was in
the sides.   For three days he has  passed but a few drops  of urine.
The complexion is a little  discolored, and there is an expression
of suffering on  the countenance.  The  pain in the head and sides
is very intense.  Abdomen slightly distended; there is dulness
for nearly an inch below the umbilicus, whilst above,  there  is
tympanitic resonance.    The pulse  is  feeble and frequent, the
tongue  slightly loaded,  the mouth bitter,  thirst  severe.  From
time to time, the patient  discharged some mouthfuls of bile.  Res-
piration is a little accelerated.
   The prepuce, red and  swollen,  permits the meatus to  be with
difficulty exposed.  On the part adjacent to the frenum, a chancre
was found, of the existence of which the patient was unconscious,
and whose base was a little indurated.   The surface of the ulcera-
tion is limited,  it extending about a line into the canal.   A little
muco-purulent matter lies between the lips of the meatus; pres-
sure on the urethra does  not increase the quantity.  An examina-
tion, per rectum, detected a slight enlargement of the prostate.   The
ganglia in the groins are slightly enlarged (for what length of time
patient does not know).  The glans, like the prepuce, is red.  The 
CHANCRE.
211
 meatus, very contracted, will not admit an ordinary silver cathe-
 ter ; a small, gum elastic instrument, a little larger than a raven's
 quill, introduced within a stylet, passes with facility.   The pain
 is somewhat severe.   Haifa pint of urine was evacuated.  Its flow
 was arrested (the eyes of the catheter having become obstructed).
 A second catheter of the same kind, introduced in the same man-
 ner, encountered  some difficulties at the meatus, after which it
 passed with ease ;  it gave exit to nearly a pint of muddy, highly-
 colored urine, which  exhaled a decided ammoniacal odor.   The
 urine issued in a jet.
   In withdrawing the sound,  it was closely embraced by  the
 canal.   After  the use of the instrument,  some  drops  of blood
 appeared at the meatus.   Some hours afterwards, I  attempted
 again  to introduce the catheter; it  was arrested on a level with
 the bulb.  A large  cataplasm moistened with laudanum was ap-
 plied to the perineum (he had taken no bath at the hospital).  In
 the evening the patient felt better;  he passed his urine without
 the  catheter.  Abdomen still swollen, general  condition same as
 in the morning.   Laudanized cataplasms to the perineum, and to
 the abdomen.   On the 19th, M. Vidal saw the patient.   Condition
 same as  yesterday.  Examination by the rectum detected a slight
 enlargement of the lateral lobes of the prostate, which were sepa-
 rated by a slight furrow.   This  enlargement  was not painful on
 pressure.   No  pain in the perineum.   M. Vidal  enlarged  the
 meatus with a  bistoury.   A silver catheter  then passed to  the
 bladder  without difficulty; nearly a pint of urine was evacuated.
 Cataplasms with laudanum; two pots of whey ;  twenty leeches to
 the perineum.   In the evening, the  catheter was readily passed.
 Respiration more difficult than in the morning; fatigue increased.
 The urine deposited a sediment, having the  aspect of blackish
 powder.
   20th.—Passed a restless night; thirst troublesome; countenance
 somewhat  changed  from yesterday; abdomen more distended.
 The severity of the other symptoms has not increased.  Bath;
 laudanized cataplasm.  In the  evening, the  lips of the wound
 assumed the aspect of a chancre.  Patient is much worse; eyes
 hollow;  cheek-bones  prominent;  naso-labial prominence  very
 marked; pulse small, intermittent; pulsations from 110 to 120 in
 the minute;  no chills; abdomen moderately distended, but little
 painful.   Patient is troubled with vomiting of bile.
   21st,—Bad night;  delirium.   Pulse very feeble, and  intermit-
 tent, 130.  Vomiting, almost constant, of pure bile; severe thirst;
 dyspnoea increasing.   Abdomen tympanitic.  Constant  agitation
 of the patient in bed.
   Catheter passed readily, and brought away a little urine. When
 it reached  the  bladder, it seemed to be closely embraced by the
 neck of this organ, and its  movements were limited.  Apply one
 oz. of Neapolitan ointment to the abdomen; laudanized cataplasms.
 In the evening, the  patient was a little better, and could urinate
 without the catheter.
i   22d.—The slight improvement of yesterday has not  continued. 
212            VTDAL "ON VENEREAL DISEASES.
Violent delirium during the night;  anxious respiration; counte-
nance rapidly changing;  pulse  thready and very frequent;  con-
stant vomiting of bile.  Lungs perfectly sonorous, except poste-
riorly, along the pulmonary depression, where the sound is a little
obscured,  and mucous rules  are  heard.   The  abdominal walls,
constantly distended, were a little painful on pressure.   Pain in
the sides  very severe.  Catheterism; bath; continuation of the
mercurial  ointment; tilleul, two  pots (the whey yesterday pro-
duced a slight diarrhoea) ; laudanized cataplasms.  In the evening
pulse was  almost imperceptible.  Countenance  of a yellow  com-
plexion;  features  very sharp; lips dry;  tongue coated;  sides
constantly painful on pressure;  slight d'lirium; extremities  cold.
The catheter evacuated some spoonfuls of urine.
  23d.—Patient was delirious the whole night.  Constant picking
of the bed-clothes.   A small quantity of urine was passed by the
instrument.   Forty leeches to  the  abdomen;  bath;  laudanized
cataplasms.   Noon.—Abdomen  less swollen;  eyes  convulsed;
lips of  a  violet color;  extremities cold.  No pulsation at the
wrist.   Died at four o'clock in the afternoon.
  Autopsy, forty hours after death.   Weather cold and dry.  The
body exhibited no signs of putrefaction.  Cadaveric rigidity  very
decided.  The abdominal walls, having been opened by a horizon-
tal incision below the umbilicus, were found infiltrated with a red-
dish brown liquid, and were evidently softened.   Adhesions, con-
sisting of false gelatinous membranes, existed throughout the con-
volutions of the intestines.   The bladder adhered likewise to the
parietes of the abdomen; it had mounted about an inch above the
pubes.  Ite external surface was of a deep violet color.  In order
to expose the parts most involved, the urethra was divided through-
out its  entire length  by its superior wall;  the symphisis pubis
was also  divided.   An incision was made through  the prostate
from its pubic surface, and the bladder was opened by its anterior
wall.   It contained but little urine.   Its internal surface was gen-
erally red, particularly about the  trigonem.  On the right side of
the bladder was found an ulceration about the diameter of a twenty
centime piece; this ulceration penetrated through the whole thick-
ness of the organ; beneath it were false membranes themselves
perforated, at  two  or three points,  by which the bladder commu-
nicated with the abdomen.  (As before stated the original sketch
has been reduced to one-fifth its size.)
   The edges of this ulcer were clearly formed, and round, resem-
bling a cap surrounded  by a well-developed vascular band;  on
this cap were seen  small irregular whitish layers, which seemed to
be  sub-mucous and a little hard,  like incipient  vegetations;  they
were  scattered over the whole internal surface of the bladder,
but in much less number, than around the perforation.
   The prostate was but little enlarged; the volume of each lobe
being about  that  of  a small nut.  Its substance was highly in-
jected.  The  urethra was perfectly sound.   At the meatus, the
chancre was found, to which we have alluded.  Testicles sound.
The soft parts in the lower pelvis were softened  and somewhat in- 
 
 
 
j 
CHANCRE.                      213
filtrated with  urine.  In the abdomen  were traces of a  violent
 eritonis.   Sero-purulent effusion, large quantities of false mem-
 rane, covering all the  contents of the abdomen; as well as be-
tween the liver and the diaphragm.   The  kidneys presented no-
thing unusual; by pressure, however, a milky fluid was made to
issue from some of the calices;  in other respects they were per-
fectly sound.  The stomach and intestines when examined  from
their internal surfaces were sound.  The  liver was congested. The
spleen, very friable, was reduced almost to a pulp.  The heart
was  sound.  The lungs presented  no  traces  of tubercles;  they
were a little congested only, at their posterior surface; a portion,
of their surface taken from this  region would  not float in water.
The brain was slightly injected.  The inguinal  and  cervical gan-
glia were red and moderately swollen.
  There was, in this case, a solution of continuity in the bladder,
which  permitted the urine  to be  effused into the cavity of  the ab-
domen,  an accident  which was  mortal.  The  retention of urine
could have resulted only from the  enlargement of the prostate,
which, however, was not  considerable.   An obstacle existed at
the meatus, where was seated an indurated chancre;  but this ob-
stacle was trifling, for a gum-elastic catheter, of small size indeed,
(a little larger than  a raven's quill,) could  be introduced into the
bladder.   Thus, the obstacle was not sufficient to cause of  itself a
rupture of the bladder.   The perforation, moreover, did not pres-
ent the characters of a lesion entirely physical.
  1st. Did the instrument (the  catheter) perforate  the  bladder?
Besides that it wanted the characters of an entirely physical lesion,
it may be  added, that the catheter was  at  first introduced by a
well-informed pupil; it was small, of gum elastic, and as the stylet
was not used, consequently it must have been very flexible.  After
the division of the meatus,  I myself introduced the silver catheter,
and always with the greatest care..  I found no resistance, and its
introduction therefore required no effort.  In no instance was the
catheter allowed to remain.  Thus, the rupture or perforation of
the bladder, does not appear to  me the very probable result of a
physical lesion.   There  remain two other-hypotheses.
  2d. As there was a chancre  at the meatus, a very inoculable
one,  we may suppose that the first small catheter became charged
in its eyes with a certain quantity of virulent pus, and which being
thus carried into the bladder produced a chancre, or perforation by
ulceration in this organ.   To this may be objected the short time
which  elapsed between this inoculation and the phenomena that
announced the approaching death of the  patient.  But may not
the progress of chancre in the bladder be much more rapid than
that  of other  parts?  The place to which I  have assigned this
case, shows that I incline towards the opinion that it was a vesical
chancre.   This, however,  is  only an hypothesis, and I think it
would be difficult even  after having examined the preparation, to
decide positively  on its nature.
  3d. Now, for the third  hypothesis.  Small firm elevations like
vegetations were observed  in this case.  They are well represented 
214
VEOAL ON VENEREAL DISEASES.
in the annexed plate; they are seen at several points of the blad-
der, at the basfond, and  around the perforation.  It is evident
that, had these growths been somewhat analogous to arterial con-
cretions, the bladder could not have retained its normal consist-
ence ; it could not have been dilated here as at other points.  Now,
it may be supposed that the urine, meeting with an obstacle to its
passage, has distended  the bladder in the same manner as when
it was sound,  but which now diseased, yielded at its most fragile
part, viz., the  seat of these  morbid growths.   According  to this
hypothesis the chancre at  the meatus must play an important part,
jthough a physical one; it  obstructed the passage  of the urine.
But whence  these morbid  growths in the bladder?  The sub-
ject having had several  attacks of blennorrhagia, having also
nad a chancre at the meatus for a  longer period than that which
he  mentioned, these productions may be regarded  as venereal
warts.
  Prognosis.—This should be regarded both  in reference to the
local symptoms and the constitutional disease.  Considered in the
latter point of view, all chancres are equally grave,  since, in their
early stages, all resemble each other: the varieties do not become
established until the absorption of the virus has  already taken
place.  The effects of this poison on the  system, the formation of
a diathesis, do not therefore at all depend upon  the  character of
the chancre, but the state of the system, its susceptibility to  its
action, and the manner in which it reacts.  Here, hygienic condi-
tions, idiosyncrasy,  a  well-directed  treatment, exert a  great in-
fluence in the  establishment of the diathesis and the constitutional
disease.  I will not repeat what I have  said as to the connection
existing between the indurated chancre and the syphilitic diathe-
sis, and the pox.   The indurated chancre does not produce the pox: it
proves  only that general infection  has already taken  place.  In the
second point  of view, it  is  evident that the phagedenic chancres
are the most grave; the gangrenous, diphtheritic and serpiginous
forms may give rise to very serious effects.  For example, we find
the gangrenous chancre destroying  the  penis, whilst the serpigin-
ous may dissect the region of the nates.   The effects, then, are not
confined to the part or parte invaded by this terrible ulceration,
for the constitution becomes exhausted by the pain, the abundance,
and duration of the suppuration, which are the common effecte of
the serpiginous phagedenic chancre.
   Treatment.—1st. Abortive Method.—To destroy the chancre with
caustic, the knife—in  fine,  to substitute  for it a simple wound,
capable of speedy cicatrization, and thus preventing general infec-
tion, was Hunter's idea, which some have tried to realize in France.
But for  this  purpose,  three things are requisite:—1st, that the
virus shall not have had time to enter the system; 2d, that in the
case of localization, we should  know the limits of the affected
locality; 3d, as those who maintain that chancre  is local, admit
that it is so only for a limited time,  it is necessary to fix the limits
of  this time.   Now, these facts have not  been furnished by those
who believe that chancre  is a local  affection, whilst the contrary 
CHANCER
215
has been proved by well-authenticated  cases.   Indeed, chancres
have been destroyed by the caustic, or knife, but general infection
has not been prevented; sometimes, even in these cases, the chancre
has returned and the pox has followed.  The reader should here
consult the  paragraph, entitled,  Incubation, not the  localization of
chancre.  I there spoke of a physician who saw the very first ap-
pearance of the chancres on his own person, who cauterized them,
and in whom they cicatrized, and yet the pox was not prevented.
Facts of this kind are not rare, and analogy corroborates this view
of the subject.  We know that the first effect of  the syphilitic
virus has often been compared to the bite of a viper or the sting
of a venomous animal.  M. Ricord often  compares chancre, on its
first appearance, to the bite of  a viper.   I believe that this is a
very just comparison, of which we may be satisfied by the perusal
of the following case, which may be found in almost every medi-
cal journal.   The case is most authentic, proving the simultaneous
production of the local and general effect, and that cauterization
was completely impotent to destroy the effecte of the poison.  M.
Dumeril would certainly have  died,  if  the bite of a viper was
always mortal.
   " M. C. Dumeril was walking, on the 12th of this month, in the
forest of Senars.  Having discovered  a viper which, from  its size,
appeared to belong to a new  species  in  our climate, the  learned
professor seized it with his hand, expecting, by breaking ite dorsal
spine,  to kill it; but, either because the animal was  too strong, or
that he was  not properly seized,  he bit his adversary deeply.  Five
successive bites on the hand and arm did not induce this votary of
science to relax his hold, and the suffocated viper became his prize.
M. Dumeril fortunately was accompanied by his son, a physician.
The latter instantly sucked the wounds, and cauterized them with
oaustic potash.  Notwithstanding these precautions, and imme-
diate attention, the poison produced its effecte.  M.  Dumeril, after
two protracted fainting fits,  was seized  with vomiting.   In this
condition he was carried home, where  he  remained for twenty-four
hours under the influence of the poison.   At the end of this time
the alarming symptoms disappeared, and the learned professor re-
sumed his course at the Jardin des Plantes."*
   Thus, in spite of every precaution and attention,  the poison en-
tered at once  into  the system, and  produced its  constitutional
effects.   The reader may refer to what I  have stated about the ex-
periments of M. Renaud, to prove the rapid action of the  virus of
glanders, and what M. Bousquet  has established  respecting the
vaccine virus.  Now, the same observations apply to the venereal
poison.
   But, let us examine the so-called abortive method, and the other
plans of local treatment.  I will afterwards mention that which I
deem the most efficacious in promoting the cicatrization of chancre,
and in preventing general infection.  M. Ratier, an  advocate of
cauterization, and believing in the existence of the  pustule as the
* Gazette Medicalc, Sept. 20th, 1851. 
216             VIDAL  ON VENEREAL DISEASES.
earliest symptom of chancre, calls his method  of treatment the
ectrotic method.  According to M. Ratier, the pustule is about the
size of a grain of millet-seed; it is filled with serum, more or less
transparent; it remains for a short time a perfect  pustule; it ap-
pears from about the third  to the  eighth day.   M. Ratier advises
the excision of ite  summit, with flat curved scissors, the complete
evacuation of the  fluM  which it contains, and washing it with
water in which has been  dissolved a sixth part of  the chloride  of
soda.  The result of these  proceedings, under the circumstances,
is certain: it is less so when the pustule is left to break, in which
case  some of the debris remains.
  I would remark, that it appears to me very difficult to  find a
pustule of the size of a grain of  millet-seed, the summit of which
may be excised with flat-curved scissors.  And then the debris I
( Vid. Ratier, Methode ectrotique, Archives de Aledicine.)
  M. Ricord  once was  satisfied with cauterization made ■ by a
crayon  of nitrate  of silver.   He  now resorts  to  monohydrated
nitric acid, and  to the Vienna paste, according  to the following
formula:

                  $.  Quick Lime,   5 parts.
                     Caustic Potash, 6 parts.

        Mix and dilute with sufficient alcohol to make a paste.

  One word in  passing,  in reference to the necessity of abandon-
ing the nitrate of silver for  caustics, of the power of those just
mentioned,  this implies  some failure  of success  by the  former
method, and a deep penetration of the virus  during the earliest
stages of chancre,  that is  to say,  at a  time when the abortive
method is regarded possible and rational.  [The very first case in
the Treatise of M. Ricord,  shows that cauterization, even before,
or at the fifth  day, does not always prove effectual.  In speaking
of the localization of chancre we proved even by  M. Ricord him-
self,  that cauterization must often fail, as the limits of the sphere
of infection in chancre cannot be ascertained.  Mr. Lane is dis-
posed to rely on the abortive treatment for a much longer period
than M. Ricord,  and observes, that he should be much surprised
to find any sore  which healed within a fortnight of the  application
of the original poison, followed by secondary symptoms (Lect. in
Lond. Lancet, July 30, 1842, p. 597).  Now in page 594, he incul-
cates in strong terms, that an ulcer with or without induration, may
be followed by constitutional disease.   The secondary accidents
he attributes to the continued absorption of the matter reproduced
by the  primary  sore, " the enormous quantity thus generated and
retained in contact with the living tissue  may be judged of, when
I  tell you that  hundreds or even thousands of  persons might  be
inoculated daily from a single ulcer." (p. 498).  On the same page,
Mr.  Lane admits that the poison of syphilis, when applied to the
living tissue in a fluid state, is  instantly absorbed into the circu-
lation, but in the ordinary mode of application, the quantity is too
small to produce  any appreciable effect.  Now, one of the most 
CHANCRE.                       217
perfect  examples of complete  constitutional infection which has
ever come under our notice, followed a very small primary sore,
which was thoroughly cauterized on its first appearance, notwith-
standing,  besides,  that  the  patient, a very healthy robust man,
was  immediately salivated.   With the  greatest deference to so
high an authority, we feel confident that numerous facts might be
quoted to show that even M. Ricord in assigning the fifth or sixth
day  as  the*period  on which we may rely on escharotics, in the
abortive treatment of syphilis,  has gone farther than experience,
even his  own, can warrant.  The  action  of morbid poisons has
been most ably discussed in the  Lecture, to which we have re-
ferred,  and which we strongly recommend to the reader's attention.
Mr. Lane's practical belief may be inferred from the following extract
of a letter with which this gentleman has kindly favored us, dated
June, 1853 :  " I give mercury so as slightly to affect the mouth,
not only in indurated  chancre, but in all  primary sores, unless
some more than ordinary reason forbids.   I give it not so much
in order to heal the sores (except when indurated) as a preventative
of the constitutional contamination (the italics are our own).  I prefer
escharotics, however, when  patients will  submit  as the surest
means of protecting the constitution.  I  use pure nitric acid for
this  purpose.  This acid we  believe to be  the  surest  escharotie
which we possess.—G. C. B.]
   An opinion may be formed of excision by the results of circum-
cision during the existence of chancres on the edge of the prepuce.
The results of this operation are very various.  I have sometimes
cut beneath chancres which appeared to  be not  completely cica-
trized,  and the wound by means of sutures healed by the first in-
tention.   At other times I have excised nearly four lines beyond
a  chancre  perfectly cicatrized,  the wound was made  in parte ap-
parently completely sound,  and  yet two  days  afterwards  this
wound has been transformed into a large phagedenic chancre.  I
have made incisions into indurated prepuces which resembled a
shell covering the glans, and yet the wound has speedily cicatrized;
at other times, and in  analogous  circumstances, it has assumed a
bad  aspect, an  obstinate serpiginous character.   This method,
therefore, has several inconveniences.  The principal, is, that the
edges of the wound are likely to put on the specific character of
the chancre, which renders  excision as irrational as cauterization,
for they are based on a false idea of the connection between chancre
and the organism, since  they suppose the localization of the former.
   The  abortive method, therefore, does not prevent general in-
fection, nor has it the efficacy attributed to it.  But is it attended
with the risk asserted by those  who regard it is a wolf among the
sheep ?   In destroying and healing a chancre, do we thus prevent
the elimination from the system of the virus, which is therefore
left  to  produce its deleterious effects on  the system ?  I believe
that this opinion has been carried too far.  I believe that infection
has taken place even whilst the chancre is forming;  the local and
general action are simultaneous.  The danger lies not here.  When
cauterization succeeds in destroying and cicatrizing the ulcer, the 
218             VLDAL ON VENEREAL DISEASES.
 patient, and sometimes the inexperienced practitioner, repose in
 false security, and do not resort to general or specific treatment to
 prevent  the development of constitutional disease;  hence, under
 such circumstances, it  is more likely to appear and to be severe.
 Besides the other risks which M. Chomel attributes to cauteriza-
 tion, he insists upon that  to which we have just alluded.  Depuy-
 tren was an avowed enemy of cauterization ; he called it the most
 fatal of methods*
   It is therefore useless to search for the best methods of destroy-
 ing chancres, we must learn how to treat them.
   2. Dressing.—Even  here  M.  Ricord would cauterize.   If the
 chancre  be not thus destroyed, we  may always diminish its ex-
 tent, reduce the surface of absorption, and consequently the chan-
 crs of infection.   (This,  by the way, is  a condemnation of the
 practice of those surgeons who inoculate with the matter from one
 patient to  another;  for in  multiplying  the chancres, that  is,
 the surfaces of absorption, they increase the chances of general in-
 fection.)  He also advises, that we cauterize with the nitrate  of
 silver or nitric acid as often as the ulceration reappears  after the
 separation  of the eschar; when it  assumes the  characters of a
 wound, and cicatrization has taken place, we should cease to cau-
 terize.   There is  here a difficulty, viz. to distinguish a real ulcer-
 ation from a wound, in other words, from the ulceration in process
 of cicatrization.
   As to dressings, properly so called, M. Ricord generally abstains
 from the use of ointments,  especially the mercurial.  He fre-
 quently makes use of the aromatic wine, according to the formu-
 lary in the codex.  M. Baumes adopts the following formula:

                    I£.  Sugar Candy,  3 i.
                         Wine,       | i,

   The following is M. Ricord's practice:
   The ulcer is washed with wine, without however irritating it, or
 causing it to bleed; it is  then covered by a bit of fine charpie
 dipped in the same wine, sufficiently moist to remain so without
 being colored; if saturated with too  large a quantity, the kind of
 maceration which results  is productive of bad effects.  At each
 dressing, to loosen the  charpie, it should be soaked with wine, so
 as not to lacerate the  parts  to which it may adhere when dry.
 According to M. Ricord, as the result of this mode of treatment,
successive chancres never appear, as so frequently occurs after the
other methods.   The aromatic wine diminishes the purulent se-
cretion, tends to  promote cicatrization by modifying the surface
of the virulent ulcer, and in acting as an astringent on the adjacent
parts, it  renders  their  inoculation impossible.    When the dis-
charge continues to  be copious, we must have  recourse  to the
vinous decoction  of  tan  bark.   M. Ricord now  prefers the fol-
lowing solution:
Lepons Oralcs, t. L, p. 108. 
CHANCER
219
                   ^. Tart. Fer. et Potas.  3 iiss.
                      Aq.              Oct. iss.

  If the ulcer be painful, the aromatic wine often augments the
Buffering; by adding from one to one and  a half ounces of the
gummy extract of opium to an ounce of the above solution, it be-
comes a useful topical application.  Among those who continue to
suffer, there are some in whom the pains are removed by increasing
the quantity of opium, whilst in others they are only diminished.
  There are cases in which we are  compelled at once to suspend
temporarily the medicated wine or the ferruginous solution, and
even to  renounce it completely.  Thus, in certain patients, sup-
puration ceases, and the ulcer remains stationary; a dressing must
then be used for some  days of emollient decoctions or of opiated
cerates.   The wine and the  ferruginous  solution may afterwards
be  resumed. In others, the ulcer being indurated, these dressings
increase  the induration, and  prevent  cicatrization.   Aside from
these circumstances, according to M. Ricord, so easy to be dis-
covered and regarded, the  means already indicated  should con-
stitute the general method of dressing.  Once the period of cica-
trization arrives, and progresses with  regularity, we continue the
dressings.   M. Ricord does  not cauterize, unless it be necessary to
repress  the exuberant  granulations.  Finally, it often   happens
that only the epidermis is wanting to complete the cure ; the sur-
face of the ulcer attains the level  of the surrounding parts, re-
mains red, is seldom covered with matter, and yet the ulcer does
not heal.   Then the gentle application of the  nitrate of silver, so
as to whiten the surface without cauterizing it, to any depth, suffi-
ces to finish the cure.  According to M. Reynaud, powerful caus-
tics, especially the nitrate of silver, increase the risks of adenitis.
This naval surgeon prefers the  mercurial solutions.  He takes
from ten  to fifteen  grains  of the bichloride of mercury to  the
ounce of distilled water.   The chancre is touched with little folds
of  charpie, saturated with this lotion, and this practice is followed
for four or five days.  It must be discontinued if the ulcer assume
a vermillioh color.   If  the aspect  be doubtful, the applications
are to be continued.  In all cases we must  void excessive irrita-
tion of the tumor.
   M. Ricord, in  cases of the regular chancre, confines himself to
local treatment, where it leaves no induration behind.  I have under-
lined the above passage, as  it leaves  us to infer  that the regular
chancre may be indurated.  For my own part, I always admit the
existence of more  or less  induration.   As it will be seen here-
after, I never confine myself to local treatment.   M. Ricord never
loses sight of  induration  during his  treatment.  Indeed, by ex-
tending, it may oppose cicatrization,  and  by the strangulation re-
sulting from the indurated tissues, it may produce gangrene, and
frequently phagedenic disease.  In ordinary cases, which are the
most simple, the indurated  chancre is dressed with:
                 I? .     Calomel (a la vapeur)     gr.  xv.
        Pomatum of cucumber or Opiated Cerate     §  i. 
220             VLDAL  ON VENEREAL DISEASES.
   Charpie smeared with this ointment is applied, and it must be
 renewed three or four times in the day.
   [Mr. Langston Parker, referring to the general applicability of
 the  treatment  by the mercurial  vapor  bath, remarks, that 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 that soft fulness which is sometimes found m such situa-
 tions, but that cartilaginous hardness which is met with under the
 skin, and which is sure, sooner or later, to end in  local or consti-
 tutional mischief.   I have seen cases which have resisted all modes
 of treatment 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 par-
 tial amendment" (On the Treatment of Secondary Syphilis, by a Safe
 and  Successful Method, ke. p. 16).   It has  been proposed to destroy
 this  persistent induration, with caustic or the knife ; but as is ob-
 served  by Mr. Egan, " An intractable species of ulcer usually re-
 sults upon the application of the caustic,  and excision but removes
 the original sore,  to be replaced by one of a less  manageable de-
 scription, which, upon healing, will,  in all probability, exhibit the
 same characteristic induration of its  predecessor" (Op. cit. p. 228).
  Mr. Key was decidedly opposed to the use of mercurial appli-
 cations, their action, in his  opinion, being to increase the  ulcera-
 tion and the secretion.  " Mercurial washes or ointments, in the
 ulcerated stage, I employ, not as a general rule, but as the excep-
 tion  in sores indolent, not sensitive,  and  secreting but  sparingly.
 In the  larger number of sores, mercurial applications are hardly
 admissible in our list of remedies : the common astringent  salts—
 as the preparations of silver, lead, zinc, and  copper—varied as the
 state of the sore will bear, check the disposition to spread quickly,
 and bring on an appearance of granulations.  To the premature
 use of mercurial dressings much of the troublesome career of their
 sores may be attributed," &c. (Report of Primary Syphilitic Cases.
 Gufs Hosp. Reports, vol. iv.).   Mr. Key  advises,  that,  in the ul-
 cerated stage, if mercury is administered internally, it should be
 given sparingly and cautiously watched, and with it he would com-
 bine the use of local astringents.  The method recommended by
 Mr. Parker is certainly that  which seems liable to the fewest ob-
 jections.—G. C. B.]
  In the case  of copious suppuration, the  chancre is first to be
washed with the aromatic wine, which may  be employed alone if
the discharge be too copious.  Should the patient be irritable, and
 an inflammatory complication exist,  and  especially when the gan-
grene above mentioned is spreading, opium should be  used both
internally and externally.  In such cases I administer both morn-
ing and evening, camphorated pills  of  opium,  the formula  for
 which I have already given when describing the means for sub-
 duing erections which occur in blennorrhagia.  The  concentrated
solution of opium answers best as  a dressing.   Antiphlogistics,
however, must  not be omitted.  Thus, when the patient is young 
CHANCRE.
221
and robust, I often resort to venesection.   I recommend bathing
and  the application  of laudanized  cataplasms,  if  the  locality
permit.
  3. Author's Method.—I attach but secondary importance to the
use of local means.  I do not generally resort  to cauterization un-
til after cicatrization has commenced, and the  chancre has passed
into the condition of a wound.  Then, if this wound granulates, I
check the exuberant growths with the nitrate of silver, applied
rather strongly ; if the traumatic surface present a languid aspect,
I stimulate it by gentle applications of the same caustic, which
then skines over the solution of continuity.  With regard to dress-
ings properly so  called,  I sometimes use a mixture  of aromatic
wine and one third of water.   I  believe that it is often better to
substitute for astringent and irritating injections those of an emol-
lient character. I have seen dressings of too irritating a nature, ex-
cite inflammatory complications.  It will here be recollected, that
the followers of Broussais attached great importance to the use  of
antiphlogistics, and that their  treatment was often followed by
success.  (Of course I speak of the cure of chancre only, and not
of the pox.)   I rely especially on general treatment, and  the fol-
lowing is that in which I have the most confidence:
   1st. General bathing;  two days of perfect rest.
  2d. If the patient be young and robust, bleeding from the  arm.
  3d. The next day, a saline purgative; Seidlitz water or citrate
of magnesia.   If  the patient be feeble, of the lymphatic tempera-
ment, I commence with a cathartic.
  4th. Pills of the bi-chloride of mercury, according to the follow-
ing formula, which is nearly the same as that of Dupuytren :

                   ]£. Hydrarg. Bi-chlor.
                      Ext. The baiq. aa gr. i.
                      Cons. Ros.  q. s.
  Ft. pil. 25.   Take one morning and evening.

   This treatment,  adopted in the early stages of chancre, and con-
tinued for two months, promotes cicatrization,  prevents the devel-
opment of secondary accidents, or if it fail to prevent, they are
singularly mitigated.  But it is very necessary that it be continued
for the time prescribed without interruption.   H from carelessness
on the part of the patient, or intolerance of his system, the admin-
istration of the pills is interrupted for only eight days, no  depend-
ence can be placed on what has been given;  the treatment must
then be commenced anew, and with much less chance of success.
But the preliminary measures, such  as blood-letting and purga-
tives, dispose the system favorably to the tolerance of the mercury.
In females, who,  by their more lymphatic  temperament,  cannot
bear repetitions of the loss of blood, we frequently observe  acci-
dents which compel us to suspend the use of the pills.
   This method has rarely failed, in other words, it has been  pro-
phylactic against  general infection in every instance  in which it
has been resorted to in time, where it has  been well managed and 
222
VIDAL ON VENEREAL DISEASES.
regularly followed.  This has been  the basis of my  practice for
fifteen years.  It has been asserted that patients thus treated have
had  consecutive accidents.  If these patients had been carefully
interrogated, it would have  been found that some one of the cir-
cumstances  above  mentioned had interrupted the constant use of
the mercurial pills, or, indeed, that the treatment had  been under-
taken at a time when the chancre had already acquired a degree
of induration which indicated the existence of the syphilitic dia-
thesis.  Then, the mercurial  treatment  was  insufficient;   other
means must be employed, which I will mention when I consider
the treatment of confirmed syphilis or that of the indurated  chan-
cre, which itself is  an expression of the syphilitic diathesis.
   [If it be true, as stated by M. Ricord in his Letters  (No. XXX.)
that the persistence of the syphilitic  diathesis is not incompatible
with good health, and that this  diathesis miay last for ten, fifteen,
or thirty years, it is difficult to estimate the prophylactic value of
mercury, or any other agent.   Even though we administer, as
advised by  him, a daily dose for six months, we cannot be sure
that  we  have prevented the future  development of the presence
of this diathesis.   We need not, therefore, be surprised at  Hun-
ter's  contradictory  statements upon this subject.   When mercury
is employed in the treatment of chancre, we find  that in a given
number of  cases no secondary  accidents  appear; again, if mer-
cury be dispensed  with  altogether, we find  that  a large number
escape, or at least never show any manifestation of constitutional
infection.   In the treatment of the true Hunterian chancre, nearly
all civil practitioners are agreed as to the necessity of  resorting to
this remedy.  Military surgeons, however, boast of extraordinary
success, from simple treatment alone.   In the  Clinical Lectures of
Mr. Carmichael, or in the  Lectures of  Dr. Graves (2d Dub. ed., p.
385),  the reader may find reports highly  favorable  to the non-
mercurial practice. Mr. Guthrie treated some 100 cases on this
plan,  and though  he arrived at the  conclusion, that " every kind
of ulcer  on the  genitals is  curable without mercury," yet he be-
lieves that in some  cases a gentle course will expedite the  cure.
(Med. Chir. Trans,  vol. ix.)   He does  not,  however,  regard mer-
cury as a specific in this  disease.  Sir  George Ballingal has fur-
nished quite a body of evidence in favor of the simple treatment,
for which see  the  4th edition of his  Military Surgery, p. 465.  K
cauterization is likely to succeed in any cases, it is in  those which
come under the care of army surgeons, for the soldiers are under
orders to apply to the surgeons on the  very first appearance of the
disease.   This is doubtless the cause  of the superior efficacy of the
simple treatment in military practice.  Indeed, we have the testi-
mony of Sir Benjamin Brodie, that Mr. Rose, who was so success-
ful with the non-mercurial treatment in  the army, in  private
practice was compelled, like other surgeons, to resort to this  reme-
dy. (Lecture in London Lancet, Feb. 1844, p. 673.) Sir Benjamin
is  a decided advocate for the use of mercury, not only as a pro-
phylactic  but a curative agent;  and  in this view of  the subject,
Messrs.  Lawrence, Porter, Cusack,  Lane,  and  Wilson coincide. 
CHANCRE.                      223
Mr. Langston Parker regards the simple, or " rational" treatment,
except in the indurated chancre, with decided approbation ;  and
Mr. Egan, in alluding to the use of mercury,  evidently considers
that ite employment should be restricted to  this form of ulcer.
The following  different  estimates of the  liability to secondary
accidents, when mercury is not used, are deserving of notice:

                      NON-MERCURIAL TREATMENT.
          According to M.  Cazenave,    -    18 in   20 cases.
                     M. Repiquet,     -    12  "   20  "
             "       M. Cullerier,     -    10  "   20  "
             "       M. Baumes,      -     6  "   20  "
             "       M. Puche,       -     4 "   20  "
             "       M. Ratier,       -     0  "   20  "
             "       Sir J. McGregor,  -    96 "  1940  "
             "       Dr. Pitcairn,     -     0 "  768  "
             "       Mr. Spence,      -    21  "  367  "
                     Mr. Bacot,      -     1  "   10  "

  According to Sir G. Ballingall,  the army  reports show that,
without mercury, one in twenty have secondary symptoms ; with
mercury, one in fifty-five cases.  The evidence, on the whole, goes
to prove the correctness of the assertion of Sir Benjamin Brodie,
that mercury surpasses all other remedies " in  extinguishing vene-
real disease;" yet there can be  no question that, even when  pro-
perly and judiciously used, it, like  all other agents, often fails to
accomplish this object.  A specific  for syphilis is yet to be dis-
covered.
  In conclusion, we can  only  add, that the principal British prac-
titioners who are regarded as non-mercurialists, may be said to be
Messrs. Ferguson, Rose, Guthrie, Hennen, Hill, Thomson, Alcock,
Todd,  and Dr.  Graves; whilst among  our own  countrymen, we
may name Drs. Chapman,  Dewes, Ware, Alexander, H. Stevens
(in secondary syphilis), Harris, Rousseau, and Phinney.—G. C. B.]
   The method of treatment which  I here recommend has been
sanctioned by the experience  of very eminent practitioners.  In-
deed, Dupuytren,  M. Chomel, Broussonnet, and  others, have ac-
knowledged the  advantages of  administering the  bi-chloride of
mercury in minute  doses and for a length of time.  M.  Chomel
strongly insists on the necessity of not interrupting the influence
of the mercury.  Dupuytren advised, after the chancre had healed,
to  continue the use of the pills which bear his  name, as long, at
least, as was required to  produce the cicatrization of the chancre.
M. Chomel, in  his lectures,  never fails to remark that it is not the
quantity of mercury  taken which best insures  a cure, but the
length of time  during, which the system has been modified by this
agent.  He recommends that the treatment should be continued for
five or six months.  M. Broussonnet gives Van Swieten's liquor in
the dose of from one to two  spoonfuls in the day till the patient has
taken as many as eighty or one hundred doses.   If the system is
antipathic to this preparation  he substitutes Dupuytren's pills, of
which he gives from one hundred to one hundred and twenty.
   3. Treatment of the Phagedenic  Chancre.^-ln. the treatment of this 
224
"VTDAL ON VENEREAL DISEASES.
variety of chancre we should pay the greatest regard to the tem-
perament of the patient, to the hygienic circumstances by which
he is surrounded, and the treatment to which he has submitted, as
well as to the complications which exist.  The digestive organs,
or the lungs, may be diseased; sometimes there exists a dartrous,
a scorbutic, or scrofulous diathesis.   The latter especially  most
requires a specific treatment, and for a long time this complication
has been regarded as 'most unfavorable: indeed, even Boerhaave
remarked that if mercury does not always cure the pox it is owing
to a strumous complication*  Mercury, instead of curing, aggra-
vates a phagedenic ulcer.  However, if it is prudent, in the ma-
jority of cases, to abstain from mercurials in the treatment of the
phagedenic sore, they should not be entirely banished, as in  some
cases they may have a real efficacy.   If our efforts do not succeed
we should not persist in their use; it is better  to resort to other
means than to some  new preparation of mercury.   Generally the
ferruginous and the preparations of iodine in small doses, the cod
liver oil are preferable.  Still we should not be exclusive in our
treatment.
   [Mr. Langston Parker states that he has seen phagedena in nose,
throat, and on the penis, stopped at once by immersion in the baths
for half or three-quarters of an hour.   "No other remedy can be
brought to bear thus speedily upon diseases of this nature, and the
mutilations and losses of substance which occur in such states take
place whilst we are waiting for the action of remedies."  (On  the
Treatment of Secondary and Confirmed Syphilis, by a  Safe and Suc-
cessful Method, p. 28.)  Surgeons are by no means unanimous in
denouncing mercury in the treatment of phagedenic chancre.  By
Wallace, Mayo, and Messrs. Lawrence, Porter,  Skey, and Ricord,
it is admitted that in  some of these cases it is a very valuable
remedy.   Mr. Porter is very decided  upon this  subject.   After
alluding to the opposition to this treament by some of the highest
authorities in surgery, he observes: " Now, with every deference to
these authorities, and with a previous acknowledgment that  cases
will occasionally fall out forming exceptions to any general rule
of practice, these are the very cases (as far as I  can distinguish
them) in which I am not only disposed to employ mercury, but to
administer it in the form and manner most likely to bring the
system under ite influence."   Mr. P. describes another form  of
phagedena produced by mercury, the medicine acting as a poison;
in such cases he would suspend it at once, and discard it altogether.
(Lect. on Syph. p. 36.  Dub. Med. Press, Jan. 20, 1847.)
   Mr. Key and Mr. Carmichael were among the  opponents of mer-
curial treatment in phagedena, and Mr. Acton (op. cit. p. 273,) says,
"let the young surgeon never be induced to give mercury under any
pretence whatever in acute cases of phagedena."  The only excep-
tion, he adds, is to be met with in a form of indurated chancre
attended with central slough.   M. Ricord acknowledges his ina-

  * Vid. Boerhaave, quoted by Astruc, lib. ii., p. 286, of the French translation.
This is a very remarkable passage. 
CHANCRE.
225
bility (Ed. of Hunter, p. 459,) to point out the cases of phagedena,
in which  mercury is likely to prove of service, though he states
that there can be no doubt of its occasional efficacy in these cases.
If we were to resort to it at all in phagedena, we certainly should
prefer Mr. Parker's mercurial  vapor bath to any other form  of
administration.—G. C. B.]
   When  we have  to treat a gangrenous chancre, the result  of
excessive inflammation, the first thing requiring our attention is
the inflammatory complication.   When I come to treat of phimosis
and paraphimosis as complications of chancre, I will point out the
course to be pursued.  The phagedenic gangrenous chancre may,
on the other  hand,  proceed from  general debility; this  should be
another reason for  abstaining from the use of mercurial prepara-
tions; here cordials,  tonics, topical  applications saturated with
chlorine  water will constitute the basis of our treatment.  Accord-
ing to M. Ricord, the local  treatment of the pultaceous diphtheritic
phagedenic  chancres  should resemble that of ordinary chancre.
The combined use of cauterization and the dressings of aromatic
wine, and especially the ferruginous solution.  The cauterizations
with  the monohydrated nitric  acid should be deep and repeated;
in some cases it should be practised twice a day to keep pace with
the progress of the disease.   The dressings should likewise be here
repeated, for the discharge  is very copious.  There are ulcerations
which are cured only after the employment of a kind of almost
constant irrigation.  During the use of the dressings we  should
guard against any lacerations, for each solution of continuity may
become inoculated,  and the removal of the skin favors the absorp-
tion of virulent pus, which will still enlarge the boundaries of the
ulcer.
   In the case of very severe local inflammation the application of
leeches has been advised.  In addition to the difficulty of making
them bite at the points of ulceration the bites may cause an increase
of the ulcer according to the depths of the tissues wounded. We
must also guard against their application near a chancre, for each
puncture made by them may be transformed into an ulcer.   If the
local inflammation compel the practitioner to resort to blood-letting,«.
the leeches should be applied at a certain distance above the ulcera-
tions. The bites should afterwards be  covered with compresses
soaked in emollient and narcotic decoctions, with cataplasms of
starch or semolia and milk; hot mucilaginous or gelatinous baths,
and particularly a diet proportioned to the general or local con-
dition, absolute rest, and diluent drinks,  are here very beneficial.
If there be much irritability or pain, with or without much inflam-
mation,  according as  the one or the other predominates we must
use the preparations of opium both generally and locally.
   M. Rieord uses the following solution for a dressing:

                 J J.  Aq. dist. lactucar.  ? viss.
                     Ext.  op. gum.     3 i.  M.

Even here this practitioner resorts to cauterization with the  nitrate
                               15 
226
VTDAL ON VENEREAL DISEASES.
of silver, and regards it as a powerful auxiliary; with him, pain
or inflammation is no objection, as he considers that the nitrate of
silver is one of the  most powerful sedatives, and the most certain
antiphlogistic when it is properly applied.  The severe pain expe-
rienced at  the moment of  cauterization  soon subsides, and an
improvement is manifested which  we seek in vain from other
medicines.   This rule has but few exceptions.
  When the phagedenic chancre continues to progress or to remain
stationary, we have seen good effects produced by carrot cataplasms,
melted yellow wax, as a digestive ointment.   In these cases, also,
recourse has been had to the most powerful caustics,  the butter of
antimony, potash, alcohol, the arsenical paste of Rousselot or Frere
Come, the actual cautery applied directly, or as an objectif cautery.
The Vienna paste, and particularly the monohydrated nitric acid,
have likewise succeeded.   I prefer the  latter caustic, for regarding
the pultaceous phagedenic chancre as a chancre complicated with
hospital gangrene, I treat it as I would the latter disease,   The
following is my method: I begin by making little rolls of charpie
sufficient to cover the ulcer;  each of these is soaked in nitric acid,
and applied over the diphtheritic layer, on which we press a little,
then another is placed by the side of the first, in such a manner as
to fill the ulcer.  A layer of charpie is placed over this first dress-
ing, then a compress, so as to make gentle pressure.   This dressing
is renewed twice in a day, and at each change the parts are bathed
with wine, in which walnut leaves  and the petals of the red rose
have been  macerated.  In  the milder  forms I am content to satu-
rate the charpie with a mixture of equal parts of tincture of iodine
and water.  In those more obstinate,  M.  Ricord recommends the
application of a blister just above  the ulcer, or a dressing composed
of powdered cantharides.   In his notes to  the second edition of
Hunter, in which may be found repeated his  advice as to the treat-
ment of phagedenic chancres, the above method is suppressed.  Was
it forgotten, or was  it not rather owing to the fact that it did not
sustain its first reputation ?  I know not.   I can say nothing of
this method from experience having never employed it.
  The edges of the  diphtheritic phagedenic ulcer are frequently so
denuded and attenuated, that their adhesion  seems impossible.  J£
the ulceration result from  an abscess, there may be considerable
separation, and the skin become  very thin, from the simple so-
journ of the pus,  without having  been  involved in the plagedenic
action.  Then, no matter what the extent of tissues to be sacrificed,
a cutting instrument may be employed, the curved scissors being
preferable,  to  excise neatly, and  to  give  to the wound the form
most favorable for cicatrization.   It is  desirable to avoid  as far as
possible the formation of scars, in certain regions, as they remain
as stigmas  of habits which  the subject wishes  not to be exposed.
But when the enlargement  of the  ulcer is the result of phagedenic
action, the knife is  more injurious than beneficial, for instead of
limiting the disease, it favors ite extension, unless we resort to the
cauterization of the wound  inflicted.   But would it not therefore
be better at once  to cauterize ?   For this purpose M. Ricord pre- 
CHANCRE.                       227
fers the Vienna paste.  He maintains that by this caustic we may
not only limit its action to the parts which we wish to destroy,
but we mny also completely destroy the virulent surface, and pre-
vent the too rapid inoculation of the  new edges of the ulcer, by
the interposition of an eschar, and a kind of vital reaction, the  ab-
sence of which, in some cases, is one of the principal causes of the
ulceration.
  Whatever may be the variety of  the phagedenic chancre, when
it detaches the frenum, and produces a fistulous track, a bridge, by
excising the  parts thus separated, and  ulcerated, and which  be-
came diseased  from contact, the cure  is greatly  expedited.  A
blade of the scissors is passed beneath the sinus, we then cut near
the glans,  and afterwards reset the portion which remains adherent
to the prepuce.  Immediately afterwards the whole solution of con-
tinuity, in other words, the wound made by the operation and the
remnants  of the ulcer, should be cauterized.
  M. Puche employs the following solution in the case of a serpig-
inous phagedenic chancre:
                IJ.   Tart. Fer. et Potas, 3 v.
                    Aq.               Oct. i.
  For fomentations.

  Internally, he administers the following syrup:

                 fy.  Tart. Fer. et Pot.  3 v.
                      Aq. Canell.       3 xiv.
                      Syr. Sacch.       Oct. i.
  Dose from five drachms to three and a half ounces a day, in a pint
of tisane of gentian.

  This syrup is  particulary beneficial when there is chlorosis or
anemia in connection with the phagedenic chancre.
.  Once I succeeded with the emplastum de vigo in a very severe
case  of secondary serpiginous  phagedenic  ulceration, which re-
sisted all  other means.   This ulceration occupied the external and
lower part of the thigh, and the same side of the superior half of
the leg.  I then applied narrow bands of plaster, as in the case of
atonic ulcers of the lower extremity.  These bands were renewed
every third day, and in less than fifteen days the phagedenic action
was arrested, and the cicatrization far advanced. The success which
I  obtained by this method is favorable to its adoption in certain
cases of phagedenic chancres.  But,  in order that this dressing par
occlusion succeed, the chancre must be so situated as to permit ite
exact application.

                ACCIDENTS  OF CHANCRE.

           PHIMOSIS  AND PARAPHIMOSIS.

   Phimosis.—This exists when the glans cannot be uncovered by
the prepuce.   There is generally a prolongation, and more or less
contraction of this envelope; or the parts naturally covered by the 
228            VLDAL ON VENEREAL DISEASES.
prepuce are swollen, or  there are tumors and  excrescences which
impede the movements of this envelope.  Its opening  is suffi-
ciently large to permit the emergence of the  ghms in its natural
state; but tumefied, hypertrophied or covered with vegetations, it
can no longer pass this opening.   Phimosis is more or less com-
plete, according to the contraction of the preputial overture.
  This condition of the prepuce  may be congenital;  it may be
 Eroduced  by an irritation or ulceration, such as chancre.  Most
 •equently it is the result of balanitis, rarely of urethral blennor-
rhagia, except when complicated with  an inflammation  of the
lymphatics or peri-urethral abscesses.  With  a chancre, we often
find phimosis; the former being surrounded with more or less in-
duration, there is a thickening and want of flexibility ;  the end of
the prepuce sometimes resembles a shell covering the glans.  The
retraction necessary to uncover the  glans then becomes impossi-
ble, or dangerous, as it may give rise to a paraphimosis. Chancres
are situated on the base of the glans, or more or less near the edge
of the prepuce.   If seated on the edge, and numerous, they may
prevent the uncovering of the  glans during  their inflammatory
turgescence, and at a later period by the cicatrices which follow,
and which form a real  stricture;  thence a permanent accidental
phimosis.   Phimosis may become permanent  from bands and ad-
hesions which unite the prepuce  and the glans in an unnatural
manner.
  The primary accidents are not alone the cause of phimosis:  the
eruptions called secondary, the mucous tubercle, more or less
hypertrophy of the prepuce,  a contraction,  may render it less
supple.   The  inflammations, chancres,  and  other lesions which
produced a  phimosis, may be aggravated by  the  phimosis itself;
the effect here becomes the cause,  and the  complicative cause:
thus, by an accidental phimosis, a certain degree of strangulation
is produced; this produces more or less obliteration of the prepu-
tial cavity, and difficulty in the expansion of  the inflamed tissues.
Especially when the prepuce is inflamed, Ave sometimes find the
skin of the penis drawn forward;  the glans, as it were, is pushed
backwards, and the prepuce  projects in front  of it, sometimes, ac-
according to Hunter, for the extent of three inches.  Occasionally
this pedicle is  a little twisted.  Sometimes it happens that the pre-
putial mucous membrane yields  more readily than the skin; it
then forms a kind of swelling, somewhat strangulated by a neck
which is  at the point where  the skin naturally terminates.   In
both these cases the narrowing of the prepuce is considerable, and
we cannot think of uncovering the glans.
  The inflammation of the prepuce, at first erysipelatous, may
assume a phlegmonous  character:  whence the abscesses which
open on the skin or in  the preputial cavity,  according as the ex-
ternal or internal envelope yields.   It  often happens that both
membranes yield equally; perforation of the prepuce then takes
place by a slough, or by an ulceration which proceeds from within
outwards.   Most frequently matters occur as  Hunter has so justly
remarked:  the glans enters the  orifice of the prepuce  and the 
PARAPHIMOSIS.
229
ulcerations; it fills the preputial cavity, and often so closely, that
the pus secreted by these ulcerations cannot find a passage by ite
natural opening.   A collection then  forms behind  the corona
glandis, a kind of abscess, producing an ulceration, which extends
both externally and internally, and penetrates the prepuce.  This
opening is almost always observed towards the end of the prepuce,
which corresponds to the dorsum of the penis, and this, either
because it proceeds  from an ulceration or  the separation of an
eschar.  When this opening is very large, the glans protrudes;
the end of the prepuce is carried downwards, causing a prominence
at this part, and giving the penis a bifid aspect.  Nearly the whole
of the prepuce has been  observed to be destroyed; mortification
likewise  causes a  true resection, a circumcision of the prepuce.
There are other still more serious ravages; the glans  may like-
wise suffer, either because the ulcer was at first seated on it, or
because it spread from the prepuce so as to involve it;  indeed,
after the prepuce is opened, a portion of the glans is  found to be
destroyed.   This is now a serious case; but it is still more serious
when the urethra, the navicular fossa, and the corpus cavernosum
are involved.

                      PARAPHIMOSIS.

   Paraphimosis, or a strangulation of the penis behind the corona
glandis by the ring of the prepuce, is an accident of grave import-
ance,  which may result  from  the  inflammation accompanying
chancres on the prepuce.  We must distinguish between the para-
phimosis which succeeds to an accidental  or congenital  phimosis,
which is observed when the glans is forcibly uncovered, and who
are attacked with a swelling of the penis; in this latter case, the
orifice of the prepuce, which before was sufficiently large to per-
mit the  movements of the prepuce on  the glans, strangles the
latter  at its  base.  The first strangulation, that connected with
previous phimosis, produces much  the  most rapid and serious
effects ; it suddenly attains its highest degree of intensity; for the
strangulation is here formed by the ring which girts the penis, and
by the penis, which, as it were, presses against the ring.  On the
other hand, when  phimosis has not previously existed, the penis
alone is strangulated;  as it  swells, it comes gradually and slowly
against the preputial ring, which wras large  enough to  allow the
movements of the penis in its natural state, but not when the latter
has become  preternaturally large.  It will  be well to remember
this double mechanism of paraphimosis when we come to consider
its treatment.
   When  the ring closely embraces the penis, when  the paraphi-
mosis is  irreducible  and complicated with the inflammation con-
nected with chancres, the glans becomes more and more  engorged,
the cavernous body becomes indurated, and there is a struggle
between the parts strangulated and those which produce the stran-
gulation.   The latter are generally the first  to yield ; in fact, the
ring formed by the prepuce ulcerates, and becomes mortified; the 
230             VTDAL ON VENEREAL DISEASES.

two layers, the mucous and cutaneous, of the prepuce are separ-
ated.  But the patient does not always obtain from these  morbid
changes a relaxation very complete, and the penis does not return
to its normal condition, for the resolution is slow;  adhesions  are
established, which  cause more or  less apparent deformity, and
which are attended with greater or less inconvenience.
   Treatment.—1st.  Treatment of phimosis.—When phimosis is acci-
dental  and highly inflammatory, when  ite primary  cause is a
chancre, the treatment is attended with very great difficulties.  lu
the first place, we  should resort to emollients, and to antiphlogis-
tics, when  the inflammation is severe, the  swelling considerable
and tense, when there is decided redness.   If the subject be young
and vigorous, we should not hesitate to  commence by a  copious
general blood-letting.  Leeches are  also indicated; but there is
danger of the inoculation of their bites, and an aggravation of the
inflammation from these trifling wounds.  They should therefore
be applied at a distance from  the penis—as, for example, on  the
perineum and the inguino-crural regions.   We should not be satis-
fied with direct antiphlogistics, but should also act on the  bowels,
with saline purgatives, such as the citrate of magnesia, and Seidlitz
water; after which we may resort to general bathing, cataplasms
covered with Goulard's extract;  injections  between the prepuce
and glans, at first  of a narcotic and emollient, and afterwards of
an astringent character.  These injections may be rendered caustic,
especially when we have reason to suspect that it is caused by a
balano-posthitis.
   If these means  do not succeed in subduing the inflammatory
accidents, if the pain is severe, and there is a difficulty in urinat-
ing, if there is an accumulation of pus within the prepuce, and this
envelope  is threatened with a perforation, and especially if con-
genital phimosis exist, many  practitioners would  imagine that
there were sufficient reasons for resorting to an operation ;  some,
indeed, would not require so strong an argument for using  the
knife.  For my own  part,  I could never  perceive the absolute
necessity for  performing this operation; I am afraid of thus in-
creasing, instead of diminishing, the inflammation by the incision,
a result which often happens.   If it is decided to operate, to make
an incision, it should not be limited to a very small extent of  the
prepuce; we should not open the abscess  only, which is sometimes
seated  towards the base of the glans, for thus the accidents may
not be at  all arrested,  and  after their disappearance, the phimosis
may return.   The  incision, then, should  extend  from the  edge of
the prepuce  to  the base of the glans.  Still we have reason to
apprehend that the wound thus made may be transformed into a
vast chancre.  It will  be seen, therefore, that the advantages of
the operation do  not  counterbalance its inconveniences, for  the
chancre in attacking the wound, is not confined in  its ravages to
the localities first invaded.   For my own part, I always rely upon
antiphlogistics, both direct and indirect.   True, after the disappear-
ance of  the  accidental phimosis, I have occasionally observed
that a portion of the glans has been destroyed.  These  ravages 
PARAPHIMOSIS.                     231
have likewise been observed by surgeons who have been in haste
to operate.   The  prepuce has also been found perforated, not-
withstanding the use of antiphlogistics, of topical applications and
injections.   For the most part, patients have come under my care
at an advanced period of the disease.  After the  cicatrization  of
chancres, and the  subsidence of the inflammation,  it is easy to
repair more or less perfectly the deformity resulting  from this loss
of substance in the prepuce.  I repeat it, the situation of the prac-
titioner is  here very  embarassmg; I have  given my experience,
and I will not indulge in any criticism of the methods adopted  by
my opponents.
   After the complete cicatrization of chancres, and  the cessation
of the inflammation, the phimosis remains when the prepuce has
not been divided.   This phimosis is congenital, or rather it is  an
accidental phimosis become permanent by  the contraction result-
ing from  the cicatrix.   In both cases, after the disease has  been
cured, it is desirable to remove the deformity and thus prevent the
chances of a new inoculation, for it is admitted that subjects  af-
fected with phimosis are more frequently infected than those whose
glans is uncovered.
   2d. Operation for Phimosis.—I will not here describe all the meth-
ods  which  have been proposed*   The  excision of the prepuce,
circumcision, having been commonly adopted, I will consider this
operation.   I add to the ordinary proceedings means of uniting
the parts, as, no matter what method we employ, after the excision
of the prepuce, the skin retracts towards the pubis, and  its mucous
membrane  is left much  exposed; a very  large wound then  re-
mains,  which  inflames,  suppurates,  and is often the  source of
hemorrhage.   Instead of excising this exposed mucous membrane,
I reverse it so as to apply it higher on the skin,  when I unite it
by sutures, or, what is preferable, the spring sutures.  The suture
maybe applied as the parts separate, or, what is better, the threads
may be passed before excision is made, which  may  be  performed
 according to two  different methods.
   A. First Mtliml.—A line is traced with  ink on the skin of the
 prepuce, in the direction of the corona  glandis, having a lozenge-
 shaped form.   This  line may be traversed with points of suture.
 The skin should  be drawn neither in front nor behind the glans.
 With a pair of dressing or  spring forceps, we seize  the dorsum of
 the penis, near the frenum, and, in an oblique direction, the whole
 of the prepuce in front of the black  line.  Whilst the operator
 with the  forceps stretches the prepuce a little forwards, an assist-
 ant seizes the sheath of the penis near its root, and  draws gently
 towards  the pubis.   The  threads  are  then  passed transversely,
 that is, by crossing the forceps on  the  dark line, they will be  five
 millimetres from  each other.   The extremity of the  prepuce seized
 by the forceps is still drawn a little forwards ; then,  with  a pair
 of strong  scissors, such as are used for hare-lip, the prepuce be-

   * Vide my Traite de pathologie externe et de medecine operatoire, t. v. 3d ed.  I
  transcribe from this work the description of the proceedings which I employ. 
232
VIDAL ON VENEREAL DISEASES.
 tween the threads and the forceps is at once divided.   This cir-
 cumcision being completed, the cavity of the prepuce is more or
 less opened, we see that the threads are passed on the glans, and in
 a direction perpendicular to the meatus urinarius.   These threads
 are then divided  in the middle, and each forms two handles, one
 on each side of the glans.  Thus, if four threads are passed, we may
 make eight sutures, four  on each side.   I use flat  needles, lancet-
 shaped, and very fine.  I remove the sutures on the fourth day.
   This method is  much  more easily executed, if,  instead of first
 passing  the threads through  the  prepuce, we push the needle ho
 further than is necessary to discover its point on the opposite side
 to that  on  which it was entered.  The needles  then cross the
 direction of the forceps, and  the incision is made  between them.
 The incision is then more neatly and easily made.   After the ex-
 cision of the  prepuce, the body of the  needles  is  seen traversing
 the preputial  cavity;  each needle is drawn by ite point, and its
 other  extremity, then presenting to  the surgeon,  enables him to
 grasp the thread.   Each  needle being  thus seized, the operation,
 in other respects, is such as I have described.
   B. Second  Method.—The black line  is traced,  as  in  the  first
 method.   A grooved director is introduced within the prepuce,
 and its handle confided to an assistant;  he.inclines it to one side;
 the beak of the director causes the prepuce to project in an oppo-
 site and distant direction, at  the  point  against which it presses.
 With the same kind of  needle as that  before used, a  thread is
  assed between this instrument and the glans.  There is then a
  andle of thread passed in the direction of the black line.   The
 needle is first entered towards the dorsum of the penis.   The
 sound is pushed a  little more towards the frenum, about two lines
 from the first stitch, and the same needle and same thread is passed
 behind the  instrument; finally, the  prepuce will  be surrounded
 with a suture with points passed.   The  thread describes a spiral
 shape, and forms a handle within and without the  prepuce.   The
 forceps should be applied  as I shall presently describe;  and with
 large scissors  the  extremity of the prepuce between the forceps
 and. the spiral represented by the thread, is removed.  The latter
 should be long, as, after the circumcision has been performed, each
 loop divided on the cutaneous  and the mucous surface, will furnish
 two ends of thread, which will serve to make a stitch.
   I admit that it requires much time to execute the proceedings;
 but they possess unquestionable advantages.  The  first results, so
 far as its appearances are concerned, could not be more satisfactory.
 After the operation no dressing is required;  a compress  saturated
 with cold water alone, is applied to the  penis;  and we have no
 hemorrhage to dread.   Now, we know that hemorrhage is a very
 frequent result of the other  methods.  On the fourth day the su-
tures are removed.   After every operation performed on the penis,
the process of cicatrization may be impeded by erections.  But the
application of  a few leeches to  the perineum, with the use of pills
of camphor and opium, and some attention to regimen, will guard
against this accident.
I 
PARAPHIMOSIS.
233
   C. Tldrd Method.— Use of the spring sutures (serres-fines).—The
spring sutures were first used for the purpose of uniting the wound
made in the operation for phimosis.  I have stated that the sutures
were to be removed on the fourth day.  Since that I have re-
moved them at an earlier period; sometimes I have left them for
only twenty-four hours, and  this  too without interfering with the
union of the parts.  I have therefore asked myself, if, for so  short
a time, it was necessary to inflict the additional,pain of the suture,
and if the little fingers could not  patiently keep the lips of the
wound united, since  union can take place so promptly.  I then
had  the  spring sutures made  by  M. Charriere.  These instru-
ments,  which were of steel, being  in my opinion too  heavy and
too difficult of retention in the same  place, I furnished M.  Luer
with the idea of spring sutures, seines-fines, here represented: a, is a
spring suture, the branches of which are still uncrossed; b, branches
crossed, instrument closed; c, instrument opens when pressure is
made on the great inferior ring; d, the handle which enables us to
seize  the instrument.  These  are  small spring sutures.   M. Luer
makes them at least one half smaller.   Oculists find them very
serviceable in their operations on the eye-lids.  When the smallest
size  is used, a porte serre-fine  becomes necessary, for the fingers
cannot retain  their hold, and  they conceal the point to which we
would apply them.   M. Luer has  contrived a very ingenious
instrument for the above purpose.   In order to obtain a complete
and speedy union, it is desirable that the skin and mucous mem-
brane  be perfectly applied  to each  other.  Whilst  the surgeon
takes hold of the  instrument and presses on the large ring so as to
open  it,  the assistant, with two small dissecting forceps, one in
each hand, applies the skin and mucous  membrane accurately to-
gether, and when they are nicely adapted to each other, the sur-
geon  applies the  instrument,  after which the pressure is discon-
tinued.  The two membranes  may also be well  adjusted to each
other, by pressing on the middle of the wound, and  according to
its direction, with a small grooved  sound.   We thus replace the
cellular tissue  which has a tendency to portrude, and prevent it
from  interfering with the union of the wound.   Indeed, if a por-
tion of the cellular tissue interpose between the lips of the wound
union  by the first intention is  impossible.  I will not disguise the
fact that  this  method is  difficult and delicate in its application*
but a cure may be thus obtained  in twenty-four or  thirty hours.
Such success has attended not only my own practice, but that of
all my confreres who have tried  to apply these instruments with care.
  Permit me  to  refer to what constitutes a real improvement in
the art of correcting the deformities of the penis.  When  I en-
tered on  the service of the Hopital du Midi, circumcision was per-
formed, according to the method recommended by M. Ricord  who 
234            VTDAL ON VENEREAL DISEASES.
 then stated in his work:  "The results of circumcision  after my
 method, have appeared to me more favorable than those obtained
 by other proceedings.  A cure has been effected in from twenty
 to twenty-five days."*
   Now a cure has been  obtained with these instruments in from
 twenty to twenty-five hours.
   3d.  Treatment  of Paraphimosis.—We shall commence with sed-
 atives, and antiphlogistics, as recommended in the treatment of
 inflammatory phimosis, connected with more or less strangulation.
 Before we attempt reduction, it is well to remember the two varie-
 ties of paraphimosis which I have established, that which has been
 preceded by phimosis  and that which may produce  it, the glans
 being  naturally uncovered.  It is  certain that if we reduce para-
 phimosis on the subject who has congenital phimosis, he will have
 a vicious conformation, at the price of very severe pains.  It is
 better then to operate, and we should not only incise the ring by
 which  strangulation  is produced, but extend the incision equally
 in front  and  behind the glans.   This is the course to be pursued
 when paraphimosis is irreducible.  In other cases, punctures over
 the tumefied  and  cedematous parts, the application of cold com-
 presses, and circular compression, produce generally good effects.
   M. Seutin has proposed, for the purpose of  acting on the glans,
 reducing its volume, and favoring reduction, the  use of  forceps
 with spoon-like  ends, which will closely embrace this organ, and
 effects  complete compression, more uniform than that produced by
 the fingers of the surgeon.  In every case when the disease  is com-
plicated with  chancre, the latter should also receive our attention,
and we should not be confined to local treatment.
                      CHAPTER VI.

                           BUBO.

  Bubo is an engorgement of the  lymphatic vessels, and princi-
pally of the  lymphatic ganglia;  its most  frequent cause is the
action of the syphilitic virus on these organs.
  Seat.—As the word  bubo denotes, it is with  the  engorgement
of the ganglia  of the  groin that we are now chiefly concerned.
However,  almost  all the ganglia which have their efferent vessels
not far from the skin and  the  origin of mucous membranes, may
become engorged as the result of inoculation from some  point of
the integuments.  Besides  the buboes of the inguinal region, those
of the neck of the axilla, and the fold of the arm, are those which
are most frequently observed.  In the groin there are still differ-
ences of seat: thus, buboes may be above or below Poupart's liga-
ment ; the first we called crural; the others are  called abdominal;
when the  latter are near  the median line, the root of the penis,
* Traite pratique des maladies veneriennes, p. 775. 
bubo.                         235
they are known as pubic buboes.  I shall soon speak of the in-
fluence of the position of chancres on the seat of buboes.
  Causes.—Sex seems here to  exert a decidetl influence;  at least
twice the  number of buboes are seen in the male more than the
female.  Different grades of society also show a great disproportion;
thus the working classes, those  who  are careless of their persons
during the  existence of a chancre, and those who are engaged in
very hard  labor, are the persons most liable to be affected with
chancre. To be persuaded of this difference we have but to com-
pare the patients treated in hospitals with those in private  prac-
tice, and note the predisposing causes.
  The syphilitic  virus  is  the principal cause of buboes; but  it
does not always reach a ganglion in the same manner.   It may in-
volve a gland after having ulcerated or inflamed the tegumentary
surface with which it comes in contact, or indeed after a traumatic
solution of continuity, or even without any alteration  of the in-
teguments, in other words by physiological absorption.  This would
imply that  a bubo may follow a chancre, a blennorrhagia, an in-
oculated wound, and may even occur without any of these lesions,
that is to say it may be  primary (d'emblee).
  Chancre  is certainly the most common starting point of a bubo.
Hunter established this fact completely.  M. Philip Boyer main-
tains that  chancre is always followed by bubo, which is equally
incorrect with  the opinion entertained by others, that there can
be no syphilitic chancre without a bubo.
  Bubo is generally observed during the earliest stages of chancre,
that is during the first week; it may not occur until one or two
months after the natural disappearance of chancre, or after its ci-
catrization  has been effected by remedial measures.   I do not be-
lieve that the speedy cieAirization of a chancre has any particular
connection with the production of a bubo.  Occasionally a very
long time  passes between the cicatrization  of a chancre and the
appearance of a bubo, proving that there is even here a period of
incubation.
   In the male, buboes most frequently follow chancres on the pre-
puce, whilst in the female they follow those seated near the meatus
urinarius.  The position of a chancre on the penis may have an
influence on the  seat of a bubo.  The connection here, however,
is not so precise as to furnish a categorical answer to the question;
given the  seat of  chancre, what will be the seat of bubo ?  It is
known only that bubo generally occurs on the*same  side  as the
chancre; thus the ulceration of the left side of the prepuce is fol-
lowed by a bubo on the left side of the groin, and vice versa.   How-
ever, the contrary may  happen from a decussation or  anastomosis
of the lymphatics.  When there is a chancre on each side  of the
prepuce, there is generally a bubo in each  groin.  A chancre of
 ihe frenuin  gives rise indifferently to a right or left bubo,  some-
times to both.  Notwithstanding all that has been  said,  even nu-
merous chancres may exist without being followed  by bubo, as is
at present  exemplified in  Ward No.  10 of my service.   It must  be
 well understood that we are not to confound with buboes ganglia 
236
VIDAL  ON VENEREAL DISEASES.
 only a little more enlarged than natural, and which of course may
 have existed without any manifestation of chancre.
   Blennorrhagia is 'Jess frequently the starting-point of bubo than
 chancre, and when adenitis is developed, it is then said to be the
 result of sympathy or extension of the irritation.   A really syphi-
 litic  bubo,  arising from the absorption of the virus, it is said can
 only follow a urethral chancre.  This hypothesis  I have already
 combatted,  as I have shown  that there may be a really syphilitic
 blennorrhagia without a urethral chancre.
   Bubo may also result from the physiological absorption of the
 virus; that is, without having been preceded by the three orders
 of lesion already indicated, viz. without inflammation, ulceration,
 or solution  of continuity..  This is proved by analogy, by authori-
 ties, and by facts.  It is well known that a vast vascular network
 covers the whole body;  the virus penetrates this network ; it is so
 subtile that it may traverse the most external layer of the integu-
* ments, without any solution  of continuity, and, as it  is called, by
 imbibition.    The network to which  I have alluded sends  out
 branches of lymphatics, which become loaded  with virus, and
 bear it to  the  vessels and the glands.  The whole of this  route
 may be  traversed without any lesion  of the conducting vessels,
 because they do not react.   But if the first network reacts, we ge-
 nerally have a  chancre f if  the vessel, a chancrous inflammation
 of the lymphatics ; if the  gland, a chancrous adenitis, a  veritable
 syphilitic bubo.  Some writers on syphilis do not fully admit
 this; they acknowledge  only that a lymphatic vessel may be tra-
 versed by the virus without suffering the least injury.  Now the
 same observation  applies to  the other tissues.  Analogy, indeed,
 proves that the virus may pass from  the skin  to the  ganglion
 without wounding any part, and the facta upon this point are con-
 clusive.   Thus,  when variola is not  inoculated (and it is  no  long-
 er inoculated), how does the virus enter the system ?   By the same
 avenues as  the  syphilitic virus, and no  previous solution of con-
 tinuity is required.   Does not  the  virus  of glanders sometimes
 affect animals and man without any previous solution of  con-
 tinuity ?  Is there not a glanders cVemblee ?  Consult on this sub-
 ject the most weighty author%—Hunter.  Now, Hunter admits
 the bubo d'emblee in the  sense  received  by us.  'Twas particu-
 larly when  treating of buboes that he pointed out the four surfaces
 by which pus may be absorbed: 1st, by an ulcer; 2d, by an in-
 flamed surface ;  3d, by a traumatic surface ; 4th, by a common,
 that is to say a  sound surface.   These three kinds of absorption
 are not merely theoretically indicated  only.   Hunter  fully appre-
 ciated them, and studied them in view of facts.  He clearly show-
 ed that absorption most frequently occurs by an ulcerated surface,
 and that by sound surfaces  it is least frequently observed.   On
 this point the English surgeon has shown an extreme distrust and
 the greatest hardihood.
   He advises, for  example, that women should be avoided, as it
 is never known whether  they are or  are not affected with blennor-
 rhagia ; he  remarks that before an opinion is formed,  they should 
bubo.                         237
be most carefully examined, and then we shall often discover that
a small  chancre is the cause of the infection, a circumstance that
has more than once happened.   " We should," he observes, " pay
especial attention to every circumstance connected with a case of
this kind." (p. 480.)  Hunter, moreover adds, that every engorge-
ment in the  groins  is not a venereal bubo.  Thus, we here find a
great genius, a keen and accurate observer, who admits the exist-
ence of the  primary bubo.  We may assert that this  doctrine is
now becoming again in vogue, since this form of bubo is admitted
not only by those who  have always  sustained this opinion, but
by the  disciples of M. Ricord;  for example, by M. Reynaud (de
Toulon)  and  M. Gibert.   M. Reynaud declares very positively that
he has treated persons who, after a suspicious intercourse, had fre-
quently examined their penis, without discovering anything; and
that they became affected with  buboes which  were followed by
very decided consecutive accidents  (p. 55).  M. Gibert positively
observed a case of primary bubo, the matter of which he success-
fully inoculated.  M. Ricord very simply objects to this, that M.
Gibert deceived himself, or was mistaken. Observe that this reply,
especially when politely stated, might be made to every observer;
to MM. Lagneau, de Castelneau, Cazenave, Baumes, &c.  In the
work of the last-named author, cases sixth and seventh leave no-
thing to be desired on this subject, since they were inoculated with
success.
  [During our recent  visit to  London, Mr. Lane very politely
showed us, at the Lock Hospital, two cases  of the bubo d'emblee.
In one of these cases inoculation had produced the characteristic
pustule.   The brief notes of the case, as made under the supervi-
sion of Mr. Lane, are as follows:—Thomas Hughes, at. 22,  admit-
ted into the  Lock Hospital, May 5th, 1853. Six weeks previously
had  last connection.  At the time of our visit, 26th May, he had
had a bubo for a month.   No trace  of a sore on the penis or any
other point.   Both Mr. Lane and myself, after diligent inquiry,
could detect no other symptom.   Matter from the bubo was inoc-
ulated on the left thigh on the 21st May.  On the 26th, character-
istic pustule, which we saw,  was perfectly developed, and Mr. L.
directed it to be cauterized at once.   Mr. L. informed us that cases
of primary bubo not unfrequently came under his observation, but
that this was the first instance in which he had produced positive
results or inoculation.  M. Ricord, in his Treatise (Am. ed. pp. 187,
190), has recorded eight cases of the bubo d'emblee ; and Dr. Judd,
in his works on the venereal, has detailed several of the kind.  M.
Ricord, at pp. 74, 75, of his Treatise (Am. ed.), has given us incon-
testable proof of the existence of this form of bubo.  . He quotes
authority after  authority in  support  of  what, in his  Letters
(XXV.), and  his Notes  to Hunter, (2d ed. p. 521,) he treats with
ridicule; indeed, in referring to the successful inoculations of M.
Gibert,  he very complacently observes, that he either deceived him-
self, or was deceived (M.  Gibert s'est trompe ou a ete tromp?)!
  Dr. Graves, in his Lectures (Dub.  ed. 1848, vol. ii. p. 385), quotes
from Dr.  Roe's Report  of venereal patients treated in the 38th 
238            VLDAL ON VENEREAL DISEASES.
Regimental Hospital, the following:  "Buboes  were often seen
without any ulcers on the penis," &c.  M.  Ricord admits in his
Treatise, p. 222, Am. ed., the devolopment of abscesses formed by
the imbibition of matter from an adjacent chancre, yet, in his Let-
ters (XXV.), he denies the possibility of such imbibition!—G. C. B.]
  For my own part, I have seen several instances of the primary
bubo.  As I did  not inoculate the primary  accident,  I waited
the development  of constitutional disease.   In Ward No.  11
there  was a case of  double bubo, on a subject whose glans penis
was quite uncovered; he had  had these swellings for five days;
he watched himself carefully; the buboes were positively the first
manifestations  of  the disease;  he had neither a discharge nor  a
sore.  I was  enabled to watch this patient for a long time,  and  I
saw a papular eruption developed.  Another patient entered with
a bubo still more  recent than the first; there was nothing in the
antecedent circumstances that  could lead to the suspicion of any
other primary  symptom; only, he described perfectly a roseola
which had disappeared.  This I did not see.   But a swelling after-
wards appeared in the superior  maxillary bone, which resulted in
necrosis, and I extracted  a fragment of bone to which were at-
tached two of  the teeth.  The  separation of the sequestrum, and
the healing of the wound,  were  remarkably rapid, under the influ-
ence of the iodide of potassium.
  Besides the buboes from absorption of the syphilitic virus, it is
admitted that there are those produced by an extension of irrita-
tion or inflammation, or by sympathy, independent of syphilis.
  The virus, having acted on the whole system, may cause an en-
largement  of the glands and  establish a consecutive bubo. In
fine, bubo is said to be inflammatory or indolent, acute or chronic,
according to the prevalence or  absence of the phenomena  of in-
flammation.  Still other divisions have been made ; these it is un-
necessary for me  here to notice, as I am now considering these
swellings in an etiological point of view.
  Symptoms.—I shall first describe the more general symptoms;
in treating of the  varieties, and especially of inflammatory bubo,
I will complete the sketch.
  Bubo is occasionally  preceded by febrile  excitement; this
ceases only after the appearance of  suppuration.  In  corpulent
subjects, especially females, fever sometimes exists for several days
before a bubo  is suspected, particularly when it is small.  The
tumor is generally of an oblong shape, its  grand axis  following
the direction of the bend of the groin.  In other situations,  as the
elbow and the axilla, it assumes a globular form.   If the swelling
consist of one gland alone, if it be already inflamed, it is of a reg-
ular uniform shape;  if, on the contrary, several glands are affected,
and inflammation  be still  absent, the  swelling is more or less ir-
regular in form.  Sometimes the tumor is divided into two segments
—a superior, and an  inferior;  this disposition is observed when
the very dense  cellular tissue at the bend of the groin has resisted
the development of the gland;  it then produces in this situation
a kind of strangulation, a depression, and the  tumefaction takes 
bubo.                         239
place on the side of the abdomen, or the thigh, where the adhesion
of the skin offer the least resistance.
  Varieties.—Buboes have been divided into many varieties, ac-
cording to the phenomena, and the symptoms which they present.
I shall describe but two varieties;  the inflammatory, and the
non-inflammatory or indolent bubo, and in my description of these,
I shall point out the characters of the sub-varieties.
  1. Inflammatory Bubo.—Bubo is generally the result of the ac-
tion of the syphilitic virus on a portion of the lymphatic system;
it is the bubo from absorption.   But this absorption  may occur on
an ulcerated, an inflamed  or a sound surface.  In the latter case,
it is called primary bubo.  I  have  already stated, that this kind
of bubo  was  admitted by Hunter, that it was consistent with
reason, and  that it had been established by clinical facts, and by
experiment.  Whatever the surface of the absorbtion, the virus
generally passes at once to the lymphatic glands, by their afferent
vessels.  These vessels are generally insensible to the poison which
they carry;  if they do re-act, a virulent angiolencitis is developed,
which may be regarded as a bubo of the lymphatic vessels.   It is
well here to note the possibility of the virus passing through the
lymphatic vessels without necessarily infecting the vessels them-
selves, a  fact admitted by those writers on syphilis who deny the
existence of the primary bubo, and this too for the reason that the
virus cannot penetrate our tissues unless by means of an  ulcer!
Now we  here find this same virus  traversing the lymphatic ves-
sels, leaving them, for the most part, perfectly sound.
  It has  been maintained, that in the bubo from absorption one
gland only is affected, except  in the case of very large  chancres,
which may oommunicate with a great number of lymphatic ves-
sels.  Nevertheless, there is in my service  a patient affected with
chancres on the penis;  he inoculated himself with these chancres
through  a crack on his finger ; at this  point was a chancre almost
imperceptible, and yet  it was followed by a bubo at the bend of
the  arm, and in  the axilla.   We here see that the virus passed
far beyond the first gland that it encountered.  Another erroneous
idea is, that when the virus is once beyond the lymphatic vessel
and gland, it can be no longer inoculated, or transmitted.   When
once this virus has. entered the circulation, it may still produce
effects, even on the individual in wrhom it has been absorbed, but
not on another person, for these effects, which are secondary  acci-
dents, cannot be inoculated, nor are they contagious.  This serious
error, against which elinical facts daily protest in vain, has been
completely refuted by experiment.  It has, indeed, been proved
that a sound person may contract syphilis not only from the mor-
bid secretions furnished by  secondary  accidents,  but  from  the
blood of the  individual affected with  these same accidents.  Be-
sides, who  will say that  the virus  can reach the gland only by
means of the  lymphatic vessels?   Every circumstance goes to
show,  on the contrary, that this poison may directly enter the cir-
culation, and tlirough the latter, reach  every part of the system. _
   Bubo  may likewise occur independently of any specific syphilitic 
240
VEOAL ON VENEREAL DISEASES.
 action;  it is then  maintained that the inflammatory radii from a
 chancre or an inflamed surface involve the glands; in which case
 it  is called bid)o from extension.  The sympathetic bubo should be
 produced by an irritation reflected from the point primarily ailected
 to the gland.   We may remark in passing, that this sympathetic
 reaction has been singularly abused.   That bubo may be produced
 during the existence of a chancre or an inflammation of the integu-
 ments from which  lymphatic vessels  arise leading to the  affected
 gland, can be admitted according to our general ideas of morbid
 sympathies; but it  is difficult, if not impossible, to acknowdedge the
 sympathetic bubo  without  a starting point.   For  example, when
 buboes  have been  observed,  without any previous lesion  on the
 genital organs, without ulceration or inflammation, it has been pre-
 tended that they were sympathetic!   But sympathetic of what?
 Where is  the starting point of this sympathy ?  What directs it to
 the gland?  They conclude by answering, coitus, a single act of
 sexual intercourse!  This arises from denying the absorption of
 the syphilitic virus by a sound surface, in other words from closing
 their eyes to facts!
    However it may be, buboes by extension, sympathetic buboes,
 can only be, I repeat it, inflammatory accidents, and not syphilitic;
 compared with buboes  by  absorption, they  may be  regarded as
 benign, for they contain no virus, and are not inoculable, as is the
 case with  buboes by absorption.  It will be remarked that buboes
 by extension, by the propagation of the  inflammatory foci, those
 that are regarded as the most common among benign buboes, occur
 precisely in those cases where chancre is but little inflamed, often
 when it is cicatrized, and almost never when the ulceration is really
 complicated with inflammation.   Observe what occurs after opera-
 tions  on the penis, such as extirpations, ligatures, cauterizations
 of excrescences, cauterizations sometimes deep, incisions, excisions
 of the prepuce  immethodically made; now these lesions, each of
 which always produces an inflammation more severe than common
 chancre, are yet followed by no adenitis, by no bubo from exten-
 sion or sympathy;  whence I conclude that there is nothing more
 rare than what is called benign bubo, that is, adenitis, a simply inflam-
 matory  adenitis, either  from extension  or sympathy.  I believe
 even that the last, having no starting point, is ontirely hypothetical.
   I proceed to describe  the several phases of inflammatory bubo.
 We shall find even here, sub-varieties which- have been separately
 described  by certain authors. Inflammatory bubo is  sometimes
.preceded by a  fever,  which continues whilst the  swelling is in-
 creasing.  We have then, as I have already stated, primary bubo.
 The patient complains of an unusual sensation in the region which
 is  to be the seat of the inflammatory tumor; to this succeeds a
 pain, or rather it extends along the thigh; there is pain and diffi-
 culty in motion. The gland or glands are tumefied;  at first they
 retain some mobility, which in a short  time is lost.   The phleg-
 monous period has  already commenced; for, at the same time that
 the glands enlarge, in the majority of  cases the  cellular tissue
 becomes involved  in the inflammation, the progress of which is 
BUBO.
241
then still more rapid.  The tumor presents an elastic feel, which
differs from the indurated thickening of glands and cellular tissue.
The skin is of a deep violet red color over  the centre and around
the tumor.  The pain is generally exasperated and shoots in dif-
ferent directions, or it may remain unchanged.   Its violence does
not always correspond with the severity of the inflammation.   In
fact, we may yet hope to disperse these tumors and prevent sup-
puration, especially if the most absolute repose be observed.
  The inflammatory phenomena  are more decided and  produce
greater reaction when the glands affected are deeply seated; their
enlargement is then prevented by aponeurotic layers which bind
them down, and produce some symptoms of strangulation. If the
inflammation continue, as is most frequently the case, pus forms,
and then we have a suppurating bubo.  In the majority of cases the
matter forms  in the cellular tissue, which becomes  agglomerated;
fluctuation is then easily and promptly  detected, for the matter is
more  superficial and the  abscess is unilocular.  The skin is of a
deep violet red color.  When the suppuration, instead of being
peri-glandular is intra-glandular, the pus may at first form several
little foci in the organ; its presence  is then difficult of detection
on  account of this circumstance,  and because it is more distant
from  the  surface.   It  afterwards becomes collected in  a single
cavity hollowed out of the gland, and beneath a certain thickening
of the parts we may perceive fluctuation, which  becomes more
evident  when  the  intra-glandular foci communicate with  the pus
of the cellular tissue surrounding the  ganglion.
  When pus has formed and become collected, both general and
local excitement cease, and the  movements of the  thigh  are less
difficult.   But the skin becomes thin and bare, of  a deeper color,
and if in the first stage of suppuration, some hope may still remain
that the tumor may disappear without any solution of continuity,
this hope is now entirely lost;  indeed, if the tumor be not opened
it will open  spontaneously.  When  the inflammation has been
severe and acute  the pus has the qualities of what is called good
pus, phlegmonous pus; if the inflammation has progressed rather
slowly, and if it has been, as it were, arrested from  time  to time,
as often happens when glands are  inflamed, the pus is  then thin,
mal-assimilated, and filled with coagula.   The pus may assume this
double character when there has been a simultaneous suppuration
of the gland and  the cellular tissue by which it is surrounded-
In all cases it may be more or less mixed with blood, occasionally
it  happens even, that the cellular tissue, or peri-glandular tissues,
contain nothing but blood.
  Whether we  do or do  not  interfere, though the  tumor  be
opened  early or late, the solution  of continuity may assume the
characters  of  chancre;  we have then what is  called glandular
chancre, which may present the different aspects that have served
to establish the varieties of chancre.  Thus this  solution  of con-
tinuity should have the aspect of common  chancre, or  it  may be
more or less indurated, and thickened at its base and borders, cor-
responding to the indurated chancre;  finally, mortified  portions
                              1G 
242
VTDAL ON VENEREAL DISEASES.
may be detached, the ulceration spread rapidly over one or several
points, and resist all treatment: consequently, we should have the
phagedenic chancre in all ite different forms ; and here the same
hygienic circumstances shall prevail, the  same idiosyncrasies, the
same therapeutic measures, which exerted an  influence over the
characters assumed by .the ulceration, absolutely as I  have de-
scribed when considering the causes of the deviation in the form
of what is called regular chancre.
  If the bubo be opened with a bistoury or lancet, if the opening
be made at a proper time, and in the manner that I shall hereafter
describe, there is a strong probability that the skin will contract
ite natural adhesions, and that the wound will soon become healed,
without leaving any trace of  deformity.  If, on the contrary, we
wait for the swelling to open spontaneously, if it be  opened at too
late a period, or in an improper manner, the skin will not become
adherent, or it will be but imperfectly re-established: more or less
of it will slough, and there will  be a great loss of substance, or
many openings, which will remain a long time fistulous.  In both
cases, the reparation of the wound  will be slow, an unequal, de-
formed, and strongly-marked vicious cicatrix  will  remain,  to
remind the patient of an  event which, in the majority of cases, he
would prefer should be unknown.
  2d. Non-inflammatory or Indolent Bubo.—This generally consists
of several  enlarged glands, which are movable, not painful, and
do not, at the commencement, present any phenomena connected
with true inflammation,  except the increased  size.   A great im-
portance has  been attached to bubo  in forming the diagnosis of in-
durated chancre:  M. Ricord even denominates  it the necessary
companion  of this  disease.*   But he must know that  a similar
glandular enlargement may be observed in strumous subjects wdio
have never had a chancre ; it  may  exist  in the other varieties of
chancre, in that called regular common chancre, which is regarded
as deprived  of all specific induration; add to this, the fact that
this same engorgement differs in no respect from consecutive bubo,
since it exists in connection with indurated chancre,  itself an indi-
cation of the existence of the diathesis, since it is observed with
the train of accidents called  constitutional, its value is  singularly
diminished of the  indolent  bubo  in  the diagnosis of  syphilitic
ulcerations. ^  The  indolent bubo,  consecutive or primary,  may
assume  an inflammatory character; but its pus is not considered
inoculable.
  Diagnosis.—We  are -now particularly concerned with inguinal
bubo.  Let us first exclude hernia, aneurisms, and abscesses, by
congestion, the tumors produced by  which are easily distinguished
from bubo.  The  marks  of some  wound, or laceration, certain
cutaneous inflammations,  a furuncle at some point corresponding
to the distribution of some lymphatic vessels leading to the glands
of the groin;  the knowledge of these lesions will prevent us from
confounding the  glandular engorgemente which sometimes result  '

                  * Notes to Hunter, p. 552, 2d ed. 
BUBO.
243
from them, with syphilitic buboes.  The difficulties are not great
when, with the bubo, other syphilitic accidents coincide; if the
latter are consecutive, the bubo is constitutional, indicative of the
diathesis;  if the accidents are primary, bubo might be indolent in
the case of indurated chancre, or inflammatory in the case of regu-
lar, common chancre.  The difficulty is real, and not easy to be
surmounted when we cannot discover the starting point of the
inflammation which has invaded the gland, when there is nothing
on the integuments to indicate that the  virus has penetrated the
system, when,  in fine, there  is a primary bubo.   Some have
thought that these difficulties might be  obviated by resorting to
inoculation,  which  should  produce  a chancre, in the case  of a
syphilitic bubo, and which will fail if the contrary be true.  But
this proceeding cannot be adopted except where suppuration is
already established; it is important to decide before this event has
happened, and even when it has, inoculation is difficult and uncer-
tain.  Indeed,  in the  case of a  true syphilitic bubo, suppuration
may have invaded but the cellular tissue surrounding the gland,
when it is supposed that the gland itself has suppurated.   In  such
a case inoculation would lead to  no result, for the pus of the gland
alone contains the virus.  If we pass through  the cellular tissue,
and reach the suppurating gland, we cannot be sure of obtaining
the virus,  as the bubo may be composed of two glands, each of
which  may contain different kinds of pus; the matter obtained
may come from the gland, which  does  not  contain specific  pus,
thence another failure of inoculation, and that, too, in a case where
there is really  a virulent bubo.  Further still, we are not even
certain of obtaining virus in extracting matter from a gland, the
suppuration of which has  been specific, for we may be too  late,
that is, at the time of reparation, when the pus secreted is  no
longer virulent.  Inoculation, therefore,  does not remove the  diffi-
culties ; it rather creates more.   Clinical experience must furnish
us with the principal information required  to form a diagnosis; it
is the combination of certain  constitutional and local symptoms,
together with the antecedent circumstances, that can lead  to prac-
tical truth.  In the last analysis, what tumor may be confounded
with bubo ?  The scrofulous.   Now, the scrofulous,*or, if it please,
the strumous tumor, occurs in subjects who have had certain ante-
cedents from infancy, from  puberty, whose signification is known,
and their systems nave had certain marks which cannot deceive
those who have studied the temperaments.  Again, it is rare that
there is the tumor in the  groin only;  but we find them in other
regions, as the neck, for example;  and in the groin, even, we find
an  enlargement of more than one of the deep-seated glands, as well
as in the pelvis; in fact, it is rare that the strumous bubo  does not
involve the supra-aponeurotic  glands.  In  its development  and
progress,  it resembles other strumous tumors.   The  engorge-
ment begins  in one or two  glands,  it  forms  slowly,  and is
attended with little or no pain.   This indolent  character remains
for a long  time, and the  skin  continues sound, not changing
even ite color.   But under the influence of a  physical cause, 
244            VIDAL ON VENEREAL DISEASES.
or some excitement of the system, sometimes without any appre-
ciable cause, the inflammation attack., the glands already engorged;
the pain is now severe ; there is  an erysipelatous redness of the
skin, and thickening of the cellular tissue.   These phenomena may
be but temporary, and the tumor may thus be .many times re-
newed.  It finally softens, and forms not one but several foci con-
nected with  the lobes of the different  glands;  and as the deep-
seated  glands of the groin and pelvis may be simultaneously
affected with the superficial, the suppuration may be very pro-
found.
  In describing the suppurating  inflammatory bubo, it must have
been" remarked that it was  attended by a different train of phe-
nomena.   The tumor, in this variety of bubo, is of limited size,
its progress is acute, its suppuration rapid, and generally it formed
but one focus of matter.  After  the bubo is opened, it does not
present that successive degradation of strumous pus, which  is at
first thick and well assimilated, then demi-serous with flakes, and
which always becomes more liquid and of a redder color.   When
the bubo is once opened, be it strumous or  venereal, it becomes
an ulcer which in both  cases may possess analogous characters,
but between which differences exist, which I will indicate.  Both
ulcers may have a fungous base,  of a dull gray color.   But in the
ulcer from a venereal bubo, a false membrane covers the base,
and we may remove it by gentle rubbing; then the color of the
wound is of a more or less lively red.   In  the strumous bubo, the
base of the ulcer, on the contrary, is formed by the  gland itself,
which is more or less fungous,  and has the gray color, which can-
not be made even momentarily to disappear.   These glands more
or less hypertrophied, sometimes rise above the level of the skin,
which tends  greatly to retard the healing of the ulcer.  Further,
the skin around  the  ulceration  is thin, not red, but more or less
livid.  When the ulcer is venereal, there is  always more or less
inflammatory turgescence, and the cellular tissue of the base, that
which lies under  the skin, is more or less rigid; the gland does
not so soon become exposed.  Venereal ulceration, besides, makes
too rapid progress in the commencement to be afterwards suddenly
arrested, and then to march speedily towards reparation.  The
contrary is true of strumous ulceration, which is slowly established,
which progresses slowly,  and heals still more slowly.
  But, unfortunately,  both the  strumous and  the venereal dia-
thesis may be so blended, that the bubo having  the characters of
both, may render  the  diagnosis  very difficult.  Hunter  very
justly remarked : "There are buboes which  are nothing else than
a gland endowed with a scrofulous  disposition,  in which the mor-
bid action has been provoked by venereal irritation."*  Occasion-
ally we meet with a bubo which has been preceded by a  chancre
on the penis, or a urethral blennorrhagia has inflamed, suppurated,
and  opened  in the same manner as a syphilitic bubo; the stru-
mous engorgement then  manifests itself, and it assumes the char-
* On Bubo, chap. iv. 
BUBO.
245
actors which I have described.  Here the venereal accident, on the
part of the penis, has  excited the scrofulous disposition of the
glands of the groin, and  has given to the strumous adenitis an
active character, which did not belong  to it before the venereal
irritation was superadded.  There are  cases where  the bubo _ is
truly venereal; its  onset,  its progress,  the  ulceration which  in-
vades the skin, all prove it; we then have evidently what is called
a glandular chancre.   But the scrofulous principle which, so to
speak, had remained in its essence, began to act, and then it could
produce two effects: it might complicate the venereal ulcer, cause
it  to be  transformed into a phagedenic ulcer, which is a very
grave affair;  or, the venereal symptoms disappearing,  scrofula
gained the ascendency, the  ulcer and the tumor assumed the
characters which I have just assigned to the strumous ulcer  of
bubo*
  From what I have stated, it will be seen that the difficulties  of:
forming  a  diagnosis are real;  and, in the present state of the
science, it is not possible entirely to remove them.  But the knowl-
edge of these  difficulties will cause the young practitioner to  be
at least guarded  in  announcing his opinion, to be prudent in his
treatment, and to be discreet in his remarks before interested per-
sons or in courts of justice.  Thus, what we  should here avoid is
being too absolute, that  is, when we come to the treatment,  we
should not persist in the administration of mercury when several
courses of this mineral have not had a happy result.   We should
then remember the  possibility of a strumous complication, and act
accordingly.
   [In the  Compendium de Chirurgie Pratique, of Berard  and  M.
Denonvilliers, vol. 1st, p. 43,  a case is reported which occurred at
the Hopital du Midi, in  1812, and in which one of the internes
opened  an aneurismal tumor, supposing that it  was a bubo!—
G. C. B.]
   Prognosis.—This  may be inferred  from what I have stated in
speaking of the different varieties of buboes and their complica-
tions.  The most terrible of all is the strumous complication which
may convert the ulcer of a bubo into a phagadenic^chancre.  We
then  observe those extensive  denudations of the groin, which
invade even a part  of the abdomen, and exhaust the unfortunate
patient by his sufferings and  the abundance of the suppuration.
   [Mr. South states, in the second volume of his  edition of Chel-
ius (p. 90), that  he  has known a sloughing bubo  destroy fife, by
ulcerating the femoral artery.—G. C. B.]
   Treatment—Nicholas Massa recommended that buboes should be
allowed  to suppurate;  he regarded them as a kind of emunctory
destined to rid the  system of the  poison and to render the patient
less liable to consecutive  accidents, to the confirmed pox.  This
opinion, which  others would call error, has always  found sup-
porters.   Hveu  at  the present day we find in  the work of  M.
liaumes, that subjects in whom buboes have suppurated, are less

  * Vide an article by M. Gabalda, in the Bull. TJierapeut., Jan. and March, 1846. 
246
VEOAL ON VENEREAL DISEASES.
frequently  troubled with  consecutive  accidents.  To this it has
been replied, that suppurating buboes coincide with  the common
chancre which does not generally produce the pox. I  have already
shown that this assertion is not true.
  [It is to be regretted that upon this, as on  so many other doc-
trinal points, the views of as weighty an authority as M. Ricord,
should be so contradictory. For example, in his Treatise (Am. ed.,
p. 76), he remarks: " Experience having shown that buboes which
do not inoculate are never  followed  by  secondary accidents."
Now in his Letters, (xxvii., p.  199,) he asserts  that: " Every bubo
which  suppurates specifically, that is, which furnishes inoculable
pus,  is never followed by  constitutional infection!"  Which  of
these doctrines are  we to believe?  One thing  we  know to  be
true, viz., that constitutional infection sometimes occurs after a sup-
purating  bubo,  whether such  suppuration be specific or  non-
specific.—G. C. B.]
  For  my own part, I will not here discuss the question, whether
it is better to promote or to prevent suppuration  in a bubo;  for I
believe it to be almost impossible by any of the ordinary means of
treatment to obtain  either of the results.  The bubo that should
suppurate,  will suppurate, no matter what we do, and the bubo
which  should disappear by resolution will thus disappear in spite
of the application of the ordinary suppuratives, except they be too
violently used.  Does it  follow that I would dispense  with the
treatment of buboes ?  No.  I believe, on the contrary, that we
have a preventive treatment;  a palliative treatment, and a surgical
treatment to employ.
  1st. Preventive Treatment.—Among subjects affected with chancre,
there are those who greatly neglect hygiene, who do not observe
repose, who labor, and who abandon themselves to pleasure; these
are the persons in whom we most frequently meet  with buboes.
As to the frequency of this accident, there is a marked difference
between  the working population who frequent our hospitals, and
the patients which  we treat in private practice.  This fact, to
which I alluded in speaking of  the etiology of buboes, should in-
duce the  practitioner to recommend  hygienic  measures to the  pa-
tient, and to insist  that he  avoid fatigue, and observe the  most
absolute repose.   A well directed local treatment of  chancre may
prevent the formation of a  bubo.  M. Ricord advises that  we
should not irritate a chancre.   I would remark that it is a practice
with  him  to  cauterize them, and to  dress them with aromatic
wine.
  2nd. Abortive Method.—This consists in cold applications, the local
abstraction of blood, and the  use of compression.  A kind of cau-
terization with a solution of fifteen grains of the bichloride of mer-
cury to an ounce of water, has also been  employed.   The skin is
first removed by means of a blister.   This painful and uncertain
method is now abandoned even by those who recommended it.   I
shall again allude to this treatment, which is better adapted to  the
suppurating bubo.
  The glans have been incised subcutaneous!)-.  I know not  the 
BUBO.
247
results thus obtained.  Some have gone  so far as  to propose the
subcutaneous division of the lymphatic vessels which pass from
the chancre of the glands.   To this I would reply:  when the
glands are already infected, what  advantage can possibly follow
the section of the one or more of the lymphatic vessels ?   If infec-
tion had not taken place, then the incision might be preventive.
But is this advisable for a disease which may not be developed ?
Again, supposing that chancre is certainly followed by bubo, can
we predict what gland will be affected, or  on which side it will be ?
Is it  possible in all  cases to strike upon the lymphatics of the
glands which will be affected ?  Is it  exclusively the office of the
lymphatics to carry the virus to the glands ?
   Further, to appreciate  the value  of tbe abortive  method in
general, we must ascertain the facts relative to the dispersion of
buboes.   Does this  often  occur?  Clinical observation, on the
contrary, teaches that bubo once formed, in  other words adenitis
once  established with more or less inflammation of the surround-
ing tissues, is very seldom observed to disappear in the rapid man-
ner that resolution supposes.  I assert that it is very rare;  I do
not maintain that it is impossible, for I have seen some exception-
able instances of the disappearance of the suppurating buboes, but
they were immediately followed  by a phlegmonous inflammation
of the cellular tissue of the scrotum, an inflammation which is
known to be connected with mortification of the parts.  In these
cases it was a kind of metastasis.
   The proper treatment has reference to three varieties of buboes.
   1st, the inflammatory bubo: 2d, the suppurating bubo : 3d, the
chronic indolent bubo.
   3d. Antiphlogistics.—In the treatment of inflammatory bubo, anti-
phlogistics are plainly indicated.  In some cases they may produce
resolution, and frequently limit the extent of the inflammation, as
well as the purulent cavity, if the  inflammation become really
phlegmonous, and terminate in  abscess, if, in fine, suppurating
bubo succeeds to the inflammatory bubo.
   As in every case  of adenitis, when the patient is young  and
vigorous, when the inflammation has decidedly an acute character,
when the  premonitory symptoms and the reaction are marked by
fever of an inflammatory grade, it is well to begin with a general
blood-letting, and  afterwards resort to the application of leeches.
In the majority of cases, we rely on the local abstraction of blood.
which is repeated and proportioned to the volume of the tumor, its
tension, and the pain of which it is the seat.  We may apply  from
ten to for+y leeches.   The largest number should be applied
at first; and  when the leeching is repeated, a smaller number may
be used.
   The mercurial ointment, not as ordinarily applied in small quan-
tities, but in thick layers, as in the treatment of peritonitis, may
produce a sedative and reall}' antiphlogistic effect.  But if we do
not perceive a marked  result on the first or second day, and if we
find it necessary to continue the application, we are in danger of
producing an annoying salivation.   I therefore employ mercury 
248
VLDAL ON VENEREAL DISEASES.
only as  a topical application, and  do not believe that we should
aim to affect the system bv these frictions.  I cannot believe that
when we have to treat genuine bubo \s, we can cure them in four or
five days by means of mercurial frictions,  as Swediaur maintained.
  Our topical applications should be  confined to rice or linseed
cataplasms, or to those of semoule, and of bread.   When there is
much pain they may be moistened with laudanum ; in other cases,
we may use Goulard's extract.  Rest,  a  diet more or less rigid,
soothing drinks, gentle laxatives, complete  the  treatment  of in-
flammatory bubo, of adenitis.  Too  often, notwithstanding these
means, and especially  when  they have not been  employed, the
tumor retains its volume;  it becomes more and more tense, crepi-
tating and of a deep red color.   The fever continues, the redness in-
creases,  and soon a constant  throbbing pain is felt.  The patient
is troubled with  sweats, and the formation of matter can now no
longer be questioned.  When fluctuation is felt, should we open
the tumor or leave it to nature ?
  4th. Spontaneous opening of Bubo.—In all ages some practitioners
have preferred  to leave to nature the opening of the abscess and
the evacuation of the pus.  Swediaur, who especially taught this
practice, maintained, that abscesses thus left to open spontaneously
were more rapidly consolidated, and when  cured left less deformity
behind.    Swediaur,  however, is less absolute than is  stated  in
books;  he admits that there are cases in which the surgeon should
dilate the natural opening, and in which he  should even open the
bubo with the knife.  However it may be, Swediaur stands at the
head of the advocates for a spontaneous opening, and  he has ad-
duced the strongest arguments in favor of the expectant method
of treating buboes.  As to the speedy consolidation, that is, the
cure, we may reply, that in allowing the  pus to  remain-we favor
the exposure of the gland, and its suppuration in cases where the
surrounding cellular tissue alone is inflamed, by permitting the
cavity to increase, and the abscess, which  is  never simple, to be-
come  still more  complicated, and of course to  retard the cure.
As to the deformity I may be still more explicit;  I  may  assert
and can prove that there is a great difference between the natural
and the surgical proceeding, such as I practice, be it well under-
stood.   Indeed, in the majority of cases, spontaneous  opening
does not occur until the skin has been detached, and become very
thin;  this perforation besides  is but a form  of mortification, and
around this first loss of substance, there is more or less skin ready
to mortify, and  which most frequently does mortify;  thence  an
enlargement of the first breach or rather other openings form.   In
the most favorable cases this skin requires a long time to become
again adherent.  If there be but one  opening, it enlarges unequal-
ly ;  its thin, sharp borders, sink down towards the bottom of the
abscess.  Should there  be several openings, they often become
converted into one large unequal breach, which is never completely
covered by the surrounding skin, and an inodular tissue appears,
an irregular cicatrix, depressed, stellated,  and evidently deformed;
if the openings  do not become blended  into one, the fistula to 
BUBO.                         249
which they give rise are exceedingly difficult of cure.  These re-
sults are seen  principally among patients who have received no
care, who have worked and walked, and observed nothing like
repose.   The movements have then affected the diseased parts,
and this, together with the chafing, has promoted  the separation
of the skin.   It will presently be seen that the openings which I
substitute for those  which occur spontaneously, are not attended
with such inconveniences, nor  do  they leave behind  deformities.
But, before  describing my method,  I  must rapidly  expose and
'judge those which have preceded it, and which are still preferred
by other practitioners.
  5th.  Blistered surface  dressed with bichloride of mercury—a
method of which  a wrong  estimate has been formed, and which
has been badly applied, especially at Paris, is that of M. Malapert.
This physician proposed to open thoroughly the suppurating bubo
by means of a concentrated solution of the bichloride of mercury;
but  he  proposes to act  particularly upon  the  cavity, so as to
modify it specifically ;  he  supposes, also, that he thus  acts on the
whole system.  M.  Malapert, therefore, proposes to fulfil a double
indication, and his treatment is intended to produce both a local
and  general  effect.   M.  Reynaud, of Toulon, who has most fre-
quently and perfectly employed the  method of M. Malapert, does
not apply it for the purpose of opening and evacuating the bubo
to more  advantage than the other methods.   It is only in this
point of  view that I judge it, for I believe that medicines to coun-
teract a diathesis should be administered internally.  The follow-
ing is the proceeding:
  When suppuration is first detected in the bubo,  a blister of the
size of from a fifty centime to a franc piece, according  to  the vol-
ume of the tumor, is to be applied to the point of fluctuation.  The
vesicle is opened, and on the denuded  dermis is placed a  pledget
soaked in a  solution of the bi-chloride  of mercury,  of the strength
of fifteen grains to the ounce  of liquid.   Two hours afterwards
an eschar is already formed ; should it not be completely formed,
the application is to be renewed, and then an emollient cataplasm.
Thirty-six or forty-eight hours  after the formation of the eschar,
and  as soon  as it is detached,  a purulent liquid exudes from the
fissures.   The discharge  is more abundant in  proportion as the
eschar becomes detached  at several points ;  after it has fallen off,
the cavity is sometimes entirely emptied.   During the discharge
of the liquid, the walls of the cavity contract, and the cavity itself
is soon effaced.
  It is obvious that a cauterization of this kind can be rationally
employed only in the case of a superficial and very limited sup-
puration, and  even when the  abscess  is subcutaneous, we occa-
sionally  find it necessary to return to a second application of the
caustic pledgets, which renews  the pain.   In employing the pro-
ceeding of M. Malapert, wre must therefore wait until the suppura-
tion has  been for awhile established, for there  is then more or less
detachment, more or less denudation  of the skin ; it is  likewise not
uncommon to see the eschar very rapidly separated, and the open- 
250             VTDAL ON VENEREAL  DISEASES.
 ing which it leaves becomes enlarged by the mortification of the
 integuments, which were at first  only attenuated.   In fine, this
 method is liable to the inconveniences which follow the spontaneous
 opening of the tumor.  If the abscess be deep seated, and the pus
 be situated within the gland, the difficulty, and even impossibility
 of reaching  it by a  very superficial cauterization, can be appre-
 ciated.  Add to  this, if the pus  be contained in more than one
 cyst, a part only can  be evacuated, thence the  necessity of renew-
 ing the blister and  the pledget;  in other words, to inflict double
 pain to finish the matter, if we finish it at all.
   It will be seen that the  supposed advantages of this  method
 are:  1st, to empty the abscess gradually so as to permit the cavity
 to  contract upon itself; 2d, to stimulate the interior of the cavity,
 and thereby promote  the adhesion of its walls.  The first I believe
 to  be a real advantage;  but I think that it  can  be more easily,
 more surely, and less painfully obtained by the method of punc-
 turing which I will describe.  As  to the second advantage, I will
 say that the interior  of the  cavity is always sufficiently excited to
 produce an adhesion of its walls; when it does not take place, it
 should be attributed to every other cause than  inertia.
   6th. Instead of perforating with the caustic solution, M. Reynaud
 often employs small sized cauteries, which are  heated  to a white
 heat, and with which numerous punctures are made.   This is not
 a new method; for a  long time it  has formed a part of the thera-
 peutics of abscesses in general, especially of cold abscesses.   Ite
 object is to open the purulent cavity, and, at the same time, so to
 modify its walls as to promote their approximation and adhesion.
 This method is more rapid than that by blisters; it  is painful, but
 the pain is not repeated  as in the  method by the caustic solution.
 Still, even by these little cauteries, a loss of substance is produced,
 by which a breach is left, which is increased by the sloughing of
 the surrounding skin.  Thus we do  not avoid the  deformity  or
 deformities  which attend the cure.  Moreover,  M. Reynaud, of
 Toulon, who has extolled and much employed this method, frankly
 acknowledges, that after these trifling cauterizations, this separation
 and destruction of the skin, he has observed solutions of continu-
 ity sometimes complicated with hospital gangrene.  Although it
 may be  more easy to manage these little  reeds  than the  solution
 of the bi-chloride  of mercury, we can never accomplish with them
 what can be done with the point of a bistoury or a lancet;  thus,
 with the actual cautery we cannot  penetrate deeply, and still less
 obliquely.
  7th. Potash.— Vienna Paste.—Other caustics, potash alone, and the
 Vienna Paste, are employed for the purpose of freely opening the
 cavity, of modifying it deeply, and for destroying a portion of the
 skin over  the glands that has been  a long time affected.  It is par-
 ticularly in  cases  of indolent buboes with a  strumous complica-
tion, that  these caustics have been used.  Long and deep sinuses
form, which fill up with difficulty, and the traces which it leaves
behind are very apparent.   Now  a mark of this  kind, in such a
region, is a stigma, which may become of serious importance.   It 
BUBO.
251
must  not be supposed that  the  elegant man, or the coquettish
female, is the only person who has a dread of such traces, of such
souvenirs ; among the  masses, and  in classes apparently the most
indifferent to such matters, wre occasionally find individuals who
are sadly mortified when compelled to carry a deformity claiming
such an origin.
  8th. Incisions.—Excisions.—In all ages, the knife has been substi-
tuted for the cautery; incisions, more or less extensive, have been
performed, and portions of skin so altered as  to retard cicatriza-
tion, have been excised.  These extensive incisions, with or with-
out the  removal of portions, have  for the most part the inconve-
niences  attached to the cauterizations which  I have described.
But the knife  is more easily  managed than  the caustic,  and I
prefer to extirpate a detached portion of skin, of little vitality, or
a gland which presents an  obstacle to the healing of the parts,
than  to  act upon them with the Vienna paste.   Besides, as with
the knife we may give to the wound a certain  regularity, we may
expect  a cicatrix less  irregular, less  deformed, than after cau-
terization.
  9th. Simple and multiplied punctures.—Proceeding of the Author.—
As may well be supposed, I do not here raise the question of pri-
ority  for the purpose of deciding it in my favor.  I write for  the
practitioner, who, perhaps, cares but little for the hand that offers
him a therapeutic measure.   What he chiefly wishes  to know, is
its  efficacy,  and how it is to  be employed.  I will only remark,
therefore, that in the first edition of my work on surgery, I recom-
mended small  incisions, punctures with  the lancet,  and I claim
only to  furnish arguments in favor of this practice, and to teach it
more in detail than others.   I pass, then, at  once to the modus
faciendi, to the proceeding  that  constitutes  the basis of  my
practice.
  We commence, if possible, by shaving the tumor.   As it is  sel-
dom  that a bubo has not had at  least one plaster  applied,  we
should remove ite effects. The instrument required for the punc-
ture is a straight, sharp bistoury, the blade of  which  is not larger
than  a penknife ; or we may use a lancet.   If  the suppuration be
not extensive, and the abscess recent,  we make but one  puncture,
or  one  incision, of a centimetre in extent, over  the fluctuating
point.  We sometimes find that but a single gland has suppurated,
and it is then emptied of the pus which it contains ; the other and
adjacent glands are only engorged; should they afterwards  sup-
purate,  they should be treated like  the first.  We may thus open,
and successively puncture, as many as four glands.   It is especially
among  scrofulous subjects that this  peculiarity presents, and which
mu>t be treated by successive punctures.   When  suppuration
exists within the gland, it is more  difficult to be detected, because
more deeply seated; we must then extend our incision to a greater
depth in order to reach the  cavity.  Tins is another  argument in
favor of the knife  over the caustic,  as with  the knife we may
reach any desirable point, and the instrument may assist  us in our
explorations. 
252
VIDAL ON VENEREAL DISEASES.
   Should the purulent collection be of greater extent and more
superficial, and the skin more or less  detached, we must make
several punctures at the same sitting.  But instead of making them
at the most fluctuating point, we  must avoid the centre of the
tumor, and regions where the skin is thin ; instead of being direct,
they should then  be  sub-cutaneous, so  as to  reach  the pus by a
circuitous route ;  h, is, therefore, towards the circumference of the
tumor that we should enter the knife, the  point of which is di-
rected towards the centre of the cavity.  In this manner,  the skin
is divided where it is  inherent, intact, and in possession of all its
vitality.   When  punctured where  it is thin, denuded, and pos-
sessed of  but little vitality, the opening is likely to become en-
larged from mortification, which  is hastened  by the puncture, an
enlargement of the openings is thus produced, the result of which
is a general communication.  A large breach  of continuity is now
formed, to which the  air has  access, placing the bubo in the unfa-
vorable circumstances of those that have been freely opened by
the caustic or the knife.  In making the punctures at the points
indicated, if the tumor be not compressed  (it  should not  be com-
pressed for a few days after the operation), it is gradually emptied,
and the cavity is, m a measure, filled  by the contraction of ite
walls.  The cure is then much more rapid, and it leaves no un-
pleasant traces behind.  The cicatrices of these punctures, indeed,
resemble  those of leech bites; and, like  the latter, they finally
completely  disappear.  The  punctures  thus  made, obliquely  and
towards the circumference of the tumor, excavate passages of
which the  walls sometimes  contract too  speedily on themselves,
whereby  they become  obliterated  before the pus  is completely
evacuated.  But, as  several  openings are made, and as it is  rare
that all are obliterated by compressing the tumor slightly once a
day, the cavity may be discharged  through the openings that re-
main.  It will be remarked, that I here  advise compression which
I so  recently proscribed; but  it wrill doubtless be remembered,
that it was for the few days following the operation, when the pus
is still abundant, and the openings perfectly free,  that I recom-
mended to abstain from compression. Sometimes all the openings
have a great tendency to close speedily.   I formerly tried to keep
them open by means  of a tent of charpie;  I now prefer to let them
'close, after  which, if  any pus  remain, I make one or two more
punctures.  Sometimes what remains becomes absorbed, and there
is, of course, no necessity for repeating the punctures.
   The advantages of this method are obvious; 1. It is of easy and
rapid application; 2.  It is less painful than the others; 3. It pro-
duces more speedy  cures;  4.  It  leaves no  deformity.  I know
what objections may  be urged against it.  It may be said that it
is really advantageous only in the case  of sympathetic buboes, or
those which result from the extension of the inflammation, or from
irritation  of the genital organs, in other words, when the abscess
is of a simple character; it may be urged that in the case of really
syphilitic buboes it has not the same advantages, as the little open-
ings will become inoculated and transformed into so many chancres, 
BUBO.
253
which may become united and confounded into one, constituting
one vast ulcerated breach of continuity.  In the first place, the
proof of the inoculation of these little punctures is very difficult to
be found; and if I should reckon syphilitic suppurating buboes
by the number of those which having been thus opened, were
inoculated, I should find  that there wrere but a  small  number of
buboes in my service which had that nature.  Lhave not witnessed
this inoculation more than three times in a year.  But I would
observe, that when a bubo is established I adopt general treatment.
Others will say that this goes  to show that many buboes, even
syphilitic, produce a pus that is not inoculable.   They may explain
the fact as they please.   It may also be said that I do not often
penetrate the substance of the gland, and that I reach the surround-
ing cellular tissue only, which is possible.   What I maintain, for
I treat the question in its  practical bearings only, is, that in adopt-
ing my proceeding buboes are sooner cured and without deformity,
which cannot be  claimed for the other methods.   I  have stated
that I have rarely observed the  inoculation of the  trifling wounds
thus made;  I will add, that I have seen one or two instances in
which some of the wounds became invaded, the others remaining
unaffected.  But  if all the wounds did become inoculated,  thus
forming one vast chancre, it would then  possess the inconveniences
of the other methods, of the free  incisions, and cauterizations which
I know are exposed to the action of virulent pus.
  The students who have followed my visits, and who have been
attached to my service, have been able to observe and compare the
results obtained by this method with those that have followed the
others, and they can appreciate its value.  M. Caillant, one of my
internes, has  collected a very considerable number of cases which
deserve publication.
  10th.  Puncture  with Injections of Iodine.—M. J. Roux, of Toulon,
and Marchal (de Cold) have proposed simultaneously to inject the
purulent cavity with the combination of iodine, employed in the
radical treatment of hydrocele.  In the first place, we empty the
abscess by a  puncture, and with a small syringe, introduce into
the cavity the tincture of iodine diluted with equal parts of water.
This  mixture then takes the place of  the pus,  comes in contact
with the walls of the cavity, stimulates  and so modifies them as to
promote  the  adhesions which should obliterate  the cavity.  The
iodine acts also as a resolvent on the engorged glands, which is of
great advantage in cases of strumous complication.
  11th. Compression.—Compression has been proposed both as an
abortive means,  and consequently to  be  employed at the com-
mencement of buboes, and as a resolvent means, to be used in the
case of chronic indolent buboes.   In speaking of the abortive treat-
ment, I have already stated that it is  impotent,  and among the
abortive  means I include compression.   But, if it be well supported
and continued for a long time, if the surgeon knows how to resume
its use when the tumor has a tendency to be reproduced, very good
effects may be derived from compression in the case of strumous
buboes, especially if, at  the same time, we administer internally 
254             VIDAL  ON VENEREAL DISEASES.
medicines adapted to the nature of the case, and to the diathesis
under the influence of which these tumors are developed.  The
preparations of iodine are here suitable, as are the mercurial, when
the indolent bubo is a consecutive accident, or one of the effects of
indurated chancre.
  Ri>t is an excellent auxiliary to compression; the patient should
observe it as much as possible.   We may compress with the spica
bandage, under  which may be placed graduated compresses; or
we  may use a hernial truss, the pad of which should be adapted to
the volume and form of the tumor.  At the  Hopital du Midi, a
little apparatus has been  successfully used which  was invented by
a former externe. It is a little oval pad covered with leather.  It
is fixed by a strap which, being attached to the extremity of the
pad, at the internal  part of the inguino-crural fold, passes around
the thigh, reaching on its external surface, an iron loop attached to
the external surface of the pad passes through it, and having been
reversed is passed around the pelvis, gaining the opposite side of
the body, then  arriving  at the  anterior wall  of the abdomen it
descends  obliquely  towards the compressive pad, and passes
through  a buckle on its internal side, by the aid of which  the
apparatus is tightened at pleasure.  An apparatus is required for
each side.*
  [Another method of pressure  has been recently recommended .
by Dr. J. H.  Clairborne, in the  Stethoscope and  Virginia Medical
Gazette.  He  states  that  in his hands it has proved incomparably
superior to any other discutient.  It consists in the application of
Collodion, which, when applied too thickly, he has known to con-
tract  so  tightly  as to split the epidermis, in fissures around  the
borders.   He recommends its application in thin layers, allowing
one layer to dry before another is made.  The  above account we
gather from the Nashville Journal of Medicine  and Surgery for
June  1853, p. 351.—G. C. B.]
  12th.  Various Combined Methods.—It is rare that in the treatment
of bubo, especially its chronic form, different means are not resorted
to, and that these means are not alternated, and in a certain manner
combined.  Thus,  in the treatment of bubo,  which M.  Ricord
regards as the necessary accompaniment of the  indurated chancre,
local mercurial frictions, the plaster de Vigo, and general treatment,
should go hand in hand.  According to the same practitioner, a
combination very often efficacious in the  treatment of non-specific
indolent  bubo consists in the employment of blisters,  mercurial
ointment and cataplasms, as long as we obtain an amelioration;
but if it  remain  in statu quo,  the  blister is allowed to dry in order
that we may resort to compression, which in turn is continued whilst
it produces a diminution, and is abandoned if it produce no effect for
the blister; and thus in succession these means are  employed until a
complete cure is  obtained, f  I have been desirous of noticing this
combined treatment as it was proposed by M. Ricord himself.  The
* Ricord, Traite pratique des maladies veneriennes, p. 588.
f Ricord, Traite, &c, p. 588. 
VEGETATIONS.                     255
obscurity of the formula will perhaps be noted at once as well as
the difficulty of its execution.
  In conclusion, I still  advise the general treatment adapted to
the nature of the tumor; this is the best of all resolvants.
                    CHAPTER VII.

                      VEGETATIONS.

  These are parasitic growths appearing on different parte of the
integuments, and which resemble certain vegetables.
  Situation.—In the  male, they are  observed most frequently on
the mucous membrane, covering the glans and lining the prepuce;
in the female, at the entrance of the vagina; we may find them,
and not unfrequently, in the vagina itself;  I have seen them  on
the neck of the uterus and surrounding the nipple.   In both sexes
they occur in the vicinity of the anus, in the urethra, especially at
the entrance of the canal;  they are met with also in the genito-
crural fold, at  the umbilicus, on the lips, mouth, and base of the
tongue.  I once saw them  on  the  mucous palpebral lining, in a
subject that  had suffered from blennorrhagic ophthalmia.
   Varieties.—All seem to penetrate the dermis, and to be more or
less  expanded.  Their mode  of insertion and expansion, their
pedicle, and color, present differences which have caused them to
be compared  with warts,  cauliflowers, leeks,  strawberries,  and
raspberries.  Some are sessile,  having no pedicle—they are small,
and. their surface is fissured: these are the paler vegetations called
warts.   When  there is a kind of  stem, of one or more lines in
length, with a swelling of a deeper color, in the shape of a fur-
rowed head, it is called the leek.  If the stem give  rise to many
branches, which shoot off so  as to form several united bouquets,
then we have the cauliflower excrescence.   There are other vegeta-
tions with protuberances strongly marked, of which the shoots  are
less  distinct, the prominences less  decided; they are quite red;
they have been denominated strawberry excrescences or raspberry
excrescences, according to the  depth of their colors.  (Vid. plate 4,
fig. 1.)   The form  of the  vegetations occasionally depends upon
the seat which they occupy: thus, in a prepuce  somewhat narrow,
they are pressed between this envelope and the  glans, and assume
more or less the form of the crest of the cock (fig. 1, plate 4); the
same sometimes occurs when they are seated between the nates.
   Structure.—All of these  vegetations  are more or less vascular,
and especially the last-named varieties.  By prolonged maceration
all that part above the level of the skin becomes  discolored and
reduced to a whitish pulp,  without  any regular organization, and
resembling coagulated albumen ; it is easily removed by scraping.
Thrown on  hot coals, this matter desiccates, hardens, turns yellow,
and emits an odor like that of burning horn, or other productions 
256
VIDAL ON VENEREAL DISEASES.
  of the  epidermis.  In fact, M. Sibert has discovered, by means of
  the  microscope, that these vegetations contain only cells of the
  epidermis and a vascular element.*  The point at which they are
  inserted into the integuments appears to be somewhat thicker than
  in the  normal state;  it is  redder, and  traversed by numerous
  vessels, some of which penetrate the vegetation.   The dermis seems
'  also to be a little thickened.  The epidermis is not perforated, but
  rises with and covers the vegetation.  Sometimes the vegetation is
  but a disease of the mucous or cutaneous follicle, preceded  by a
  little black spot on the skin ; the secretion of the follicle becomes
  more and more concrete, the follicle itself suffers a kind of extro-
  version, and presents a granulated base,  on which are seated rough
  projections in the form of a leek.
    Symptoms.—Frequently the appearance of the vegetations is not
  preceded by any modification of sensibility.   The patient some-
  times experiences a slight pruritus at the point where the vegeta-
  tion is about to shoot forth ;  this pruritis  increases, and there is a
  sensation of pain until the production appears.  Once developed,
  it is often indolent or only painful when chafed.  At other times,
  it is painful even without  the application of any irritating cause.
  There are cases  in which it  may be said that there is no pain in
  the vegetation, but the latter may be the exciting cause of if: for
  example, when numerous and voluminous vegetations are enclosed
  within a narrow prepuce, they are  a source of irritation, and in-
  flame the lining membrane of the glans, as well as of its envelope;
  they distend, and  stretch the latter so as to produce severe pains,
  which cease on the division of the prepuce to a sufficient extent to
  expose  the morbid mass.  In  these cases, especially after they
  become exposed to the air, they assume the color of the raspberry.
  A discharge as  now  secreted of a very disagreeable odor.  The
  vegetations themselves may be the seat of a congestion bordering on
  inflammation.  Sometimes they  slough,  and this is one method of
  cure.  But as this mortification  is but partial, the cure is not com-
  plete ;  roots  always remain, from which  the  vegetations may be
  reproduced.
    Complications.—Accidents. —The venereal accidents which I have
  regarded as the starting point,  the cause of the vegetations, may
  also  exist as complications; thus, chancres more or less advanced,
  a blennorrhagic inflammation, mucous tubercles, according to their
  seat  and volume.  Vegetations  may themselves give rise to acci-
  dents, and interfere with important functions ; as of the urethra,
  the vagina and the penis.
    The possibility of a cancerous  transformation of the vegetation is
 generally admitted.   I am inclined to believe that those which have
 been regarded as cancerous transformations, were primarily of that
 character; in other words, that the venereal vegetation did not exist.
    Diagnosis.—This  is easy when observed on their first appear-
 ance, and when their development has been watched.   But, under
 the opposite circumstance,  it is more difficult.   The vegetations
Physiologic pathologique, t. L, p. 23. 
VEGETATIONS.
257
on the glans and prepuce furnish the most frequent examples of
difficult diagnosis.  Thus a vegetation incarcerated within a narrow
prepuce in a state of phimosis, may be very difficult of detection.
111 nay be regarded as an indurated chancre, a calcareous concre-
tion, or a deposit  of sebaceous matter, according to  its volume,
consistence, and insensibility. At a clinical trial of the concrous of
the  central  bureau, a patient was submitted for examination who
had  a congenital phimosis.  This patient, already advanced in
years, for a long time  had had a tumor within the prepuce.  By
pressing  through the skin, this tumor  was insensible and very
hard; the introduction of a probe produced no pain, and gave exit
to not the slightest particle of blood.   The majority of the jurors
remained doubtful of the nature of the tumor, and in this uncer-
tainty  the candidate participated.  An incision  of the prepuce,
afterwards made, revealed the existence of a very old vegetation
which possessed but little vascularity.  Lately there  was in _ my
service a young man who had within his prepuce a very decided
induration, clearly representing a vegetation; the appearance of
an eruption (roseola) disclosed the fact of the existence of a chancre,
with a very indurated base.
  But the  cases most obscure, and those in which the  diagnosis is
really of great importance, are those of old degenerated vegetations,
which invade and cover the glans, and which present  a cancerous
aspect.  The morbid masses, in these cases, exhibit softening at
certain points, and  at others indurations ; some become mortified;
hence, they have a grayish aspect, an unequal consistence, and are
the  seat  of a sanious  fetid discharge.  If to this  condition, we
add the emaciation of the subject, the pallid countenance, the ef-
fects of a prolonged suppuration, and it must  be  admitted, some-
times of treatment, it will be  perceived how easily these  vegeta-
tions may be confounded with cancer of the  penis, and we need
not be astonished that such errors have been committed; the mis-
take may be so complete, as to induce the practitioner to  ampu-
tate the penis.  This error, sometimes, is not removed even after
amputation and dissection of the parts.  The  cause of this is the
atrophy of the glans caused by the compression of the vegetating
mass; this  is occasionally so great  that the  glans seems to have
disappeared. But when the diagnosis has been clearly established,
when the vegetations alone have been removed, the glans gradu-
ally recovers ite form, and almost its ordinary volume.  The diag-
nosis, I repeat, is  here  very obscure, and we are deceived in a
double sense  Indeed, in certain cases, true vegetations have been
mistaken for cancer, and* vice versa.  The first mistake was com-
mitted in my service, by one of my former internes, who has writ-
ten  on venereal diseases, and the other by surgeons who quickly
decided to sacrifice the organ.   Besides their microscopic charac-
ters, vegetations are  to  be distinguished from  cancer, after their
removal, by their great vascularity, which causes them in a short
time after separation to diminish one half in size.  During life, the
diagnosis is much more difficult, especially if the early develop-
ment has not been  seen.  If observed at the onset, it will  be
                               17 
258             VLDAL ON VENEREAL DISEASES.
found that cancer  does not at first appear as a pimple, but as an
ulcer; and it is surrounded by more or less induration.  Vegetations
seldom exist alone;  they first appear by several shoots, and the
surrounding tissues are soft, except when they spring up  on the
induration around a chancre.  Age, also, should be taken into
consideration.  Thus when the subject is young, there is greater
probability that induration may exist.   We should  also have a
regard to glandular engorgemente ; thus, in the vegetations which
do not succeed to  a chancre nor to a blennorrhagia, there is no
glandular enlargement.  When  cancer of the penis exists in its
early stages, there  is almost always a very hard and  indolent en-
larged gland, before  it undergoes the process of softening.  But
here, as in all other cases, this circumstance should be noted, with-
out attaching to it too great importance.   Glandular enlargements
are among the most common causes of mistakes in diagnosis.
  Causes.—Blennorrhagia, balano-posthitis, and chancre, are  the
principal causes of vegetations; thus they may  shoot forth  at a
point of the integuments only, that has been inflamed, excoriated
or ulcerated; in fine, vegetations may be the first as well  as the
last symptoms of contagion.   We see vegetations succeeding im-
mediately to posthitis, we know that they may shoot forth on the
cicatrix of a chancre, and they may appear on the glans without
inflammation or previous ulceration; the same may occur at the
anus.  As a consecutive accident, they may occur at any period
of syphilitic infection.  I have now in my service, three patients
with vegetations around the anus; one of them is young, and
has  acknowledged unnatural  connexion; the second, for  three
months has  had  a  chancre on the penis; and the third  has
also  had a chancre on the same organ; but for five years his sys-
tem  has been fully infected,  and the vegetations have  been the
last  to appear.  Vegetations may, therefore, belong both to  the
primary,  and the consecutive accidents.
  Nature.—It has  been maintained that they are not of venereal
origin.  According  to some  writers  on  syphilis, they are  but
parasitic growths generated under the influence  of the  irritation
excited by a blennorrhagia or chancre, or  produced by some other
irritating cause, as  for  example, the irritating discharges secreted
by the genital organs  of the pregnant female.   I deny that any
irritating cause may give rise to them;  there are cases, indeed, in
which they shoot  forth, without any  previous  irritation.  We
never find a vegetation appearing without  an antecedent, without
venereal  accidents, without some preceding intimate connection.
Thus irritation of the glans and the prepuce without sexual inter-
course is not uncommon in very young boys ; vulvar inflamma-
tions are often observed in young virgin girls ; yet we never find
vegetations occurring at this age, nor after this kind of inflamma-
tion.  But if the subject has had connection,  the  case is different;
then, vegetations may shoot forth from  the slightest irritation.
Again, the syphilitic nature  of  the vegetations  is incontestable,
when they appear as  consecutive accidents, long after the chancre
that  preceded them.   There is another argument against the doc- 
VEGETATIONS.
259
trine that these vegetations are the result of simple irritation;  and
that is, their very decided tendency to reproduction.
  Transmissibility.—This is now placed beyond doubt, by the ob-
servations of the majority of writers on syphilis, and especially of
M M. Baumes and Reynard (of Toulon).  The latter thus remarks:
" Incontestable facts prove that the form of syphilis which I am
now considering (vegetation), without being so uniformly conta-
geous as  chancres, are capable of being directly transmitted."*  I
am  at present  treating a young girl who had connection for the
first time with  a man affected with  vegetations on the corona
glandis;  she has vegetations on the vulva, and these have been
preceded by no other symptoms.  I should remark, that the vege-
tations on  the  young man grew on the cicatrix of an indurated
chancre, but the chancre had been completely cured for two years.
  Treatment.—This is both general  and local.  Those who pretend
that vegetations are  not caused by the syphilitic virus reject the
general treatment, and proscribe mercury.  Those,  on the contrary,
who believe in the specific character of these morbid growths, re-
commend a general treatment.  The remedies indicated may be
inferred  from the circumstances in which they'are developed.  I
have  shown  that they may appear in all -stages of syphilis,  and
that they may be the first apparent symptom of infection.  Now
when they appear during  the  existence of a diathesis,  they are
rarely alone, but are accompanied  by other accidents requiring a
general treatment; hence all doubts of the propriety of the latter
are removed.   Sometimes, they appear after all the other accidents,
and then general treatment has in most cases already been adopted,
and this  has consisted either of the preparations of mercury or of
iodine.   Constitutional remedies may now produce no effect: the
vegetations have become localized, they no longer have deep roots,
but are  a  kind  of  remnant of the disease.  Topical  treatments,
trifling surgical operations,  should now be preferred; for if entirely
extirpated, they do not return, as is so often observed under other
circumstances.
  When vegetations are primary, when they constitute the first ap-
parent symptom of the infection, we should still pursue a general
treatment,  if we would not expose the patient to the liability of
frequent returns, and if we desire to prevent complications. More-
over, facts go to show the efficacy of a general  treatment; a  re-
markable instance  may be found, in the work  already mentioned
of  M. Reynard (of Toulon).f  Under the influence of the concen-
trated syrup of sarsaparilla,  with the addition of the corrosive sub-
limate and the extract of opium, in fifteen days well-marked vege-
tations will become  softened within, and drop off, no more to re-
turn.   I shall never forget the case of a young girl I found in the
ward of  St. Louis when I entered on service at the Lourcine. Both
the labia majora and the  labia minora were covered with small
vegetations which produced an intolerable pruritus, and even severe

             * Traite pratique des maladies vencriennes, p. 310.
             f P. 312. 
260             VTDAL  ON VENEREAL DISEASES.
pain.   All kinds of powder and ointments  had been  employed;
some of the vegetations had been removed with the knife, but had
reappeared, whilst the others remained.  No general treatment had
been undertaken; mercury had not been administered,' perhaps
because the young patient was feeble and of a lymphatic tempera-
ment.  I thought  best, however, to prescribe Dupuytren's pills,
and in  less than twenty days the vegetations began to wither,
and by degrees they fell off spontaneously.  I have observed other
cases of the kind, but  truth compels me to admit that vegetations
most frequently remain in spite of general treatment.   We must
therefore resort to topical treatment, to the ligature, and to excision.
  There are numerous topical applications which have been greatly
multiplied  on  account of nervous patients who  dread  anything
hke an operation.  Saturated solutions of  opium, crude opium,
iodine of iron, sulphate of copper, and calomel, have all been used.
The most successful method is the following:

                     ]J. Savine,     3 i\.
                        Alum Calc,  3 i£.

  Reduce to a very fine powder.  Wash the vegetations twice a day with
red wine; cover them afterwards with a thick layer of the powder.   In the
course of three or four days the vegetations become feeble, and the patient
may begin to remove them with his finger nails.  After each separation,
tliere is  a slight bloody discharge, which may be arrested by t/ie vinous
lotio)i, after which the powder is reajjplied.

  When the vegetations are not very numerous, and  have not a
large base, this method is successful,  and the patients are delighted
to operate on  themselves, and to cheat as it were the hands and
knives of the surgeon.
  Some practitioners  prefer cauterization;  for this purpose,  the
nitric and  the hydrochloric acids, the nitrate of silver, and  the
butter  of antimony, have  been employed.   That  most used  at
the present day, and which is the most efficacious, is the nitrate
acid of mercury.  A  vegetable, silk, or silver ligature has also
been used, but this  method, tedious in ite effects, equally painful
with cauterization or  excision, is now generally abandoned by
surgeons.   Some patients still submit to it; they gradually tighten
the knot, and  as they themselves operate, and  can suspend  ite
action  when they please, they actually  suffer  more  than they
would  under  the hands of another.   But topical  applications
cannot  reach  the root  of  the  vegetations;  if  with  ligature  or
caustic, we act to such a depth, we should produce most violent
pain, and of longer duration than that resulting from excision.   A
cutting instrument should therefore be preferred when we have
reason to  suspect that the roots of  the vegetations  are not very
deep, when their base is large, and when, in  fine, we  would pre-
vent a return.  A forceps may be  used to seize the vegetation,
and it may be excised with flat curved scissors. When it is some-
what large, but little  prominent, as we often find on the  genital
organs of the female, it  is sometimes difficult to  seize it, it glides 
MUCOUS TUBERCLE.
261
between  the  blades.  I use small forceps (a dents de rat), which
will  embrace the quantity and only the quantity of the mucous
membrane required to  be removed around  the  vegetation,  and
this is extirpated without  being torn.   My rat-toothed forceps are
much employed by oculists in their operations on the eye-lids and
the eye.   Some surgeons  cauterize the wound left by the opera-
tion ; but it is unnecessary if the'limits of the skin have been sur-
 Eassed; if they have not been passed, then the extirpation has not
 een well performed;  if we resort to caustic, then we inflict two
operations.  It  is better to seize the whole  thickness of the integu-
ments, and not be too saving of the parts removed.  Especially
should this rule be followed, if the integuments be more or less
altered and thickened, either by the venereal affection on which the
vegetation has sprouted, or by ite age, which by long irritation of
the skin, has developed on its tissue a hypertrophic action.
   After  the  operation, blood often  flows  in great  abundance,
especially when the excrescence is seated  on the glans.   Cold ap-
plications should be applied at  first, and the parts should after-
wards be dressed as in the case of a simple wound.  It should be
well understood that  extirpation is not to be attempted, if there
exist chancres which have not healed, for the wound may then be
inoculated.   As a  general rule, we should not operate until all
complications are removed.   However, there is often around the
vegetations an  irritation, an inflammation even, that subsides only
when these excrescences have been removed.
                     CHAPTER VIII.

                   MUCOUS  TUBERCLES.

  These are also called, according to their aspect and form, flat
pustules, flat tubercles, mucous pustules, mucous patches or papules,
[and condylomata.—G. C. B.]   They consist of elevations of which
we may have a very correct idea if we imagine the application of
disks more or less perfect, or portions of a disk, to the integuments.
  Situation.—These tubercles form on the mucous  membranes and
portions of skin which, either naturally or from disease, resemble
mucous membrane: thus, the  skin on the genital organs,  on the
parts adjacent, and at the bend of the thigh.   In the female, they
are  more frequently observed on the vulva;  whilst in the male,
they are found  at the margin of the anus.   The scrotum, penis,
perineum, are also frequently affected.  They have been observed
at the genito-erural fold, at the umbilicus, in the external auditory
canal, and behind the pavilion of the ear, in the axilla, the  mouth,
the commissures-of the lips, on the tongue, the internal surface of
the cheeks, on the tonsils, and  the walls of the palate, at the en-
trance of the nostrils, the ale of the nose, the base of the toes,
around the nails, the nipples, and the neck of the uterus.  These 
262
VIDAL ON VENEREAL DISEASES.
tubercles  may  occupy nearly all of these regions, on the  same
subject, and assume all the  forms  which I shall soon describe.
At present (March lGth, 1852,) there is in my service a man  forty
years of age, who has tubercles on his ears, nose, lips, tongue,
right axilla, at the genito-crural fold, on the scrotum, perineum,
anus, and between his toes.
   Causes.—Mucous tubercles  are  more  frequently  observed in
females, owing  perhaps to  the extent of the mucous  membrane
lining their genital organs, and the delicacy of their skin ; children
and  lymphatic subjects are also strongly predisposed.   Want of
cleanliness is favorable to their development: indeed, a female
seldom comes to the Lourcine from the country, in whom mucous
tubercles do not exist.  Corpulent persons, whose acrid perspira-
tion  accumulates in the genital fold, the irritation produced around
the margin of the  anus by prolonged walking, and especially by
constipation, are among the causes  which favor  the development
of those venereal accidents.  The surface of the  integument fre-
quently exposed to the action of the matter discharged in blennor-
rhagia, is  sometimes covered with  mucous tubercles.  It is ad-
mitted, that chancre may be transformed into a mucous tubercle,
and this too at the moment when a chancre is healing, but healing
irregularly ; in such a case, the  tubercle is only  a transformation
of the chancre.   The truth  is, that a tubercle may appear even at
the point where a chancre is seated,  as it  may appear on a surface
simply inflamed;  such sometimes being the result of a balano-
 osthitis.   It may therefore be regarded as a consecutive accident,
 ut it may, likewise, be  altogether primary;  in other words, it
may  be the first accident  observed to follow a suspicious con-
nection.
  In females,  the mucous tubercle most frequently exists as a
primary symptom; in the  male, on the  contrary, it is generally
found to follow a chancre on the penis and urethral blennorrhagia,
whilst it is itself followed, some time afterwards, by the same dis-
ease  at the anus.  This, moreover,  is one of the accidents which
most compromises the classification of diseases, the syphilitic acci-
dents, into primary and secondary, if we attach to  this classification
a doctrinal and absolute sense.
  Symptoms.—The mucous tubercle may  appear one or two weeks
after coitus, and often during the existence of chancres, or of blen-
norrhagia.  Sometimes there is  a period of incubation of two or
three months, and even longer.  Occasionally they appear at once
(d'emblee); they then constitute the first symptom of the pox.
  They resemble disks, or portions of a disk, glued on the surface
of the integuments.  Sometimes they have an oval form.  The
smallest are simple papules which increase to the size of a lentil;
the largest, the  true clusters, seldom exceed the size of an Ameri-
can  dime (fifty centime  piece).  When several pustules  come
together and become confounded into one, they may be of very
large size.
  Instead of remaining in the state of patches  adhering by one
entire surface, these excrescences, especially when of long standing, 
f \o  i    ',  (/<•?
>f!\ '   //r-Z-jfts/*'^  " ' ■■ "^«</-<Wi
rs (SA*tj
A  Vr. 
•1 
MUCOUS TUBERCLE.
263
become now and  then detached and pediculated, assuming the
form of the vegetations in condyloma.   Thus, in the patient to
which I have alluded,  who was almost covered with tubercles,
those in the axilla and the genito-crural fold strongly resembled
the vegetations of which I have spoken.
  When seated on the mucous membranes, the color is  more or
less of a lively red, whilst  on the skin, in  the majority of cases,
they are brown.  Around them the coppery areola of the syphilitic
eruptions is often  observed.   The surface  is  sometimes  smooth,
slightly fungous, and sometimes presents a  macerated appearance.
Occasionally they are completely fungous,  and of a  violet color.
In persons of a brownish color, even when they grow on the skin,
they are fissured, and appear as if irritated.   They may have an
eroded  and even ulcerated surface, resembling that of  chancre,
especially that form known as the ulcus elevatum.
  They  generally secrete  a  serous like, or sero-purulent fluid,
which has a peculiar and repulsive odor.  The pus becomes  more
strongly marked as the ulceration is established and the pustules
are irritated.
  Seldom does the mucous tubercles exist  alone, especially about
the anus and the vulva.   They may be  extremely numerous, and
as I have already stated, occup}T several regions; generally they
occur in groups, or  are arranged  in order, on a line more or less
curved: thus, they will appear on the edge of one of the labia, or
on  one side of the nates.  Then, in the majority of cases, if the
person be careless, we  observe on one of the labia or nates, tuber-
cles precisely like those on the opposite side.  It is not uncommon
to find two, one of which  seems moulded on  the other, to such a
degree as to resemble the valves of a shell.   This resemblance of
two tubercles, situated on organs adjacent to each other, is another
argument in favor of the contagion of this form of syphilis.  (Vid.
Plate IV. Fig.  2.)
   In this symptomatology I have particularly dwelt on the charac-
ters of those most  known, viz. those on the  genital organs and
around the anus.  There  are others less known, either from their
infrequency, or because they are so situated as never to lead to the
suspicion of their existence, or, in fine, because their characters are
less marked, and probably, also, because, up to the  present time
they have not been described.  I proceed to point out the appear-
ances by which they may be known,  which will complete the
general sketch and facilitate their diagnosis.
   In the nasal region they may be found either without or within
the nostrils.  The first resemble those  at  the  angles of  the lips;
they are seated in  the groove that separates the cheek from the ala
of the nose.  They are of smaller size than  those on the lips, being
occasionally not larger than the head of a pin.  Sometimes we
find in the groove above mentioned an elongated scale,  which is
very thin, ulcerated, and transformed into a  fissure.  After this
has healed, there remains a dark red shade, which cannot deceive
the observing physician, and which may become a precious sign in
forming a diagnosis.  Within the nostrils,  at their entrance, these 
264
VTDAL ON VENEREAL DISEASES.
layers are less frequently observed; they generally form a swelling
with crusts, the fall of which exposes a red and gray surface, then
the crusts are renewed until  a cure  is completed.  The cure is
retarded by the excoriations produced by the patient in his efforts
to relieve  the itching.
   On the toes and around the root of the nails, the tubercle has
nearly the same characters.  Almost always the patches are ulcer-
ated and  resemble  rhagades of the anus.   The  most prominent
portion  is of a bluish color arid round between the toes.  They are
elongated at the root of the nails and follow the direction of their
base.  The ulceration differs in -the two cases.  Around the nails,
they are irregular fissures, with edges more or less turned over on
the nails.   These layers are painful and emit the most fetid odor,
when the patient does not observe  cleanliness.   They are very
speedily affected, and are quickly cured.
   In  the aural region, it occurs at the  junction of the concha with
the mastoid  region, around the  auditory canal, and assume the
form of the swelling wmich we find at the entrance of the nostrils.
It may  also be found even in the auditory canal.
   On the neck of the uterus, it is often of a reddish gray color, very
round, distinct, and a little larger than a lintel.  It has been seen,
at the same time, on both the  upper and lower lip.
   At the  umbilicus, the patch  occupies in part or entirely the um-
bilical depression;  it is ordinarily prominent,  of a reddish-gray
color, humid, and of a sickening odor.   Sometimes there is pruritus,
but rarely pain.
   Around the nipple we sometimes find an  excavation, fined by a
layer which somewhat overlaps it; it has a grayish aspect, is humid,
smooth, and  there is an oozing of muco-purulent matter.
   In the buccal region, the mucous tubercle is constantly seated on
the external border of the lips, at the commissures, and  on the
internal surface of the cheeks; on the edges of the lips are little
projections, generally, of an elliptical form, varying in number and
covered with crusts.  They frequently exist undetected, and often
disappear but readily return.  These patches almost  always co-
exist with a similar condition  of the throat and the genital organs.
   At  the  labial commissures it is of a granulated aspect; there are
at least  two of nearly equal size,  one on the superior, one  on the
inferior lip; one fissure separates them, a fissure that remains after
the removal of the patches.  These are likewise very often undis-
covered.  We see  nothing  but the fissure which is regarded as
being independent of syphilis.
   On the tongue, we find patches on the apex, the base and borders.
They are  very large, of an elliptical form, and sometimes ulcerate.
In the female these patches almost always coincide with a  similar
affection of the vulva.
   On the velum palati and tonsils,  mucous tubercles are of frequent
occurrence, especially on the latter.   They often escape detection
at their origin, for  then they  are not prominent; they are round,
multiple,  sometimes confluent, and  almost always of a grayish-
white color.  Occasionally they ulcerate at the centre, or at other 
MUCOUS TUBERCLE.
265
points of their surface.   The tonsils  are often enlarged and of a
red color, which spreads to the  surrounding parts.  With  the
patches in this region there existe symptoms of angina, pain in the
throat, exasperated by deglutition, catarrh, and a little coryza.
  In the axilla, where pustules  are rare, they are sometimes  seen
prominent  and a little pediculated.*
  Diagnosis.—The description which I have given constitutes  a
true diagnosis.  The ulcus elevatum alone can be confounded  with
the tubercle in question.   But this form of chancre  generally ap-
pears on the edge of the prepuce, where tubercles are not common,
and it is preceded by a true ulceration; besides, it requires a much
longer time for its  cure.
  [There is one point connected with the diagnosis of the mucous
tubercle to  which for a moment we solicit the reader's attention.
Waller, who is at the  head of a large venereal hospital at Prague,
has reported,  among other cases, that of a nurse named Watzka,
who became affected by suckling a syphilitic child.  In describing
the mucous tubercles which formed on  this nurse's breast, he
states that the one on the right breast was of the size of a bean ;
that on the left of a pea, and that they rested on  a broad base.
M.  Ricord would impeach the  accuracy of Waller's  diagnosis, on
the ground that they rested on a broad base, and asserts (Letter
xxix., p. 221) he knows not what  may be regarded as mucous tu-
bercles  at  Prague; but at Paris,  those described by M. Waller
would be considered as  very excellent  specimens of indurated
chancre with a broad  base!  The  nurse's nipples became affected
from  mucous tubercles on the child's lips.  Now let us examine
a few French authorities upon  the  subject  of this  broad base of
mucous tubercles.
  In  the Bibliotheque du Medicin Practicien, vol. vii., p.  260, it is
stated that " mucous  tubercles  vary in  breadth from the simple
papule, the size of a lentil, to a  tubercle as large as a half dime
or  dime piece.  Again, at page 261, quoting from MM. Baumes
and Reynaud, we find that their volume varies from that of a small
lentil to a dime piece."
  M. Rayer (Lond. Ed. by Dr. Willis, p. 812) observes, " that these
tubercles attain a size but little less than that of a shilling" (Eng-
lish).    At p.  813  he remarks, that when  situated  on the breast
they sometimes ulcerate to a greater extent than they are ever ob-
served to do in any other part of the body."
  M. Cazenave (Bulkley's 2d. Ed. from Transl. by Dr. Burgess, pp.
303, 304) states that "these tubercles are  occasionally as small as
lentils,  at other times  thick, of  a deep livid red color, and as  large
at the base as a sh Ming" (English).
  M.  Simon (Gustav.) in  his work "On the Diseases of the Skin,
as  elucidated by  Anatomical  Investigation," Berlin, 1848, (Med.
Chir.  Review,  April, 1849, p. 357,) says, "the diameter of the broad
condylomata (mucous tubercles) varies from that of a lentil to that

  *  Vido, a memoir of MM. Deville and Davasse in the Archives generates de medi-
cine. 
266
VEOAL ON VENEREAL DISEASES.
of a groschen (in size equal to the American quarter eagle, or $2.50
gold piece).
  M. Ricord's contempt of the diagnosis made  by M. Waller in
the above case, arises solely from the fact of his (M. Ricord's) op-
position to the doctrine of the  transmissibility of secondary acci-
dents, and all who do not join in his faith must suffer from his un-
sparing sarcasm and ridicule.—G. C. B.]
   Contagion.—Inoculation.—The contagious character of the mu-
cous tubercle; in other words,  its transmissibility from  one  indi-
vidual to another by intimate contact, is generally admitted, since
it is almost universally acknowledged that  it  may be a primary
accident.  M. Ricord is, with but few exceptions, the  only writer
on syphilis that denies its contagious  nature.  However, we shall
find  certain doubts expressed in his  work, certain contradictions
which  would  place him among the contagionists.  However this
may be, those practitioners who have the opportunity of seeing
both together, know what credit to attach  to  the contagiousness
of these pustules.   They  will see on the left side of the scrotum a
flat tubercle resembling that on the right side of the vulva with
which  the man had had frequent connections.   I retained for a
long time in my  service  a patient affected with the mucous tuber-
cles  at the  margin of the anus, of which I  have had a sketch
taken; those on the right nates seem moulded on those of the op-
posite side, as represented in plate 4, fig. 2.   The following is a
report of the case made by Mr. Pellagot, one of my internes.  This
case  shows not only the  remarkable relation existing between the
tubercles on both sides of the anus, but it is an excellent example
of the multiplicity of the syphilida on the same subject.  •
   G. (Alain,) set.  25, currier by trade, of bilious temperament, and
good constitution.  Admitted  3d Nov. 1851, into  Ward 9,  bed
No.  7.
   1845. Blennorrhagia, which lasted six  months.   Treated by
copaiba.
  1849, (Sept.) Blennorrhagia and chancre on the prepuce.  The
former lasted two months, and was treated by  cubebs.  The
chancre was cauterized by the  nitrate of silver.  At the  end of
about fifteen days it was cicatrized.   No other treatment.
  1850, (October.) Blennorrhagia, chancre on the glans, suppurat-
ing bubo in the right groin.   The patient was treated at the hos-
pital at Nantes.   For a  month he took a fluid which he believed
to be a solution of iodine.
  1851, (August.) A wrarty  excrescence was  developed on the
skin  of the penis,  at the very place where a chancre had pre*
viously existed.   Two others, smaller than the first, grew  on the
edge of the prepuce.  They appeared four  or  five days after the
last coitus.
  Eight  or ten days after the appearance of these vegetations he  •
had  a  urethral blennorrhagia.  The patient is positive that there
was no abrasion on the glans;  for  fifteen days  he has observed
absolute continence.
  Six weeks after the vegetations, three weeks after the urethritis, 
MUCOUS TUBERCLE.
267
mucous tubercles  appeared on the scrotum and  at  the anus.
Balanitis, followed by phimosis.  At the same time an exanthe-
matous syphilitic eruption.  Finally, twelve days since, there was
a lichenoid  eruption and alopecia.   On the 3d Sept., at the time
of his admission, in addition to the vegetations on the prepuce,
the urethral and balanitic discharge, the  patient still presented
various kinds of eruptions.   On the lower extremities,  and the
arm, copper-colored spots without elevation, having had at first a
rosy color for the extent of a  franc piece.   These spots are parti-
cularly remarkable  on the legs, where they are more numerous
and larger than elsewhere.   On the chest  and the  forehead lich-
enoid eruptions; on the neck squamas of psoriasis, and on the
whole  side crusts of the pustules of ecthyma.
  Finally, on the  scrotum, and at the anus, mucous tubercles
abound.   At the anus, especially, these excrescences assume a re-
markable  disposition.  There  is indeed the closest resemblance
between the tubercles on  the  right and those on the left side.
The patient  declares that their appearance was not simultaneous,
but that there was some days interval.   On the 5th he was placed
under the influence of pills of the proto-iodide of mercury, and in
three months the patient left, cured.  (Vide  Fig. 2, Plate 4).
  For  a long time experiment has corroborated the results of ob-
servation, and Wallace repeatedly inoculated the mucous tubercle
from a diseased to  a  sound subject with success.   And  yet, not-
withstanding our frequent and easy communication from Dublin,
attempts have been made in France to conceal the results obtained
in that city!  Wallace  denuded the skin,  by a blister or other-
wise, and applied to the denuded  surface  portions of the mucous
tubercle, or charpie impregnated  with the matter secreted;  he
thus produced, almost at pleasure, tubercles which varied in form,
but which belonged to the class of accidents called secondary.
   M. Bouley, a hospital physician, whose  attention was   aroused
by my experiments in inoculating  syphilitic ecthyma, undertook
with M. Schneph some bibliographical researches and experiments,
which form  a part of an elaborate memoir published in the Annates
des maladies de la peau et de la syphilis, (vol.  iv., Oct.  and Nov.,
1851.)  This memoir contains the report of numerous cases, copied
from the  work of Wallace; they leave no  doubt whatever of the
transmissibility of the mucous and of other  tubercles belonging to
the class of  accidents called secondary.  This memoir is invaluable,
particularly on account of a case reported  under the supervision
of M. Bouley,  by  M.  Schneph, interne at  the Lourcine.  This
case, which  cannot be  too frequently studied, itself resolves two
questions of the highest importance, for it proves: 1st,  that the
mucous tubercle may be inoculated; 2d, that a subject  that has
been completely infected with syphilis, and passed through all the
different stages of the disease, may have a second attack.   The
following is a synopsis of  the report:       s
   Patient, a female, at the  Lourcine  (service of M. Bouley).  Had
suffered from constitutional syphilis, as was manifested by disease
of the fibrous and osseous system; she had gummy tumors and 
268
VIDAL ON VENEREAL DISEASES.
necrosis.  A blister was applied to the arm, and, after the removal
of the epidermis, for three days it was dressed with charpie im-
pregnated with the secretion of mucous tubercles on another pa-
tient in the same hospital.   On the fifth day after the inoculation,
the blistered surface  had healed; but on the seventeenth day,
lenticular pimples, of a  copper color, covered the blistered part;
on the twenty-seventh, crusts appeared, and the eruption was pro-
nounced ecthyma by M. Cullerier, which by M. Cazenave was re-
garded as syphilitic.  A second blister, dressed simply, and not
inoculated, promptly dried, and was followed  by  no eruption.
  There was here, therefore, as in other cases of inoculation that I
have  known,  a  long  incubation.  It lasted  seventeen days.  A
constitutional  syphilitic accident afterwards  appeared,  but in  a
form  less profound than  the patient  had already experienced;
since  the accident inoculated was a syphilitic eruption, a cutaneous
affection, whilst the others involved the fibrous  and osseous sys-
tems.  Further, forty-eight hours after inoculation, there followed
a syphilitic  fever, connected with the new infection.  There was
intense cephalalgia, the  crusts of the ecthyma remained, and there
was an appearance of tumors in the  subcutaneous cellular tissue,
together with  a  kind of imperfectly-defined  nodes, like those on
the female from whom the matter was taken for inoculation.  This
new syphilitic excitement was advantageously modified by mer-
cury, although it had resisted the iodide of potassium.
  Thus, I repeat,  this  case at once destroys two dogmas:—1st,
that of the non-transmissibility of syphilis in ite secondary form;
2d, that which proclaims that syphilis cannot affect an individual
but once during life.
  Waller, physician to  the hospital at Prague, has inoculated by
another proceeding : instead of removing the skin of a blister, he
scarified the parte.  The subject inoculated was a young lad who
had never  suffered  the  slightest venereal symptom.  The matter
of inoculation was taken from a subject affected with mucous
tubercles.  Charpie was impregnated with the secretion of these
pustules, and applied to the little wounds already made  on the
thigh of the young lad.  The whole was secured by dressing, par
ecclusion, that prevented the contact  of any other substance than
the charpie saturated with the morbid secretion.   There was at
first a little inflammation, or, to speak more properly, some red-
ness,  which disappeared at the end  of four  days; finally, it was
not until the twenty-eighth day from the inoculation, that tuber-
cles and papules appeared at the place of inoculation, and symp-
toms of general infection.
  There were, in  this  case,  at first,  inflammatory phenomena,
which were soon extinguished, an eruption  which aborted, and,
some  time afterwards, the effects of the virus were produced in the
most incontestable manner.  We may often  meet with analogous
cases; the eruption which first appears may  abort, and after this
the true syphilitic eruption is observed to follow.
  [There is abundant proof, as we have already shown, that inocu-
lation with  the  matter  of chancre does not  always  produce the 
MUCOUS TUBERCLE.                   269
same  invariable result, the so-called characteristic pustule; and
such,  as might be expected, is the case with that of secondary acci-
dents—as, for example, the mucous tubercle.  We have mentioned
the fact that Dr. Skae, of Edinburgh, in four out of thirty-six in-
oculations of the matter from mucous tubercles, produced positive
results,  but,  "in the only cases in which  my inoculations suc-
ceeded,  the effect took place within one or two days,"  (Cormack's
Lond. and Ed. Month. Journal, July, 1844, p. 620.)   "In all  of
these, the first appearance presented in the seat of the  inoculation
was a pustule on the seconder third day, as in inoculating from a
chancre.  At length a scab formed,  which appeared to be seated
on  sores depressed below the level  of the adjoining surface, but
without  the  elevated or hardened edges, or the defined circular
form  of chancre.  These continued to increase in size, preserving
the same appearance and covering, until they met each other and
coalesced.   On the 14th day, these crusts became detached, and a
fungoid excrescence, having  all the appearance  of a condyloma,
shot up from the sore." We quote from the abridged  account of
Dr. Skae's article, which originally  appeared in the Northern Jour-
nal of Medicine for April, 1844.—G. C. B.]
  Whoever  peruses the remarkable work of Waller,* may see
with  what rigorous  precision he has selected the elements of cer-
tainty,  when, from  his  own clinical observations,  he remarks:
u Strongly as the above cases show the  great probability of the
contagious nature of secondary syphilis, I could not  and would
not rely on them alone;  I sought, certainly, and believed that  it
could be found only in inoculation.   The following is  the princi-
pal instance of inoculation:
   " Durst, a3t.  12, No. 1396, for several  years was  affected with
tinea favosa, of the head, a disease for which  he had been several
times treated in the  institution; his health is  perfectly good, and
he  never had an eruption of any kind, nor was he ever troubled
with  scrofulous affections.  As his  disease compelled  him  to re-
main for several months in the building,  and as he had never had
syphilis, he was considered a proper subject for inoculation: which
was performed on the  6th August, 1850.   A scarificator, perfectly
clean, was applied to the anterior surface of the  right  thigh, and
into  the wounds thus made, still  fresh  and bleeding, pus  from
mucous tubercles was inserted.    For  this  purpose,  a narrow
wooden spatula was employed, together wdth charpie  saturated
with  pus, which was gently rubbed on the surface of the wounds,
and which was afterwards there deposited and secured.   The mat-
ter for inoculation was taken from a woman (named Nemee), who,
indeed, presented the cicatrix of a chancre, but who, at the time,
had no primary sore.  On the labia majora and minora there were
mucous pustules, covered with an exudation partly croupy, partly
purulent.  These croupy exudations, besides, existed  throughout

  * De earactcre contagieux de la syphilis secondaire, by Dr. Waller, translated into
French, by M. Axonfeld,  in the Annates des maladies de la peau  et  de la syphilis,
April,  1851, and Gazette des Hopitaux, for the same date, by M. See. 
270
VTDAL ON VENEREAL  DISEASES.
the throat, and in the commencement were attended with an ulcer-
ation of the tonsils; an eruption of blotches covered  the whole
body.  This woman,  at the same time,  had a vaginal blennor-
rhcea.
   "On the next day, August 7th, and  the following days, the
wounds made by the scarifier and  the  intermediate skin, were
slightly inflamed;  but at the end of four days the wounds were
all closed:  there was no trace of inflammation, and the whole sur-
face in general resembled that which  has healed after scarification.
   " On the 15th August, I remarked at  the seat of inoculation,
some red spots, and on the 30th August, consequently twenty-five
days after inoculation, I discovered fourteen cutaneous tubercles,
the majority of which had arisen' even in the cicatrices  of the
wounds.  These tubercles were  almost all confluent;  four only
situated on the  edges were isolated; their base was large, then:
size that of a lentil, in many that  of a pea; hard to the  touch;
most were of a deep red, some of a deep yellow color; their form
was perfectly round;  on some  there was a slight desquamation;
nothing abnormal in the other parts of the  body—(no treatment).
On the following days, the tubercles still increased in volume, and
became blended  together ; they then  represented a patch about the
width  of a dollar (thaler), were  soft, projecting  half a fine above
the level of the  skin, and covered with grayish scales, which be-
came thickened and finished by forming the large crust common
to tubercles.  In cleaning  this surface with hot water, the crust
became detached, and the tubercles then appeared under the form
of flattened elevations, slightly excoriated, but which were promptly
covered with new, thin, dry, and grayish scales.
   " The 27th September, twenty-seven  days after the appearance
of the  tubercles, and fifty-two after inoculation,  a maculated syphi-
litic eruption appeared on the skin covering the lower part of the
abdomen, chest,  and back.
   " These spots  were for the most part united,  some were a little
prominent,  isolated, of the breadth of a millet-seed or a lentil, of
an  oval and elongated  form, some of a  pale yellow, others of a
reddish-gray  tinge, without areola,  itching or pain, completely
dry, without  crusts and  scales.   The next day, and the follow-
ing, the number of these spots  prodigiously increased, and  the
whole  body was covered.   There was no febrile disturbance nor
was there any symptom of catarrh, &c.  In the early part of Octo-
ber, some of these spots became elevated into pimples, others into
tubercles, and altogether had a physiognomy so characteristic, that
without inquiring  into the antecedents,  any physician would at
once have pronounced them to be syphilitic.  There was no affec-
tion of the throat; but as  this papular and tubercular eruption
sufficiently proved the success  of the inoculation, I now feel jus-
tified in giving publicity to the case."
  I still repeat that there was here, between the inoculation of the
secondary accidente, and the true resulte of the infection, a period
which  is not observed to follow the inoculation  of chancre.  And
I would here especially remark, that the wounds  for the inocular 
MUCOUS TUBERCLE.                  271
 tion were dressed with charpie, and that they were thus guarded
 against any other fortuitous inoculation.
   When I come to treat of ecthyma, I shall detail the facte con-
 nected with the inoculation of this secondary accident, which will
 present  the same peculiarities.  Occasionally nothing appears on
 the point inoculated for a long time, the true  syphilitic eruption
 being the first to manifest itself
   The case which  I  am about to relate, in detail, the particulars
 of which were carefully collected by my former interne, M. Pella-
 got, differs from those which have been published by the experi-
 menters whom I have quoted.  We here find the morbid secre-
 tion of  a mucous  tubercle producing in- the  first place a most
 abundant and most  fetid  suppuration,  then an ulceration, and
 lastly, a patch analogous to a mucous tubercle.  As it has been
 pretended that the blistered surfaces, which after the inoculation
 became  transformed into tubercles,  was nothing more than vege-
 tating blistered surfaces, I was careful to make the counter proof;
 on the right arm, indeed, we  observed a blistered surface, which
 on being irritated for four days with strong blistering ointment,
 desiccated, healed without ulceration, or papules, whilst the same
 surface dressed  only  twice a  day with the  morbid secretion, be-
 came the seat of the most active inflammation, and of an ulcera-
 tion, in fine,  of a patch analogous to mucous tubercles.  In addi-
 tion to the students who ordinarily attend my visits, the subject of
 these experiments was seen by Drs. Morel,  Chausit, Auzias, Tur-
 enne, and M. Gosselin.
   P. aet. 19, tinsmith,  temperament  lymphatic,  constitution  very
 good, was admitted, July 17th, 1851, into Ward No. 10, bed No.
 1, service of M. Vidal.   Had  had  no previous venereal disease;
 Four or  five months since had a  chancre on the corona glandis.
 This chancre  lasted a  month,  after which it  cicatrized.   An indu-
 ration remained in the situation of the chancre.   Itchings begin to
 be felt about the anus, and mucous tubercles to appear.
   Present condition.—On the glans, where the chancre was  seated,
 the mucous membrane is red,  thickened, and unbroken. Between
 the glans and the prepuce, there exudes  a very thin scanty sero-
 purulent fluid.   Two  inguinal glands much developed, on the
 right side, a small one on the left.  The whole are indolent.  The
 sub-maxillary and  anterior cervical glands enlarged.   Posterior
 cervical  glands  not visible.   About the anus are three mucous
 clusters non-ulcerated.  Up to the present time has submitted to
 no treatment.
   On Thursday,  July 24th, a small blister was applied to the left
 arm.   It was covered with a watch-glass.   Pills of mica panis.
   Friday, July 25th, first dressing.  The epidermis raised by the
 blister is removed.  A disk of blotting-paper covered with cerate,
 with an opening in the centre, of one and a half centimetres in di-
 ameter, is so applied to the wound  as to secure the margins.  The
 central part  is dressed with carded cotton saturated with pus
taken at  the moment of dressing from mucous tubercles about the
anus of  a patient, in  bed No. 38,  of Ward  No. 8, service of M. 
272             VIDAL ON  VENEREAL  DISEASES.
Puche.   The whole is covered with a watch-glass, and secured by
straps of diachylon plaster*
  Saturday, July 26th.  Second and last dressing with the same
pus as before.  The  old dressing is removed.  Suppuration con-
siderable.  The odor resembles that from mucous tubercles.  The
wound is converted  into  a whitish diphtheritic-like pellicle,  with
black spots at certain points.  In removing this pellicle, which ad-
heres, and is torn by pulling, a slight bloody  exudation is  pro-
duced.  The edges of the watch-glass have cut the  skin and  pro-
duced at its upper part a superficial  excoriation which is distinct
from that produced by the blister.
  Sunday, July 27th.  The solution of continuity which was be-
fore superficial, is deepened and has assumed the form of an ulcer,
the edges of which are perpendicular to the base.  The latter  is of
a yellowish-white color,  and  secretes  a large  quantity of  well-
formed pus, but of an intolerable fetor.  In wiping with a compress
the surface of the wound, we remove in part the  false membrane
that covers it, and then there  is a little  bloody exudation.  The
excoriation, produced by the edges of the watch-glass is converted
into a deep notch which suppurates abundantly.   The watch-glass
is no longer used.   Simple dressing with cerate.
  28th. The ulcers  remains the same.  It secretes an enormous
quantity of  pus always very odoriferous.  The edges are red, per-
pendicular,  and the  base  of the sore yellow.  No enlarged glands
are felt in the axilla.  Simple dressing with cerate, and renewed
twice a day.
  30th, 31st.  The wound retains the  same  characters; the  sup-
puration  always  abundant  and  nauseous.  Dressed night  and
morning.
  August 1st. A blister similar to that  on the left is applied to the
right arm, and like the latter is covered with the watch-glass.
  2d. The blister on the left arm remains in an ulcerated state;
that on the right  is  dressed for the first time.   The epidermis is
removed, and a round shield of blotting-paper covered with blis-
tering  ointment is placed upon the  wound.  It is covered  with
a watch-glass.  The left arm dressed with simple cerate.
  3d. Left arm.—Flesh granulations  begin to appear on the base
of the ulcer which is partly cleansed,  and is now of a coppery-red
color.  The suppuration is still very considerable and disagreeable.
Dressing, simple cerate.
  Right arm.—The blistered surface has copiously suppurated; its
surface is red, and the granulations not diminished.  The watch-
glass has produced  a complete circular notch.  Dressing of blis-
tering ointment;  watch-glass no longer used.

  * The following was the diagnosis of M. Puche, in reference to the accidents on
the patient that furnished the matter for inoculation.  Indurated chancre on the
edge of the prepuce for four or five months, treated by an apothecary and healed.
Mucous tubercles on the scrotum of fifteen days' standing.  Mucous tubercles at
the margin of  the anus.  Roseola nearly effaced. Ulceration on the right  pillar
of the velum palati.  Rheumatic pains.  No other symptoms.  The pus  for inoc-
ulation was taken from clusters  about the anus. 
MUCOUS TUBERCLE.                  273
  August 4th. Left arm.—The fleshy granulations have multiplied.
The base of the wound is now on a level with ite edges.  The su-
perior ulcer, caused by the watch-glass, does not yet seem inclined
to cicatrize.   Simple dressing.
  Right Arm.r—The blistered surface is of a rose color, and is not
depressed.  The  circular  notch produced by the watch-glass is
effaced and replaced by a superficial excoriation.  Dressing, blis-
tering ointment.
  Aug. 5th. Left Arm.—The ulceration is replaced by a red layer,
from two-fifths to four-fifths of a line in height, surface of a cop-
pery red, and irregular.  The circumference of this layer is quite
limited and not hard.   All  around it, that portion of the blistered
surface which has  not been in contact with the specific dressing is
red, without granulations, and covered with thin crusts formed by
concrete  pus.   The wound produced by  the watch-glass healed
without  granulating.   The  suppuration  is  somewhat less  but
always fetid.   On wiping the wound with linen, it produced but a
slight bleeding.  Dressing of simple cerate.
  Right Arm.—The wound presents  the same aspect; it is of a
rosy color, granulated, and  not ulcerated.  Dressing with the blis-
tering ointment.
  Aug. 6th. Both blisters dressed with the cerate.
  9th. Left Arm.—The notch made by the watch-glass has healed.
The diameter of the fungous growth is somewhat less, and it still
projects from  two-fifths to  four-fifths of a line above the level of
the surrounding parte. It  is circumscribed  by a reddish-brown
circle,  and its surface always presents the same irregularity, soft-
ness to the touch, still furnishing a little pus somewhat less odorifer-
ous.  Simple dressing.
  Right Arm.—Nothing special.   Cicatrization has commenced.
  Aug. 11th.  Left Arm.—The wound is as large as a franc piece,
and distinctly circumscribed. The  granulations covering it are
united together in such a manner that the  surface is less unequal;
it is of a pale red and somewhat copper colored, soft to the touch,
and a little bloody when chafed by the linen.  The suppuration,
however, is now small in quantity;  it still has an odor.   Simple
dressing.
  Right Arm.—Completely cicatrized.  No dressing.
  Aug. 23d. The  left arm has been dressed every morning during
the visit of M. Vidal.  The cluster has not changed its aspect;  it
is always about four lines in diameter, rising above the level of the
surrounding tissues which have resumed their natural color.  The
surface is covered with soft fungous growths,  not bloody, of a yel-
low color, and furnishes a certain quantity of pus.
  27th. No change.
  29th.  There is an inflammation which appears as if inflated.
Above this is an ulceration which is hollowed on a rose-colored
  Erotuberance, covered with a cicatrix thin and transparent, which
  as been produced in the twenty-four hours.
  30th.  The  rose-colored  tubercle,  in the  centre of which the
wound existed, has disappeared.   The ulceration is now on a level
                               18 
274             VTDAL ON VENEREAL DISEASES.

with the surface of the skin;  it is superficial, of a yellow color,
and always of the same extent.
  The patient left the hospital.   Nothing on the penis.  The muc-
ous tubercles about the  anus are dry and have almost entirely
disappeared.  No eruption on the skin.   During his stay in the
hospital discovered  no roseola.
  In the second week of  September, the  patient, who resided at
Versailles, came to see us.  He exhibited the arm inoculated, and
in the  centre of the blister we found an  elevation, resembling a
waistcoat button. It was dry, and of firmer consistence than the
tumefactions which  we have already observed  at the same place;
in fine, it resembled certain mucous tubercles that form on the skin
of persons of dark complexion.
  Such is the case as reported by M. Pellagot.
  It may be objected, that, in this case, the blister on the left arm,
was but the exciting cause of the accidents observed on that limb,
as the  subject inoculated was fully infected wdth  syphilis, and had
mucous tubercles at the anus.  But why did not the second blister,
that on the right arm, produce the same effects ?
  An ulcer, with a yellowish base, followed the active inflammation
of the inoculated blister, and on this base a papule was developed.
It may be urged that this ulceration was a chancre, and the papule
a transformation of this chancre, which remained  susceptible of the
change.  At first, the glands, in the vicinity of the  points inocu-
lated, were not  enlarged.   I am perfectly aware that we may have
a chancre without a bubo, and yet I note this circumstance.  Fur-
ther, it is of but little consequence whether  this was a chancre or
some other form of  ulceration, for I do not pretend by inoculation
to reproduce the same form of lesion as that which furnished the
matter for the purpose.  This is not the question; but the prob-
lem is, to know whether a syphilitic affection can  be communi-
cated by the product  of papular  eruptions.  Some may go so far
as to say that I took the matter from a chancre, instead of a papu-
lar eruption.  To this, I reply, that Mr. Puche made the diagnosis
impartially.
  These  facts leave no  longer room for doubt: the mucous tu-
bercle may be inoculated and is contagious.  I have already stated
that M. Ricord  stands almost alone in denying ite contagiousness.
But even by his own  words, we may compel him to acknowledge
the contrary.   Indeed, at page 182 of his Traite pratique des mala-
dies veneriennes,  we  find these words  which  I transcribe:  " But
contagious by some incomprehensible vital action, and which cannot
be explained, the mucous tubercle cannot be transmitted by inocu-
lation." Thus, M. Ricord is evidently a contagionist, and he makes
a distinction between physiological inoculation, which is contagion,
and experimental inoculation.  The latter only he rejects.   MM.
Baume's, Reynard (of  Toulon) and other writers on syphilis who
regard the mucous tubercle as  contagious, do not admit its trans-
missibility by inoculation.  In a  practical point of view, this re-
jection is of no importance if we admit its contagiousness.  But
it is probable that if the writers on syphilis who deny the second 
MUCOUS TUBERCLE.                  275
mode of propagation, had adopted the proceedings of Wallace; if
they had repeated to a sufficient extent his experiments; if they
had not formed their conclusions until the required  period of in-
cubation had passed, a very long time when secondary accidente
are inoculated; if these writers had properly performed their ex-
periments, they would have  observed resulte analogous to those
witnessed by Wallace,  M. Bouley and all those who are  aware
that the circumstances are different in the case of inoculation with
the matter of secondary accidents,  from those  which attend  the
same proceeding with that from primary  accidents.
   Treatment.—Regarding the mucous tubercle as a consecutive
syphilitic  accident, it may be stated that it is  one which soonest
appears and disappears.   Rest and cleanliness are often sufficient
to cause its  disappearance from  the genital organs and the anus,
and this, too, in  the  course of twenty days, especially when they
are not of long standing, nor complicated.
   Patients in my service affected with tubercles about the anus or
the genital organs, take a hip-bath daily, except on the day of
using the general bath.  By these repeated washings, and rest in
bed, the tubercles shrink,  and  rapidly disappear.   M. Baumes
adds from one to three drachms of corrosive sublimate to the hip-
bath.   He applies a lotion of pure chloride of sodium, if the tuber-
cles are not ulcerated and surrounded by an inflammatory areola.
When these  complications exist, it is better to dilute the chloride
with a certain quantity of water, so that it may  produce only a
slight smarting sensation, and not a real pain.
   The following is the formula of M. Baumes:

                  ft. Chlor. Calc. vel Sod. 3 vi.
                      Aq. dist.           3 xvi.

   This solution  may be changed for that of the acetate of lead,
sulphate alumina and potash.  Some practitioners prefer corrosive
sublimate.  From three to fifteen grains may be dissolved in two
ounces of water, according to the susceptibility and irritability of
the parts.  We  have then  in view not only the  local treatment,
but a certain  influence on the diathesis, which I believe to  be an
illusion.   The nitrate of silver is the substance that should be pre-
ferred.  It not only hastens reparation, but it is the agent which
most promptly subdues the pain, relieves the smarting sensations,
and the pruritus with which the patient is harassed during the
night.   The  tubercles about the anus and perineum, which  are
more or less ulcerated, and the secretion of which inflames the sur-
rounding skin,  are  those which  produce the greatest suffering.
Relief is afforded by  the following application:

                     ft. Nit. Argent. 3 iss.
                        Aq. dist.    | iiiss.

   This may be repeated every three days, until the  tubercles  are
evidently modified. 
276            VTDAL ON VENEREAL DISEASES.
  After  each  cauterization, the hip-bath is to be  used,  and the
parts should be washed with a decoction of poppy-heads, or a
dilute  solution of opium.   They  may also  be touched with a
crayon of the nitrate of silver, especially when we wish  to limit
the action of the caustic, as in cases of superficial ulcerations, or
if the tubercles assume the form of condyloma; we may then,  by
cauterizing a little more thoroughly, gradually destroy the excres-
cence, to the extirpation of which by the knife the patient may be
opposed.  The crayon is  especially to be preferred  in  treating
those tubercles which grow in cavities or on the uterine neck.
Those in other regions may be sprinkled with some inert powder,
such as amidon, or calomel (a la vapeur).
  I have never been  an advocate for the use of ointments,  either
of mercury, the oxide of zinc, or of the iodide of sulphur.   I have
always found that their application only irritates the parts.   Some •
practitioners employ them after the cure of the tubercles, in order
to remove the stains that are left behind.
  M. Baumes places a high value on the following ointment:

                       ft. Calomel, 3 iiss.
                         Axung.   | viss.

  At the commencement of my remarks on the treatment of the
mucous tubercle, I stated that this accident is one that  most
readily disappears, either from cleanliness or from the treatment
which  I have already  mentioned.  I  should also add, that it is
one of the accidents that most frequently returns, and that is most
speedily and surely reproduced, either under the  same or some
other form, when the above  measures only  are adopted.  We
should, therefore, administer a general mercurial treatment, which
should be  commenced at the same time  with the local, or after
some days of  repose, especially if there be marked irritation, or
inflammation.   The latter is the course which I generally pursue.
In the case of inflammatory complications,  when  the subject is
young, I begin with blood-letting from the arm ; this depletion is
employed for  the double purpose of subduing the inflammation,
and of preparing the way for the action of the mercury.
  M. Baumes  recommends the corrosive  sublimate according to
the formula of Van Swieten, or in pills.  I prefer the proto-iodide,
which I administer as stated in speaking of the treatment of con-
firmed syphilis.   I give the pills,  when the  tubercles exist with
other accidente which show  that the syphilitic diathesis is  estab-
lished.  On the other hand, when we  have  reason to regard the
tubercles as primary, the corrosive sublimate should be preferred. 
PART   SECOND,
CONSECUTIVE  VENEREAL DISEASE  (VEROLE).
  The diseases which form the subject of our present investiga-
tions have been called consecutive, because they generally follow
those considered in the previous section, and because the syphilitic
virus has so acted  on both the fluids and the solids as to create a
special  constitution, for which reason these consecutive affections
are also called constitutional; writers also speak of a syphilitic diath-
esis or confirmed verole, or simply the verole.
  I shall treat of these diseases in two different chapters.   In the
first,  I  shall consider them in general;  I shall thus pass in review
their characters, the period and order of  their appearance;  I shall
inquire into the causes that produce them, and shall consider the
syphilitic fever, and the state of the blood during  the verole; I
snail afterwards discuss  the question, whether it is possible to
have syphilis more than once, and shall  conclude with an import-
ant chapter, viz., the treatment of syphilis.  In the  second chap-
ter, I shall treat of consecutive venereal diseases in particular.
       CHAPTER  I.

GENERAL   REMARKS.
                        SECTION I.

                       CHARACTERS.

  The  title of this chapter indicates what I have already stated,
that the diseases which we are now investigating appear after
those which  have been studied in the preceding section.  But I
have not been absolute, and by my reserve I wish to show myself
faithful to the principles which I have advocated in considering
the subject of physiological absorption, which is the introduction of
the syphilitic virus into the system, without  ulceration, and with-
out previous inflammation of the surface to which it is applied. 
278             VTDAL ON VENEREAL DISEASES.
Virus absorbed by a sound surface  may produce  precisely the
same effects upon the system as that which has given rise  to the
so-called primary  accidente,  the  diseases of this  second section
may therefore  be  primary; they may appear at once  (d'emblee),
and. be the first manifestations of syphilis.   But they are commonly
observed after a longer or shorter interval from the first syphilitic
impression; they are apt to  appear themselves  at several points,
and in different regions at the same time, or successively, and may
extend over a large surface; on this account they are called gene-
ral affections.   The syphilida, which  may be seen  growing at all
points of the cutaneous surface, present a remarkable example of
this form of venereal disease.  On the contrary, the lesions most
frequently primary are generally confined to the narrow sphere of
contagion, hence they are called local.
  All the tissues may be invaded by syphilis, from the epidermis,
the dermous and cellular, to the fibrous, osseous,  and parenchyma-
tous tissues.  The lesions assume the most varied forms, from the
simple pimple, to the largest  sized tumor.  Their  color is of a
reddish, coppery tinge, peculiar to the majority of  these  diseases;
it is so characteristic, that it has been called the syphilitic tint.  As
a subjective  symptom,  nocturnal pains  often exist; they  are so
inseparable from certain consecutive  lesions, that  their existence
alone leads to the suspicion of syphilitic infection.  Their progress
is generally slow;  we do not observe those severe inflammations
which attend the primary accidents.  They are rather alterations,
which are slowly destructive  ; for obstinate ulceration seems to be
the characteristic  of syphilis when left to itself, and it infallibly
produces this effect in bad  constitutions,  and where complications
exist.  If the influence of specific treatment in primitive venereal
disease may be questioned, such is not the case here,  for nature, in
the majority of cases, is impotent, and simple measures  are of no
avail.  On the contrary, in certain of the syphilida, the mercurial
treatment, and in  certain tumors the iodides of potassium, exert
sometimes  so  prompt, so direct an influence, that it is impossible
to deny their efficacy-  But even here, we should  not exaggerate
the power of therapeutical  agents, and undervalue that  of the vix
medicatrix  naturae, which alone may  cure the worst cases, when
heroic means have failed.   We  will only observe, that such are
very exceptional cases.

                        SECTION  II.

             PERIOD, AND  ORDER OF APPEARANCE.

  When several consecutive accidents occur, they generally appear
at different epochs. This fact has been noticed by every observer.
It has even  been assumed,  that they appear in a certain order.
But  these  periods have  not  been definitely fixed, and this order,
as is proved by observation, is not completely regular.
  According to Hunter, the period at which consecutive accidents
appear,  varies according  to  the susceptibilities of the  parts in- 
PERIOD, AND ORDER OF APPEARANCE.         279
volved.  In this point of view, there are parts of the first order and
parts of the second order.   Those of the first order, that is, the most
susceptible, are the skin, tonsils, nose, throat, internal  surface of
the mouth, and sometimes the tongue; in other words, the skin
and  certain mucous membranes.  Those of the second order are
the periosteum, the aponeuroses,  and  the  bones.  Hunter attrib-
uted great influence to the air as a determining cause of constitu-
tional  affections, believing,  as  he did, that  the morbid action was
exerted more directly on the integuments,  in consequence of the
contact of the air  producing there  a greater susceptibility.   Ap-
plying the same theory to the evolution of diseases  affecting the
second order of parts, Hunter showed that  the parts  of the skele-
ton  nearest to the skin, were affected before the deeper seated
bones; thus  the bones  of  the head, the tibia, the ulna,  the ossa
nasi,  become more frequently and more  quickly affected  than
those of other parts.   He  also supposed  that  the susceptibility
might depend on the structure of the bones; it therefore depended
both on the proximity of the skin and the hardness of the osseous
tissue.  Hunter, moreover,  acknowledged Jhat this order might be
inverted, and he admitted the possibility of the lesion  of the  parts
of the  second order, the first having  never been affected, that is to
say, Hunter having a mind eminently disposed to generalize, lost
no opportunity of so doing;  but as he was at  the same time a
profound observer, the  exceptions  did not escape him, as he was
sometimes sufficiently candid to acknowledge.  Hunter, besides,
never spoke of immutable laws, as he was too well acquainted with
the  nature  of disease;  he was well aware, that it is particularly
during the existence of disease that laws are not constant.
   Thus in adopting the philosophic views of Hunter, and receiving
his  theory at ite proper value, we  may admit and sanction, to a
certain extent, the two orders of lesions he established,  and this
too from undoubted analogies and proof the most direct.  Indeed,
when the syphilitic virus  is  applied to the living tissues, every
part does  not react equally against it, or rather, are  not similarly
affected at  the same  time.  The integuments, as a  general rule,
are the first affected, or furnish the  first manifestations of the im-
pression thej have received.  This is not peculiar to  the syphilitic
virus; all morbid agents of this class produce analogous effects ;
indeed,  the  virus of rubeola and of variola manifest their first
effects on the skin by exanthematous and pustular eruptions,
which are  irritated by the syphilida; for the rubeola  and the
variola are repeated by roseola and a certain form of ecthyma.  The
parts belonging to the second order, according to Hunter, are the
fibrous and osseous tissues of a much lower grade of action and
vitality than the skin and mucous membranes; consequently, when
morbid  changes occur it is only after they have manifested  them-
selves on the integuments.  The skin, besides, being exposed  to
view,  its slightest changes of color and stains are seen even from
the commencement, whilst  analogous  phenomena, passing  in the
subcutaneous tissues,  the periosteum and bones, cannot be known,
for  there the  lesions become appreciable  only after a tumor has 
280
VTDAL ON VENEREAL DISEASES.
 formed, when in fact they have existed for a much longer period.
 Thus, whatever view be taken  of the  matter, it will be seen that
 the cutaneous affections must  be  observed, before those  more
 deeply seated. This has  been noticed by the most simple  ob-
 servers, but those who know how to interrogate nature completely,
 will admit it as a general though not an absolute rule.  M. Ricord
 adopts the division of Hunter, and denominates the diseases which
 affect the parte belonging to the first order, secondary accidents,
 and those of the  second, tertiary accidents, because he places at the
 head primary accidents.   Syphihs  may therefore  be completely
 embraced in the following summary :

                     1st, Primary Accidents.
                     2d, Secondary Accidents.
                     3d, Tertiary Accidents.

 This division is  an old triade ; for we find it complete in Thierry
 de _ Hery, and it  has been  traditionally handed  down by every
 writer who has followed him*  M. Ricord has rejuvinated it, has
 rendered it popular, by descending from his high philosophical
 position, and  by representing it as  based on experiment.  This,
 too, has been done at a time when this method was much in voguej
 and it has been represented as being capable of simplifying the study
 of syphilitic diseases.  It is, therefore, greatly admired by certain
 minds,  which  are satisfied with a superficial investigation of mat-
 ters, and which have  not  the time  to sift  them to the  bottom.
 Those,  however, who  like  a  thorough investigation, discover in
 this classification, serious  and  very grave  objections.  But as
 most of its opponents were not convinced of the utility of resort-
 ing to experiment, as they believed in ite  dangers  and judged it
 unmoral, they  are disposed to neglect and even censure this means
 of popularity;  hence their  little success compared with those who
 attach so much importance to this method of investigation.   How-
 ever,  among these opponents, there are some, who relying  chiefly
 on observation, still  know  the  value of experiment, and  believe
 that when  employed  within  certain  limits,  it may be  advan-
 tageous to science, and that it does not violate the laws of morality
properly  interpreted.   They  therefore experiment  more philo-
 sophically ;  that is, without losing sight of observation, and not
 satisfied m addressing  the mind alone, they speak also to the
senses, and  it was especiaUy by means of experiments, that they

  * "Thierry de Hery. La Methode curatoire de la maladie venerienne, p. 133. Several
symptoms or accidents are common to this disease, some of which  precede, others
follow, and others again supervene on these.  Those which precede are ulcers of
different  kinds: ardor urince, buboes, which being said to precede, though they
may be equivocal, and may or may not arise from contagion, do, nevertheless^
moat generally precede, and may serve  as precursors of the disease.  The others;
which we call consecutive, are pustules and ulcers on all parts of the body, princi-
pally on the private parts, the fundament, the mouth, the throat, the forehead, and
the emunctones.   In hke manner, there  is also a falling off of the hair commonly
called peloda, articular pains, often also  wandering, but seldom nodosities.
  "The latter which we call superadded or extraordinary, which appear after im-
perfect cures, &c,  <fcc, <»c.                                ir 
PERIOD, AND ORDER OF  APPEARANCE.         281
successfully attacked the errors of this  method.  In speaking of
mucous tubercles, I have already shown their inoculability, a fact
which had been denied by the advocates of experiment, that is, of
partial experiment:  we shall soon  meet with remnants of the
errors of this  same experimental method.  I commence with the
classification*
  1st. Primary Accidents.—There is  but one, viz., chancre, which
once cured, cannot be reproduced unless  by fresh contagion.  It
may be inoculated but cannot be transmitted hereditarily.
  A.  It has already  been demonstrated  in this work  (first sec-
tion), that there is a virulent blennorrhagia; chancre,  therefore,
is not the only primary accident.  B. It is very true that chancre
may be inoculated, readily inoculated; but it must be added that
it cannot always be inoculated.
  2d.  Secondary  Accidents. — These  embrace certain  cutaneous
eruptions, as well as certain affections of the mucous membranes,
and their dependencies, and particular  morbid conditions of the
eye, and lymphatic glands.  These  accidents, without  being in-
oculable, can be transmitted only hereditarily; they seldom occur
before the third week after the  primary accidents,  and still  more
rarely after the sixth month.
  As to the transmissibility of the secondary accidents, aside from
hereditary descent, the doctrine is proved by the fact of the  in-
fection of the nurse by the child affected with consecutive tubercles,
and the contagiousness of the mucous tubercle in the adult; it has
been proved by the experiments of M. Cazenave, Wallace, Waller,
M.  Bouley,  M. Richett, M. Litthmann, by my own, and  by those
of other experimenters.  Under the  head  of mucous tubercles ex-
periments  have already been mentioned, and when we come to
treat of the pustular  syphilida, we shall find certain  facts which
leave no doubt on the subject.  The  distinction,  therefore, between
the  primary and  secondary accidente, which rests  on  their trans-
missibility,  a  distinction to which so much importance has been
attached, is  destroyed both  by experiment  and clinical observation.
Both primary and secondary accidents are inoculable.
  B. With reference to the time of  the appearance of secondary
accidents, it has  been  stated, that as a  general rule, it  is seldom
before the  third  week, and rarely after the sixth  month.   This,
nevertheless, is not true, at least according to those observers who
have devoted especial attention to the subject.  Thus, MM. Legen-
dre, Martins, and Cazenave, have fixed upon a medium far above
the  maximum time laid down by M. Ricord.  M. Legendre, one
of the most distinguished pupils at the San Levis,  author of a re-
markable thesis on the syphilitic eruptions, thus remarks: " I have
obtained, as a general medium, from  the time of the appearance of
the primary to that of the secondary accidents, (syphilida,) five
years, precisely the same result as that  mentioned by M. Martins
in his Memoir.,'
  3d.  Tertiary Accidents.—These  consist in special alterations of

  * The propositions are numbered; the objections are indicated by the letters. 
282
VTDAL ON VENEREAL DISEASES.
the sub-cutaneous cellular tissue, of the testicles, and the fibrous
and osseous tissues of the deeper seated organs.  These accidents
cannot be inoculated, neither can they be transmitted hereditarily
with their peculiar physiognomy; yet, by a kind of degeneration
or modification of syphilis, they may become one of the most fruit-
ful sources of scrofula.
  A. I shall be guarded in my remarks on these points.   It will be
necessary, moreover, to consider these questions again in our remarks
on infantile syphilis.   I will say, however, in advance, that this doc-
trine of the transformation of one disease into another, especially
into the formation of a diathesis,  is an ancient one, and that there
are but few arguments in its support.  B. M. Ricord observes that
tertiary accidents never appear before the sixth month, and may
manifest themselves several years after the appearance of the pri-
mary accidents.   To this I would reply, that I have seen cases of
periostosis at a much earlier period, even during the existence of
the primary accidents, and long before the sixth month.  Besides,
it may appear d'emblee, that is, as the first manifestation of syphilis.
  In conclusion  we would  remark, that the division into three
orders, based on their transmissibility or non-transmissibility, is only
arbitrary,  and that the period of their manifestation is-not perfectly
defined. .The fact, moreover, besides, even though it be exceptional,
yet the actual occurrence of both the secondary and tertiary accidents
demblee, destroys the value of any character derived from the inter-
val of the primary and the other accidents,  since the pox may
consist simply of a syphilitic eruption or an exostosis, without any
other preceding syphilitic affection.
  It should also be known that the three divisions above mentioned
cannot represent  all the distinct accidents, all the phases of syphilis.
Thus, after chancre, sometimes long after its cure, a really syphilitic
bubo may appear, which cannot strictly be considered as a primary
accident, since  it has been preceded by another accident.  It is
denied a place among the  secondary accidents, since it is inocula-
ble, and the doctrine is, the non-inoculability of secondary acci-
dents.   A successive accident has  therefore been established.  But
as the same accident, the same bubo, may exist without a preceding
chancre, d'emblee, it is therefore sometimes primary, sometimes suc-
cessive!  Now, examine carefully the different accidents belonging
to the third category, and it will be found that from the  special
affection of the sub-cutaneous or sub-mucous tissue, this kind of
tubercular cutaneous disease, to the appearance of an exostosis, a
very long time, even years may  pass.  These tubercles are  fre-
quently even nearer  the  secondary than the tertiary  accidents.
They have been called the accidents of transition.  Thus, we have
two orders of accidents, the successive and those  of transition, which
altogether raises  to five, the  number of orders of syphilitic acci-
dents, or, if disposed to admit them only as fractions of accidents,
perhaps this number will not be maintained; but, in either case
the triade will be compromised, for it is  necessary to fix on some
definite  terms.   It must not be supposed that these phenomena
are always developed in the same manner, having the same relations 
EXCITING  CAUSES.
283
in the three great divisions; they will be found, on the contrary,
to change  according to the requirements of the  system.  Then
comes the inversion, that is, the appearance in the last place, of an
accident that passes for secondary, as in the  case of certain of the
serpiginous syphilida, which, occur after an  exostosis.   I have
already stated, that Hunter  alluded to this inversion, and  that
Thierry de Hery placed these serpiginous ulcerations among the
lesions of the third category;  he called them  wandering (canibu*
laii/s) ulcers.
  I do not state  these numerous objections for  the mere pleasure
of the act, but to render the young practitioner familiar with  the
exceptions, especially since they are so numerous  and important,
and to show that what appears very simple when seen from a dis-
tance and in the schools, may in reality be very complex when
closely examined, and in the presence of nature.  In the majority
of cases, indeed,  the cutaneous venereal disease does follow next in
order to the priniary accidents;  then come the sub-cutaneous affec-
tions.  In both  orders the highest forms  are first observed;  the
 f)eriod passed in incubation, in relapses, tends to aggravate  the
 esions which are about to appear.   Thus  we see the cutaneous
lesions assume at first the light and superficial form of the exan-
themata, and after awhile,  sometimes after repeated relapses, reach
the state of the perforating tubercular syphilitic eruptions.   As to
the sub-cutaneous lesions, we observe the cellular, then after awhile
the fibrous and  osseous tissues attacked, and finally the  viscera
become invaded, and the diathesis after a time passes into a state
of cachexia.   Such is the general course of events, but this is not
always the case, a fact which should be carefully remembered if
we desire the truth, and would avoid deception.
                        SECTION HI.

                     EXCITING-  CAUSES.

   I have already stated that the syphilitic  virus  may remain a
cause without effect, and that the diathesis may not be established,
by the simple absorption of this agent.   Other causes are required
to develop  this diathesis.   These  have been sought  for in the
idiosyncrasy,  sex,  age,  temperament,  hygienic and pathological
conditions.
   It is evident that every  subject is not equally favorable to the
development of the diathesis;  some there are, who are completely
refractory to its influence.   In them, the virus, when  introduced
into  the  system,  remains always in an inocuous state, or rather
it  is  destroyed and expelled in some unknown manner;  indeed,
well-marked chancres in certain subjects, when left  to themselves,
or treated by very mild and insignificant means, have been radi-
cally cured; in other words, the reparation of the ulcer has been
complete, and nothing of a syphilitic character has been observed
to  follow in these patients.   The  advocates of the physiological 
284            VLDAL ON  VENEREAL DISEASES.
doctrine, those who deny  the  existence of a virus, and whoso
treatment corresponds with such an  opening,  have  published
numerous facts, to show that the virus in its effects may be limited
to the production of the primary accidents.  This is a well-known
fact.  But we do not know the influence of age, constitution, tem-
perament, sex, which  can most frequently assure us of this im-
munity.  It has been supposed that strumous constitutions were
most favorable to the development of the consecutive  accidents.
Facte have  proved only, that under such circumstances, syphilis
produces its greatest ravages, and nothing more.  We must also
take into account the fact that very numerous cases have occurred
to prove that most excellent constitutions have equally suffered
from syphilis as have those the most deteriorated.   As to the in-
fluence of sex, I can only say, that at the Lourcine, in  the female
service,  comparatively speaking I have less frequently observed
cases of confirmed syphilis than at the Hopital du Midi, where only
males are now treated.  This I speak from memory, as I have no
statistics by which to establish the influence of sex in the produc-
tion of consecutive  accidente.   But it is generally admitted, that
in the female, syphilis is less grave than in the male.  As to age,
it may be observed, that during infancy, syphilis being hereditary,
we find only the so-called secondary accidents ;  these are generally
pustules, bulla, and seldom erosions, in which case the disease is
very severe.   As we pass  from infancy, constitutional  syphilis is
less common.   In the adult, consecutive affections become again
more frequent and aggravated.  These accidents, then, are not
only attended with greater danger, but the graver  are more fre-
quent than the lighter forms of the disease.
   There are hygienic circumstances, and  others which may be
called pathological,  which exert a real influence on the  production
of  consecutive accidents.   Thus, inadequate nourishment,  exces-
sive indulgence at the table, excessive fatigue, a sudden change of
temperature, may exert a powerful influence  on  the development
of constitutional syphilis and its relapses.  It has been known to
appear after going from a warm to a colder or more humid climate,
and cures been known to follow the opposite change.   The  influ-
ence of temperature, however,  on the  production of consecutive
symptoms, should  not be  exaggerated, for facts  show that both
cold and heat may in turn prove  an  exciting cause; thus I have
observed the case of  a blacksmith who  had syphilitic eruptions
only on the fore-arm, the hands, and parts most, exposed  to the
fire of the  forge.   Carelessness, want of cleanliness, and misery,
seem favorable to the development of certain  accidents ; thus we
may daily witness this  truth  among the unfortunate workmen
who enter the Hopital du Midi, covered with mucous tubercles,
and who obtain prompt relief by simple repose, and local and
general bathing.
   As to the pathological circumstances, syphilitic eruptions have
been seen to follow an attack of fever.  But who knows that this
was not a syphilitic eruptive fever ?  A syphihde has really been 
SYPHILITIC FEVER.                   285
seen to follow  an inflammation of the  abdomen, and the  chest.
However, on this point, that is, the influence of pathological cir-
cumstances, writers on syphilis  are less unanimous than on that
of hygiene.

                       SECTION IV.

                   SYPHILITIC FEVER.

  This, strictly speaking, resembles that of the eruptive fevers, for
it occasionally precedes the syphilida, and generally subsides when
the eruption appears; it also sometimes  remains, or existe, in con-
nection with some one of these symptoms.  If fever consisted
entirely in an acceleration of the pulse, surely there would  be but
very few syphilitic fevers, preceding or  accompaning the consecu-
tive accidents;  syphilitic fever, such as that observed by M. Cas-
telneau,* and described by M. Chausit,f attends only the primary
accidente.  It is not that the blood is not profoundly altered when
this fever  follows the consecutive accidente, but it then has the
chronic character which these accidents  generally^assume, and the
troubles of  hematosis are generally manifested by symptoms of
chloro-anemia.
  The modifications of mobility and sensibility are less obscure.
Thus before the  appearance of certain syphilida, the patient com-
plains of painful weariness, weakness,  and loss of muscular power,
precisely m the same manner as is observed when the eruption is
about to appear in infantile syphilis.  What is particularly well
marked, are the changes, which have  been compared to neuralgic
or rheumatic pains.  They are felt principally on the head,  in the
vicinity of the  articulations, sometimes in the lumbar region; they
are the  rheumatic pains of modern  writers.   They precede the
appearance of the lightest forms  of accidente, called secondary,
and may likewise usher in those more deeply seated, and accom-
panied with relapses.   These rheumatoid pains are not constant,
there being often a kind of intermission, and the paroxysms are
excited by heat, especially when in bed.  According to M. Ricord,
the patients who thus make day of night, may invert the order of
the attack of the paroxysm.  This is not absolutely true.  The
same  writer has attempted to  make a distinction between these
pains and osteocopes, which belong to another stage of the disease.
The  rheumatoid pains are not at each paroxysm seated  in the
same place, and during the intermission, pressure does not repro-
duce them; on the contrary, some patients find relief by resorting
to  compression, at the moment when the paroxysm commences,
and by moving the painful  limb.  Exposure of the limb  to the
action of cold,  produces also the same happy effect.  The color of
the skin, and the temperature, remain unchanged, nor is there any
tumefaction.  The case is quite different when the pains depend
upon profound lesions of the bone.

         * Vide Annates des maladies de la peau et de la syphilis, t. iL
         f Vide the same journal for April, 1852. 
286             VTDAL  ON VENEREAL DISEASES.
  Hunter alluded to the syphilitic fever, and those who are en-
gaged in examining claims of priority, should know that this wri-
ter first asserted that this fever strongly resembled the rheumatic
fever.*   In  speaking afterwards  of the constitutional symptoms,
he speaks of pains like rheumatic pains.f   But generally, Hunter
regarded this fever as an accompaniment of the consecutive lesions
and not as a forerunner of the disease.
  M. Ricord has attached great importance to the enlargement of
the glands in the posterior cervical region, as the first  indication of
infection. This glandular enlargement, which is but a consecutive
bubo, really occurs in the region mentioned;  but the same con-
dition exists in every region where glands are found, and when
sought  for,  may  generally  be detected.   I will  repeat, besides,
what I stated in speaking of adenitis, which is regarded as the in-
evitable companion of indurated  chancre;  viz., the same tumors
may be produced by the  slightest ulceration, the  least pimple on
the skin ; and as they depend upon  a strumous affection,  and  may
be anterior to the syphilitic attack, their importance should not be
over-estimated in forming a diagnosis.
                        SECTION  V.

         STATE OF  THE  BLOOD IN SYPHILIS.

   I have already proved, and shall again demonstrate, that certain
morbid products, during an attack of syphilis, are inoculable; as
to the normal secretions, these will be considered when we  come
to treat of the  causes of infantile syphilis.   We shall find that
syphilis may be inherited from the father, by a certain alteration
of the  semen.   I shall also discuss the question, whether a nurse
can by her milk infect the child.
   We are now to consider the state of the blood in syphilis.   Ac-
cording to Waller, the deglobulization of the blood during the syph-
ilitic  diathesis would seem  partly  probable, from the aspect of
the patients, and certain  other accidents from which  they suffer;
but a demonstration based  upon the analysis of the blood has not
yet been made.   Doctor Serch, at the request of Waller, subjected
to a quantitive  analysis,  the blood of several venereal patients,
without arriving at any  positive results.   M. Grassi, however, is
said to have made analyses which showed that in the blood of sub-
jects  affected with  consecutive  acccidents, the proportion of glo-
bules is diminished, and sometimes, in a very notable manner, the
contrary obtains when the  patients are under the influence of the
primary accidents.   The  proportion of albumen was inversely to
the quantity of the globules.  This has led M. Dour vault, who has
published the experiments of M. Grassi, to say: "In proportion
as syphilis infects the system, the nutritive fluid gradually loses its
* Hunter, by Babington, Am. ed.
f Ibid, p. 659. 
STATE  OF THE BLOOD  IN SYPHILIS.           287
strength, by the resolution of its globules into albumina."*  I can
only say, that subjects laboring under primary symptoms are some-
time." very debilitated, and their blood is not rich in globules, whilst
others whose systems are fully saturated, are plethoric.
  The question  has been considerably agitated whether the virus
is only mixed with the blood, its connection being only physical,
and therefore ite properties  remaining unmodified, or whether its
properties are modified and changed.  According to Waller, the
idea of the simple mixture of the virus with the blood, is opposed
to  the principles of physiology, and experiment  disproves it, by
demonstrating that inoculation made with the blood is incapable
of reproducing a primary chancre, whilst  secondary syphilis may
be thus communicated to sound subjects.  Carmichael  mentions
two  facts in confirmation of this; and they are also  corroborated
by Waller.  The latter physician besides, has performed a most
conclusive experiment, the details of which I will relate.   Accord-
ing  to  Hunter  the   blood  possesses  no  contagious  property.
"Could  a  syphilitic inflammation be  excited in a previously-
healthy  wound, no person in whose blood the venerea^ poison cir-
culated, that  is who had constitutional syphilis,  could  escape a
venereal ulcer whenever he was bled or received the scratch of a
pin; the little wounds thus inflicted, would become transformed
into  so many chancres.  Indeed, if the point of a pin or a lancet
should be dipped  in veneral pus, their punctures would become
chancres.f   Here is a doctrine, that lately has singularly obscured
the question of the inoculability of secondary accidents.  Hunter
maintained that the  virus combined with the blood, produced the
same effects as the pus from a chancre;  of course, it would produce
chancres on  the patient himself.  Such being the case,  it follows
that it would produce the same effect when inoculated on a sound
person.   Waller has already responded  to  Hunter. Moreover,
the  question  should be differently framed.  It should be  not
whether the blood may transmit such or such  a form of syphilis,
but whether it can transmit syphilis under any of its forms.   J£
not thus enlarged,  it amounts to  nothing.
  Those who deny the possibility of transmitting anything by the
blood, base their belief upon the facts showing that wounds on
 Eatients whose system is completely contaminated with  syphilis,
 ave been seen to heal like those on sound subjects, and on the
immediate union which has followed after certain operations per-
formed on persons infected with syphilis.  This only proves that
blood which, to a  certain extent, has been changed, or which is
mixed with a morbid poison, may supply  the means  necessary to
cicatrization.   This,  moreover, had already  been proved by the
very numerous cases of union by the first intention, after the ex-
tirpation of a tumor, and during the existence of a decided cancer-
ous diathesis: as, for example, after the palliative operations  for
cancer, when  there  can be  no doubt as to  the alteration of the
* Gazette Medicate, 1850, p. 200.
f Hujiter, by Babington, Am. ed., p. 239. 
288
VTDAL ON VENEREAL DISEASES.
blood.  But these facte, furnished by pathology, and which I once
undervalued, do not prove that the blood of a  syphilitic subject
cannot, under any  circumstances,  act  even upon the individual
himself, and produce syphilitic accidents in  a certain order, and
that this same blood may not be the vehicle of the poison, in trans-
mitting the latter to the foetus, through the mother.  No one has
ever denied the first; the  second, which Hunter seems to reject,
is  now proved  by carefully-observed facts:  thus,  the  mother's
blood is the medium of communicating to the  child,  to  another
being, the syphilitic poison.  Both analogy and facts  afterwards
lent their aid to prove that syphilis may be transmitted by inocu-
lating a sound person with the  blood of one diseased.  M. Diday,
who,  among the first in France, started  the question of transmit-
ting syphilis  by other humors than the pus of chancre, speaks of
the inoculations  of glanders, of carbuncle, and of hydrophobia.
   " Nothing," he observes,  " goes to prove that the  blood of a
syphilitic  subject, when inoculated  on  a sound person, will not
communicate to the latter the disease."   Returning to  the proofs
furnished h& Hunter of the non-transmissibility by the  blood, in a
note M. Diday adds :  " Hunter's argument proves but this, that  he
has here  confounded the primary  chancre  with  constitutional
syphilis.  Because  the  blood does not  produce the former, is it
right  to infer a priori that  it cannot produce the latter ?"*  I have
already mentioned-  that Waller is in the possession of two facte of
contagion from the  blood, and  that  he  has  made an experiment
that has not been answered ;  here it  is:
   " Experiment with the blood of an individual affected with secondary
syphilis.—F., a lad,  set. 15, entered No. 5676, in infancy, had been
troubled with the rickets,  and, for  the last seven years, had been
affected with lupus exfoliativus on the right cheek and beneath the
chin ;  this lupus, of the diameter of a little more than half a dollar
(American) piece, with the exception of a small space on the cheek,
had been cured, after long  treatment,  by cauteriza'tion and the
hydriodate of potassa.   This lad had  never had syphilis, and,
being a proper subject for inoculation, it was performed on the
27th July, 1850, on the  left thigh. I took the blood  from a
female (Frennd), in whom secondary syphihs had been developed
under our observation.  This young girl, in other respects in most
excellent health, had lately several times contracted primary sores,
without having ever been affected with  secondary syphilis.   But
during the treatment of the two last chancres, which succeeded
each other after a  fourteen  days' interval, she  began  to become
emaciated and pale, and, when the last  chancre was healed, and
there  remained only a uterine  catarrh,  tubercles appeared on the
face, and spots on the surface of the whole body.
   " The inoculation was made in the following manner; the skin
was scarified with a new scalpel, and, by means of a cupping glass,
from  three to four drachms of blood were abstracted.   Notwith-

 * Extract from the Gazette Medicate, Sept. 29th, 1849, first article on Prophylaxis,
by M. Diday. 
STATE  OF THE  BLOOD IN SYPHILIS.           289
standing the rapidity with  which the latter was done, the blood
was still partly coagulated before it could be  carried from the
patient's chamber to that of the person to be inoculated.   The
wounds from the operation (performed on the child as in the pre-
ceding experiment)*  were carefully cleansed and cleared of the
bloody clots by warm water;  the  blood for  the inoculation was
then inserted into these wounds, partly by means of a small piece
of wood, and  partly by charpie saturated with  the blood, which
was applied and secured on the scarified parts.  Neither inflamma-
tion nor suppuration followed; at the end of three days the wounds
were completely closed.  The  patient continued well.
  " On the 31st August, thirty-four days after the inoculation, I
observed on the left thigh, at the point of inoculation, two distinct
tubercles, of the diameter of a pea, of a  pale reddish tint, dry on
their surface, and attended with neither  itching nor pain.  In a
few days they increased in size, became united at their base, and
covered with scales, and both were surrounded by a dull red areola.
The base of the tubercles,  that is, the subjacent skin, and  sub-
cutaneous cellular tissue, became  firm, tense, and an ulceration
formed on the surface of the tubercles, which became covered with
a thin and brown crust.  In this manner, about the 15th Septem-
ber, an ulcer had formed,  the diameter of which equalled that of a
pigeon's  egg, a coppery-red areola surrounded its borders, and it
was covered with the crust above mentioned.  This crust having
been removed, the base of the  ulcer became visible; it was  of a
funnel-shape, lardaceous, and bled easily at  ite edges.   For some
days previously an isolated tubercle had appeared on the  right
shoulder, as large as a pea, of  a red color, and covered with  thin
scales.  The patient could not tell the time of the first appearance
of this accident.  The general health remained good.
   " On the 26th Sept., and the two following days, F. complained of
a want of appetite, and sleeplessness.  On the 1st of Oct., sixty-
five days after inoculation, and thirty-two from the appearance of
the first tubercles, an exanthematous  eruption  was observed in
the lower  part of the abdomen, on the back, chest, and thighs;
this we pronounced a well-marked syphilitic roseola.   The spots
were precisely hke those above described (in the first experiment),
only at certain points they were somewhat  more elevated.   The
ulcer on the  thigh had acquired the breadth of a thaler (little
more than the American half dollar), and still preserved its funnel
shape, its lardaceous  base, and coppery edge. A few days after-
wards these spots became so numerous, that the entire  body,  not
even the face excepted, was covered and appeared speckled. There
was neither itching nor pain, nor symptoms of catarrh, nor fever.
On the 6th Oct. several  spots,  particularly on the inner aspect of
the thighs and on the abdomen, became  raised into pimples or
tubercles, and thence the diagnosis of the eruption, even without

  *  Waller alludes to the experiment mentioned at the end of the  first section,
■whilst treating of the mucous tubercle.  Small wounds were made with the scari-
fier.
19 
290
VTDAL ON VENEREAL DISEASES.
knowing the antecedents, was attended with as little difficulty aa
in the preceding case.*
  It will have been remarked that the wounds were covered with
charpie saturated with blood, and that this dressing was secured.
The wounds were therefore removed from  the  influence of every
other contagion.  Moreover, the period of incubation was so long
that no one could for a moment suppose the intervention of the pus
from a chancre, for it is known that after the inoculation of this pus,
the local phenomena are not slow in their manifestations.  M. Ricord
maintains that there is then never a period of incubation.


                        SECTION VI.

        CAN A PERSON HAVE, SYPHILIS MORE THAN ONCE?

  It has been  pretended that  the consecutive accidents express
the  true syphilitic diathesis, and cannot be repeated in the same
individual, or more strictly speaking, that a person can have syph-
ilis but once in his life, thus  assimilating this disease with  variola
and rubeola, which ordinarily occur but once in the same individ-
ual.  Up to the present time, this law which they would establish,
is based on mere assertions, and of  analogical proofs.  Now on
this point, above all others, statistics are required.   But it is diffi-
cult to find cases so complete that we may know that the syphilitic
diathesis is exhausted, that it has produced all which it can produce,
What is still more  difficult, is, to  collect under one head, a suffi-
cient number of cases to form statistics, the result of which may
be  erected into a pathological law having a real value.   The diffi-
culties, we may add the impossibitities of  such an undertaking,
arise from the duration of syphihs, the modifications and even the
suppression of  certain of ite manifestations by  treatment, and
finally from its relapses.  Typhoid fever,  variola, rubeola, and
other diseases which are  supposed to resemble syphilis, f are of an
acute nature, and continue but for a very short period; a  large
part of mankind therefore remain liable to repetitions, which we
may expect, and appreciate.  On the other hand, in order that
syphilis may have  spent its full  force, a  considerable length of
time is almost always required.  The three stages characterized
by the accidents called primary, secondary, and tertiary, have a very
unequal duration, but as a general rule it is long.   The length of
the interval between the appearance of each accident varies also,
and it is in general considerable.  Take into calculation the num-
ber of days, and sometimes of months, required for the reparation
of a chancre;  note the months which intervene between the latter
and the syphilida, and the duration of the cutaneous  affections;
remember also the lesions of the parts beneath the integuments,

  * Waller, Du caractere contagieux de la syphilis seeondairc, translated into French
by M. Axenfeld, in 8 vols, of the Annates de lapeau et de la syphilis.
  f The uncist have finished with the discovery that we can have hydrophobia
but once. 
      CAN A PERSON HAVE SYPHILIS MORE  THAN  ONCE?   291

the glandular engorgements, the tumors of the cellular tissue, nodes,
par< i^  ivmatous affections, like those of the  testicle;  add to this
the time required before the fibrous  and the osseous tissues may
be invaded, and the gummy tumors, the exostoses show  them-
selves with all  their characters, that the  patient may have what
are called tertiary  symptom-;, and  the  really tertiary symptoms;
make this addition of the time required that these different affec-
tions may be established,  and  then it will be seen how high is the
number to which it is possible to arrive.
  True, this is the chronic progress, unmodified by treatment, a
circumstance not likely to occur.   The patient  is nearly always
subjected to treatment, and receives from some practitioner a mer-
curial preparation.   Now, it is admitted that these preparations
have  almost always the  effect of retarding or of preventing and
even of suppressing the development of the  secondary accidents.
The length of time that a more or less imperfect  treatment may
abridge the duration of the venereal disease,  should therefore be
represented when we speak of the full period  of the disease.  This
is not all: in the column of the time required for the establishment
of completely-confirmed syphilis, should figure the number which
represents the time required for the removal of this diathesis, and
the time required for its  cure.  Now, multiply by  2  the time re-
quired for the  establishment of the disease, and we shall scarcely
obtain that needed for its  cure.
   Add the whole together, and the sum will represent a period of
such length as  to render it impossible for the subject to gain a new
chancre.  It is known,  besides, that some very distinguished prac-
titioners maintain  that confirmed syphilis is incurable.  An indi-
vidual affected with tertiary symptoms will always remain in that
condition.   If, therefore, my calculation be correct,  and  this
opinion just, when we  assert that an individual cannot have but
once a disease which lasts for life,  we proclaim a truth which is
only but too  true, an unfortunate  circumstance for the unicists,
especially since they have already stated  that we  can  have the
hydrophobia but once!   I shall  still be met with the objections
that observation proves that certain subjects have been able to ob-
serve the origin, development, and disappearance of their diathesis
in so short a space  of time, as still to retain the power of enjoying
pleasures, which expose  them to syphilitic  inoculation.   This is
true, and these are the cases  precisely which furnish examples of
the double infection.  They may, indeed, contract a new chancre,
a fact doubted by no one;  they may afterwards have consecutive
accidents,  symptoms of syphihs, which  every  one admits, but
with a different explanation.  Thus the  unicists do not attribute
the last accidents to the  last  chancre, but to the first, that is  to
say, to the  chancre most remote;  and these accidents instead of
indicating a new infection, according to their ideas, are but a re-
lapse of the  old disease.   The first virus has remained dormant
during a certain period of life, and on being roused new accidents
appear.  This  is all hypothesis,  coming to  the support of other
hypotheses, for the second consecutive aeeidents may be less pro- 
292
VTDAL ON VENEREAL DISEASES.
found than the last which  closed the  era of  the  first contami-
nation.                                                  #
  Thus, statistics are wanting in favor of the unicity of syphilis,
and opposed to it are clinical facte, which, in unison with  experi-
ment, do not permit  the least doubt as to the  possibility of one
person having several attacks of the disease.  I have already re-
ferred to the inoculation performed by M. Bouley, physician of the
Lourcine, who succeeded in producing a second syphilitic infection
in a woman laboring under genuine tertiary symptoms.  When
treating of the  mucous  tubercles I analyzed the remarkable case
reported by the interne of M. Bouley, which  report forms  part of
an extensive article published in the Annales des maladies de la peau
et de la syphilis, (Nov. 1851.)  I believe that when this experiment
of M. Bouley shall become well known, we  shall no longer place
any value on syphilitic vaccination;  in other words, that the pox
will not be given to patients to prevent the pox.
  Moreover, the effects of the diathesis vary in number, intensity,
and gravity, and all cases of syphilis  are not  alike.   There are
different degrees; some are more grave, more complete than others;
between the simple roseola and the most  transient  and benign
manifestations of the diathesis, to necrosis, caries, and the visceral
affections, showing a profound cachexy, there are several degrees.
As it has been proved that the virus may be limited in its action
to the production of a chancre, and after its reparation, may leave
the constitution perfectly sound, it is alsq established that this same
agent may produce  only a syphilitic eruption, the cure of which
depends upon that of the infection.  But as chancre may be repro-
duced  by a new inoculation, by another  infection, syphihs may
also  occur the second time.  I have already stated, that such in-
stances are regarded as relapses, and I have proved that such an
opinion is a mere hypothesis. Those observers who have care-
fully watched many  cases of syphihs have observed relapses, espe-
cially after an attack of blennorrhagia,  which are passed in silence
by the unicists,  probably because blennorrhagia is not  regarded as
syphilitic.  Thus,  an individual  may have  repeated attacks of
syphilis, especially of the milder forms.  This may be explained
by the fact of an incomplete saturation of the system; it  is said,
that the first infection, being of short duration, still left the system
time to become  susceptible to the diathesis;  the  second infection
is explained by the greater power of the new virus which has been
inoculated, and by the larger quantity taken into the  system.  It
matters not, the fact remains, and the  syphilitic unicity, which is
but an hypothesis, vanishes.  Neither the treatment nor the pro-
phylaxis based upon it, can have any foundation, any future.


                       SECTION VH.

                     THERAPEUTICS.

  The treatment of  syphihs may be prophylactic or curative.  I
shall consider the latter only, the former having formed the subject 
THERAPEUTICS.                     293
 of a separate chapter.  On the appearance of what has been called
 the epidemic of the fifteenth century, practitioners viewing it as a
 new disease, with zeal and anxiety endeavored to find a means of
 combatting and arresting  the scourge.   They resorted to all the
 powerful therapeutic agents then in use.  Analogy soon led to the
 employment of mercury, as for a long time this metal had triumphed
 over certain very obstinate cutaneous diseases; now, as syphilis
 often appeared as a disease of the skin, they were naturally led to
 try mercury; the resulte were so satisfactory, and so well sustained,
 that this metal  obtained,  and still retains, a sway that cannot be
 seriously contested.  I shall therefore enter upon  the therapeutics
 of this disease, by first considering this powerful agent.

                       I.—MERCURY.

   Mercury was first administered externally, and  afterwards in-
 ternally.
                   EXTERNAL EMPLOYMENT.
   This metal has been combined with resins  and with fatty sub-
 stances ; it also enters into the composition of  ointments and pom-
 mades.   In this latter form, and  by frictions, mercury is  most
 frequently employed externally, and next to these in the form of
 vapor.
   Mercurial Frictions.—1.  Ordinary Method.—These are made with
 the double mercurial ointment,  called the napolitain, which, how-
 ever, is not an ointment but a mixture of equal parts of lard and
 mercury.
   AVhen frictions were first used, their employment was always
 preceded by a  cathartic  and blood-letting.  The latter may evi-
 dently be of service when the patient is young and of good con-
 stitution ; but it might be injurious in cases where the patient has
 already become  enfeebled, or where he is naturally feeble.   As to
 the cathartic, its use may be generalized with  less inconvenience.
   To derive success from frictions the skin should be previously
 prepared.  There must be either a degree of permeability, or rather
 of sensibility favorable to the  absorption of mercury.  For this
 purpose hot baths and diluent drinks are useful, and their employ-
 ment is also indicated during the whole  course of the  treatment.
 Five or six baths ordinarily suffice for the preparation, and even
 if it be difficult  to  procure them, we may, in  simple cases,  defer
 their use to the moment when we commence the administration of
 mercury.  The bath should generally last for an hour, and should
 be of a temperature nearly equal to that  of the body.  In  indi-
 viduals whose skin is naturally too dry we  promote the  good
 effects of the bath by rubbing, immediately afterwards, the whole
 surface  of  the body with the naked hands or a  piece of flannel
 immersed in the oil of almonds, or other analogous oils.
   Feeble subjects, already exhausted by syphilis or some other
protracted malady, should not bathe so frequently as robust sub-
 jects.  With such persons we may even abstain  entirely during 
294
VTDAL ON VENEREAL DISEASES.
the preparatory treatment; and after the first frictions have been
applied, the practitioner can judge according to the strength of
the patient, whether one or two  baths may not prove  advanta-
geous.
  Cold  baths have also been prescribed  during the preparatory
treatment.   They are adapted only to individuals not  very ro-
bust, the state of whose strength seems to require it, and they
should be used only during the hot season.  Then they produce a
tonic effect, whilst at any other period of the year they would only
add to the  debility of these  same patients.  If, during the treat-
ment by frictions, the bath cannot be employed, we should sub-
stitute for them frequent lotions of soap and water.   According to
M. Lagneau, during these preparatory measures we must prescribe,
as it is called, a soothing and humid regimen; the patient should take
only of such aliments as are of easy digestion, such as white meats,
aqueous vegetables, and stewed fruits; wine, the company of fe-
males, and violent exercises, should be avoided.  I approve of the
latter measures, but I am not of the opinion that it is necessary in
all  cases to follow the regimen prescribed by M. Lagneau. Certain
patients, on the contrary, require the use of tonics, for mercury
produces great debility.
  Mercury, in every form, should be  proscribed, when  the vene-
real accidents are complicated with acute inflammation, and par-
ticularly when this condition which is observed almost exclusively
in cases of recent infection depends upon the age and vigor of the
subject.  Before we resort to the use of frictions, the pain and  ir-
ritation should be subdued by means of diet, repose, baths, and
antiphlogistics, both local and general.
  When the patient is once prepared, we should commence with
the frictions.   The first day,  which at the latest  should be the
second  after the administration of the purgative,  we prescribe a
bath in the morning, and in  the evening we should employ fric-
tion on one of the legs, from the internal malleolus and sole of the
foot to  the knee.  A drachm  of mercurial ointment should  be
used, and the friction should  be continued from twenty minutes
to  half an  hour.  On the third day, another bath of longer  or
shorter  duration, or  lotions according to  the strength of the pa-
tient.    The friction  should now be made on the corresponding
thigh, from the  knee to near the scrotum; on the sixth day, it
should  be  made on the fore-arm;  on the eighth, on the arm ; and
on  the following days the frictions are repeated on the opposite
extremity,  commencing in  the same manner, and following the
same  course, but constantly on one of the two days, and on the
internal face of the thighs, where  absorbent vessels exist in great
numbers.  The patients should cover these parts, after the frictions
have been made, with thread  stockings, linen drawers and waist-
coat, which should be worn day and night, so as not to lose a part
of  the  ointment on the clothes,  which besides become so soiled
that it is difficult to remove the stains.
   During  the winter, in cold  and humid countries, the  parts  on
which the  ointment has been rubbed should be covered with flan- 
THERAPEUTICS.                     295
nels, especially if the patients are compelled to be much exposed
whilst engaged in their avocations.
  As to the baths, during the course of the  treatment, they should
be repeated more particularly when the patient is  of a dry and
bilious temperament, or very irritable, or when the nature of the
symptoms require it, on the same  days that we employ the fric-
tions.  Towards the end  of the treatment, they should be used
only once in three or four days.  For the sake of cleanliness, the
parts on which the  ointment has  dried, should be  washed with
soap and  water.  Patients who by debility or other causes are
prevented from using the bath, should. also wash their skin each
time, with the  soap  and water.  The treatment may, perhaps,  be
compromised by causing the  frictions to be too rudely made, and
thus at once inflame the parts  subjected to the operation, irritate
the skin, and retard the complete introduction of the mercury into
the system.  Frictions  should therefore be used with gentleness
and care.  At the fifth or sixth application, the quantity of oint-
ment employed should be doubled, being therefore two drachms;
we have, at this time, but little  reason to apprehend  a salivation,
which does not occur until after the eighth or twelfth day.  During
the days that the friction is applied, the baths and lotions  should
be continued, and at other times the patient should  be permitted
to rest.  In the meantime, a diluent or sudorific tisane may  be
given, according as  we have to treat a primitive or consecutive
affection, and the external symptoms should be treated as the case
requires.
   The success of the antisyphilitic treatment  does not absolutely
depend upon the application of the frictions in the order which I
have indicated.  The result will be the same if, to please the pa-
tient, the mercury be applied to the inferior extremities, and even
to the legs exclusively, being  careful, however, not to apply it
twice to the same part, in order not  to  irritate  the skin.    When
the strength permits, it is better that the patient himself make the
application.   Should he be too  feeble for this purpose, it may  be
made by an assistant whose hand should be covered with a thin
glove or a bladder, that it may not absorb a portion of the medi-
cine.  In cases of excessive corpulence, an assistant will also be  re-
quired.  Patients may continue  their  occupations, and take then
walks during the treatment; for moderate exercise, by promoting
perspiration, prevents the mercury from acting too much upon the
mouth.  But changes of temperature, cold,  and  especially cold
combined with dampness, should be avoided.  Thus, patients
should exercise in the open air when the sun shines brightest, and
not during the close  of day or during the coldness  of night.
  Those, who strictly follow  the rules prescribed, may expect a
speedy cure.  It  must not, however,  be supposed that a radical
cure has been  effected from  the fact that the external symptoms
have been removed.  Daily experience  teaches us that notwith-
standing the occasional very prompt disappearance of these traces
of infection,  to destroy completely the syphilitic diathesis, the mer-
curial frictions must be continued for about twenty or thirty days 
296             VTDAL  ON VENEREAL DISEASES.
in cases of recent infection, and for  a much longer period when
they are of long standing.  This is the opinion of our predeces-
sors, as expressed by M. Lagneau.  According to this practitioner,
the ordinary quantity of mercurial  ointment required to cure a
recent case of syphilis, is not far from four to five ounces.  To
overcome obstinate and troublesome  symptoms, this quantity may
be raised to from six to eight ounces.  Instances have occurred in
which even two pounds have been used in a single case.
  2d. Method of Pihorel.—After the  usual preliminary treatment,
Pihorel applies frictions to the soles of the  feet, the palms of the
hands, the internal surface of the thighs, or the arms and wrists,
with the following ointment:

                  $. Ungt. Napolitain,    | iii.
                     Sulph. Cale. Ammon.  3 i.
  Mix thoroughly.  Use at first half a  drachm, morning and  evening;
the dose should be increased to two ounces for each application.  The parts
arc to be previously washed ; cover them, after the ointment has been ap-
plied, with mittens, stockings, or gloves, which should be worn for two or
three hours.

   Besides the other advantages of this method, it is claimed that
it does not soil the patient's linen, because the sulph. calc. ammon.
causes the ointment of Pihorel to unite readily with the soap and
water.
   The inconveniences attending the method of treatment by fric-
tions, its want of cleanliness, and the difficulty of appreciating the
quantity of the metal absorbed, have led to the adoption  of other
means, of which I proceed to give a  detailed account.
   3d.  Method of Peyrile.—The accessory measures are here omitted.
The frictions are confined to the mucous  lining of the glans and
the prepuce.   The penis is bathed before  the ointment is applied.
Frictions  are made  with two  fingers,  and continued  for fifteen
minutes, twice a day;  a drachm of ointment is used.   After three
or four daj's, symptoms of salivation appear.   The  frictions are
then to be omitted, and not to be resumed until after the expira-
tion of forty-eight hours.  The quantity of ointment  is increased
till a drachm is employed in the morning, and the same quantity
in the evening, that  is, double  that  used at first.  According to
Peyrile, twelve days suffice for recent affections,  and twenty-five
for those of long standing, the cure being  thus  made  certain!  It
occasionally happens that these  frictions irritate  the glans, and
cause it to become tumefied, thus causing the patient considerable
anxiety.  He  should be  informed of the  probability of such  an
occurrence.  Warm  local baths, and the discontinuance of the
mercury for twenty-four hours, are sufficient to restore the parts
to their normal state.
   4th. Method of Scatigna.—This is called the  mercurial treatment
by application.  From fifteen grains to one drachm of ointment  is
applied to each axilla, and the naked arms are brought against the
trunk.  This is repeated  every second day; in the  evening the 
THERAPEUTICS.                     297
patient lays down well covered, and thus remains until the follow-
ing morning.  So active is the absorption, that nothing remains
in the axilhi.
  This  application  is less  filthy than that  by the ordinary mode
of friction.   The exact  quantity of mercury absorbed  may be
known; but in certain subjects it irritates the axilla, the  internal
surface  of  the arms, the  side of the chest,  producing  a  papular
erysipelatous eruption.
  5th.  Method of Cirillo.—He employs frictions with an ointment
of bi-chloride of mercury mixed with lard, according to  the fol-
lowing formula:

                   5. Hydrarg. Bi-chlor, 3 i.
                      Axung.           | i.
   Triturate in a glass mortar for twelve hours, and add:
                    Hydro-chlor Ammon.  § i.

  The preliminary  measures are  baths, lavements, decoctions of
dog's-grass, and sarsaparilla.
  A drachm of the  above ointment is rubbed on the soles of the
feet, the application to be made in the evening only.   This part is
selected because other portions of the skin might become irritated,
and even excoriated by the  medicine. These frictions are repeated
every second day.  On the fourth day, a  bath is  administered,
and on  the following day one and a half drachms are to  be used.
This  course  is to be  pursued until the cure is completed, with
diluent drinks and  a bath every third or fourth day.   The quan-
tity of ointment employed should never exceed two drachms at
once.
   6th. Method of Clare.—It is proposed by the English surgeon to
produce absorption  of the calomel by the mucous membrane of the
mouth.  Half a grain or a  grain of calomel is rubbed on the in-
ternal surface of the mouth, in the vicinity of Steno's duct, two  or
three times in a day.  But, as the calomel may thus be swallowed,
Clare rubs it on the gums and internal surface of the lips, direct-
ing the patient not to  spit or to swallow the  saliva until the powder
has been completely absorbed.  The patient must also be careful
to take no  drink for half an hour.  In serious cases, Clare  employs
as a supplementary application, an equal number of frictions on
the tongue, calomel in all  cases being used, even in the  dressing
of the ulcers in the mouth and on the genital organs.   Clare aims
at a salivation, and as, by  his method, this is speedily produced,
and sometimes with  beneficial effects on the external symptoms,
he imagines that he has thus effected numerous and speedy cures,
which, in the majority of cases, could  have been but temporary.
That Clare himself has  observed relapses, is proved by  the fact
that in cases especially of confirmed syphihs, we find that he gen-
erally uses  the corrosive sublimate.
   This  method was not  well received  in France, and is not here
much employed, for whatever  may be the precautions  taken, a
part of the powder is  either swallowed or rejected with  the saliva. 
298             VTDAL  ON VENEREAL DISEASES.
 The quantity absorbed, therefore, cannot be correctly estimated,
 as  salivation  occurs most frequently and quickly, and especially
 as the results obtained by those who have imitated Clare, are  far
 from corresponding with those proclaimed by the inventor him-
 self.  M. Brachet  has vainly attempted to revive in France the
 method of Clare, by employing a modification of it, Avhich consists
 in  placing the  calomel or  the  mercurial salt on  the end of the
 tongue, and  with  the latter organ frictions are made against the
 palatine arch.
   Lotions and Mercurial Baths.—The use of corrosive sublimate
 lotions is a very old practice; they were employed as dressings to
 certain  primary ulcerations.   Mathiole < afterwards, with a view of
 acting not only locally, but upon the whole system, bathed the
 surface of the whole body with a lotion composed  of two ounces
 of corrosive sublimate to six pounds of water, distilled with plan-
 tain, roses, and solanum.  This treatment was proposed both  for
 the primitive and the consecutive accidents.  But as  cutaneous
 absorption varies  greatly in different subjects, and even in the
 same individual, under different circumstances; as the integuments
 sometimes inflame, and thus become painful (for the proportion
 of the sublimate is large), these lotions have been renounced.
   M. Meyrieu would substitute for these lotions frictions, with two
 and a half drachms of a solution, composed of half a drachm of
 corrosive sublimate, two ounces of water, and half a drachm of
 alcohol.   These frictions are made in succession to the soles of the
 feet, the legs and the thighs.
  . The sublimate solution is now used  externally only under the
 forms of baths.
                       BI-CHLORIDE BATH.
                  IJ.  Hydrarg. Bi-chlor. | ii.
  Dissolve in a small quantity of distilled water mixed with alcohol, and
pour into a sufficient quantity of common water for a general bath. 1 Vhen
 intended for a child tlie quantity of sublimate should not exceed one
 drachm, and in the  adult not more than two ounces.

  Fumigations.—This is certainly one of the most ancient methods
 of administering mercury:  for certain  cutaneous  affections were
 thus treated long before the so-called epidemic of the fifteenth cen-
 tury.
  Mercurial fumigations have at times been highly extolled, then
 neglected,  but never completely abandoned, since, even  at  the
 present day, they are still used in certain obstinate affections of the
 throat, nasal fossae, and syphilitic accidents which have  resisted
 every other method of treatment.
  The red sulphuret of mercury (cinnabar) was at first, and is still
 for this  purpose employed.   Calomel, mixed with the protoxide
 of mercury,  has been  occasionally substituted for it.   Calomel
 with  albumen, the metalhc mercury united with the chloride of
 iron, and, finally,  mercury alone and  its red oxide mixed with
 inert substances, have all been tried. 
THERAPEUTICS.
299
  As the fumigations arc generally employed in cases of long
standing, it is well to unite with them sudorifics.  From the time
of Glauber and Lalouette, a large box has been used in which the
patient may receive the mercurial vapor, without being  forced to
respire it, as was the ancient custom.   This box is the same as that
perfected and rendered useful by MM. Gales and d'Arcet, for the
treatment of the itch and other cutaneous affections.
  There are no fixed and  positive rules for  the administration of
mercurial fumigations, for the nature, the severity of the case, and
the temperament of the  patient, may compel the practitioner to
vary daily the application of this method.  However, it is very
common  to  employ the fumigation every other day.  Sometimes
they are used two days in succession, and the patient is allowed to
rest on the third.  Occasionally he is suffered to rest for forty-
eight hours.
  Two drachms of one of the powders which I shall soon men-
tion, are  generally employed.  In moderately-severe cases,  from
twenty to twenty-five fumigations are  used, but  in severe cases,
the number reaches as high as thirty, forty, and even higher.
  I have already stated how fumigations are  generally adminis-
tered : the  patient being placed in a large box.   When we wish
to act locally, we make use of a funnel to direct the vapor, or the
shower-bathing apparatus to be found in a multitude of establish-
ments in Paris.  The extremity  of the tube conducting the vapor
is directed on an exostosis, on the genital organs, to the throat and
nasal fossa, in  the case  of obstinate ulcerations.  Of course, in
order to reach cavities, the calibre of the tube must be diminished,
and we must proceed gently,  with small quantities of the mercurial
preparation.   As  the  saline powders possess  a great degree of
activity,  the gray oxide of mercury should be preferred.
   [Mr. Langston Parker is doubtless the warmest partisan of this
mode of treatment, and, so extensive has been his experience, that
his remarks are entitled to the greatest consideration. Its advan-
tages, he states,  are, that in ordinary cases, it requires no confine-
ment ; never impairs the appetite;  does not produce salivation,
or ulceration of the mouth,  mercurial erythismus or blotches on
the skin; and, if  associated  with internal treatment by mercury,
reduces what is required to an exceedingly minute quantity.   " In
addition to this, treatments according to my plan are safer, quicker,
more certain, less frequently followed by  relapses, indeed very
rarely so, and again are capable of working cures in obstinate cases
which have  resisted all  other modes of treatment."  He applies
the vapor of the bi-sulphuret, gray oxide, bin-oxide, or iodide of
mercury in a moist state, to the whole surface of the body, by
which, after the continuance of the process for twenty or thirty
minutes, profuse perspiration is induced.  This process is repeated
as frequently as the  nature of the case may require till a cure be
effected,  and is or  is not associated with internal medicines.   The
patient is placed on a chair,  and covered with an oil-cloth, lined
with flannel, which is supported by a proper framework.  Under
the chair are placed  a  copper-bath, containing water and a metal 
300
VLDAL ON VENEREAL DISEASES.
plate, on which is put from one to three drachms of the bi-sul-
phuret of mercury, or the same quantity of the gray oxide, or the
bin-oxide.   Under each of these a spirit lamp.  Heated air, com-
mon steam, and the vapor of mercury, are thus applied to  the
whole surface of the body in a moist state.   At the end of twenty
or  thirty minutes, the lamps are removed, and  the temperature
gradually allowed to sink;  when the patient has become moder-
ately cool, the  coverings are removed, and  the body rubbed dry.
A cup of warm decoction of guaicum, sweetened with syrup of
sarsaparilla, is then administered.  The apparatus can be modified
to suit  particular cases.   Mr.  P.  considers this method vastly
superior to  that by the dry fumigation.   His little volume, " On
the Treatment of Secondary, Constitutional, and Confirmed Syphilis, by
a Safe and Successful Method," we most cordially commend to  the
attention of those who desire to become acquainted with the true
value of mercurial fumigations in the treatment of syphilis.  In a
recent interview with Mr. P., he informed us that every day's  ex-
perience strengthened his faith in the efficacy of this  plan.   Dr.
Gibson  also speaks  highly in praise of this method, and recom-
mends ite  administration in a  manner  similar to the above.—
G. C. B.]

                 INTERNAL USE OF MERCURY.

  Metallic Mercury—In this state, it has been  employed from  the
earliest period of the mercurial treatment.  To divide it, and thus
facilitate its  administration, the mercury has been united with
other substances.  A considerable number of formulas have at
times been praised, and in turn abandoned.  Two remain, and will
probably remain in practice : they are those of  Belloste and  Se-
dillot.

          PILLS OF  BELLOSTE (Modification of Baumes).

                 ]J.  Quicksilver,       3 i.
                     Potass. Bi-Tart.   3 i.
                     Biagrydium,       | i.
                     Jalap,           | i.

 Made into pills of three grains each.  From two to six to be taken daily.

  These pills resemble those of the famous Cheradin-Buberousse,
which had so great  a reputation; but they are  now  rarely em-
ployed in the anti-syphilitic treatment.  They are intended to
act chiefly as a purgative.   For  that purpose from  twelve to
twenty may be given in the day.  I have observed  the good
effects of these pills in cases of very obstinate mesenteric engorge-
ments.
  When we wish to act at once on the syphilitic virus, the follow-
ing pills are to be preferred: 
THERAPEUTICS.
301
                      PLLLS OF SEDILLOT.

                  $.  Ungt. Hydrarg.  § iii.
                      Sapon. Offic.     f ii.
                      Pul. Glycyrrh.   \ i.

  Make into pills of from three to five grains each, which contains about
one grain of the metal.   From two to ten are to be taken in the twenty four
hours.

  M. Rayer, who highly praises Sedillot's pills, makes them accord-
ing to the following formula:

              ]J. Ungt. Hydrarg. duplex, gr. xlv.
                 Sapon.  Offic.          gr. xxx.
                 Pulv. Glycyrrh.       gr. xv.

  Make into pills of three grains.  Dose, two for a female, three for a
male, during the day.

  Instead of taking the ordinary mercurial ointment, the metal is
mixed with the butter of cocoa, and the pills thus made are  very
much employed:

   fy. Ungt. Hydrarg. with butter of cocoa recently prepared, § ii.
      Sacch.  Pulv.                                      3 h\
      Muc. Gum Arab. q. s. ft.

  Forty-four pills, of which from three to twelve may  be taken in the
twenty four hours.


                MERCURIAL COMPOUNDS.

   Metalhc mercury, as we have seen, must be administered in very
large doses to produce the desired effects, and this is  an incon-
venience ;  it has therefore been combined with other substances,
and thus been rendered much  more active, whilst it may be ad-
ministered in much smaller quantities.
   The  Chlorides of Mercury.—These are  among the combinations
most employed, especially the bi-chloride.
   1st.  Proto-chbride.>—The proto-chloride, or calomel, which was
formerly so much  employed, and is now but seldom used in the
treatment  of affections really syphilitic.   Being insoluble, to pro-
duce curative effecte, it must be aohninistered in very large doses,
and then it  too frequently and too speedily produces salivation,
and acts too powerfully on the intestinal canal; it is used as a
 fjurgative much more frequently than an anti-syphilitic.  The fol-
 owing  formula is still retained in the anti-syphilitic therapeutics,
because it is  less apt to excite ptyalism than the others:

               $.  Hydrarg. Proto-chlor. gr. iv.
                   Opii.               gr. ii.
                   Ex.tr.  Glychirr. moll.  3 i. 
302             VTDAL  ON VENEREAL DISEASES.
  2d. Bi-chloride of Mercury, or Corrosive Sublimate.—This prepara-
tion was long since known, when Rich, Wiseman, Hoffman, and
Boerhaave recommended it as an anti-syphilitic.   Its use was much
more efficacious and more extensive when Van Swieten regulated
ite mode of administration after  the practice of Boerhaave.  The
following is the formula for the famous liquor which still bears the
name of Van Swieten.  I copy it from the last Codex:

                    VAN  SWIETEN'S LIQUOR.

               ]J.  Bi-chlorid. Hydrarg.   1 pt.
                   Aq. pur.           900 pts.
                   Alcohol reet.        100 pts.

  This  compound contains the one-thousandth part of corrosive
sublimate.   It is administered at first in the dose of a tablespoonful
in a glass of sugared water, milk,  or  gruel, which destroys the
metalhc taste of the liquor, which is  more or less decomposed.
  M. Puche prefers the following solution :

                 CHLORO-MERCURIAL SOLUTION.

                 IJ.  Bi-chlor. Hydrarg. gr. xv.
                     Sal. Marin.        3 i.
                     Aq. dist.          | xvi.
  To be  used in all cases of constitutional syphilis, in doses of from one to
one and  a half ounces in t/ie day; let tlve patient drink half a pound of
some sudorific tisane, at four different doses, after regular intervals.

  To obviate the disagreeable taste of the solutions of  the bi-chlo-
ride,  and to disguise the medicine, it  is now  made into pills.
Various formulae are used.   The following  is the one which was
preferred by Cullerier and Dupuytren:

                 CULLERIER'S MERCURIAL PILL.

              IJ. Bi-chlor. Hydrarg.  gr. xv.
                  Farin. Trit. Hyb.  § ss.
                   Gum pulv.        3 ss.
                  Aq. dist. q. s. ft.
  Fills of two and a half grains each.  Dose, two morning  and evening.

  In describing the treatment of chancre I have already mentioned
the formula which I  prefer; it nearly resembles that of  Dupuytren.
My formula contains the  fifth  part  of  a grain  of the sublimate.
That of the illustrious surgeon just named was as follows:

                     DUPUYTREN'S PILLS.

            IJ.   Bi-chlor. Hydrarg. Jg- to \ grain.
                 Ext. Opi. Gum,   \ or \ grain.
                 Ext. Guaic.       grs. 4.
  Make  one pill.  Dose, two in tlie day. 
THERAPEUTICS.     •               303
  I have already stated that I employ the bi-chloride  in cases of
primary affections only.  In  confirmed cases of syphilis I adopt
the following means:
  Combinations of Iodine and Mercury.—These were introduced by
Biett.   They are therefore new agents, and yet they have already
attained a reputation surpassing that of the bi-chloride of mercury.
There  can be no doubt, as has been proved, especially  by  M.
Cazenave,  that the syphilitic eruptions are beneficially modified
by the  compounds of iodine  and mercury, and this, too, after the
bi-chloride has failed.
  Biett tried at first the bin-iodide; he united it with the expressed
juice of the lactuca sativa (thridace).  But its great activity and
difficulty of management caused the proto-iodide to be preferred by
Biett and his pupils.
  M. Puche has returned to the bin-iodide ;  he combines it with
iodide of potassium, as  follows :

        M. PUCHE'S SOLUTION OF IODINE AND  MERCURY.

                 IJ.  Bichlor. Hydrarg. gr. viii.
                     Hydriod. Potass,  gr. viii.
                     Tine. Saffron,     § i.
                     Aq. pur,         | xvi.
  From one to four ounces a day in a sudorific tisane.

  M. Puche employs this solution in cases of indurated chancres
to prevent constitutional infection; and especially in the treatment
of the tardy secondary accidents.
  The following pills may be substituted for the solution:

          M. PUCHE'S PILLS OF  IODINE AND MERCURY.

                $.  Bichlor. Hydrarg.   grs. viii.
                    Hydriod. Potass.    grs. viii.
                    Aniyl.             3 iss.
                    Gum Arab.         3 ss.
                    Aq. q. s.  ft.

  Fills fifty.  They slwuld be covered with gelatine to protect the fauces
from tlieir irritating effects. Dose, from two to ten in tlie day.

  The above  formulas are  copied from the notes of M.  Puche
himself.   The proto-iodide,  however, is the preparation preferred
by the great majority of practitioners.  M. Cazenave, for example,
gives it in doses of from one to three  grains  in the day.   In  the
milder forms of the syphilida,  and in subjects somewhat irritable,
he  uses the following:

               IJ.  Prot. Iod. Hydrarg.   grs. viii.
                    Thridace             3 v.

  Blake twenty pills.  One to be given at first, then from two to four in
twenty-four /tours. 
304             VTDAL ON  VENEREAL  DISEASE&
  In the severer forms, as for example the tubercular, this is the
formula adopted by M. Cazenave :

               I£.   Proto-iod. Hydrarg.   3 ss.
                   Thridace,            3 i-

  Make forty pills.  Dose, one at first, then from two to four in the
twenty-four hours.

  This is the quantity most generally administered by M. Ricord
in all  cases of secondary aft'ections.  He makes fifty pills  with
forty-five grains of the proto-iodide, and the same  quantity of
the thridaces, and a certain quantity of  opium and  conserve of
roses.
  As I am satisfied that the interruptions of the mercurial treat-
ment are injurious, and as large doses  of the proto-iodide act
promptly on the mouth, and the  intestinal  canal, I gradually ac-
custom the system to  the  influence  of this medicine.   I  adopt
the following formula:

                      AUTHOR'S FORMULA.

               ]J.  Proto-iod. Hydrarg.    gr.  xv.
                   Thridace,            gr.  xv.
                   Conserv. Ros. q. s. ft. pill 30.

  One to be taken morning and evening.   Occasionally I have given but
one in  tfie day.   Gradually tlve dose is increased, so that instead of
thirty I make but twenty-five pills ; tlien tioenty containing fifteen grains
of tlte proto-iodide.  In subjects with a very irritable intestinal canal, es-
pecially females, for the thridace I substitute four grains of tlte gummy
extract of opium.

   Cyanuret of Mercury.—-Biett and Parent-Duchatelet have praised
this salt.  The latter has even made experiments for  the purpose
of determining the practical value of the new anti-syphilitic agent.
He commences by giving TV of a grain, at the onset of the attack;
then it is increased  to TV  \ of a grain, and even to  \ a  grain.
Parent makes tinctures of  the cyanuret, also pills, solutions, gar-
gles, and pommades.   According to  Parent and others who pro-
claim the praises of the cyanuret of mercury, this compound has
the following advantages:  1st, it does not produce the pains in
the epigastric  region,  which is partly attributed to  the salts of
mercury; 2d,  it is less easily decomposed  than the bi-chloride;
3d, being more soluble than the latter salt, its action should be
more prompt, and hence its more rapid cures.   It would seem that
these and other advantages  have not given to  the cyanurets of
mercury a precedence  over the bin-iodide  and the proto-iodide,
which are still most frequently employed.  True, as  I have already
stated, the cyanuret was introduced at a later period, and experi-
ence has not yet fully decided on its virtues.  The following are
Parent-Duchatelet's pills: 
THERAPEUTICS.
305
              PLLLS OF CYANURET OF MERCURY.

              $.  Bycyanid. Hydrarg.  gr. v.
                  Opi. crud.           gr. xii.
                  Mic. pan.           3 i«
                  Mel. q. p. ft. pil. 96.

  Each pill contains TV grain of tlie cyanuret, and | grain of opium-
I liave already mentioned the dose of the cyanuret administered  by
Parent.

       II.—OTHER MERCURIAL PREPARATIONS.

  The acetate of the deutoxide of mercury, which forms the base  of
Heyser's pills, has also been employed.   The proto-tartrate  of mer-
cury has been highly recommended by Pressarin, a surgeon  of
Lyons; it forms a hquid called the vegeto-mercurial  water.   It is
known that the proto-nitrate and the  acetate of mercury  consti-
tute the active  part of the syrup of Belief, so highly praised by
Bouvart, and which exists only in name on some labels.  Finally,
we  have also the deuto-nilrate, and then the  proto-phosphate of mer-
cury.  All of these compounds, the offspring of industrious minds,
or the desire of doing  something when nothing better could  be
done, have now fallen into that oblivion which they merited.

       III.—ACCIDENTS  PRODUCED BY MERCURY.

  The introduction of  a certain quantity of mercury into the sys-
tem occasionally produces accidents which it is  important  to un-
derstand,  that they may be avoided and combatted; at the head
of these must be placed, salivation or stomatitis, after which may
be placed mercurial tremors.

                 SALIVATION AND STOMATITIS.

  This accident has been observed from the most remote periods,
when mercury was employed in the treatment of certain cutaneous
affections.  Thus, Avicenna prescribed the  gargles which should
be  employed.  The  attention of our predecessors was  more par-
ticularly arrested by the more or less considerable  flow of saliva,
and this phenomenon was attributed to the  action of the mercury
on the salivary glands, or other secretory organs.  At the present
day, it is supposed  to be the result of an inflammation of the
gums and living membrane of the mouth;  the action on the sali-
vary glands is completely denied, though without cause.
  Salivation is  much  less common now than in former times, as
we endeavor to avoid it, regarding it as an accident, whilst our
predecessors provoked it with large doses of mercury, or by the
method of its administration, believing it to be a favorable crisis in
the  treatment of venereal diseases.  However this may be, it is
important to be acquainted with this accident, both on account  of
its prophylaxis,  and ite therapeutics properly so called.
   Causes.—Children  under seven years of age are very seldom
                               20 
306
VTDAL ON VENEREAL DISEASES.
saHvated.   During the period of the first dentition, indeed, mercury
acte  rather on  the digestive organs than on the mouth.  Certain
temperaments and morbid conditions  predispose in an  especial
manner to ptyalism;  thus the lymphatic, the strumous, and scor-
butic, or the latter alone.  Certain states of the intestinal canal, of
the mouth, predispose to ptyalism; as for example, habitual con-
stipation, and especially neglected carious teeth.  Salivation is ob-
served more frequently in females than in males.  In females the
mercury more frequently acts on the intestinal canal, which  has
led to the assertion  that females do not well tolerate the use of
the medicine.
  Certain  modifications of the integument,  especially  sudden
changes, may produce  salivation.  Thus the  sudden exposure to
the action of cold and moisture, by checking perspiration, promote
the development of  ptyalism, for  this  reason it occurs less  fre-
quently in summer than in winter.   This should teach us to pro-
tect the patient from  the effects of cold during the administration
of mercury.  But it  has also been  observed, that a high tempera-
ture  may produce the  same  result.  This  is  especially the case
with artificial heat; thus,  when it was  the  custom to confine pa-
tients after the use of frictions, in small and heated rooms, patients
who passed  their days over heated stoves were most generally
salivated; a fact explained by the determination to the head under
such circumstances.  Whatever opinions may be entertained with
reference  to  the  action of heat  or  cold, the practitioner should
guard the patient from the excesses of either.
  Vain attempts have  been  made to  combine mercury with the
substances which should so modify ite action as to prevent saliva-
tion.  For this purpose it has been united with sulphur, camphor,
&c.; but  the mouth under certain circumstances and in certain
doses, always becomes affected.  This arises from the fact, that the
special  action on the  mouth  does not  depend upon this or that
mode of preparation, since whatever the latter may be, when once
introduced into the system, its effect on the constitution and the
mouth is the  same; for all mercurial compounds undergo a change
which reduces  them to a single  form.  Such at least was  the
opinion of Hunter, and M. Mialhe has lately proved  that every
mercurial compound, when introduced into the stomach, becomes
changed into  the bi-chloride of mercury.  Thus the effect depends
not upon the particular preparation, but on the quantity of mercury
taken into the system.  We  can  therefore  understand how the
preparations and applications which permit  the speedy and abund-
ant absorption of the metal, without immediate unpleasant conse-
quences, will most frequently produce salivation; the compounds
on the  contrary, whose local  effect is powerful, will more rarely
excite ptyalism, for the reason that the quantity used is necessarily
moderate.  From this  it'follows that mercurial frictions, the local
action of which is unimportant, and which enables us to introduce
a large quantity of mercury into the system  in a short space of
time, are speedily followed by salivation; the same result attends
the internal administration of the insoluble salts, as, for example, 
THERAPEUTICS.                     307
the proto-chloride of mercury.   The bi-chloride and the bycyanide
of mercury very seldom produce ptyalism, because the corrosive
action compels the practitioner to administer them in very small
doses.   Thus, salivation depends upon the quantity used within a
given time, and not upon the form in which the metal is adminis-
tered.   Of course this quantity depends also upon the individual,
for some are salivated after two applications of the frictions, whilst
others are never so affected. I have already remarked that chil-
dren under seven years of age  do not become salivated.
  Symptoms and Progress.—From what I have stated, it is evident
that the commencement of salivation varies according to the quan-
tity of mercury at first  administered.  Thus, when  the employ-
ment of frictions was almost general, ptyalism was often observed
on the fourth day.  At the present time, with the proto-iodide for
example, in doses of one and  a half grains,  and this quantity be
adhered to, salivation generally occurs during the  course of the
first week.   Each increase of the quantity increases the probability
of ptyalism; thus patients have been seen to tolerate well the or-
dinary dose of the proto-iodide for eight  or  fifteen days, and yet
whenever one grain  was added  to the  the above quantity the
mouth would become affected.   But if we proceed more cautiously,
if instead of increasing the dose one  grain, we add fractions of
a grain, the dose may be increased to three grains daily without
causing the mouth to suffer
   I proceed to examine the symptoms beginning with the mildest,
or those included in the first degree.  At first there is redness and
tumefaction of the gums; they are very painful especially on pres-
sure ; they are soft and have a fungous feel; they bleed and sepa-
rate  from the necks of the teeth which are slightly loosened. The
gums on the lower jaw are first  affected, and generally the mu-
cous membrane behind the  wisdom teeth, especially when they are
not fully through, or are in the process of cutting; then follow the
upper gums, and finally, the cheeks, the edges of the tongue, and
the lips become affected.   At the points subjected to pressure by
the  molar teeth, especially at the depressions corresponding to
the bodies of the teeth,  and on the ridges corresponding to the in-
terspaces between them, the effects may also be discovered.  Be-
tween the inferior  and superior depressions is a very prominent
ridge, directed horizontally from before backwards;  it arises from
the  separation made  by both jaws, a  separation more prominent
than  natural, which is explained by the swelling of the mucous
membrane of the adjacent  parts, and the pain which prevents the
teeth from coming in contact with each other.  The arch and the
velum of the palate, its pillars, the tonsils, the uvula, and occasion-
ally  the pharynx, become involved in these pathological changes.
The glands of the mouth are often enlarged, the tongue is turgid,
red and painful on motion, and its edges have the appearance of
festoons which are the imprints of the teeth ; ite papillae are some-
times more prominent than in the normal state.   All the move-
ments of the tongue  and the  buccal parietes are more or less im-
peded or rendered impossible, by the swelling of these parts, and 
808
VTDAL  OX VENEREAL DISEASES.
those of the tongue in particular by the tumefaction and the pain.
The mouth has a repulsive and  peculiar fetor.  The patient is an-
noyed by a constant disagreeable  metallic taste.   The sub-maxil-
lary glands, in which  the lymphatic vessels of the mouth termi-
nate, are engorged.  Sometimes the  upper part of the neck be-
comes tumefied;  and the lips and  cheeks puffed to a considerable
extent.
  As I have stated, it was once supposed that the salivary glands
were the parte primarily and principally affected.  At the present
day, some  authors believe that they are never involved.   This
opinion is erroneous.  Nevertheless, it is very certain that  even
in the case  of inflammation of these glands,  its severity does not
always  correspond with the  quantity  of  fluid secreted.  The
lymphatic glands are at least  as often affected  as the salivary
glands, which is very seldom,  and perhaps never the case unless
when the inflammation extends from the lining membrane of the
mouth, as may occur in any inflammation of this membrane. These
cases of adenitis seldom attain any considerable severity, and very
rarely terminate in suppuration.   Such a termination is still more
rare with the salivary glands.
  The quantity of saliva which escapes is sometimes very trifling,
particularly in the first degree of the affection;  but  if the treat-
ment be not gradually suspended in twenty-four hours, the pa-
tient may lose much more than would be imagined.  Cases have
been cited in which as much as eight pounds  have been lost in
this space  of time.  The head is flexed, and  supported by the
hand, the lips swollen, the tongue tending to protrude from the
mouth, and the latter is open to permit the saliva to escape.
  Fallopius asserted that the saliva thus discharged,  contained
mercury in solution.   M. Colson  has again advanced the opinion,
that we may assure ourselves  of the presence  of the metal by
plunging into the saliva a blade of gold or of copper.  Chemists,
such as Christison, Rhodes,  Meisner, and  Bostock, who have re-
peated this experiment and employed proceedings the most deli-
cate and varied, have constantly arrived at negative results.  Ac-
cording to  Bostock, the most remarkable  character of the saliva
in syphilitic patients, that is, in those who have been subjected to
mercurial treatment, consists in the very great  diminution in the
proportion  of the mucus.  The saliva is rather serous than mu-
cous.  Indeed, this fluid in  ptyalism is secreted in too great an
abundance  to be completely elaborated;  the same condition ob-
tains with all the secretions.
  I have thus described the symptoms in their highest intensity,
of the first  degree of stomatitis.  In the second degree, these symp-
toms in becoming developed, impress a new  character on the dis-
ease which now presents another aspect.  Bright red patches ap-
pear at every point of the buccal mucous membrane in contact
with the teeth.  But the peculiar characteristics are diphtheritic
productions, a kind of plastering which is seen on the free border
of  the gums,  and the upper surface of the tongue; these pseudo-
membranous  formations are also to be seen on the internal surface 
THERAPEUTICS.
309
of the lips, cheeks, on the sides  of the tongue, .precisely at the
points which correspond to the dental arches.
  When the symptoms reach the third degree, the diphtheritic for-
mations  disappear, and in their place are found ulcerations and
loss of substance of the mucous membrane.
  The fourth degree is characterized by a more considerable loosen-
ing of the teeth, which sometimes drop out; for the inflammation
of the mucous membrane, which in the first degree was confined to
the internal layer of the dental follicle which is in connection with,
and adheres to the neck of the teeth, now involves the periosteal
lining of the sockets of the teeth; thence the separation of the
surfaces which it covers, that is the teeth and alveoli; and thence
the loosening and loss of the former and the necrosis of the latter.
The action of the mercury may be such upon the mouth,  that the
gums, the tongue, and the  cheeks,  sometimes mortify.   These
cases are excessively rare, for this  blind and obstinate administra-
tion of mercury, when the mouth is already affected, is  not a char-
acteristic of our day.
  The cases are exceptional in which we observe a fever some-
what  peculiar during the course of a salivation.  In some cases,
the pulse becomes a little frequent  and the skin hot; there are
cephalalgia, sleeplessness, general prostration, and anorexia. Occa-
sionally there is considerable discoloration of the tissues, the face,
especially, being very pale;  the  patients become emaciated, di-
arrhoea and  tremors supervene, with or without paralysis; but
these are complications which are very seldom observed  at first,
and only when we persist in administering mercury, notwithstand-
ing the existence of the stomatitis.
  It is rare that stomatitis passes through the three degrees, which,
for the purpose of  facilitating their study, I have described.   At
the present day it is almost always  partial, and confined to one
point of the gums, or of the buccal mucous membrane, and it lasts
for some days or weeks.
  Diagnosis.—The mercurial are liable to  be confounded with the
syphilitic ulcerations.  I pointed out their differences when speak-
ing of chancre.  M. Grappin has established further distinctions in
an excellent Tliesis.  He observes:
  " The diagnosis of mercurial stomatitis is never difficult; it  can-
not be confounded with simple stomatitis, and  that  produced by
certain agents, as  emetics  for example,  for it is rare that we are
not informed of its cause, and this knowledge suffices; even in the
absence of such  information, the fetor  of the breath, and the
loosening of the teeth will soon remove all doubts.   It is easy also
to distinguish mercurial ulcerations from those produced  by the
syphilitic  virus.   Indeed, the first  occupy the internal  surface of
the cheeks, lips, and sides  of the tongue, and correspond to the
projections of the teeth; the others most generally affect the inner
surface or borders of  the lips, the commissures,  the  upper  surface
of the tongue, as well as ite sides, the velum palati, the tonsils, the
superior and middle part of the pharynx.   These syphilitic ulcers
are  deep, and circular, with elevated and  perpendicular edges; 
310             VEOAL ON VENEREAL  DISEASES.
their base is of a grayish dirty color; the mercurial are superficial,
irregular, and covered with whitish membraniform  concretions,
and are few in number; lastly, the ulceration is always preceded
by redness  and tumefaction of the mucous membrane, and ptyal-
ism.   Add to this the fact, that mercury always aggravates mercu-
rial ulcerations, whilst the syphilitic  are advantageously modified
by it."*
  Prognosis.—This  may be  regarded in  two points of view: 1st,
with reference to the local disorders and the effects on the consti-
tution, and independently of the consequences which  salivation
may produce in the treatment of syphilis; 2d, with reference  to
this treatment.
  A.  As to the general and local disorders resulting from the use
of mercury, administered as at the present day, it may be said that
it is rare, exceedingly rare.  Thus  it is  necessary that  we  obsti-
nately adhere  to the doses and the mode of administration which
affect the mouth ; and that  the patient be placed under unfortun-
ate hygienic conditions, and his constitution be  profoundly debili-
tated, in  order that we may observe these mortifications of the
cheeks, of the tongue and gums, which leave behind such losses
of substance, and deformities, to interfere with the functions of the
parts.  The general effects are, nervous symptoms and exhaustion,
results of a salivation not  only  abundant, but very prolonged.
Now, I repeat, it is rare  that practitioners do  not prevent these
accidents by the moderation of the doses,  and the precautions
which they take to suspend the administration of mercury when
the mouth begins to be affected.
  B.  As to the second point of view, that is, its bearings upon the
treatment of syphilis,  the opinion is no longer entertained as form-
erly, that it is of advantage. It was  supposed,  indeed, that the
virus might be drained away by means of the perspiration, an
intestinal flux, and  especially by a flow of saliva, and there was a
method of treatment called that by salivation, which was  for a long
time followed, and is yet occasionally employed by some practi-
tioners.  This is now avoided as much as possible, and  the treat-
ment adopted in ite place has been denominated that by extinction.
  All practitioners, however, do not  equally dread the occurrence
of salivation.  Some there are who do not believe that it is injuri-
ous,  nor  do they imagine that it is  of advantage; at least their
method of  administering mercury would go  to corroborate this
assertion.  Thus these practitioners, in the treatment of the syphil-
ida, are not afraid to give the proto-iodide of mercury in doses of
three grains and more in the day.  They know that it may pro-
duce a certain degree of salivation,  and as they can arrest it by
suspending for awhile the  use of the mercury, they administer
large doses.  But if  they suspend  the mercury, they  arrest the
treatment.   Now, in my opinion, this is a great inconvenience,
and a cause of failure and  relapses.  This I have already stated.
Salivation,  therefore, whether  voluntarily or  involuntarily pro-
* Grappin, These de Paris, 1846. 
THERAPEUTICS.                    3H
duced, is unfavorable in both the points of view I have indicated,
for it may prove injurious by the disorders directly caused by the
mercury, and  because  it compels the practitioner to interrupt a
treatment, the success of which greatly  depends upon the contin-
ued employment of its means.  However, there are certain cases,
but very  rare, which  would  seem to justify the practitioner in
provoking a slight salivation; but then it is for  the purpose of
combatting accidents which  might rapidly compromise organs of
great importance;  thus I have observed, that in serious cases_ of
syphilitic  iritis, we may derive a  certain  advantage from saliva-
tion ; it then effects a derivation on the part of the mouth, which
promptly relieves the eyes.  I shall return to this  subject in treat-
ing of iritis.
   Treatment.—In the first place, salivation  is to be  avoided, that is
to say, we must have a prophylaxis.   I have  already alluded to
the want of success of  the combinations of camphor and sulphur
with mercury.  In describing the method of  Pihorel, I showed,
also, that the combination of mercury with ammoniated lime, had
been unsuccessfully tried in preventing  stomatitis.  It is better to
prepare the patient properly as I have recommended;  blood-letting
in certain young and vigorous subjects,  cathartics  and baths in all
cases, may singularly promote the tolerance of the mercury.   But
the best prophylaxis is that  based on the knowledge of the causes
which I have already described.   Sudden changes of temperature,
and  especially humid cold,  must be avoided.   The patient, how-
ever, should  not  be closely confined in small and heated rooms.
I have stated that the accumulation of patients who have submit-
ted to  frictions, in a small ward  heated by a stove, was a deter-
mining cause of stomatitis.   Above all, the use of mercury in
large doses should be avoided, for it is the  quantity administered,
and not its mode of administration, that especially produces  sali-
vation.  If it be  deemed advisable to  introduce  a large quantity
of mercury into the system, we  must proceed cautiously at first,
in order to establish a kind of tolerance  of the medicine.   We can
only  succeed by  commencing with small doses, and continuing
them for a length of time.
   The curative treatment of ptyalism consists  in the use of both
direct  and indirect means.  Soothing and astringent gargles con-
stitute the first.   Experience  confirms  the utility of both, but at
different stages of the salivation.   The soothing, for example, are
better adapted to the first period of the irritation.  When the in-
flammation  is severe,  it is  even necessary to  add to every six
ounces of the gargle, be it of warm milk, barley-water, or of marsh
mallow, ten or fifteen drops of laudanum.
   Gargles, alone, are insufficient when the stomatitis has become
very intense,  and we must then resort to local  depletion.   We
may apply from fifteen to twenty leeches  below the inferior mar-
gin of the lower jaw, between the angle  and the chin.  While the
leech bites are bleeding, it is well  to let the patient's feet be im-
mersed in very warm water.  At a later period we may substitute
for the emollient  applications oxycrate or lumps  of ice over the 
312
VTDAL ON VENEREAL DISEASES.
lower jaw.  The  patient may likewise introduce fragments of ice
into the mouth.  These means  should be continued whilst  the
symptoms remain unabated, but when they begin to subside, and
the irritation has sensibly diminished, we should  resort to the  use
of astringent gargles, such as plantain water, with a certain pro-
portion of alum, water acidulated with vinegar or a few drops of
sulphuric acid, a decoction of roses, of gall-nuts, or of tannin.
  The mercurial ulcerations become so indolent towards the ter-
mination of ptyalism, that they will not heal, although subjected
to the stimulation of the astringent gargles  of  which we have
spoken.  They must then be touched with caustics, such as  the
nitric or sulphuric acids, Lanfranc's collyrium, the sulphate of cop-
per, the pierre infernale,  and the hydro-chloric acid.  The latter
acid has already been much employed.   It may be applied with a
brush to the different seats of ulceration, and thus produce a de-
cided improvement in their condition.  The same effect may be
obtained with the crayon of nitrate of silver.   These caustics may
be  employed even at the commencement of the disease, in which
case they should be applied  to the parts of the gums  and cheeks
primarily affected.  Stomatitis may thus be arrested,  if not very
severe, and  especially if at the  same time the mercury be discon-
tinued.
  A gargle  composed of one-eighth part of the chloride  of soda
has also been used with advantage.  But we may meet with patients
in whom this application will excite too much irritation; the acrid
character which it gives to the gargle, becoming sometimes insup-
portable.  In such cases it  is better to use a proportion of one-
sixteenth or one-twentieth in some mucilaginous vehicle.   Under
other circumstances, on  the  contrary, the atonic condition of  the
mercurial ulcers may be such as to require the application of  the
chloride of soda, diluted with but a very small quantity of water.
  M. Lagneau has also  employed, for the same purpose, lozenges
composed of the chloride of soda, gum and sugar, with the addition
of  some aromatic substance.  Sometimes  he administers these
lozenges with the view only  of removing the offensive fetor of  the
breath in persons  who are subjected to mercurial treatment, and
who are not yet salivated; he uses them in cases where the breath
becomes offensive from other causes.
  The internal use  of opium has likewise been recommended to
relieve salivation, but the experiments made at the venereal hos-
pital with this medicine have not been favorable to its reputation
as an anti-sialagogue.   On  this account, however, opium should
not be absolutely  rejected in cases of ptyalism.  When we wish to
diminish great irritation in the mouth, laudanum may be  success-
fully employed.                           •
  Hunter had great faith in the efficacy of opium.  He has stated
that when  the effects  of mercury  are felt in  the mouth and
pharynx, the application of  opiated lotions to these parts  is often
of advantage.  It allays the irritability, and consequently the pain;
it also diminishes the secretion.  The following formula has been
extolled: 
THERAPEUTICS.
313
              No. 1.  fy. Caps. Papav. contus.  § ss.
                        Scm. Lin.          § i.
                        Aq. bull.           | vi.
                        Syr. Mel.          § ii.

        No. 2.  T£. Dedoct. rad. Marsh mallow, ^ vi.
                   Laud, of Sydenham.       20 to 30 m.

  Whatever may be the modus operandi of the direct means em-
ployed to arrest salivation, as they can act only temporarily on the
local  irritation without  modifying the  cause  producing  it, we
should, according to M. Lagneau, consider  them  only as accesso-
ries to other  anti-sialagogues which have a tendency to displace
this irritation or to render the mercury incapable of maintainihg it
by causing it to  undergo, if we  can believe some authors, new
combinations.   At the head of these indirect means must be placed
cathartics.   They transfer the irritation to the intestines, and may
thus prevent ptyalism, and their continued use is an excellent cu-
rative means, when salivation has been  produced.  In the latter
case it is an established principle that they must be administered
much more frequently.   Purgatives often promptly arrest the pro-
gress  of a salivation in the course of five or six days.  Sometimes,
however, it is not suppressed under from fifteen  to twenty days.
But even their purgatives are not without their advantage, for
they may prevent the aggravation of the buccal irritation, even if
they are insufficient to arrest its progress.
  It is customary to prescribe an ounce of the sulphate of soda or
magnesia, to be taken in three glasses of chicory water, or a bottle
of the solution of the citrate of magnesia.  M. Lagneau  recom-
mends a pill  of soap and aloes according to the following for-
mula:

                 IJ.  Sapon. Offic.     § ii.
                    Pulv. Rhei.       % i.
                     Aloes. Pulv. (fine) § ss.

  Make into pills of one grain each, of which from three to six are to be taken
in the day.

  Hot baths are frequently employed in cases of salivation.   Their
efficacy is explained by the cutaneous excitement diverting the vital
forces which act too violently on the salivary apparatus, in which
case their action may be compared to that of purgatives or other in-
direct irritants.   Foot baths may have the same effect, and may
be used with  benefit;  the  latter act especially  as derivatives, rf
to them we add mustard powder or two ounces of hydro-chlorio
acid.  Recourse has also been had to the abstraction of blood by
cupping, or to dry cupping, to rubefacients  and dry frictions, in
order to transfer  the irritation to organs remote from the salivary
glands.   For this purpose even blisters have been used.   They are
especially useful  when the salivation is disposed to continue very
obstinate;  for it sometimes happens that ordinary means fail, and
we are obliged as a last resort to employ those of a severer  nature. 
314            VIDAL ON VENEREAL DISEASES.
Blisters like the cups may be apphed to one or both arms; but the
nucha of the neck is the place generally selected on account of ite
proximity to the parte.
  Mussa Brassavole,  who wrote in 1551, believed  that salivation
was produced by mercury reaching the mouth in its metallic state.
He recommends  that the patient  should constantly hold  in his
mouth a piece, or ring, of  gold, in order that the mercury may
combine with it, and thus lose its sialagogue properties.   These
experiments have been repeated by the most skilful chemists of
our day, but they have never been able to detect a single atom of
mercury on the gold.
  [The evidence upon this subject, afforded by the carefully-con-
ducted researches of Dr. Samuel Wright, of Birmingham, England,
is not without its value, confirming, as it does, the conclusions of
Devergie and others, who  have failed to detect any portion  of
mercury in the saliva of those affected with stomatitis.  In his
lectures on the physiology and pathology of the  saliva, published
in the London Lancet,  Sept. 1842, p. 803, he remarks: "As far
as my own experience is concerned, and I have operated largely,
and with much patience, I can offer  no evidence in favor of the
presence of mercury in the saliva of people suffering from mercurial
ptyalism.   I have employed all the most eligible and delicate pro-
cesses recommended by Christison, especially the galvanic test and
destructive distillation, but not in one instance have I succeeded."—
G. C. B.]
  The affinity existing between sulphur and mercury having long
since been remarked, this simple substance was early recommended
for the purpose of arresting the progress of salivation.  It is given
in substance, in the form of lozenges.  Some advantage has been
supposed to be derived from this agent notwithstanding our igno-
rance of its  manner of acting on our organs.  Perhaps  it is a
derivative.  It may also act as a stimulant to the  alimentary canal,
and by increasing the activity of the functions  of the skin.  M.
Lagneau, who seems to be  an advocate for the use of sulphur,
reproaches it as well as other anti-sialagogues, with not constantly
fulfilling the expectations of the practitioner, but as its employment
is sometimes followed with  good effects, he  recommends it more
strongly, as it is very innocent and does not prevent the simulta-
neous use of  purgatives, of gargles, and other appropriate  means.
This practitioner has seen sulphur thus administered,  three times
arrest a ptyalism  during the same treatment, in a subject whose
mouth became constantly affected by the slightest dose of mercury.
  Pearson observed the efficacy of sulphuric acid administered as
a beverage, a sufficient quantity being used to give it an agreeable
acidity.   M. Lagneau, Avho has used both the mineral and vegeta-
ble acids, speaks of it in the highest terms.
  I have thus noticed briefly as possible most of the means which
have been employed in  the  treatment  of  salivation, but I should
remark that all are not possessed of the same degree of efficacy.
Slight cauterization with hydro-chloric acid or the nitrate of silver,
and the use of purgatives, constitute the basis both of the direct 
THERAPEUTICS.                    315
and indirect treatment.  The other means are accessory, with the
exception of local or general  depletion in young and plethoric
subjects, and when there is manifest congestion of the mouth.  It
should be well understood that first of all, the administration of
mercury is to be suspended.
   Cholic and Diarrhoea.'—Mercurial Tremor.—At  the present day
perhaps  mercury produces more  frequently morbid effects upon
the intestinal canal, than it does salivation, for it is almost always
administered internally.
   Diarrhoea, and especially cholic, occur in  certain patients after
every dose of mercury, and continue during the day and following
night.   This accident is more frequent in females, and  is much
more frequently observed after the administration of the proto-
iodide, than the bi-chloride of mercury, either because the latter is
administered in smaller doses, or  perhaps on account of its more
frequent combination with opium;  for the formula of Dupuytren
is very much used.  It is  especially in cases where the mercury is
thus administered that we observe constipation.   It is  not very
rare, indeed, that  hospital patients who are treated for primary
accidente, with the pill of  Dupuytren  are thus affected.   But this
is an inconvenience of much less importance  than diarrhoea and
cholic;  in  the latter case the  mercury should be either discon-
tinued or its dose  so diminished as no longer to produce abdominal
trouble.  In all cases it is better to combine it with opium.
   Mercurial tremors I believe to  be very rare. I have observed
them but in three  instances, once  in a  gilder, and once in a patient
who for a long time had "made use of frictions.  There is at present
in my service  a patient in whom this  accident has followed the
administration of mercury in  baths.   As facts of this kind  are
rare, and as the cases are generally wanting in details, the circum-
stances  connected with this case besides seeming  to possess a real
interest,  I here insert the particulars  which I have  been able to
collect in regard to this patient.
   L. (Alf.) set. 19.  Admitted March 15th, 1852, into Ward 9,
No. 1.   He has several times  been affected with blennorrhagia.
The  last attack was in 1848.   The treatment prescribed was very
irregularly followed.  The patient suffered but little; the inguinal
glands were indolent.  During the latter part of 1849 (L. was in
the hospital of Dijon) the discharge ceased at the moment of the
appearance of a cutaneous affection, which the practitioner regarded
as psoriasis.  The patient made use of  corrosive  sublimate baths
for three weeks, one every day.  The quantity used in each bath
is unknown.
   After the tenth bath, L.  felt slight pains, accompanied with mus-
cular contractions, especially in  the arms.   Soon a  little tremor
followed, which was but of short  duration.   The  patient  lost his
appetite  and suffered constant cephalalgia, with profuse perspira-
tion.  There was  constipation as well  as  considerable  debility,
without much emaciation.
   During the twenty-second bath, L. had  violent  attacks with
foaming at  the mouth, and was  insensible for two hours.  There 
316            VTDAL ON VENEREAL DISEASES
was convulsive rigidity of the extremities.  With returning  con-
sciousness, he was seized with a general tremor so violent as  to
render walking very difficult.   Five or six days afterwards, the
patient's  condition began to improve, and in the course of three
weeks, the legs and arms alone remained affected with the tremors.
He then left the hospital at Dijon.  His disease diminished under
the influence of simple baths ;  the tremors became intermittent;
he rarely, however, passed an entire day without an attack, having
from one to twenty during  the day. (Their duration was  gener-
ally from three to ten minutes.)  Stimulating drinks, and  strong
mental emotions,  exerted an influence in producing their attacks.
The baths of corrosive sublimate effected no  change in the  con-
dition of the cutaneous  affection, which was not cured  until  two
months afterwards.
  Notwithstanding  this affection of the nervous system, the pa-
tient indulged in sexual intercourse, and contracted a chancre, for
which  he came under our  care.  This chancre, of a serpiginous
form, was very painful; he had also  intense cephalalgia.  The
tremor, confined to the limbs,  diminished under the influence of
baths and  mild purgatives.   Of course I refrained as much  as
possible from the  use of mercury when I commenced the general
treatment.   The above  is an  example of epileptiform  mercurial
tremors.
  As to the morbid affections.of the skin and the kidneys, de-
scribed in some books as the resulte of mercurial treatment, I am
not aware  that such have  been carefully observed, and if they
really deserve to be  called  accidents.  If the reader have noted
our remarks upon the morbid effects of mercury, he will have be-
come convinced that this medicine produces those of a grave char-
acter only when it has been improperly administered.  By  avoid-
ing those proceedings which suddenly introduce into the system
too large a quantity,  as, for  example, frictions, and by moderating
the doses for internal use, we may almost always prevent,  not
only the  slight inconveniences  of the mercurial treatment, but the
morbid effects which may be  regarded as the accidente of this
treatment.
  In conclusion, briefly, we would  state, that the  bi-chloride  in
small doses for the  primitive  accidents, the proto-iodide in little
larger doses for the secondary accidents, are the two forms under
which mercury renders most service in practice.


                        IV.—IODINE.

  The introduction of iodine  into the treatment is a recent  and
most happy event.  It may, therefore, be of some interest to know
how it occurred.   In 1821, Coindet announced that an addition
had been made to our therapeutics of a new resolvent, of precious
discutient, viz., iodine.   At  the same time, a revolution was going
on in England against mercury; and France became converted  to
the opinions promulgated by Broussais.  Mercury became unpop- 
THERAPEUTICS.                     317
ular, not only because it failed to cure venereal diseases, but be-
cause it provoked or aggravated  the consecutive accidente.   The
innovators, therefore, proscribed  mercury from the therapeutics
of syphilis, and employed only soothing remedies, and anti-phlo-
gistics, in other words, the means  authorized by the physiological
school.  But the inefficacy of these means, in many cases, soon
became apparent.   Mercury  they would not reinstate, for  that
would be a recantation, but  they sought a new specific.  Iodine
arrested their attention, and to this remedy they resorted.  Thus,
in 1823, we  find Richond-Desbrus prescribing  this metalloid in
cases of bubo and  blennorrhagia; in England the advocates of
the same doctrine entered the same  path, and iodine was  pro-
claimed an anti-syphilitic.


                V.—IODIDE OF POTASSIUM.

  Pure iodine was too difficult to manage, its effects were too
diversified, too opposite even, for symptoms of intoxication were
sometimes observed after very small doses, whilst in other in-
stances very large doses might be taken with impunity.  It  was,
therefore, deemed advisable to combine this metalloid with other
substances, and Buchanan, of London, was the first to unite it with
amidon.   He obtained an iodide of amidon, which was employed
with  the  iodide of  iron, both in  France and London, as an  anti-
strumous,  anti-syphilitie  remedy, but  this  was  done without
method,  and,  it must  be confessed, not  with full  confidence.
Then (1836) appeared the famous lectures of Wallace*  This was
the inauguration of the iodide of potassium as an heroic remedy
against syphihs. One hundred and forty-two cases of venereal
disease attested the virtues of the new medicine.   And we must
not omit here to mention that Wallace employed a formula which
even to this day passes for one of the best.  It is as follows:

                    T£. Hyds. Potass. 3 ii.
                        Aq.         § viii.
  A tahlespoonful to be taken four times in a day.

  In this manner the patient takes nearly half a drachm of the
iodide in the day, which quantity, it was asserted, in the majority
of cases, is sufficient to overcome the worst cases of syphihs.
  Soon  Wallace had  followers both in Germany and  France.
Cullerier, M. Ricord, and other practitioners still,  experimented,
and extolled the iodide  of potassium in such a manner as to excite
a real enthusiasm.   They did not, however, go so far as to pro-
scribe mercury, but the latter was compelled to co-operate with
the new agent, and M.  Ricord took upon himself to make the fol-
lowing distinction in the treatment, viz.,  tertiary accidente were to
be treated by the iodide of potassium, and the secondary by mer-
cury.  This gave rise to objections, which I shall make known.
"■ The Lancet, March, 1836. 
318
VEOAL ON  VENEREAL DISEASES.
  The iodide of potassium has many arguments in its favor:  first,
the truly admirable cures obtained *by it, in a short space of time
(as I shall  hereafter show), the facility of its administration, and
the absence of  all real  danger, which is not the case with pure
iodine and the other preparations.  Further, the iodide of potas-
sium being very soluble  in water, it may be taken in all kinds of
vehicles and drinks.  Its action being infinitely less  irritating than
that of pure iodine, it may be administered in very large doses:
a practitioner in Paris, indeed, having given an ounce, and  even
more, in a  day.  It may  be used in as small a quantity as one and
a half grains.   There are but few substances capable of being ad-
ministered according to so great a variety of formulas, and under
so many different circumstances  of age, taste, convenience, and
even caprices of the patient.  The dose may also be proportioned to
the degree  and nature of the accidents; for I shall,  in another place,
show that the iodide of potassium may fulfil a double indication.
  I shall not here insert  all the different formulas which have been
proposed for its administration, for, as has been stated, they are innu-
merable.   I shall mention only the principal and most important.
  M. Ricord employs the following :

                  ]J.  Iod. Potass,   gr. iss.
                      Syr. Papav.    §" i.
                      Aq. dist.     § iii.
  The dose  is to be increased every five days about eight grains, until we
reach one and a quarter ounces in t/ie day, a quantity which should rarely
be exceeded.

  A year afterwards, the same practitioner  taught  that we might
commence with fifteen and even thirty grains a day, and that the
patient would always tolerate two  and two  and a quarter ounces
in the day.
  Finally,  in his notes to the  second edition of Hunter, M. Ricord
observes :  " When tertiary accidents alone exist, the most success-
ful treatment consists in  the use of the iodide of potassium.   We
may commence  with forty-five grains in the day.  This is to be
taken in three doses, in  three  glasses of the decoction of sarsapa-
rilla, of hops or soapwort.   Every five days the dose is afterwards
to be increased from fifteen to thirty grains, which I rarely exceed."
The two following formulas shows how large is  the quantity given
by M. Puche:

  HOSPITAL FORMULA FOR THE SOLUTION OF THE HYDRIODATE
                          OF  POTASSA.
             IJ,.  Hyd. Potass.   3 iii.
                 Aq.           \ xii.
                 Cochineal, q. s. f. rose-colored solution.
  To be used in cases of chronic syphilis and tertiary symptoms, whether
ecthymatous ulcerations,   tubercles,  periostitis,  exostosis,  and  caries.
Dose, from one to four ounces in a pint of bitter or sudorific tisane.  To
be taken at six different times at regular intervals. 
THERAPEUTICS.
319
               SYRUP OF IODIDE OF POTASSIUM.

               I£.  Hyd. Potass.           3 J-
                   Anisette of Bordeaux,   3 iss.
                   Syr. Sacch.            3 xiv.
                   Cochineal, q. S.

  Dose, from one to four ounces a day in half a pint of cold water.   The
whole to be taken in four doses at regular intervals.
  N.B.—T/ie dose of the hydriodate of potassa in this syrup may be in-
creased to three ounces.

  I employ the iodide of  potassium both  as a  tonic and an anti-
syphilitic.  I never give more than fifteen grains to fulfil  the first
indication, and rarely exceed one drachm for  the second object.
Let me explain :  I  believe that almost all cases  of syphilis may be
sucessfully treated  by mercury, if this medicine be properly man-
aged ;  but sometimes the system is antipathic to it, and then,
instead of producing curative, it produces' morbid effects: thus,
patients  who  are excessively debilitated, cannot  be treated  with
mercury, which  evidently depresses  the vital forces, since it is
called  a hyposthenisant.   I  give, in these cases,  the iodide of
potassium, in doses from one to one and a half  and fifteen grains,
but never in larger quantities.  With these doses I do not propose
to act upon the diathesis; I  aim not directly  at the virus, but I
endeavor to act upon the  system, to strengthen it, and to place it
in the best possible condition to  resist the intoxicating agent, and
at a later period  to tolerate  the  use of mercury.   The  iodide of
potassium is not, therefore, a specific, and when it cures, it does so
indirectly, by a contre-coup.   The stomach regains its  tone under
the  influence of these minute doses, the appetite becomes keen,
nutrition active, the strength re-established, and it is not uncom-
mon for the patient to acquire  a certain  embonpoint.  But some-
times the venereal affection  continues obstinate.  If the case be
one of the superficial  syphilides, it does not  disappear;  it may
even become aggravated; now is the time to interpose the use of
mercury, which may be employed  alone, if the patient's strength
be restored, or its use may be conjoined with that of the iodide of
potassium.  At  a  later period  of the disease, when the fibrous,
osseous, and deeper-seated tissues, are involved, it is of great im-
portance to  give specific doses, those which act directly on the
malady.  We may commence with  half  a drachm, and  the  same
week increase the dose to one or one and half drachms a day.  The
following is my formula:

                   1^. Iod.  Potass.   3 ss.
                        Aq. dist.     3 viii.

   A tablespoon fid to be taken morning and evening  in a glass of hop or
soapwort tisaiie.   The dose  may be gradually increased to six spoonfuls,
and as, according to this formula, each spoonful contains fifteen grains
of iodine, toe give, therefore, one and a half drachms a day.  I do not
ordinarily prescribe the latter quantity. 
320
VLDAL ON VENEREAL DISEASES.
  At the Ilnpital du Midi, the bottles containing the iodide are
marked with transverse lines on their sides, so as to make divis-
ions, each of which contains a tablespoonful of the solution, or
fifteen grains of the iodide ; the whole bottle contains eight spoon-
fuls.  I have them made containing sixteen spoonfuls.
  It is evident that the iodide  of potassium, in a large close, acte
directly upon the diathesis; first, by the beneficial modifications
which it produces on the disease in an incredible short space of
time, and before the general health  appears to  be the  least im-
proved ;  2d, by the failures  which occur  when less than fifteen
grains  have been  administered, and  the success obtained by in-
creasing the quantity in precisely the  same cases.   I have known
a young literary character, who had  a chronic ulceration at the
base of the  tongue sufficiently deep to lodge the extremity of the
finger.  This patient was treated without  success for six months
with the  iodide, which was not given  in larger quantities than
eight grains in the day.  He had been treated in the country.  On
his arrival at Paris he came under  my care, and I commenced
with thirty  grains a day;  this quantity was increased to one
drachm a day during the first week, and in  thirty days the ulcer
had completely healed.
   [There can be no question that the iodide  of potassium is often
administered in doses  too feeble to  derive  all the benefits that
this remedy is capable of affording.    Dr. Graves recommended
thirty grain doses three times a day.   During our  recent visit to
London  we saw some inveterate cases of syphilis,  which  had re-
mained for many months in the hospitals, and we ascertained that
they were taking but two grains three times a day!  But can the
iodide of potassium cure even the tertiary stages of syphilis?, We
believe not, and such we find is the opinion  of many experienced
practitioners whom it has been our privilege to meet not only in
Europe but our own country.   As  remarked by Sir  Benjamin
Brodie (Lect. in Lond. Lancet, Feb. 17, 1844), " You may remove
slight symptoms by giving it for a time, and severe symptoms, by
exhibiting larger  doses;  but in the latter  case, so far as I have
seen, it does not make a permanent cure, for the symptoms return
again.   As a prophylactic, it is not to be compared with mercury."
   In a letter recently received from Mr. Langston Parker,  he
says, " I believe the curative effects of iodide of potassium  have
been over-rated.   It suspends disease, but  often fails  to  cure.
Iodic cachexia, which is common from its prolonged use, is worse
than any symptom which mercury produces.  I have known it
taken by patients for three, seven, and in one case  (a surgeon) ten
years ; it always kept the disease in check, but when discontinued
the symptoms became worse."
   In this view of the subject, as we have been personally assured,
Drs. Musey, Willard Parker, and John Watson, coincide.   At the
Dublin Lock Hospital,  we are informed, that in cases of much de-
bility, they  now employed a combination of iodine and soda in-
stead of the potash.  It is administered in  ten-grain doses  three
times a day.  For a full account of the evidence in favor of iodine 
THERAPEUTICS.
321
and  its compounds, we would refer the reader to the elaborate
article of Dr. Hocken in the Ed. Med. and Surg. Jour. vol. lxi.,
and  the  work of Dr. Dunglison on New  Remedies, last edition.
—G.C.B.]
  The iodide of potassium may also produce a prophylactic effect;
it may assist the mercury in preventing the formation of the last
stages of syphihs.   Thus I often give it  in small doses, after a
complete mercurial course, in the treatment of primitive or sec-
ondary accidents, which have exhibited an unusual degree of ob-
stinacy, especially when the patient is feeble.  I then dissolve the
iodide in the syrup of fumitory, or of burdock, of which a table-
spoonful is to be taken two or three times in the day in a glass of
hop  tisane.
  I have already shown that the  use  of the  iodide  is not to be
restricted to  the tertiary accidents, but that it has been used dur-
ing every period of the anti-syphilitic treatment.  If we examine
the  list of cases reported by Wallace, we shall find  that it  con-
tains those of secondary accidents, and of late  this  medicine has
been proposed not only in the second stages of syphilis, but  even
in the first, the so-called primitive accidents.  MM.  Payan* and
Bazinf have published facts, going to show that  this powerful
agent may in certain of these cases produce happy effects.
  I  am far from wishing to dispute these facts,  for I possess those
of an analogous nature, having experimented  with this medicine
in every stage of syphilis.  I have seen  chancres and secondary
cutaneous affections cured during the employment of this remedy;
but  ite therapeutic action has never appeared so prompt and well
defined, as when it is employed in the treatment of very chronic
tertiary affections;  in fine, I have never been able to satisfy my-
self beyond  a  doubt of its efficacy in the other forms of the dis-
ease.  In these new applications  the  cure  may doubtless be re-
ferred to the iodide, but we should  not overlook the efforts of
nature, for in  almost all a sufficient time elapsed to  permit  such
a result.
   [The  recent  memoir of M. Melseus " On the Employment  of
Iodide of Potassium as a Remedy for  the  Affections caused by Lead
and  Mercury,''1 has attracted considerable  attention.   He main-
tains  that, after its absorption into the blood, it combines with the
metallic poison, and forms with it a new and soluble salt—liberates
the  poison from its union with the injured part—dissolves it out,
so to speak, and sets it afloat in the circulation.   Thus free, as
supposed, in the form of a double iodide of mercury and potas-
sium, it escapes through the kidneys, in combination with any ex-
cess of iodide  of potassium that may be present, and both remedy
and  poison  are cast out together.  Dr.  Wm. Budd has given  an
analysis and translation of this memoir in the Jan. Number (1853)
of the Brit,  and For. Med.  Chir. Review, and another notice of it
by Mr. Parkes, Clin. Prof, in University College, may be found in

          * Vide Journal de la Societe de Medicine de Bordeaux, 1844.
          f Gazette des Hopitaux, 1843.
                                21 
322            VLDAL ON VENEREAL DISEASES.

the April Number of the same Journal.   Dr. Budd has appended
numerous remarks corroborating the views of M. Melseus.   Some
twenty  years ago Dr. Judd, in his  Treatise on the  A'enercal, p.
564, thus remarked:  " After mercury has produced ptyalism,
broken  down the general health, and begun to bring scrofula into
action, iodine then appears to act in a far more salutary way than
in cases wherein no mercury has been taken.   Is it not possible,
nay even likely, that under these circumstances  the iodine  (espe-
cially the hydriodate of potash) being taken into the system, forms
an Hydriodate  of Mercury in the living blood ?   Seemg that Bin-
iodate of Mercury, in a solution of Hydriodate of Potash, formed a
crystalline triple salt, I attempted to procure  similar crystals from
the blood after a course of mercury and Hydriodate of Potash,
but failed."  He then resorted to  other experiments,  from which
he  concluded that both mercury and iodine were  present in the
blood.  The perusal of Dr. Jucld's remarks upon the subject has
satisfied us, that to him is due  the credit of first promulgating
the views now broached by M. Melseus.   To those engaged in the
investigation of this subject we would recommend the perusal of
the interesting  Essay of our esteemed friend Dr. J. W. Corson,
entitled " Cases testing the  Iodine of Potassium,  as an Antidote to
the Injurious Effects of Mercury, and corroborative of the Experiments
of M. Melseus,'"  published in the  New York Journal  of Medicine
and Collateral  Sciences, Sept. 1853.—G. C. B.]

     ACCIDENTS ATTRIBUTED TO THE IODIDE OF POTASSIUM.

  Strictly speaking, these are not true accidents; they are, in the
majority of cases, pathogenetic effecte which subside on the dis-
continuance of the  remedy, and  which  never  assume a serious
importance.   These  effects are manifested on the mucous mem-
brane of the nose, eyes, mouth, stomach, and intestines; they may
likewise be observed in the urinary organs, the skin and nervous
system.
  The most prompt and common effect is upon the pitulary and
ocular mucous" membrane.   The majority of  patients are attacked
at the commencement of the use  of  the iodide of potassium, with
coryza which is sometimes  very acute.  At the  same time well-
marked symptoms are observed of catarrhal opthalmia, with more
or less decided serous chemosis and oedema of the eye-lids; some-
times  this amounts but  to a simple  redness.   It is rare for both
mucous membranes to become the seat of a muco-purulent  secre-
tion.  I have seen a patient at the Hopital duMidi, whose conjunc-
tiva at first became tumefied, after which followed a sanguineous
effusion into the cellular tissue of the eye-lids, which absolutely
discolored them like an ecchymosis.  The patient, seen at a dis-
tance, seemed to wear large glasses of a violet blue color.   I treated
him for  a chronic engorgement of the testicle; he was very  much
debilitated; he took only fifteen grains of the iodide of potassium.
  Salivation frequently occurred; it resembled  that of pregnant
women,  consisting of a kind of regurgitation of a saline saliva, of 
THERAPEUTICS.
323
a metallic and bitter taste.   To a certain extent it was like a mer-
curial salivation, for in some patients an erythematous, oedematous
tumefaction of the gums occurs;  but this congestion never amounts
to an inflammation as in the case of a  mercurial ptyalism.   Fur-
ther, it is never accompanied with ulcerations of the fining mem-
brane of the mouth ; it has neither the peculiar odor nor fetor of
the breath.  According to M. Payan, chemistry has been able to
detect the presence of the hydriodate of potassa in the saliva.*
  In the majority of cases the digestive organs tolerate well the
use of the iodide of potassium,  and we often observe an increase
of the appetite, especially when it is administered in  small doses;
but sometimes patients complain of a pain and  uneasy sensation
in the region of the grand cul-de-sac of the stomach.   This pain
sometimes resembles that of pleurodynia.   This did not escape
the attention of Wallace; he speaks  of a cough and difficulty of
respiration.  But  the pain in these cases is more  profound than
in pleurodynia.  In certain cases the thirst is increased, although
generally the appetite alone is augmented, and nutrition promoted,
so that the patients soon acquire a degree of embonpoint.  Some-
times, but more rarely, vomiting and diarrhoea are observed.   M.
Payan mentions the case of a scrofulous child, in whom the iodide
of potassium  produced a chronic gastro-enteritis, which required
nearly a month for  its removal.  A chronic gastro-enteritis, how-
ever, Avhich soon  subsides, I must say is an accident of very little
importance, and I would add, that M. Payan attributes the  dis-
ease in this case to faulty nutrition.
  Symptoms of bronchitis have also, though rarely, been noticed.
Certain affections  of the skin may also appear;  these most gener-
ally assume the form of acne, and ecthyma, with very small pus-
tules.  I treated a patient  in town whose  face was covered with
an eruption which resembled the first appearances of variola,  and
this  occurred  on  the next  day after the commencement of the
administration of the iodide of potassium, if we exceeded fifteen
grains at a dose.  It is  still more rare to meet with the spotted
malady of Weslohl.  M.  Payan  cites an example in  his memoir.
The patient was of a lymphatic temperament.  He had taken the
iodide for two months.   Spots  appeared on both legs resembling
ecchymosis resulting from a contused wound.
  The urinary organs are very much affected in certain subjects,
and  the secretion of urine greatly augmented in the majority of
cases.  M. Payan has seen  a patient who voided  seven pounds of
urine in twenty-four hours.  He took eighteen grains of the medi-
cine  in  the day.   It should be stated, however, that this patient
had a chronic  affection of the bladder, and perhaps of the kidneys.
  The circulation, apparently, is not affected.  According  to the
Italian school, the frequency of the pulse is diminished.  M. Payan
assures us, on  the other hand, that it is accelerated.  The cases of
hemorrhage, which  have been very  rarely observed, have been

  * Vide a work by this physician on the employment of the iodide of potassium,
«fec, p. 221. 
824
VIDAL ON VENEREAL DISEASES.
regarded, sometimes as passive, sometimes as active.  I have seen
a patient affected with nasal hemorrhage, after haying taken thirty
grains of the iodide in two days;  he was excessively feeble.  As
to the nervous  system, says M. Ricord, some patients experience
what is called an iodic intoxication, and which is characterized by
an impairment  of  the voluntary  movements,  twitchings of* the
muscles,  a sense of weight in the head, a kind of mental inactivity,
and occasionally by slight disturbance of the intellect.
  "The iodide of potassium has been accused of producing atro-
phy  of the glands,  particularly  the  mammary,  and  the testicles.
It is indeed one  of the most powerful resolvents with which I am
acquainted, but it affects only the  diseased  parts, the atrophy of
which it  may sometimes produce, but this is not ite only oper-
ation."*

                   VI.—IODIDE OF  IRON.

  The iodide of iron is sometimes employed  in  the treatment of
the last stages of syphihs.  According to M. Bouchardat, the phy-
sicians at the Hotel-Dieu have for ten years been  accustomed to
administer this heroic agent in large doses, for the removal of syphi-
litic  accidents of long standing, and which have resisted the prepa-
rations of mercury.
  I  am  satisfied that the iodide  of iron is a therapeutic agent of
certain power;  but I am confident  that in cases where mercury
has proved ineffectual, the use of the iodide of potassium will be
followed by the greatest success.
  The iodide of iron is  particularly adapted  to cases where a de-
cided syphilitic cachexia exists, and  a state of anemia, or of debil-
ity complicated  with  scrofula.  M. Baumes has observed, in cases
of imperfect plasticity of the blood, and of obstinate ulcerations,
the  most prompt and remarkable effects from pills of the proto-
iodide of iron.   The formula is M. Bouchardat's formula:

                       fy. Iodine, 3" iiss.
                          Fer.    fijr.
                          Aq.     3 iiiss.
  Subject the whole to a temperature of 60°, until the liquid is discolored;
pour off, and rapidly evaporate in an iron mortar.   When the water is
nearly evaporated, add:
                           Mel.  3 ii.
                 Pulv. Gum. and Marshmallow. q, s.

  Make one thousand pills, each of which will contain about  one and a half
grains of the proto-iodide of iron.  Dose, four,  to  be gradually increased
to twenty and thirty a day.

  This is a very convenient form for  administering the proto-iodide
of iron.   But it should not be forgotten, that the patient  wiU not
* Notes to Hunter, 2d ed. 
THERAPEUTICS.
325
tolerate the quantity here indicated, except when the salt contains
red iodine in a free state.   The physicians at the Hotel-Dieu have
often remarked to M. Bouchardat, that they could not administer
the same quantities to patients in private as  in hospital practice.
This chemist attributes the difference to the presence of free iodine
in the pills made by  ordinary chemists.   According to him, this
inconvenience may be obviated by the following formula:

                    IJ. Proto-iodid. Fer.  3 iiss.
                       Carb. Pot.
                       Mel.          aa gr. 1£.
                Pulv. Gum. and Marshmallow. q.  s.

  Make one hundred pills.  From one to ten to be taken in the day.

  What answers still better, is not to increase the doses of the
proto-iodide, and for  the  reason, too, that it is necessary to act
upon the system a long time before a cure can be really effected.
  I employ most generally the syrup made  according to the fol-
fowing formulas:

                   5. Proto-iod. Fer.  3 if
                      Syr. Sacch.     § xvi. M.

  Dose from five to six tablespoonfuls in the day.

                  ]J.  Syr. Sudorif.     | xvi.
                     Proto-iod. Fer.  3 i. M.

  Dose, two tablespoonfuls daily ; may be increased to six spoonfuls.


           VII.—GOLD,  SILVER, AND PLATINA.

  Gold in the form  of powder, or combined with oxygen, anti-
mony, silver, or amalgamated with mercury, has been employed
as an anti-syphilitic.  Ucay, in his Nouveau traite de la maladie ve-
nerienne (1699), remarks:  " The virtues of this  remedy cannot be
too highly praised."  Ucay was not the only admirer of this reme-
dy at this epoch; silence, however, soon usurped the place of
these pompous eulogies, and it became buried in complete oblivion.
At a later period (1811), Chrestien  prescribed gold as a new reme-
dial agent in the treatment of venereal and lymphatic affections.  Serre
(of Montpelier) experimented with silver, and platina.   Chrestien
employed especially equal parts of the hydrochlorate of gold and
of soda, in the form of powder; he  also made use of the oxide pre-
cipitated by tin or potash  or metallic gold, in a state of minute di-
vision.   " These three preparations  succeeded completely, no mat-
ter  what  the nature  of  the venereal symptoms for which they
were prescribed."* The powder was administered according to the
method of ClareJ by  making frictions  on the gums, the internal
* Lagneau, t. ii., p. 193. 
326             VLDAL ON VENEREAL DISEASES.

surface of the  lips and on the tongue.  Chrestien also employed
the following pills:

                $. Hydrochlor. Aur. et Sod. gr. i.
                   Ext.  Daph, Mezer,       gr. xii.
                   Syr.  Simp.q. s. f. pill 15.

  Dose, one in the day ; to be gradually increased to three or more daily.

  Gold has always retained ite advocates at Montpelier, especially
with the members of Chrestien's family.  Experiments have been
made, with  every  precaution, at Paris, by M. Legrand, and at
Toulon, by M. Reynaud.   Remark how it has been employed and
judged  by the  latter  surgeon.   I  will afterwards mention the
opinions formed of this agent by some other writers on syphilis,
and, in passing, will also allude to  their  estimate of silver and
platina.
  M. Reynaud used the  same combination as did  Chrestien: one
grain of the salt and two  grains of the iris powder, or lycopodium,
moistened with water  and alcohol so as thoroughly to mix; the
whole being divided  into twelve equal parts.  One of these was
rubbed on the tongue and  internal surface  of the cheeks every
morning.   The patient  moistened  the right index finger with
saliva, dipped it into the powder, and made frictions on the tongue
from five to ten minutes ; the end of his finger was thrust against
the cheeks.   The latter  point is selected for  the frictions, if from
any  cause it cannot be  made  upon  the tongue.  They may be
used upon the gums, but then it would be difficult to guard the
teeth against the action of the gold, and to prevent the disagree-
able dark color which it  produces on their  necks.  A copious se-
cretion of saliva follows, this should be entirely swallowed, as it is
loaded with particles of the salt.
  After this first series of frictions, M. Reynaud resorted to a sec-
ond, dividing  the same quantities of the medicine into ten parts,
and  afterwards  a third  series, the powder having been divided
into eight parts, a fourth into seven, a fifth into six, a sixth into
five, a seventh into four,  and the eighth series into  three parts.  In
the more  inveterate cases, he made several experiments* with the
third and  fourth divisions, so as nearly always to administer more
than Chrestien, and sometimes to reach as high as  from twelve to
fifteen grains of the auriferous salt. According to M. Reynaud, from
six to nine series of frictions were ordinarily required, in other words,
from six to nine grains of perchloride of gold and soda were used.
Often, especially in the worst cases, this practitioner conjoined  the
use of the oxide of gold in the form of pills, which  were combined
with the extract of the bark of mezereum, but most commonly
with  the  extract of cicuta,  or of the woody nightshade, in  the
proportion of one grain  of  the  oxide of gold, to  nine  grains of
either of the extracts which  was made into  ten pills, each contain-
ing a tenth of a grain of gold.  Two of these were  given  in  the
day, morning and evening, and the latter either an hour before or 
THERAPEUTICS.
327
an hour after eating, in this manner from eight to ten or twelve
grains of the oxide of gold were administered
  Tisanes of soapwort, of chicory, or sarsaparilla, are prescribed
as accessory means.   Of course proper attention to hygienic meas-
ures is to be observed.
  M. Reynaud  remarks that he has never observed the disorders
of the  mouth  and  the gastro-intestinal  affections which  some
authors have attributed to the influence of the preparations of gold,
and he has eniployed them at least in a hundred instances.  Fre-
quently they produce no appreciable effect upon the system, some-
times they give rise  to a  little  general excitement, and in a few
cases only, is this excitement accompanied by a slight cephalalgia
or febrile reaction, which the temporary cessation of the remedy
causes soon to disappear.  M. Reynaud observes in conclusion,
that almost always, under the influence of this  treatment,  he has
seen the tertiary accidents of the syphilis gradually diminish, and
finally become completely cured.*
  It will be  remarked that I have  not commenced the exposition
of the opinions entertained in regard to the efficacy of gold, with
any expression  which  can be  regarded  as malevolent.  It has
been my desire, rather, to give the views of an  author, who may
be regarded as its advocate.  But I cannot refrain from remarking
that M. Reynaud is also a great partisan of the iodide of potassium,
a remedy which, as is known, overcomes the same accidents which
M. Reynaud seeks to combat with the preparations of gold.  The
great advantages attributed  by Chrestien to the latter aroused the
attention of  the Societe de Medicine, and Cullerier (the uncle) was
charged to make experiments with them at the Hpital du Midi.
These were not favorable to what was then called the new method.
Thirteen patients were  submitted to this  treatment, and thirteen
entrusted to the vis  medicatrix naturce.  The lesions  in all  were
the same, and the results were identical.f  According to M. Ri-
cord, gold has  alwaj^s been ineffectual as a general method in the
treatment of primary affections, and  in that of the general con-
secutive accidents, it is medicine of a most doubtful reputation.
The majority of cases cured by this remedy are far from being in-
contestible cases of syphilis,  and when it has been administered in
those of an unquestionable character, after the use of  other means
and of  mercury in particular, it proves, according to M. Ricord,
not the virtues of the new medicine, but the advantages of suspend-
ing for  awhile an injurious treatment.
  The preparations of silver in all their forms, and after the indi-
cations  pointed out by M. Serres (of Montpelier), have seemed to
M. Ricord still more uncertain than those  of  gold, both in the
treatment of primary and of confirmed syphilis. They were ad-
ministered at first in small quantities, and gradually increased to
the enormous doses of from fourteen to sixteen grains daily.  M.
Ricord  obseA^cs that these  doses produced only irritation of the

  * P. 398.
  f Vide, the detail of experiments in tome ii., p. 195, et suiv, of M. Lagneau. 
328
VTDAL ON VENEREAL DISEASES.
digestive organs, which rendered it necessary to discontinue  its
use.
  M. Cazenave and Biett experimented with the preparations of
gold.   According to these practitioners, the  results have always
been so doubtful as to give them but little confidence in the value
of these agents.  As to the preparations of silver, in twenty cases
treated with the cyanuret, the  chloride, iodide, and the phosphate
of silver, in none were they crowned with success.  But, Biett and
M. Cazenave did not treat the primitive symptoms which may dis-
appear under almost every form of treatment, but their cases were
those of secondary accidents, those which are called  symptoms of
confirmed or constitutional syphilis.
  It is  already apparent that  the experiments of Cullerier, Biett,
MM. Ricord and Cazenave, are far from according with those  of
Chrestien.   To these practitioners may be added numerous others,
who have  arrived at  the same  conclusions.   M. Payan  having
examined these facts and opinions, thus concludes :  " The treat-
ment with gold cannot be established as a general  method; it
should be reserved,—1st, for those cases in  which mercury  has
failed; 2d, where a decided intolerance of the mercurial prepara-
tions forbids its use; 3d, for those where the inefficiency of mer-
cury is to be attributed to a strumous complication; 4th, for those
where the symptoms depend less on syphilis than on  a mercurial
hypersaturation which may engender accidents  perfectly analo-
gous to those of tertiary syphilis."
  For my own part, I believe that our therapeutics are not so rich
as to permit us for  a slight cause to reject any means, especially
when accompanied with the honorable testimony which has been
awarded to gold;  but it will be remarked that those who wish to
retain in practice the preparations of gold,  have especially em-
ployed  it towards the  latter stages of the disease, after mercury
hate been sufficiently used, or after it has failed.   Now this is the
period of the disease, during which, at the present day, the iodide
of potassium  is chiefly  used, the  advantages of which  cannot
be  questioned.  What then  remains for the  preparations  of
gold?   The cases alone which  are refractory to the iodide  of
potassium.


                  VIII.—DOUBLE  SALTS.

  In speaking of the iodurete, I have already alluded to a double
salt, employed by M. Puche,  viz., the iodhydrargyrate.   Others
were used very anciently;  that which has been  handed down to
us, and which has always maintained a certain degree of  reputa-
tion, is  the  soluble mercury of Hahnemann.  M. Cazenave goes so
far as to say that it is one  of the most useful preparations in the
treatment of the syphilitic eruptions.   It is of easy management
and  toleration, which renders it  particularly adapted to delicate
and feeble subjects.   The activity of soluble mercury is not great,
but it suffices in cases of superficial eruptions; and in those of long 
THERAPEUTICS.
329
standing,  it may perhaps be  used with  advantage.   In severer
cases it is better to resort to the proto-iodide of mercury.
  The soluble mercury of Hahnemann is composed of

                  92.2 Protoxide of Mercury.
                    1.9 Ammoniac.
                    5.9 Nitric  acid.

  As this salt is  readily decomposed, Hahnemann preferred the
form of powder, after the following formula:

     POWDER OF THE SOLUBLE MERCURY OF HAHNEMANN.
                     Soluble mercury.
                     Opium,            aa. gr. i.
          Powder of tragacanth  or liquorice, 5 to 10 grains.

   M. Cazenave employs the following pills:

              SOLUBLE MERCURY OF HAHNEMANN.
                       Thridace, aa. \ ss.
   Make forty pills : one to be taken morning and evening. M. Cazenave is
 reported to have given as many as four daily.

                  IX— SUDORIFIC WOODS.

   These woods, which at one time had so great a reputation, have
 now  fallen into the most complete disrepute.   Even guaicum,
 which nearly dethroned  mercury, is now regarded but as an acces-
 sory means, or as a  vehicle for other remedies.
   We know that this wood was first brought from  St. Domingo
 by the Castilians, who  used  it medicinally.   Leonard, Poll, and
 especially Ulric of  Hutten, who owed  it a certain debt of grati-
 tude, extolled it beyond measure.
   The following tisane of guaiac is still employed conjointly with
 the preparations of mercury:

                   7£. Guaiac (rasped),  3 iv.
                      Aq. Com.        2 quarts.
   Macerate twelve hours, reduce it to one half, then add:

                       Rad. Glycchir.   § i.

   Sarsaparilla is stifi used in the form  of decoction during the
 administration of mercury, especially in the treatment of the con-
 secutive  accidents.   With  some practitioners, it is  from custom
 rather than from any conviction of its utility, that  it retains its
 place.  It enters besides into  the composition of certain tisanes and
 syrups, as we  shall hereafter  show;  as for  example, in the tisane
 of Amoud, and the syrup of  Cusinier.
   The simple sarsaparilla tisane is prepared according to the follow-
 ing formula: 
330
VIDAL ON VENEREAL DISEASES.
                    I£.  Sarsaparilla,  3 iv.
                        Aq. Com.    2 quarts.

   Macerate twelve hours, and aftencards bruise the roots in a marble mor-
 tar, and reduce to one half the quantity.

   The tisanes of China root, of sassafras, and other sudorific woods,
 are prepared in the same manner.  The roots of lobelia and astra-
 galus are no longer used.  As to the soapwort, its leaves are much
 used at the present day, in the preparation of a tisane in which the
 hydriodate of potassa is dissolved.


      X.—COMPOUNDS, PARTLY MINERAL, PARTLY
                        VEGETABLE.

   If with an unprejudiced mind we carefully examine the majority
 of these compounds, we shall soon become  convinced that  their
 efficacy depends  on the mineral substance they contain.  Thus,
 the syrup of Cusinier alone possesses no efficacy, but united with
 corrosive sublimate it then becomes a powerful remedy.  The
 tisane of Rittmann is of therapeutic value only on account of the
 proto-chloride and the sulphuret of mercury  that it contains; that
 of Feltz is due to the sulphuret of antimony, and thus it is with all
 the tisanes, all the compound syrups, and all the robs ; when uncom-
 bined with other agents they have but a moderate action.
   I give the formulas for two of the compounds which have enjoyed
 the  greatest  reputation, and the  absence of which might here be
 regretted;  I refer to the syrup of Cusinier and the tisane of Feltz:

                      SYRUP  OF CUSLNIER.

                 $.  Sarsaparilla,       fti.
                     Aq. Com.         foxii.

   Macerate for twenty-four  hours, and reduce to four pounds.   Having
 decanted the liquor, subject what remains to the same operation twice.  Mix
 these three decoctions, and add:

                     Flowers of borage,  § ii.
                     White  Roses,      f ii.
                     Aniseed,          | ii.
                     Senna,            § i.

   Boil until reduced one half;  add:

                     Sugar,            %i
                     Honey,          g,i.

   Dose, half a glass  three times in a day, with the sarsaparilla tisane.

   This is the syrup of Cusinier, of the first, second, and third boil-
ing,  that is after we add one, two, or three grains of the bi-chloride
of mercury to each  pint of the  syrup, according as we wish to 
SYPHILITIC ERUPTIONS.
331
increase, or more properly speaking, to  realize  its anti-syphilitic
virtues.
  M. Baumes prescribes, morning and evening,  with two or four
tablespoonfuls of the syrup of Cusinier, half a tablespoonful, or a
whole spoonful of Van Swieten's liquor, the dose of which is gradu-
ally increased.
  In the place of the deuto-chloride we may introduce into the
syrup of Cusinier, the cyanuret of mercury, which is less easily
decomposed.  But M. Baumes observes that we  must then atten-
tively watch the administration of the syrup when this addition
has been made, its action on the digestive organs being severe:

                       FELTZ'S TISANE.

               ^.  Sarsap.              § ii.
                   Icthyocol.            3 iiss.
                   Sulph. Ant. (washed,)  § iii.
                   Aq.                 Riv.

  Evaporate to one pound.  A glassful to be taken daily.  The sulphuret
of antimony is ordinarily washed in boiling water.

  M.  Rayer, who employs  this preparation,  very frequently re-
marks that we thus remove a large portion of the arsenic contained
in the sulphuret of antimony, by which its efficacy is  partly de-
stroyed.   But as the proportion of the  arsenic contained in the
tisane is sometimes  too considerable when the antimony is not
washed, M. Rayer often prescribes,  in the place of the tisane of
Feltz, the following:

         M. RAYER'S MODIFICATION OF FELTZ'S TISANE.

                  I£. Decoc. Sarsap.   3 xvi.
                     Arsen. Sod.     gr. ■—.
                       CHAPTER,  II.

ON SPECIAL CONSECUTIVE VENEREAL AFFECTIONS.
                         SECTION  I.

                 SYPHILITIC ERUPTIONS.

  S'/1 drilida. — Syphilides.—Syphiloderma. —When the  syphilitic
virus has infected the systemin a certain manner, various eruptions
are produced upon the skin.  They assume almost ever}- element-
ary form of cutaneous disease, but have certain peculiarities which
reveal their nature. 
332            VTDAL ON VENEREAL DISEASES.
  So common and grave were the  affections of the skin in what
was called the epidemic of the fifteenth century, that they did not
fail to attract the special attention of observers.  From that  epoch
to a period  nearer our own, every syphilitic eruption was con-
founded under the name  of pustules.  In calling these eruptions
syphilides,  Alibert rendered a double service to science:  he created
a happy and precise denomination, and contributed to destroy the
false idea to which the word pustule, used as a generic term, gives
rise.   But it is to Biett and his pupils that we are indebted for the
proper application of  Willan's method to the  study of  the syphil-
ides, and for a classification based upon the elementary lesions of
the skin.  No one can deny the advances here made by this school;
but it is equally true that much yet remains to be learned in the
study of these eruptions.


                L—GENERAL CHARACTERS.

   I proceed, in the first place, to describe the general characters of
the syphilitic eruptions; I shall afterwards classify them, and study
each variety according to the divisions established since the  school
of Biett.
   The syphilitic  eruptions .present a physiognomy that cannot be
mistaken when once the attention has been fixed upon them. This
physiognomy consists in  the color, form,  chronicity,  and  marks
which they leave behind.
   Color.—The color of these eruptions, the ham-color of Fallopius,
the copper-color of Swediaur, has always arrested the attention of
observers.  It is  still regarded as the most characteristic feature,
that on which the differential diagnosis of these eruptions is based,
that which distingushes them from simple eruptions or those of
any other nature.  And yet  the value of  this test has been dis-
puted and even denied!   It is true, that after certain  ulcers, cer-
tain simple  eczematous eruptions, especially on the legs, we  ob-
serve the  skin to assume nearly the same tint; sometimes, also,
the spots  of purpura, before they disappear, become of a faint red
color; but  the slightest  inquiry into the circumstances preceding
the first stages of the disease will remove all doubts.   Instead of a
weH-marked tint, there sometimes exists a shade difficult of detec-
tion.   Fallopius was the first to remark: non enim ruber, non albus,
non pallidus.  There  are  cases, says M. Cazenave,  where the red-
ness  is but  slight, the tint varying from this to a  gray color.
Again, the shade may depend upon the  period  of the disease as
well  as other circumstances: thus, at the moment of the erup-
tion of roseola, of the papular form of the disease, the color is of a
bright red,  which becomes darker as the eruption becomes more
distinct, as  is represented in plate 5, fig. 1.   Is this owing to the
vascular congestion in the  first period masking the alteration of
the chromatogenous  apparatus ? or is it rather owing to the fact
that this apparatus is not yet modified ?  There are cases in which
we may distinguish  the two colorations:  thus, in certain tuber- 
SYPHILITIC ERUPTIONS.
333
cular affections, by pressing with the finger and emptying the ves-
sels, we may cause the redness to disappear; but the copper color
remains, because it depends upon a matter which is combined with
the layer of the  skin.   In the last stages of certain  lenticular
squamous syphilitic eruptions, we  observe the  coppery red pass
into an obscure grayish yellow, which is called the dirty coppery
yellow.
  The quinine tubercles and pustules leave behind livid spots of a
dark red color, like the ecchymosis  of purpura.  But even then,
if we carefully examine the whole surface  of the  skin, we shall
find places exhibiting  the coppery-red color.  Sometimes, instead
of being effaced by the long standing of the disease, the redness
continues and becomes more distinct.  Thus, we occasionally find
red spots long after the eruptions have disappeared.   Cold appears
to affect the color of certain of the syphilitic eruptions;  roseola is
one of those which it renders more apparent.
   The persistence of the color of these eruptions, their chronicity,
and the impossibility of causing them to disappear by pressure,
seem to prove that the affection, in these cases, is seated between
the epidermis and the dermis, in what is called the rete mucosum—
in other words, in the chromotogenous apparatus, of which the
secretion has been altered.
   I have already spoken of the varieties of tint which are peculiar
to the period of eruption;  I should add, that on the base, to speak
classically, there are individual shades, which depend upon modi-
fications in the integument, and its vascularity.   Thus, in certain
subjects with a fine white skin, the redness is lively in roseola, and
lichen, and especially as I have  already stated  at  the commence-
ment of these eruptions. Towards the termination,  in males whose
skin lacks transparency and vitality, the color  is always  duller;
often it is violet.  In  persons of a  bilious  temperament, the  red-
ness assumes a brownish shade.  In those of a cachectic habit, the
tint approaches that of a venous injection, being livid.   I have
now under my care a corpulent patient, of a very  lymphatic and
apathetic temperament; he has had an indurated chancre, and this
has been followed by livid spots  upon the skin, which I should
 never have regarded as syphilitic, had I not seen the development
 of all of the phenomena.  It is in such subjects that the cicatrices
 of the syphilitic eruptions which ulcerate, have a blueish appear-
 ance.   In conclusion, the  coppery tint is one of the best signs, for
 it  seldom occurs in other than  syphilitic affections; it may  of
 itself, in certain cases,  establish the diagnosis, but it must then be
 very decided, so as not to be masked by any complication with
 other diseases.  In every case we should observe all the features
 which complete the physiognomy of a syphilitic eruption.
   Form.—The most important symptom, next to the color, is the
 form of the eruption.  It is generally curved, circumscribing por-
 tions of a circle, or entire circles, or roundish spots.   This is ob-
 served not in isolated places only, and limited to small portions of
 the surface,  but whole groups of vesicles, of tubercles and scales
 are thus surrounded.  True, this feature is wanting in certain of 
334             VIDAL ON VENEREAL DISEASES.
the eruptions, as in the papular  form, and it is  found in some
cutaneous affections than the  syphilitic,  for simple herpes  may
assume the circular form.  But there are eruptions which do not
exhibit this  character, except when they  are of  a specific, of a
syphilitic nature:  thus, the elements of the tubercular eruption
grouped together, are surrounded by a circle more or less complete,
more or less perfect.  What is remarkable is, that we see, occa-
sionally, the  circle  formed partly by one and partly by another
organ:  thus, in the horny syphilitic eruption, we sometimes ob-
serve a segment of a circle  on the palmer surface of the  finger,
whilst the other segment is  inscribed upon the  adjoining  finger.
I have under treatment a patient who is affected with herpes cir-
cinnatus on the genital organs; one-half of the circle existe on the
root of the penis, the other upon the scrotum (plate 6, fig. 1).  For
a long  time  this  singular disposition of syphilitic eruptions has
attracted the attention of observers: thus the term corona veneris is
a very old one.
   Chronicity.—A syphilitic  eruption  being essentially  a chronic
affection, we find that the sensibility of the parts is  but little modi-
fied ;  thus, there is neither acute pain nor pruritus, even in those
forms assumed by the eruptions which, in  their simple state, are
sometimes remarkable for their  intolerable itching.    Heat is  a
symptom which is  also absent.  However, even  here, we must
not be too absolute, and deny any changes  of sensibility or of the
temperature,  in every stage  of  the  eruption.  Thus, of seventeen
patients, M.  Legendre remarked  that thirteen  suffered not the
slightest pruritus, but three complained of  it a little, while  in the
fourth, it was very severe.   During the first stages of a tubercular
eruption, it is not uncommon to hear patients say that they feel an
itching sensation in the evening, when they begin  to get warm in
bed, and facts are not wanting to show that a true febrile excite-
ment has preceded a syphilitic eruption.
  The chronic character of these affections is due,  not only to the
absence of alterations  of the sensibility in the majority of cases,
but to the slow pathological  processes which are observed in cer-
tain forms.  Thus, in the pustular  form, we sometimes  observe  a
large indurated base, surmounted  by a small suppurating  point;
in the vesicular variety, we  find the vesicle remaining unbroken,
and preserving its transparency for  four, five, or six  dnys, sur-
rounded by an areola, the redness of which soon  fades.
   Ulcerations.—These are  much more frequently observed as sec-
ondary lesions of  the syphilitic than after  ordinary eruptions, for
herpes zoster and ecthyma alone  offer this peculiarity.   The exca-
vated ulcer of the  syphilitic eruptions is generaUy of a regularly
roundish form, with reddish, perpendicular edges, with a grayish
and sometimes a bloody base.   These characters are especially to
be seen on the lower extremities.   Occasionally the ulcer assumes
an  oval form; sometimes its edges are  irregular  and scalloped;
then a  group of smaU ulcers  is confounded into one of larger
dimensions, the edges of which involve a portion  of the circum-
ference of the constituent ulcers: in this manner it is enlarged by 
SYPHILITIC ERUPTIONS.
335
the process of ulceration.   There is another method, viz., mortifi-
cation :  thus, at some point of the circumference, the dead skin
and the separation of the eschar produce a loss of substance which
enlarges the ulceration.   I shall return to this phenomenon  in
describing the serpiginous ulceration.  Most generally the ulcer
increases regularly in all directions, and is arrested only when it
has attained a certain diameter: thus, M. Legendre remarks that
he has never seen a cicatrix of an isolated ulcer present a diameter
of more than a five-franc piece.  The ulceration of a syphilitic
eruption has a much more decided tendency to reparation than
that which supervenes on other cutaneous  affections.  It remains
but a short time stationary, and tends rapidly to heat, whilst non-
syphilitic ulcerations of the extremities remain unchanged for two
and even three years.  But, most frequently, during the cicatriza-
tion of  a syphilitic  ulcer  at one point, another is progressing  at
another point;  or, if but one ulcer exist, whilst  one portion of it
is undergoing reparation, another is enlarging its dimensions: the
ulcerations losing nothing  in this contest with  the reparative
forces.   Thus, taking the syphilitic ulcer altogether,  we see that a
very long time is required for its cure.
  I treated, in Ward 11, Bed 26, a barber, who was  affected with
both forms of the  serpiginous ulceration to a truly incredible ex-
tent, and in this case I obtained extraordinary success from dress-
ings with the vigo cum mercurio.   This patient had  an indurated
chancre on the  penis, several superficial eruptions, ulcerations  in
the throat, and syphilitic engorgements of the testicles ; last of all,
he  had  large ecthymatous pustules, which ulcerated to such an
extent, that on the 15th December, 1851, the right inferior extrem-
ity presented two enormous solutions of continuity, which nearly
came in contact with each other;  one was situated on the external
border of the right thigh, reaching from the knee towards the
trochanter, being nineteen centimeters six and one-third inches in
length, and three and one-third in breadth; the  other commenced
immediately below the patella, occupied the external, anterior, and
somewhat of the internal surface of the leg, extending towards the
foot, and  was five inches  in  length,  and  six and two-thirds  in
breadth.  On the  external  surface of  the  knee, these two ulcers
were  not more than some two-fifths of a line distant from each
other.   Three smaller ulcers  were scattered on both lower ex-
tremities ; on the left calf of the leg, and the popliteal space, there
were two, one of which was  of the size of  a five-franc piece, the
other of double the size.   The patient was  in a very serious con-
dition, being exhausted  by the suppuration.  Internal and exter-
nal treatment had failed.  I then applied the dressings with little
bands of the vigo.  They were made to overlap as in the dressing
by occlusion; they were  renewed every three days,  and at each
dressing there was a decided improvement, so that in less than a
month, reparation was complete.  The patient regained his embon-
point, and his general condition was very satisfactory.   Sometimes
under the influence of this treatment, the patient became  affected 
336
VTDAL ON VENEREAL DISEASES.
with a mercurial ulceration on the alveolar border of the lower
jaw, and there was the commencement of a salivation.
   This case is highly instructive.  We here see a patient who had
been subjected  to  various external and internal measures:  1st,
simple cerate, opiated cerate, dressings of aromatic wine, repeated
cauterization, emollients, solutions of iodine ;  2d, combinations of
mercury and iodide of potassium ; simple mercury, iodide of po-
tassium alone, the preparations of iron, cod-liver oil, all failed.  I
employed the dressing already mentioned, and this measure was
crowned with speedy success.   Was it owing to the physical, local
action of the plaster,  or was it the result both of the local and the
general action?  I have  stated that the mouth became affected
as during a mercurial treatment, and we know that the vigo con-
tains mercury, and that it was applied to very large surfaces.   In
this case, then, a feeble subject, in the last stages of syphilis, was
cured by the external application of the mercury !
   Cicatrices.—The cicatrices left by syphilitic eruptions generally
present the following characters; they are circular, and more or
less depressed; when recent, they have a bronze color,  and some-
times their tissue is  slightly  prominent; beneath  the  epidermis,
we see the superficial vessels  broken; at a later period these be-
come effaced, and a kind of internal absorption seems to be estab-
lished ;  they lose their violet  tints, become white and more de-
pressed ; their surface, of a dull white color, is also tense or corru-
gated, shining or swollen, and sometimes furrowed with hard and
prominent bands.  Under certain circumstances they are white
from the first, but of a blueish white; they are then surrounded
by a coppery areola which tends constantly to  diminish, and the
color of which is gradually lost in the surrounding skin.  Syphil-
itic cicatrices may present bands similar to those following exten-
sive burns; they sometimes degenerate  and become covered  with
a kind of keloides.  This phenomenon has been noticed particu-
larly to occur on the cicatrices of certain cases of rupia,  and of the
serpiginous tubercular variety.  When I come to treat  of this
form, I shall relate a very remarkable example of this cicatricial
degeneration.


                       IL—VARIETIES

  Having described the general character of the syphilitic erup-
tions, I proceed, in the next place, to study them in  particular.
Following  the  example  of  M. Cazenave, I shaU establish seven
varieties:

           1.  Exanthematous.   (Fig. 1, pi. 5.)
          2.  Papular.        (Fig. 2, pi. 5.)
          3.  Squamous.       (Fig. 3, pi. 5.)
          4.  Vesicular.       (Fig. 1, pi. 6.)
          5.  Bullous.        (Fig. 4, pi. 5, et fig. 2, pi. 6.)
          6.  Pustular.        (Fig. 3, pi. 6.)
          7.  Tubercular.      (Fig. 5, pi.  6.) 
Pi  5.
m  2.
0
/'S
*&
**y.


.tr^i
»*

Efi. 3

4f
Fio  4
i,: i ;^lw~/.
iQ £ rAA.v/r  Fifi 3 < '/j";sivrjr<> flu.4-  ,"S"trt/insytiuJ
S 
 
PL 6.
,** ™ ^
>'  4
') j
^
Fid  2
w?
^  ;#  v^
^
%
•^
^
Fid. 3.
 
 
SYPHILITIC ERUPTIONS.
337
  At the head of each variety I shall offer a few remarks on the
corresponding eruption regarded in its simple states, and this for
the benefit of the young practitioner who may not remember facts
which are indispensable in the study of these eruptions.

           EXANTHEMATOUS SYPHILITIC ERUPTIONS.

  According to Willan, the  exanthemata are characterized by
red spots  of different  forms,  and scattered irregularly over the
the surface  of the body, the  skin retaining  its natural  color in
interspaces, and the eruption terminating in the exfoliation of the
epidermis.   This is the most common  form of the syphilitic erup-
tions.
  Roseola.—The syphilitic eruption which naturally comes under
this category is the roseola, which strongly resembles, both by the
disposition of its spots, and sometimes even by its  tint,  common
roseola, rubeola.  But the syphilitic eruption sooner or  later as-
sumes the coppery tint (pi. 5, fig. 1), and towards its termination,
a grayish shade.  The color slowly disappears under the pressure
of  the  finger,  and  generally  it  does  not  perfectly  disappear.
Roseola is observed principally on the anterior part of the base of
the chest, the  neck, face, and extremities, particularly the supe-
rior.  The eruption  has no particular form; the patches are ir-
regular, sometimes circular; at first  view they appear somewhat
elevated, but this  error  is soon corrected by passing the finger
over them.  They  gradually increase in  numbers, sometimes rap-
idlv, so that the, whole eruption is established in twenty-four hours.
The color of  the  roseola may vary during the progresss of the
disease, either from known or unknown influences.  Thus the
spots become more distinct under the influence of cold after emerg-
ing from a bath, and mental emotions may cause the  reappearance
of an eruption which for some time had disappeared.  This phe-
nomenon occurs especially in cases of chronic roseola. Sometimes
in the place of a coppery-red color it is a yellowish redr constituting
the salmon-colored skin.  (J. S.  Petit,  Hennen.)   Finally, a period
arrives when there is a very slight exfoliation  of the epidermis, the
tint becomes grayish, and  the portions of the skin which  have
been colored now  appear as though they were only dirty.
   Most generally  roseola is not preceded by any febrile excite-
ment, and the patient is sometimes astonished to  find his body
red, a iact which serves to distinguish this syphilitic eruption from
the corresponding simple exanthemata, and from rubeola.  But in
some eases we observe febrile  reaction from acute affections of the
skin; these eases  are  rare.   What is much  more common, is to
notice  a  slight indisposition  for two  or three days,  lassitude,
cephalalgia, and wandering pains in  the  limbs,  the pulse not
being sensibly affected.
   ltogeola  occasionally assumes a character somewhat acute, and
we then observe febrile symptoms before, and even  after, the ap-
pearance of the eruption; the patient then also experiences a kind
of pruritus, which, however, is very rare, for roseola is accompa- 
338             VIDAL ON VENEREAL DISEASES.

nied neither by heat nor itching.  These characters belong espe-
cially to- the exanthematous eruption,  which follows soon after
chancre,  the starting point of the disease, and  with which  the
eruption may co-exist.   The duration of this form of roseola varus
from three  to  four weeks.  Those who have spoken of two or
three days probably  do not know that the eruption, in certain
cases of roseola, becomes so pale as  to lead to the suspicion that it
has disappeared, though it soon becomes again distinct.
  Chronic roseola is  not attended with febrile excitement, either
before or after the eruption.  It is  sometimes developed by men-
tal excitement,  or  any excess.  It lasts for several months; and
occasionally for a longer period.   I  was astonished  to  read  the
following in the work of M. Cazenave: " Roseola is one of  the
forms of syphilitic eruptions least frequently observed."  Accord-
ing to my experience, on the contrary, it is one of the most com-
mon.  This difference in opinion probably  results  from the differ-
ence in our fields of observation.  M.  Cazenave is  attached to  the
hospital  St. Louis, where  patients enter long after they  have  be-
come infected with syphilis, and at a time when roseola has dis-
appeared, and no account is taken of it among the antecedents of
the  case. At  the  Ilnpital du  Midi, patients  are  admitted at an
earlier period,  so as generally to be treated for the first  stages of
syphilis.  Then, when  they  remain for some time, the first  ap-
pearance of  the  syphilitic eruption  is observed.  Now roseola
occurs the first after the primitive accidents, at least in the major-
ity of cases.   It is therefore possible,  that more cases of  the kind
are seen at the  Hfipital du Midi than at the St.  Louis.
  M. Cazenave classes under the exanthematous  syphilitic erup-
tion, a papular erythema, which, in  my opinion, and that of other
writers on syphilis, has all  the characters of the eruption  observed
after the administration of  copaiba, and which quickly disappears
on the discontinuance of this remedy.   This is certainly improper.
  Roseola is often blended with some  other eruption; it frequently
precedes the papular form, which seems  the second stage of a
consecutive affection of the skin.  A very common accompaniment
is an affection of certain mucous membranes, as of the throat, anus,
vagina,  prepuce, and glans.

               SYPHILITIC PAPULAR ERUPTION.

  At the close of the first chapter, I have spoken of papules which
appear  on the mucous membranes and adjacent portions of the
skin.  These papules are  generally more or less large, confluent,.
and moist; they are also called mucous tubercles. Those under
consideration are  smaller  and harder, they are distinct  and dry,
secreting no purulent matter ;  they terminate  by  desquamation or
simple resolution.  Fig. 2, plate 5, gives an exact representation
of a syphilitic  papular eruption.   We there see elevations, some
of which are larger than a pin's head, others the  size of a lentil;
their summit is covered with a httle crust;  all are surrounded by
.a copper-colored circle; they  are  scattered irregularly, some in 
SYPHILITIC ERUPTIONS.
339
groups, others are isolated.  They were particularly numerous  on
the anterior surface of the base of the chest, and on the abdomen.
The patient was fifty-four years of age;  and occupied Bed No. 4,
Ward  12, of my service.  It was preceded by an indurated chan-
cre on  the prepuce,  which  appeared on  the 20th  January, 1852,
whilst  the eruption  first showed itself on the 19th of the following
March.  Papules may appear  on all points of the  skin, but they
are more common on the back, shoulders, and nape of the neck.
After  an uncertain  duration,  they  terminate,  in the  majority  of
cases, by resolution ; they leave behind  only a slight tawny stain
at first, which gradually assumes the color of the skin, and finally
completely disappears.   Sometimes,  and especially  when  large,
they are covered, as it were accidentally, with a very light scale,
which  adheres  but  slightly.   M. Cazenave has several times seen
not only spots, but  little, genuine cicatrices follow these papular
eruptions at certain points, although these papules had not ulcer-
ated, an occurrence which is, at least, very rare in  the papular
form of syphilitic eruptions.
   Syphilitic Liehen.—This manifests itself in the form of very small
pimples, which are  often innumerable;  sometimes they may  be
called confluent, and then they present a kind of brilliancy which,
added  to their coppery color, constitutes a very remarkable tint.
According to Carmichael, this eruption often accompanies a blen-
norrhagia ; it also appears  almost  always like certain acute exan-
themata, that is nearly simultaneously, having been preceded by
cephalalgia, lassitude, anorexia, and occasionally even with a little
fever.   Syphilitic lichen is ordinarily of short duration, that is, it
may disappear in the course of a fortnight, by resolution.  It may
fade, and somertines there is a slight, imperceptible desquamation,
leaving only spots, which do not long continue.  These, I repeat,
are the ordinary characters, and  this the ordinary progress of a
syphilitic lichen ; it  may, however, pass under the same form into
a chronic state.
   Syphilitic broad papular Eruption.—The papules  in these cases
are preceded by small, yellowish, and very regular  circular  spots;
they are always isolated, and distinct, and generally scattered over
very extensive  surfaces, which are  successively invaded;  some-
times we observe them of a firm consistence, very prominent, and
of a decidedly copper color; at another point,  we find little eleva-
tions already hided, less prominent, of softer consistence, and of a
paler tint ; on one side aie yellowish spots with a rosy tint,  which
are in  proeess of being converted into papules ; on  the other, they
are of  a grayish shade, more depressed  than the  latter, and the
marks   left by the  papules which have  disappeared.  They are
separated by intervals,  at which the skin is of a peculiar earthy
color, giving to the whole a very characteristic aspect.
   These papules occur particularly on the extremities, shoulders,
nape of the neck, very frequently on the forehead, and sometimes
even on the hairy scalp.  Occasionally the patient suffers pruritus,
but it is always very moderate. Sometimes the papules are covered
with pellicles, which never exist simultaneously at  every point of 
340             VIDAL  ON VENEREAL DISEASES,
the eruption.  The pimples often remain intact.  This form con-
stantly pursues a chronic course: it may continue  stationary for
several  months, until the papules disappear by a slow and im-
perceptible resolution.  They may be complicated with  other ve-
nereal eruptions, or other consecutive accidents, such as secondary
ulcerations of the  throat, exostosis, or what is still more  common,
iritis.

               SYPHILITIC  SQUAMOUS ERUPTIONS.

   The squamous affections of the skin are  characterized by the
formation of the gayish white, dry scale, which is more or  less
thick and  adherent.  In the syphilitic eruption, these scales are
formed in a more or less elevated surface, which is of a dark red,
or coppery color.
   Syphilitic Psoriasis.—These patches  occur  on  one or several
regions of the cutaneous surface (pi. 5, fig. 3); there may be inter-
spaces,  or they may sometimes exist  in close  contact.   Their
breadth varies  from that of a lentil to that of a franc piece, or it
may even exceed this measure; they are more or less irregularly
circular, and are elevated beyond the adjoining parts.  They are
covered  with shining scales; when  they become detached, the
surface remains smooth and of a dark color.  According to Biett,
when this variety resembles psoriasis guttata, when the scales fall
off, the patch  is surrounded by an adherent white narrow border.
This is of frequent occurrence, but not sufficiently constant as to
establish a pathognomonic sign.
   Syphilitic Lepra.—It is probable that this is the affection chiefly
described under  the name of lepra  nigricans, aad which by M.
Ricord is called syphilitic annular eruption.  The patches are per-
fectly circular, from two lines to half an inch in diameter, and
generally of a  deep brown  or violet  color, or even of a blackish
tinge in  their centre.  Their edges form a circle more or less per-
fect, and are raised above the level of the surrounding parts.  This
circle is sometimes enlarged by the healing of the portions  corre-
sponding to the centre,  and the development of these at  the cir-
cumference.  The color is here, less dark than at the  centre of the
patches ; but if the affection continues without an increase of its
dimensions, the skin resumes its normal color in the centre, and
the circles alone remain colored for a  longer or a shorter time. In
the majority of cases, these circles arc formed by a tumefaction of
the tissues, but there are those  in which the scales are alone ob-
served ;   then, in becoming detached, they leave beneath  a  circle
which does not project, but which  is  simply a reddish narrow
border.   In other instances  these circles are formed by more or
less perfectly-developed papules  in contact with each other, and
whose summits are covered with crusts of greater or less thick-
ness ; the circle has then the appearance of honey comb.  These
circles meeting at different points, assume the form of the figure 8 :
when they are imperfect they are like the figure  3, or the letter S.
This form is very common. 
SYPHILITIC ERUPTIONS.                 341
  When syphilitic psoriasis and lepra affect the palms of the hands
and the soles of the feet, which is of very frequent occurrence, the
scales are thicker and  harder, resembling horn (syphilide cornee), a
fact which  is  explained by the nature of the epidermis in these
regions.  If, on the contrary, the skin be moist and contiguous to
mucous membranes, as in the vicinity of the arms, the vulva, and
the genito-crural fold, the scales are soft and pultaceous.

               SYPHILITIC  VESICULAR  ERUPTION.

  By the term vesicle, in cutaneous pathology, we understand an
elevation of the epidermis, by a serous or a sero-purulent humor.
When the latter is sufficiently abundant to produce a small tumor,
it is called a bulla.   Thus, we speak of the vesicle" of eczema, and
the bulla of pemphigus.
  The vesicular form of eruption was, until recently,  considered
exceedingly rare, because it was not  often observed, or to speak
more  properly, we  did not know how to observe it.   It assumes
all the forms of the simple affections of the skin which  are charac-
terized by vesicles.  Thus, we  have an eczema, a syphilitic herpes,
and a varicelloid syphilitic eruption.
  The vesicular eruption occurs on  almost every portion of the
skin, but particularly on  the neck, chest, and extremities, especi-
ally the superior extremities: it is seldom seen on the  face, where
venereal eruptions so often occur.   It sometimes appears shortly
after the primary  accidents  have disappeared; it happens even
that it has begun before the  latter have completely subsided.  We
know how rapidly the  vesicles of herpes become discharged.  The
vesicular syphilitic are  often complicated with other forms of syph-
ilitic eruptions and with angina;  and there are also pains in the
extremities.
  Syph ilitic Eczema.—This variety appears under the form of small
transparent vesicles, like those of simple eczema, but a Httle more
elevated; they form irregular groups  scattered in  various  places,
and are surrounded by a coppery circle.   At other times the erup-
tion consists  of patches of characteristic redness, not very bright,
and covered with very large prominent vesicles of more than or-
dinary hardness, and which remain  a  long time unbroken and
stationary;  ordinarily the fluid of the vesicles preserves its trans-
parency, or  becomes but slightly turbid; they become faded, the
areola or coppery patch is more tawny and gray, the fluid is ab-
sorbed, the epidermis subside, and there remains but a slight ex-
foliation, which contrasts ordinarly by the brightness of its narrow
border  with  the peculiar tint of the skin  first occupied by the
vesicle.  This is the progress of the most common form of syphi-
litic eczema.
  M. Cazenave has  described an impetiginous  eczema.   It consists
of groups of vesicles which cover patches of very bright  redness
and of variable extent.  These vesicles, at first transparent,  are
turbid, the fluid is sero-purulent; they become covered with crusts.
There  are  successive  eruptions which  follow a  similar  course; 
342             VLDAL ON VENEREAL DISEASES.
 sometimes the vesicles rest on copper-colored patches; the scabs,
 of much greater thickness than those  of simple  impetiginous
 eczema, have the character of other syphilitic scabs; they  are
 black, conical, furrowed,  thick, and adherent.   M. Cazenave once
 observed the  crust  covering the ulcerations  of a perpendicular
 form, and of such depth, that they left behind so many depressed
 cicatrices.  " This disease," he remarks, " had lasted for  several
 months, always retaining the same  unmistakable  characters, and
 nearly always presenting at the same time each of the lesions I
 have mentioned.   A number of depressed cicatrices  were  left,
 which covered the whole anterior surface of the abdomen."'x'
   M. Rayer observed a remarkable case of syphilitic eczema, and
 the following  is an  analysis of his report: " The eruption  was
 seated on the fore-arm.  There were small irregular groups nearly
 the size of a dime (American) piece, consisting of small  reddish
 elevations, not pruriginous, and of the size of  a pin's head ; they
 contained a turbid  or opaque  matter.   The  vesicles were more
 prominent, globular, and  as  voluminous, than those of simple
 eczema.   They  were  smaller, less  transparent, and disposed in
. more irregular groups than those of herpes.   Their reddish  and
 slightly livid hue served to distinguish them from the pustules of
 impetigo.   At other points were to be  found  little circles analo-
 gous in form and size to  those of rubeola.   In  some of these
 groups several sunken vesicles were  replaced  by a slight  exfolia-
 tion of the epidermis, distinctly presenting at several points a
 narrow border which indicated the size of the vesicles.   Where-
 ever the exfoliation had just commenced, there were spots having
 completely the hues  of ordinary syphilitic maculaB.  Finally, this
 eruption differed from psydracious pustules in  this, that the eleva-
 tions in the latter were more voluminous and acuminated,  and are
 commonly followed by crusts and sometimes by cicatrices, f
   Syphilitic Herpes.—Here we have  vesicles arranged in  circles,
 as in herpes circinnatus.   The breadth of these  circles varies
 from that of a fifty-centime piece to that of two francs.   Syphi-
 litic herpes, besides the antecedents and  other concomitant lesions
 of the same nature, is characterized by a coppery tint of the  por-
 tion of the skin occupied by the circles, a tint which at  a later
 period  becomes of a grayish hue.   These  circles  are not very
 numerous, and are widely separated, since the eruption may simul-
 taneously occupy even one  or  two  regions, and  be represented
 by one circle only.  As I have already stated, I have seen a  case
 where  the herpetic circle occupied  partly the  root of the penis,
 and partly the scrotum.  It is not unusual to observe this in  the
 other syphilitic eruptions.   M. Cazenave has described a syphilitic
 herpes  which corresponds to a variety  of simple  herpes.   The
 discs are most frequently very small  and numerous.  They occur
 principally on the chest and on the extremities.   On their  first
 appearance they may be covered by a pea, whilst at a later period
* Traite des Syphilides, p. 253 et suiv.
f Rayer, Maladies de la pcau, t. ii., p. 384. 
SYPHILITIC ERUPTIONS.                 343
the circle  may so enlarge as  to equal  that  of the preceding
variety.  The  vesicles are also very small, and become rapidly
desiccated,  a circumstance which sometimes leads to their being
undetected.  These patches may be mitaken for squamous discs,
if with a glass or a practiced  eye we do not discover numerous
points surrounded by epidermic debris, and disposed in circles.
To these characters may be added an inflammation of the area,
which seems elevated by a liquid which is speedily absorbed, and
a scale sometimes  sufficiently large to fill the circle.   According
to M. Cazenave, this is the most common form of the syphilitic
vesicular eruption.  If it had  not been described, it is because it
has at times been confounded with eczema and  pityriasis.   As
the discs are here very numerous and  scattered over large  sur-
faces, the syphilitic tint is very  decided.
   Syphilitic Varicella.—The vesicles here resemble the pimples of
varicella.   This is one  of the rarest forms of the syphilitic erup-
tions.  The vesicles appear at one point, rapidly, discharge, desic-
cate, and reappear at other points. Sometimes there is a well-marked
coppery red circle, sometimes  a very narrow border,  and some-
times an entire absence of redness around the vesicle.  The more
I reflect, the more I am  convinced that it was not this  form of
syphilitic eruption which occurred on the first  patient on whom
I first inoculated the secondary accidents.   This case I shall soon
relate; I called it syphilitic ecthyma in my report to the Societe de
Chirurgie.  But it will  be remarked, that in  my description of the
characters of the eruption, I have observed that the principles re-
sembled those of varicella.  We know, moreover, that by some
writers varicella has been ranked among the pustules.   There was
in my  wards  a patient, who was attacked by variola (for  it is
not uncommon to find variola  where we  find  syphilitis).  Soon
other patients  became affected with  analogous eruptions.  Two
patients who  had had chancres were seized with certain general
symptoms  analogous to those which are ordinarily observed in
eruptive fevers.  Then pimples appear strongly resembling those
of varicella.   They were smaller, and surrounded  by a reddish-
brown narrow border.   One of these patients would leave the  hos-
pital during the first stage of the eruption, and I lost sight of him.
I was able  to watch the other;  the vesicles  remained for a long
time, much longer than those in ordinary varicella, and afterwards
an ecthyma with large pustules followed,  particularly on the legs.
The syphilitic varicella  may be inoculated, as proved by the fol-
lowing observation:
  -------set. 26, of a lymphatic temperament, had several years since
a chancre, which, Avhen healed, left a little induration.  Two months
after  the chancre had disappeared vegetations  appeared on the
glans; these were excised and  cauterized.   No other  consecutive
accident supervened; the patient pursued no general treatment.
Five  years ago he contracted a blennorrhagia which was compli-
cated with  orchitis, and which  required five months for  its cure.
About five months since he had another chancre which  rapidly
cicatrized without leaving any induration.  Four or five days after 
344
VIDAL ON VENEREAL DISEASES.
 the  cicatrization of the chancre buboes appeared  in the groins.
 The patient then entered the hospital of Toulon, where a mercurial
 treatment was administered, but he left the hospital at the end of
 twelve days, and discontinued the treatment.  The  tumors  in the
 groins continued in an indolent state.  About twenty days after
 he left the hospital he discovered an enlargement of some of the
 cervical  glands; six weeks later very large pustules, full of pus,
 appeared on both arms and thighs.  The patient entered the Ilnpi-
 tal du Midi on the 22d October, 1849.   He was immediately placed
 under the  influence of  mercury. He took pills of  corrosive sub-
 limate for six days,  when the pus from the pustules was inoculated.
 These pustules resembled the  large  pustules  of varicella.   The pus
 was taken from two  different pustules on the left -wrist.  These
 pustules were intact.   Two punctures were  made on the internal
 surface of the thighs, one  on  each  side.  Two pustules, perfectly
 resembling those which had furnished the pus, -were speedily de-
 veloped, and four days  after the inoculation pus was taken from
 the pustules thus produced, and inoculated on the internal and
 superior surface of  the  thigh.   Two pustules similar to the others
 followed this second inoculation; all of the pustules thus produced
 corresponded perfectly with those which were spontaneously de-"
 veloped.  The patient took one hundred and eighteen pills.  For
 eight days past  he  has  taken  fifteen grains daily of the iodide of
 potassium; but a single pustule remains over the annular ligament
 of the left hand, and a slight engorgement in the left groins.   He
 asked for his discharge fifty-six days after his admission.
   I  would add, that I have never seen pustules so rapidly de-
 veloped as were those which followed the first inoculation.   It will
 here be remarked that seven years had elapsed since he was affected
 with the indurated  chancre on the penis, and that the other  symp-
 toms which had been manifested on that organ had  long since dis-
 appeared.  In conclusion, no primitive accident existed when the
 inoculation was performed.   No doubt can therefore be entertained
 in regard to the inoculation of certain secondary  accidents, and
 shortly afterwards I undertook some experiments, all the details
 of which will be found in the paragraph on the syphilitic pustular
 eruptions.  It will  then be seen that a secondary,accident was
 inoculated  from one  man  to  another,  and from the latter to a
 sound man.

                      SYPHILITIC BULL.E.

   The elevation of  the epidermis is here more considerable than
 in the vesicular variety.  These tumors are called bullce, they are
 regularly circular, and vary in size  from a pea to a goose egg.  I
 shall describe both forms, pemphigus, and rupia.
   Syphilitic Pemphigus.—This  is not described by every writer on
 syphilis.  It must be very rare in the adult, for I do  not remember
 having seen more than two patients at the Hopital du Midi in which
this eruption could be traced to syphilis, and these  two had had
chancres and roseola.  Having made no note of these cases, I can 
SYPHILITIC ERUPTIONS.
345
speak of them  only from recollection, which is too  imperfect to
render them of value.   But there is  at present,  in the  paying
department of the hospital, a patient who presents three bullae or
eruptions, in the form of pemphigus.   The following are the par-
ticulars of this case:
  T. (Claude,) aet. 24, a cooper by trade, temperament sanguine, con-
stitution good, admitted into room No. 5, on 19th September, 1851.
  Aug., 1S50. Two chancres, of from twelve to fifteen days' stand-
ing, were cauterized on the fourth day with  nitrate of silver.  In
the month of August, 1851,  a  bubo in the left groin was opened
by a chemist with caustic potash.   There existed also an excoria-
tion  at the margin of the  anus, which  the patient  attributed to
habitual  constipation.  Simultaneously with the bubo," there were
crusts  of impetigo on the scalp, ears, and whiskers.  Rheumatic
pains chiefly in the lower extremities.  Throat sound.
  At the moment of admission, there were crusts of impetigo on
the head and eyebrows; a  scar in the  left inguinal region, the
result of the potash ;  excoriations in one of the anal folds.  The
patient states that he  is subject to constipation, and to  a hemor-
rhoidal flux, which has many times been followed by ulcerations,
resembling  that with  -which he was actually affected.  The  rheu-
matic pains are not increased by the warmth of the bed.  On the
left side of the thorax, about on a level with the ninth rib, there is
a recent cicatrix, of  an oval  form, and of a coppery-red color.
(Plate 5, fig. 4, last spot.)
  Monday,  Sept. 22d. On the  left hand, on the dorsal  surface of
the fifth metacarpal bone, the epidermis  is slightly elevated by an
opaline serum.   No pains.
  24th. A bubo  of pemphigus has appears ; it has the breadth of
a half-dime piece; it is filled with a sero-purulent fluid, and is
surrounded by a red areola.  (Plate 5, fig. 4.)
  25th. The bulla has burst; in its place is seen a coppery-reddish
spot, which is dry, and a little elevated; in its centre  there is  a
small whitish point.  (Plate 5, fig. 4.)
  26th.  During  the  night, the bulla, which had formed again,
again  burst; the red spot  on which it  was situated is distinctly
circumscribed, hard, and not painful; ite coppery hue, is more dis-
tinctly marked.  The patient would leave the hospital, and he was
not again seen.
  I  would  here  remark that  this patient was young, robust, ple-
thoric, and strong.
  According to  the researches of Professor P. Dubois, syphilitic
pemphigus has been  especially observed among infante.  Krauss
studiedlhis disease as it is  met with  in  children, but he  did not
regard it as syphilitic.  M. Dubois asserts that it may assume this
character, aucl M. Cazenave, who  has  seen many children at  the
professor's clinique, is of the same opinion.  M. Depaul has most
commonly observed foci of engorgement in the lungs.(  In a me-
moir which was read before the Academy of Medicine, this honor-
able confrere maintained that this pulmonary lesion was related to
pemphigus; in other words,  that these engorgements were like 
346
VIDAL ON VENEREAL DISEASES.
those of the skin of a syphilitic nature.   M. P. Dubois defends the
opinions of M. Depaul.   M. Cazeaux is opposed both to M. Depaul
and M. Dubois.  According to M. Cazeaux, there is no  proof of
the syphilitic nature of pemphigus and pulmonary engorgements,
in the double lesion which  is found in infants.   As  to syphilitic
pemphigus, it is but  little  known, having never  been positively
seen in the adult;  in the infant it may depend upon  a state of de-
bility.   As to the engorged foci  found  in the  pulmonary paren-
chyma, they are also met with in  the foetus,  which cannot be sus-
pected of being affected with syphilis.  Thus, according to M.
Cazeaux, the previous existence  of syphilis in the parents would
be no positive proof  of the syphilitic nature  of  pemphigus and of
the pulmonary lesions  in  the child.  To establish  this, it  must
have been observed at other periods of life, and the pulmonary
lesions must  have special characters, characters which differ from
those where the lesions  are developed under other influences, as,
for example, cold.   M. Dubois replies, that children born with
pemphigus, or in whom it appears shortly  after birth, have the
aspect of old people, as is always the case in congenital syphilis;
nearly all of them die, and, in the majority of cases, we find proofs
of previous syphilitic infection on the part of one or both parents.
As to pemphigus, it is indeed rare, still it has been observed.  An
excellent example is represented in the Iconographie of M. Ricord,
and I have mentioned another.
   More recently, Professor Dubois has reported to the Academy
of Medicine the case of a woman completely infected with  syphilis,
who gave birth to a child affected with pemphigus; it died, and
at the autopsy engorgements were found in the lungs, and portions
infiltrated with blood.  I  repeat, syphilitic  pemphigus has been
seen in the adult.  It must, however, be confessed, that the ques-
tion is not yet absolutely settled.  But a practical question con-
stantly arises, to which  it were well a  solution might be given.
When parents have given birth to children who die with  pemphi-
gus, should the parents be subjected to an  anti-syphilitic treat-
ment ?  Should one of them  exhibit marks  of syphilis, there can
be no question as to the course to be pursued; the person affected
should submit to treatment.  But, must the  same  course be pur-
sued when both are free from all symptoms of the disease ?  If the
lesions in the child are really of a syphilitic character, it is  suffi-
cient evidence that the parents should be subjected to treatment.
Thus, we find that the question is constantly recurring.  Now, as
it cannot  yet be decided, in  a practical  point of view, we should
obey the dictates of common sense.  It may then be asked, is the
treatment to which the parents are required to submit, to prevent
the infection of the child in utero, attended with danger or serious
inconveniences.  Now, it is established that when mercury and
iodine are prudently  administered, they give rise  to  no accidents,
or but to slight inconveniences.  The anti-syphilitic treatment then
should be cautiously employed, and adapted to  the circumstances
of the parents.  I shall return to these questions when  we come
to treat of infantile syphilis. 
SYPHILITIC ERUPTIONS.                 347
  Syphilitic Rupia.—This is  characterized by large  bullae, which
are but little distended, perfectly round, and surrounded by a cop-
per-colored areola.  These bullae contain a darkish-colored humor,
which speedily dries, leaving a blackish crust, which is thicker
at the centre  than the circumference.  A violet-colored circle sur-
rounds these conical cruste,  which ulcerates, and always exceeds
the extent of the bulla that preceded it.  Beneath these crusts
are perpendicular ulcerations, which are sometimes of considerable
depth.
  The bullae of rupia are observed on all parts of the body ; they
vary in number and dimensions ;  they are generally few in num-
ber, and scattered irregularly over different parts.  There may be
six or eight, and sometimes from twelve to  twenty in number.
The smallest rapidly pursue their course, whilst the larger  are
more protracted  in  their progress.   In very rare cases, they are
widely and in great numbers scattered  over  the  surface of the
body; they are all of  nearly equal volume,  and resemble ecthy-
ma, from  which,  however, they differ in  their extent, the conical
form of the crusts, and their  elementary lesion, although, as in the
circumstances there is no great difference between the pustule of
ecthyma and the bulla of rupia, the  latter being more extensive
and superficial, and does not completely cover the diseased surface
like the pustule  of ecthyma.  (Cazenave.)  Syphilitic rupia may
consist of one or  two bullae only, situated more particularly on the
extremities;  they are then of considerable dimensions, which, is
increased by the progressive ulceration  at the base of  the crust.
Cicatrization may take place at certain  points, and especially at
the centre, whilst at other points the ulcer is covered with crusts,
principally at the  circumference, where  they seem to  be main-
tained by the succession of  several isolated  bulla?, and when the
ulcer assumes a phagedenic form.
   The gravity of syphilitic rupia is in proportion to the debility
of the subject.   It is  rarely complicated with  other symptoms.
Its progress is always slow.   Its  cicatrices are indelible, retaining
the circular form of the ulceration, and preserving for a long time
the characteristic impress of syphilis.  These cicatrices sometimes
degenerate, and  give  rise to what Alibert denominates Keloides.
Reparation is manifested by a drying of the crusts,  and fading of
the circle, at which point a  lamellar  exfoliation  occurs.   Plate 6,
fig.  2, represents a rupia on the superior extremity; reparation
has commenced.  The  crust  is divided into several  fragments.
We see the lamellar exfoliation.   Pressure with the finger on the
summit  of the  crusts produces  no discharge of serum.  On per-
cussion, they yield a dry and clear sound.   The crust falls off in
fragments, permitting  us to observe successively more consider-
able portions of the cicatrix.

                 SYPHILITIC  PUSTULAR ERUPTION.

   These consist in small tumors formed by the accumulation of a
 purulent humor  on the surface of the dermis by which the epider- 
348             VIDAL  ON VENEREAL DISEASES.
mis is elevated.  After  M. Cazenave, I shall describe a syphilitic
lentigo, an impetigo, and an  ecthyma.  This is an important section,
as we have here to consider, a form of  the secondary accidents, at-
tended with the formation of pus, in other words, with the circum-
stances most favorable to propagation by inoculation.
   Syph ilitic Lentigo.—According to M. Cazenave, this is the most
common of the pustular eruptions : it is the most frequently mis-
taken.  The pimples are distinct, isolated, of the breadth of a small
lentil, slightly  prominent,  of a very decided characteristic color,
imperfectly suppurating, and terminating by a small cicatrix, much
smaller than the pustule that has preceded it.  It may occur on all
parts  of the body ; it is disposed irregularly, and differs somewhat
in form according to its. situation.   On the  face, chest, and back,
it strongly resembles acne ; but its pustules are larger, more circu-
lar, and  prominent; in certain parts of their  extent, they suppu-
rate, when they become covered with  a crust, which is sometimes
very thick,  and which, when it falls, leaves a very broad, depressed
cicatrix,  that remains for a long time  like the base of a tubercle.
On the extremities, we find the pustules flattened, particularly at
their  base, which is broader,  and not so perfectly circular as in the
preceding case.  These pustules,  of a coppery hue, and a bright
red color  at the commencement, appear in the form of a small
lentil seed.  The spot which first appears is sometimes painful;
and evidently  presents  a slight elevation; the central point be-
comes prominent;  and we soon perceive, completely on its sum-
mit, a very small collection of pus, which disappears after one  or
two days, either by absorption, which is most rare, or by a rupture
of the summit, or by the formation of  a slightly-adherent crust in
the place of the coagulated humor, which crust soon becomes de-
.tached.   " Whatever may be the cause, the pimple has assumed
another  aspect; it now appears as a small, copper-colored papule,
which somewhat resists the pressure of the finger,  presenting at its
summit a small depressed cicatrix, which is sometimes completely
perforated in the centre, and which, particularly for some time,  is
surrounded by epidermic debris.   As the  eruption  advances,  it
loses  more and more its  pustular character; at  first view, it_  is
called a  papule, though  it  has several decided  features, which
should prevent such a mistake.  This  eruption, moreover, is for a
long  time kept up by the appearance of new pustules, so that it  is
easy, in  the majority of cases, to observe the  different stages  al-
ready mentioned.   This is the variety of syphilitic pustules which
is the most commonly mistaken; a fact which explains why, in
the view of certain pathologists, the syphilitic  papule is regarded,
though certainly without foundation, as one of the most frequent
forms of the  disease."  (Cazenave, p. 286.)  I will not  deny the
errors in diagnosis committed before the investigations of M. Caze-
nave ; but, even after having  profited  by his researches, I must
still regard the papule as one of  the most common forms of the
syphilitic eruption.
   Syphilitic lentigo always  pursues a chronic progress; its pus-
tules, always distinct, never  ulcerate;  they terminate by an indu- 
SYPHILITIC ERUPTIONS.
349
ration of the base, which finally subsides, leaving a completely in-
delible central cicatrix.
  Syphi I Hie Impetigo.—This assumes two forms : one very simple,
corresponding to the vesicular variety, in the form  of varicella
(lesion nearly vesicular); it is the impetigo non confluent (pi. 6, fig.
3, the first pustules).  Here  the pustules, somewhat voluminous,
remain isolated, or if confluent, it is the result  of accident, and
only two or three are involved.   A bright coppery-colored spot
at first appears, followed by an elevation of the epidermis which
completely covers this spot.  The  base of the pustules  is not in-
durated, and they form so  many small tumors filled with a puru-
lent fluid;  they  are  generally in close proximity, without, how-
ever, coming into actual contact, and are surrounded by a reddish
circle.  It is rather in the skin  by  which they are separated, than
in the distinct areola of each, that we observe  in  the commence-
ment that peculiar tint which becomes more and more decided,  as
the eruption advances.   This tint passes into the state of a macula
at the points first occupied by the pustules.
  The non-confluent  impetigo  is preceded by general symptoms
of indispositions, languor,  lassitude, &c.  The eruption may ap-
pear at once over a great extent.   Generally, notwithstanding the
appearance  of a very acute state, if the pustules are not accident-
ally broken, they may remain  for several days  unaltered.   The
liquid, however, which they contain, becomes coagulated, forming
a brownish crust, larger than  the pustule, a crust which in the ma-
jority  of cases,  becomes drier  and drier, and falls only to  leave
behind a cicatrix (pi. 6,  fig. 3, shows the pustules  accidentally
opened).    Sometimes the pustules enlarge,  the liquid becomes
more abundant, and the epidermis  is elevated to a greater extent;
then several pustules may be confounded in a single  scab, whichx
moreover, is always of small size;  but  then this scab may also
cover a superficial ulceration, it is  true, but which leaves a cica-
trix more extensive and more depressed than that of the pustule
which has passed through its different stages.
  Confluent impetigo  has always been called the puslulo-crustaceous
syphilitic  eruption.  It is produced by the union  of a great num-
ber of pustules.  Ordinarily  preceded by indisposition, and even
by  febrile  excitement,  it may commence  by  a more  or less
lively  redness  of the  skin,  which is also  evidently  tumefied.
Soon the red  part becomes  covered with small purulent  collec-
tions,  which are so much  the  more rapidly confounded toge-
ther, as  they  are situated on  an inflamed surface.  These  pus-
tules  remain intact for a very short time only;  soon one  or
more large patches appear surrounded by an extensive  copper-
colored areola,  and covered with crusts  not  very prominent, un-
equal, of greenish color, soft, at least in their earliest stages, con-
vex at their centre, and encased at their circumference in a soft in-
flamed tissue, indicating the  existence of suppuration.   Beneath
these crusts, indeed, are grayish superficial ulcerations, with slighly-
elevated borders, which secrete a sero-purulent fluid, thus forming
new crust.   As  the disease becomes modified, the crusts become 
350             VIDAL ON VENEREAL DISEASES.
more and more  desiccated, their circumference consolidated, and
they are detached by degrees at their edges; finally, they fall com-
pletely, and commonly leave  an extensive and more or less de-
formed cicatrix, according to the  number of the newly-formed
crusts.
  This variety may be observed simultaneously at many points;
it first appears under the form of distinct patches ; but, unlike the
serpiginous form, it has no tendency to invade the adjacent parts.
In its  first stages, it is of the size  and volume  which it should
maintain throughout its course.  If at each renewal of the crusts,
it increases ite dimensions, it is always within  very narrow limits,
as we also find after it cicatrices of greater or less breadth, at differ-
ent points, near or remote from  each other;  but we never find
those long tracts where the skin is ulcerated uninterruptedly and
to a considerable extent.
  Syphylitic Ecthyma.—This is formed by small isolated tumors,
having a base of a certain consistence, and a rapidly-formed crust,
which leaves behind a cicatrix, sometimes very superficial, some-
times very profound.   There are two well-marked forms of ecthy-
ma, one of which  resembles more the pustules of variola in their
early stages.  These pustules are broader than those of impetigo;
they do not, however,  exceed  in diameter that of an American
half eagle; they are of a circular, slightly-conical  form,  some-
times a little umbilicated, and surrounded by a  coppery areola.
These pustules are rapidly developed, and scattered  at once over
a more or less  extensive surface of the body, the  extremities,
sometimes  appearing very shortly after the  primary accidents.
They are filled with  a yellowish  fluid which readily  escapes,
forming a brownish crust,  which adheres but slightly (pi.  6, fig. 3).
At the end of one or two weeks these crusts fall, leaving a spot,
sometimes  a  cicatrix,  but  superficial and central.   This  is the
acute ecthyma, and may likewise be called the superficial, and  is
the form, in my opinion, which may be most  readily inoculated.
It will be seen that the patient which furnished me the pus which
I used for this purpose with success, was effected with an  ecthyma
belonging to this first  and rarest form.   With it we  may observe
other lesions belonging to the first stages of syphilis  ; thus, chan-
cre may still  exist, but this is of rare occurrence; there may be
mucous tubercles, and rhagades in the region of the anus.
  In the  second form of ecthyma, that which  in comparison with
the former may be called chronic, and deep,  the pustules are of
greater breadth; they may have the diameter of a five-franc piece,
but they are  generally oval with their greatest diameter in the di-
rection of the axis of the limb on which they are seated, for these
pustules  are  ordinarly observed on the  extremities, particularly
the inferior extremities, as the legs.   They are not numerous, and
do not appear simultaneously.   Sometimes there is an interval of
some months between their eruption.
  The pustule in this variety is preceded by a  violet-colored spot,
the epidermis is raised at the centre, and then soon forms a col-
lection of thick fluid, which seems a mixture  of pus and clotted 
SYPHILITIC ERUPTIONS.
351
blood.  Immediately around this focus there is a livid areola, it-
self  surrounded  by a  copper-colored border.  External  to  the
points where the  epidermis begins to rise, is a tumefaction which
causes the centre of the tumor  to appear depressed.  When the
pustule  bursts, the contained matter  partly  escapes, whilst that
which continues to be secreted forms a black crust, which gradually
desiccates and at  length resembles an eschar.   This form of ecthy-
ma likewise resembles, to a certain extent, the bulla resulting from
the application of an escharotic.   If the crust be  early removed,
an ulcer with a  grayish base follows, with perpendicular edges,
around  which is a whitish  border, formed by portions of  the epi-
dermis  which separate  the crusts from the circumference of the
ulcer.
  Instead of removing  the crust we leave it to fall spontaneously
under the  influence of progressive reparation, we perceive that
this crust continues to become desiccated; it seems to contract and
to sink down at  the centre.  The epidermic border to which we
have  alluded, falls off in very small layers, and permits us to ob-
serve the circumference of the crust which seems to penetrate the
thickness of  the  skin.   Finally, portions of the crust  become de-
tached at the edgeSj then they break towards the centre, and when
separated, a  more or less circular and depressed cicatrix remains,
with a syphilitic hue.
  This  is more common than the preceding  variety; it  is more
grave, and is often observed after the appearance of other second-
ary accidents, after other syphilitic eruptions, such as roseola, pa-
pulse, and sometimes after iritis.  With, or shortly after, the mani-
festation of this  form, we  observe the affections of  the  osseous,
fibrous, and  parenchymatous tissues.   We find therefore,  that the
same eruption may be sometimes secondary,  and sometimes terti-
ary, or  much nearer to the former than the latter accidents, thus
presenting us with another argument against arbitary divisions.
  Further still, between the first and second varieties which we
have described, there may be an intermediate variety. The pus-
tules then, instead of being distinct, as in the first variety, exist in
groups, are confluent at certain points, and form  a  broad crust,
which strongly resembles that of one of the forms of impetigo; in-
stead of leaving  scarcely any trace behind as in the first variety,
or a  well-marked and  regular  depression as in the second, an ir-
regular cicatrix remains more distinct than in the first, and less so
than  that in the latU r form, for  this intermediate variety is always
a superficial ecthyma.
  Inoculation of Syphilitic Ecthyma.—I wasthe first in France to show
that the so-called secondary accident might be transmitted  not only
by contagion ,but by experimental inoculation.  My experiments date
from 1849. In speaking of syphilitic varicella I have already reported
a case of inoculation from a diseased to a diseased person.  This
report forms part of a  Memoir which also contains the two follow-
ing  cases, which we are about  to relate.   This Memoir was  read
before the Soci'te de Chirurgie, and was published in the Gazette des
JIfu'taux, of 18th and  22d Feb., 1851.  As  I  had  truth on my 
352             VIDAL ON VENEREAL  DISEASES.

side, and as I knew that some of the best minds in Germany had
already confirmed my experiments, and that in France experiment
would soon decide in my favor, I was guarded in what I wrote or
spoke.  I did  not  reply to all the objections which were brought
forward in the Society and published in the journals, but left the
facts to speak  for  themselves.  The following is a report of the
case that gave rise to the most excitement.   It is one  of the inocu-
lation of ecthyma from patient to  patient in  the first  place, but
afterwards from the latter to a sound person.  It  presents two
principal features ; 1st, the phenomena  manifested by the patient
who furnished  the  matter for the  inoculation, and who was also
seen by MM. Piberet and Lafargue, internes of the hospitals in Paris;
2d, the phenomena presented by the sound person who was inocu-
lated, and which have been reported by himself.
   Case 1.—Inoculation from patient to patient, and from the patient
to a sound person.
   A servant, set. 23, of bilious-sanguine temperament, was admitted
at the Hopital du Midi on the  28th October, 1849, and occupied
bed No. 30,,Ward 11.  Had always enjoyed good health, and was
born of healthy parents.  Six weeks since he had a chancre on the
right side of the frenum; this is now cicatrized, and only a slight
induration remains.  Eight days after  it had healed the patient
suffered from  itching about the anus, which subsequently became
completely surrounded by mucous tubercles.  Rhagades exist in
the mucous folds.  Simultaneously with these \ >henomena, appeared
an eruption on the skin, which was preceded by redness on the
surface; soon followed little pimples, papules, and three or four days
afterwards, pustules.  This eruption was preceded by febrile ex-
citement.   The diameter of the pustules varied from that of a lentil
seed to that of a half eagle (American) piece.  They commenced
on the head, and became irregularly scattered  over the trunk and
extremities, and were particularly numerous on the  right side of
the chest.  The inguinal and cervical glands were enlarged.  The
circumference of the anus is covered with mucous tubercles; there
are rhagades,  and a fetid puriform discharge.  No infundibuliform
disposition.  The patient  is tormented with supra-orbital cephalal-
gia, which increases  at  night, and  continues very intense  until
morning.   Severe pains  are felt in the shoulder joints, as well as
in those of the lower extremities.  The head is covered with crusts,
which are easily detached.   It  has  been stated that the pustules
existed in greatest  number on the right side of the chest; there
were also some on the abdomen.  Altogether, there are thirty well-
marked pustules on the trunk; they are more distinct on the upper,
and on superior and anterior parts of the lower extremities.   The
broadest are on the chest.  All are surrounded by a coppery-red
circle.  All contain pus;  most are covered with a crust, the color
of which varies;  some are dark,  others white, others squamous
and adherent; others, in fine, are  of a yellow color, more  or less
distinct.  All  are surrounded by a circle, the color of which has
already been   mentioned, and are seated  on a  tissue somewhat
tumefied.  Some of the pustules«re covered by a grayish crust, and 
SYPHILITIC ERUPTIONS.
353
Beem to be of more recent development; they fill with well assimi-
lated pus.
  On the 28th October, 1849, punctures with a lancet charged with
pus from one of these latter pustules, situated on the right side of
the chest, were made on the inferior and internal part of eacji thigh
of the patient.  On  the 29th, an elevation appeared at the points
punctured, which gradually assumed the characters of the pustules
on the trunk.  Matter was taken from the inoculated pustules, and
inserted into the upper and inner surface of the thighs.  The same
results followed  as in the first inoculation.
  Nov. 1st. M.  Boudeville, interne in pharmacy, who  had never
had the slightest venereal symptom,  and who had an excellent
constitution, offered  to submit to the inoculation.  Matter  was
taken from a pustule on the left side of the thorax of the above-
mentioned patient, a pustule which had never ulcerated, which was
completely intact, and covered only with a grayish crust.  With
a clean lancet charged with this pus, inoculation was  made on the
inferior part of the palmar surface of the left fore-arm of M. Boude-
ville ;  with pus  from another pustule  in the  same region, and as
recent as the former, inoculation was made on the right fore-arm*
   The patient, who entered the hospital on the 21st  of October,
1849, I could not prevent from leaving on the 24th November of
the same year; however, he had been examined for nearly a month
by the students attached to the hospital, by those who followed
my service, and by the members of the German Medical Society,
among whom was M.  Robert de Weltz.   MM. Surmay, and de
Castelneau were invited to visit and to examine both this patient
and the student of pharmacy.  As I foresaw that this  case would
make  some  noise, it was  my wish,  as may easily be understood,
that the patient  should  himself note the circumstances of his case.
I therefore requested him to keep a record of  what passed.  But
as it was also my opinion that a student in pharmacy could not be
competent to fulfil all the conditions required of a medical observer,
I myself watched the effects of the inoculation.  The following is
the student's report, unaltered:
   " On the day  following the inoculation, the 2d November, traces
of inflammation began to appear. In the evening I felt dull pains
analogous to those accompanying suppuration.
   " On the 3d,  a papule of about four-fifths of a line in diameter,
occupied the centre of the red circle;  until the  5th November this
papule remained stationary.   The inflammatory circle followed the
same course, and extended  some trifling distance beyond it; the
papule now became remarkably convex and covered with a cracked,

  * It is important that the reader take note, that matter for the inoculation -was
taken  from  three different pustules: 1st. From the right side of the thorax, to
inoculate the patient himself; 2d. From the left 6ide of the* thorax, to inoculate the
left fore-arm of the student;  3d. From the same region, to inoculate the ri<*ht fore-
arm of the same student. So that, if it be pretended that the  matter used for the
inoculation was taken from a  chancre, we must admit the existence of three
chancres on the thorax, and, as a matter of course, the other pustules scattered over
the body, exactly  resembling those on tho chest, must  all likewise have been..
chancres!
                            23 
354             VLDAL ON VENEREAL DISEASE&
grayish crust, and beneath* this crust was  a thick, grayish-white
pus, clearer throughout than that used for the inoculation.  This
pus was several times discharged in consequence of the friction of
the linen against the pustule, but it was immediately reproduced.
  " At every period of the eruption I suffered severe  local pain,
which sometimes extended along the arm.   I discovered no symp-
toms of general disturbance.
  "During the first eight days I perceived a kind of circular in-
flammation, surmounted by a small papule which broke out on
the external and superior surface of the  thigh;  it disappeared in
the course  of four or five days.  It is probable that at this part of
the thigh there was seated, a pimple chafed by the clothes, and that
during  my sleep,  the fore-arm having been brought in contact
with it, took up a small quantity of the pus, which gave rise to a
pustule.
  " Towards the 15th of Nov. the inflammation ceased; the  pus-
tules subsided and cicatrized;  their surface soon became flat and
laminated; the puncture made by the lancet left an infundibuliform
scar of a  brownish-red  color, and presenting whitish scales, like
those of lichen.
  " Such was the condition of things until the 5th of December,
thirty-five  days after the inoculation, at which time a  change oc-
curred ;  an inflammation supervened, and two consecutive pustules
appeared occupying precisely the situation  of the  first, and I suf-
fered only a severe pain in the same locality.*   Pressure, even at a
considerable distance, produced intense pain.
  "The cicatrization was here very slow on account of the very
copious  suppuration, especially in  the pustule on  the  right arm,
which had been irritated by one of the pins used in the dressing.
Cicatrization was not completed until the 20th Jan. 1850.
  "M. Vidal, on  the first cicatrization, advised  me to submit to
treatment.   This advice I did not follow, thinking that the ex-
periment was not sufficiently conclusive from the manifestation of
local phenomena only, and I determined to await the development
of  symptoms of general infection before  I subjected myself to
treatment.   Up to the present time, March  8th, 1850, one hundred
and twenty-eight days from the date of the inoculation, no symp-
tom of general infection has appeared.
  " This report is handed to M. Vidal,  March 28th, 1850.
                                              " BOUDEVILLE."
  Such is  M. Boudeville's account of the symptoms produced on
his own person, and which may be regarded as the result of gen-
eral infection.  The following is the report presented to  me by
the  student in pharmacy on the 10th August, 1850:

  * Thus the first pustules, those which immediately followed the inoculation,
lasted about  fifteen daVs; and about twenty days after their  complete cicatriza-
tion, pustules appeared spontaneously mucli smaller than the first, and, as M. Bou-
deville goes on to say, they lasted forty-five days.  As to the  seat  of the second
pustules, it is necessary to be  precise on this point; the first  were in the middle
■of the anterior surface of the fore-arm, the second appeared a little nearer the bor-
der of the radius at a point on the circumference of the first, with the cicatricea
of which they became confounded. 
SYPHLLITIC ERUPTIONS.
355
   " Flat lenticular tubercles appeared on my scalp, a posterior and
superior cervical ganglion became enlarged, and finally there was
alopecia.   About the 25th  of April I experienced some difficulty
in swallowing, and the mouth began to inflame ; a roseola appear-
ed on the  body which lasted for three or four days, and finaUy
mucous tubercles became developed on the pillars of the palatine
arch.  Then, for the  first time, I submitted to mercurial treatment.
At first I took but one pill  of the proto-iodide of mercury ; but
rheumatic pains and  nocturnal cephalalgia induced me to take two,
three, and afterwards four a day.   The pains having subsided, I
graduaUy reduced the number to one a day, which I still continue
to take.
   "The mucous  tubercles in the mouth are now cicatrized;  a
brick-colored tint remains in  a circle completely  arrested, and  in
which the pustules were formerly seated.    •
   " No other symptom has appeared.
                                           " Ch. Boudeville.
   "Paris, August 22d,  1850."
   I repeat that this case should be examined under two different
  Eoints of view:  1st. The details concerning  the patient,  whose
  ody was covered with  pustules;  these  were  collected by MM.
Piberet and Lafargue, internes of the hospitals, and  who are still
in Paris, whose education and character are known to several of
the chief* physicians  in the hospitals of Paris.   This part has not
been, nor can it be, directly attacked.   2d. The details in the sec-
ond case were furnished by  the  student in pharmacy who was
inoculated, which, when taken in connection with those given  by
other persons, seemed  to show  a contradiction  with  the first.*
Hence arises an obscurity as regards this second part of the case
which it has been attempted to cast over  the whole so as to  destroy
its value.  But the conclusion of M. Boudeville's report has not
been attacked; it is that which establishes the fact that a  student
in pharmacy has been infected with syphilis from inoculation per-
formed by myself.  Thus, two points are  incontestably established.
1st, that the patient who furnished the pus had secondary pustules,
and that it was  from these  pustules  that I procured the matter
with which I inoculated the student; 2d, this inoculation produced
constitutional infection  (la  verole).  For  my own  part,  I have  no
doubts on the subject.   The  question  is settled, for I have not  to
 {>rove the possibility  of transmitting such or such a form of syphi-
 is, but of one of its forms.  Now I have transmitted constitutional
syphilis.  The nature  of the lesions produced on both fore-arms

  *The discrepancy found in the second case of M.  Boudeville, consists in the re-
port of a glandular enlargement in the axilla during the existence of the pustules
on the fore-arms.  Now, at page 357 et suiv, it will be  observed, that in  the first
case of this student, dating March 29th, 1860, when the extremities were no longer
affected, nothing indicated this glandular enlargement which M. Ricord had al-
ready noticed in this student 1 -I have besides proved, in several parts of this
work, that adenitis is of no particular value in forming a diagnosis.  In  this case
the enlargement of the axillary glands might have been the result of the general in-
fection. Of course, in a work like the present,  I refrain from commenting upon
the conduct of persons. 
356
VIDAL ON VENEREAL DISEASES.
of the student have been called in question.  It is pretended that
they were chancres.   This  is of but little  consequence.   The
question, I repeat, is not whether a secondary accident  may trans-
mit an identical form of  disease, but whether it can transmit any
form of syphilis.   If the  student had had at first two chancres on
the form-arm, this  would prove that with the  matter from sec-
ondary ecthyma we may produce chancres,  a fact  which would
still more compromise the doctrine of my opponents.   But there
was  nothing of the kind, for we see the pustules  which imme-
diately followed the inoculation of the student, lasting for fifteen
days;  they afterwards completely disappeared, and  twenty days
after this disappearance,  this complete   local cure  without any
traces being left, they re-appear spontaneously, in the absence of
any exciting cause#and the pustules are larger than before.  These
pustules lasted for forty-five days ;  they appeared not  exactly at
the centre of the cicatrix  of the first pustules, but at a point of
their  circumference.  Is such the course of a chancre;  No;
when the reparation  of  a chancre is once complete, it is not re-
produced.   Before another chancre can appear,  there must be
another inoculation.  This  is  the doctrine  which M. Ricord in
particular professed.   Besides, I  have already  remarked that I
was not satisfied to trust the entire report of the case of the student
himsslf.   I myself watched its progress.
  Further still, in  so important a case I was desirous of having
the opinion or a colleague  versed in such matters.  I therefore
took this student to M. Cazenave, of the hospital St Louis; I con-
sulted him as  to the nature of the pustules and the treatment best
to be pursued.   M.  Cazenave, after  a  careful  examination and
without  any previous instruction on our part, declared that the
pustules on the fore-arm of M. Boudeville were two syphilitic  ecthy-
matous pustules, that he was fully satisfied on this point, and he advised
a mercurial treatment.  It was not until then that both M. Boude-
ville  and  myself declared that these pustules were the result of
inoculation with the pus taken from two ecthymatous pustules on a
patient in the Hopital du Midi.  This led M. Cazenave himself to
experiment, and shortly afterwards he published a case of success-
ful inoculation with the matter of a sj^philitic ecthyma.
  But it was not sufficient to have myself proved the inoculability
of secondary accidents; it was not'enough to see my experiments
confirmed by writers  on  syphilis, who it was supposed coincided
in my opinions, stronger  evidence was required, and it was neces-
sary that experiments should be undertaken by those whose senti-
ments were in sympathy with my opponents.   In this point of
view, the report of the two following cases is possessed of  great
importance.
  Being under the necessity of taking a journey to the  South, my
colleague, M. Puche, was willing to take charge of my service, and
made the following experiment, the details of which  were  care-
fully collected by my  former interne, M. Dumenil.
 • Case 2.—Ward 11, bed No. 26; admitted 30th October.  Tem-
perament sanguine;  constitution very robust;  embonpoint  con- 
SYPHILITIC ERUPTIONS.
357
 siderable.  Aged 24 years.   Fifteen months before, this patient
 had had chancres.  He was treated by M. Vidal, at the  office of
 consultation, at the commencement of his  disease,  and took but
 twenty mercurial pills.   The chancres were cauterized by another
 physician.   He never had any glandular enlargement more decided
 than that which now exists.   During the first weeks of the exist-
 ence of his chancres, he had sore throat, but he was subject to this
 before.  No rheumatic pains; no cephalalgia, no alopecia.   In the
 left groin is  a superficial gland somewhat enlarged and indolent.
 The patient declares that it has always existed.  Behind the right
 sterno-mastoideus is a gland very much enlarged, which likewise
 existed before his venereal attack.  Traces of chancres are found
 on each side of the frenum; the cicatrices are depressed  but not
 indurated.   Blennorrhagia is  present, and this is of  three months
 standing.   In front of the right internal malleolus is  a brownish
 cicatrix produced,  according  to the patient, by his boots, some
 three  months since.  It should be remarked,  that  he had worn
 these boots for a long time, and they had never caused the slightest
  ain.  This ulceration has the same characters as that seated still
  igher on the leg.   It healed spontaneously in the course of fifteen
 days.  On the anterior and external surface on the middle third
 of the right  leg are five  ulcerations covered with a black, thick
 crust, which are also of three months' standing.   These ulcerations
 are of a circular form; one of them is elongated in a vertical direc-
 tion ; they are deep, with prominent, perpendicular edges; a sani-
 ous pus covers their base; a deep-red areola four lines in diameter,
 surrounds them.   But slight induration is felt at their base.   Two
 of these ulcerations resulted from the fall of a piece of wood, which
 produced a solution of continuity.   The others appeared spontane-
 ously, in the  form of little white pimples.  Four or five small pus-
 tules exactly resembling those of acne are scattered over  the leg.
 The diameter of these ulcers above mentioned is about two fines.
   Nov. 1st, 1850.  Inoculation was performed on the anterior sur-
 face of the right thigh, with piis taken from one of the ulcers which
 we have described, and which succeeded to the contused wound.
 The puncture was made with a lancet carefully cleaned for the
 purpose.  The point inoculated was covered with a watch-glass.
 Iodated water,  3 iss.; calomel and jalap, grs. xv.; dressings to the
 ulcers of straps of Vigo  plaster.
   2d.  The point inoculated is covered with a sero-purulent fluid
 to the extent of about  two lines.   On gently removing this fluid
 with a piece of linen, without chafing, the epidermis is found ele-
 vated.  The  surrounding parts  present to the touch  a sense of
 engorgement, for the space of about one-third of an inch; there are
 no pains.
   3d.  A small pustule,  of the size of a pin's head, appeared about
 one and a half lines above the punctured point;  it is traversed by
 a hair.  Another small pustule, somewhat larger than the other,
 exists at the distance of two-fifths of a line external to the inoculated
point.   On the latter itself, the  skin becoming slightly tense, is a
fissure resembling an elongated ulceration; within this fissure, for 
358             VLDAL ON VENEREAL  DISEASES.
the space of four-fifths of a line, is a yeUowish  surface,  which
appears to be produced by dried pus.  The surrounding parts are
red, not tumefied, and covered with  a little dried purulent matter
like a layer of varnish;  no pains.
  4th. The redness extended over a space of about two-thirds of
an inch in diameter.  At the centre is an ulceration of four-fifths
of a line in diameter, covered with  a crust.  No  pain.  For the
last twenty-four hours the point inoculated has not been covered
with the watch-glass, which is no longer applied.
  5th. The ulceration  appears  to be almost entirely healed; the
redness diminishes, and the engorgement has almost completely
disappeared.
  6th. There exists a light grayish crust on the point inoculated.
Redness and engorgement the same.
  7th. The ulceration  yields a  httle serous fluid; it has not in-
creased in extent.
  8th. Yellow crust, depressed in the centre, <3f cup-like form, and
about two lines in diameter: slight engorgement beneath the crust;
redness remains the same.
  9th. Deep ulceration at the centre, superficial at the edges, about
a quarter of an inch in diameter; slight engorgement and redness.
  11. Crust nearly one-third of an inch in diameter, bulging at
the centre, of a brown color, and surrounded by a red areola.  For
the space of four  lines around the crust, there  is  no sensible en-
gorgement.  The ulcerations of the leg have a tendency to cica-
trize ; the bottom is elevated, the edges sunken, and the granula-
tions covering them of a good aspect.
  12th. Crusts of good aspect, prominent; no engorgement of the
subjacent tissues.  Redness the same;  itching sensations, but no
pains.
  13th. The crust, when removed, appeared thin at ite edges. At
ite centre was found a thickened portion which projected into the
centre of the  subjacent ulceration.  The latter, superficial at ite
circumference, was about four-fifths of a line in depth at its centre;
the surface of the ulceration is of a rosy hue, and secretes but little
pus; no glandular engorgement.
  14th. The crust has formed again, and presents the same charac-
ters as before, no more redness nor engorgement.   The patient left
during the day in consequence of his disobedience.
  22d. He presented himself to me;  the ulceration remains, and is
covered by a thick grayish crust, bulging at its  centre  to the ex-
tent of a quarter of an inch,  and is two lines in breadth ; desqua-
mation of the epidermis throughout to the extent of two-thirds of
an inch; slight engorgement;  no pains; pressure on  the  crust
causes the discharge of a drop of pus.
  The report of M. Dumenil here concludes.  This student ordered
the application of a cataplasm to the pustule.  According to the
patient, the crust separated the next day, and left behind a  super-
ficial ulceration, which cicatrized in  five days afterwards.
  Dec. 4, 1850, the patient presented himself to me.  I observed
sunken cicatrices at the lower part of the right  leg, at  the point 
SYPHILITIC ERUPTIONS.                 359
where the ulcerations had existed ; they were surrounded by an
areola of a brownish, coppery-red color.  On the thigh, the cica-
trices of the inoculated pustules presented the same characters; it
was somewhat larger than a ten-sous  piece.   The skin  around it
was of a very brown color.
   This case shows us an  inoculated pustule, which seems to have
aborted  on the sixteenth day, and which afterwards reappeared
and became of larger size.   If the patient had been abandoned at
the first period of the inoculation, we should have inferred that the
latter had not succeeded.
   Case  3.—I have already stated  that M. Cazenave has experi-
mented on a patient  having a tubercular syphilitic eruption; a
pustule of ecthyma broke out  on his  thigh, and the matter from
this pustule was successfully inoculated on both  fore-arms of the
patient.  The case is reported  by M. Cazenave, with all its minute
details, in the Annales des maladies de la peau  et de la syphilis.   He
states, very positively, that the patient was exactly in the condi-
tion to favor the success of the inoculation.  There was no primary
accident; the patient was repeatedly and thoroughly  examined
with the speculum, before the experiment, and again at the mo-
ment when the inoculation was performed.   The results  of  the
latter were  closely watched by several persons.   It may be  ob-
jected, says M. Cazenave, that  a chancre, in this case, was mistaken
for an ecthyma.  H so, says the physician of St. Louis,  it is one of
those arguments to which it is impossible to reply.
   In 1851, my colleague, M. Richet, then one of the surgeons of
the Lourcine, informed me that he had succeeded  in inoculating a
consecutive syphilitic ecthyma.   He also   made several  other
writers on syphilis acquainted with the same fact.  I accepted  the
invitation of my worthy colleague  to witness the case, the details
of which have been  recorded by a distinguished interne, M. Du-
breuil.
   Case  4.—B. Nathalie, aet.  21, dressmaker, admitted July 5,
1851, into Ward St. Alexis, Bed No.  9, Hospital Lourcine, service
of M. Richet.  This girl, of a lymphatic temperament, a very strong
constitution, menstruated for the first time at the age of seventeen;
it was long before menstruation  became regularly established, but
she now suffers no pain at these periods; the discharge is abundant,
and lasts for six days.  Has never been pregnant, nor been affected
with leucorrhoea.  Previous to her admission to  the hospital she
had never been attacked with syphilis.  Three weeks before her
admission, she discovered several little pimples on the vulva, and,
as they  were attended -with  considerable itching, she  scratched
them until  they bled.   This  produced small wounds,  to  which
emollient lotions only were applied.   They soon healed, but large
flat tubercles  soon appeared  at these points, which attention to
cleanliness was not sufficient to remove.
  Examination.—Mucous tubercles are scattered here and there in
large numbers both on the labia majora and minora; among them
were two of smaller  size situated at the fourchette, they were ul-
cerated  on their surface,  and appeared to be two  chancres in pro- 
360
VLDAL ON VENEREAL DISEASES.
cess  of transformation.   Nothing in the region  of the anus, and
neck of the uterus, is sound   Slight vaginitis.  Skin healthy; no
frontal cephalalgia; no osteocopes.
  Treatment.—One pill of proto-iodide of mercury, and two injec-
tions of alum daily; two alum tampons, and two baths (general)
twice a week.
  July 8th.  The mucous tubercles are cauterized with a concen-
trated solution of the nitrate of silver.  M. Richet observed before
the cauterization that no trace of chancre remained.
  9th. Patient complains  of having suffered during the  whole
night at the internal and superior parte of the left leg.  At the
point designated, a small white pimple was discovered, formed by
the elevation  of the  epidermis, and resting  on a red inflamed
base.
  12th. This pimple has become transferred into a fine pustule of
ecthyma; this pustule rises about four-fifths of a line above the
surface of the skin; it is about five lines in diameter; its acuminated
summit is formed by an elevation of the epidermis through which
we detect by ite transparency a  fluid  enclosed in the pustule.
The  point where the  epidermis is raised, that is, for a  radius of
two lines in extent, has a yellowish aspect,  the base of the pustule
presents  a bluish  and  violet hue, pressure at this, point is very
painful, and gives rise to a  sensation of induration and tension.
The  adjacent skin is of an erysipelatous redness, disposed  in the
form of an areola around the pustule; this areola gradually fades
as we leave  the pustule, ite  diameter in  every direction being
about one and two-third inches.  The patient is confident that at
this  point there has been neither excoriation nor puncture.  Be-
sides, the epidermis covering the pustule appears to be prefectly intact
throughout.
  M. Richet again examined the patient, and discovered that no
trace of the chancre remained on the vulva, and called our atten-
tion  to the fact that the effect of a single cauterization had been
to diminish the size of the mucous tubercles one half, and that
they were all shrivelled and sunken.   Then having punctured
the top of the pustule on the leg, there issued a fluid somewhat
analogous to a reddish, slightly opaque  serum; a little  drop of
this fluid was  gathered on the point of a lancet, and inoculated at
a corresponding point of the opposite extremity.  To protect the
point inoculated from the vaginal discharges, it was covered with
a watch-glass  fastened by means of a broad  strap of diachylon
plaster applied one and a half times around the limb, over which
a bandage was applied;  the  patient was confined to her bed.
  14th. The ecthymatous pustule has burst during the  night,
and  discharged an abundant sanious fluid,  which  stained the
linen red.  This  produced a hollow cup-like  ulceration, with
ragged edges,  and  a grayish  base.  A violet-colored areola of' an
inch in diameter surrounded it, leaving  here and there exposed
little whitish points formed by small collections of pus under the
elevated  epidermis.   An extensive erysipelatous  redness  sur-
rounded the whole.  Before the  pustule opened, the patient cxpe- 
SYPHILITIC ERUPTIONS.
361
rienced throbbing, shooting pains, ■ from  which she suffered  so
much as to  prevent  sleep.  Now the pain has  ceased.  On the
other hand,  at the point of inoculation, the epidermis is  raised,
forming a small vesicle of the side of a pin's head;  this vesicle is
filled with a  liquid which appears white, limpid, and transparent;
it is surrounded by a small inflammatory areola.  Mercurial treat-
ment still continued.
  16th. The ulceration which  has succeeded  to the  pustule  of
ecthyma is  about four lines in extent in all directions;  its edges
are irregular, but  have no tendency to become everted; they are
smooth, circular, and the commencement of cicatrization is already
apparent.   The base, covered at first with a whitish false  mem-
brane,  begins to become clean.   At the seat of the inoculation, the
vesicle produced by the elevation of the  epidermis, has acquired
the size of a lentil seed;  it presents a whitish and slightly-yellow-
ish aspect, and is no longer transparent   The surrounding inflam-
matory areola increases in size ; and the patient says that during
the night she suffered shooting pains in this situation.
  17th. The pustule  produced by the inoculation  rests upon  an
indurated base; M. Richet punctured it with a lancet, gathering
on the point  of the instrument a little of the purulent fluid which
escaped, and inoculated it on the right arm.
  18th. The ulceration which  succeeded  the first pustule is  in
process of reparation,  the base is of a fine red color, and is nearly
on  a level with  its edges.  This pustule has remained sunken
since the day when it was first opened.  The inflammatory areola
surrounding  it is  diminishing in size, but the base on  which it
rests is indurated, and pressure with the fingers gives exit to a
drop of pus, mixed with reddish streaks, and the patient  suffers
pain.  The  second inoculation appears to  have succeeded on the
arm ; the little vesicle formed by the elevation of the epidermis is
filled with a white and slightly-opaline fluid.  A rose-colored cir-
cle  surrounds it.  Patient  states that during the night she felt at
this  point an itching, stinging sensation.
  22d. The ulceration which followed the opening of the pustule,
and  which  seemed for a time to have healed,  again cracked and
assumed a  palish  hue, the circumference always  remaining violet
colored; it rests upon a broad indurated base.
  The  pustule produced by the first inoculation has entirely healed,
but an indurated portion of skin about two lines  in diameter, and
perfectly limited at its circumference,  constantly remains.  The
pustule on the arm broke during the night; in its place a yel-
low, and even  a somewhat transparent crust is  found,  which is
formed  by the desiccation of the  fluid contained  in  its cavity.
The inflammatory areola has completely disappeared.   The  mer-
curial treatment is suspended in consequence of incipient stomati-
tis.
  30th. The ulceration which succeeded  to the  first pustule pre-
sents a pale violet aspect, and seems no longer inclined to cicatrize.
It rests upon an indurated disk, which surrounds it at every jpoint.
The focus of induration, sole vestige of the first pustule produced 
362
VTDAL ON VENEREAL DISEASES.
by inoculation, constantly remains.  There is no longer any mark
upon the arm.
  Aug. 2d. The ulceration which succeeded to the opening  of
the pustule of ecthyma  begins  to cicatrize.  The indurated focus
still exists on the other leg, but its extent is greatly diminished.
  21st.  The ulceration  which followed the opening  of the first
ulcer has not yet completely cicatrized, but appears as if soon about
to be completed.  The indurated portion remaining at this point, is
reduced to a small nodule about the size of a pin's head.  During
the interval from Aug. 21st  and Dec. 13th, some patches of pso-
riasis appeared  on the  palmer surface of the hands ;  M. Gosselin
who now acted in the place of M. Richet, made  the patient  follow
a mercurial treatment  during the six weeks, and discharged her
perfectly cured on the 13th Dec, 1851.
  M. Dubreuil terminates his remarkable report as follows:  " This
case shows us that secondary syphilitic ecthyma, notwithstanding
all that has been lately asserted to the contrary, may sometimes be
successfully inoculated."*
  As might have been supposed, this case has met with the hack-
neyed objection, which  has been urged against every reported ex-
ample of the inoculation with other products than those of chancre.
M. Richet having successfully inoculated, could not have used mat-
ter from a secondary accident,  because it is a law that secondary
accidents  cannot  be inoculated.  The pustule, therefore, from
which the matter was taken must have been a primitive pustule, a
chancre.  Whence came this chancre ? demands M. Richet.  The
female inoculated was sojourning at the Lourcine, and  had no pri-
mary accident when the ecthyma appeared on the leg.  Then a
person in the same ward is accused, from whom the chancre  pus
was taken.  But, replied M. Richet, there were no chancres in the
ward.
  Those who  have examined the facts in a purely scientific point
of view, have long since become satisfied.   Thus my experiments
have been confirmed in Germany by physicians  who were  un-
acquainted with what I had attempted. M. Cazenave has experi-
mented and succeeded  as well  as myself.  At the Lourcine,  two
colleagues, not at all interested in what I was doing, experiment-
ed independently ; one of them, M. Bouley, succeeded in producing
a mucous tubercle in a  woman too who had already had syphilis,!
and the  other, M. Richet, successfully inoculated a secondary ec-
thyma.   Those  acquainted with the state  of medical matters in
Paris, can comprehend  the  importance of these facts, coming as
they do from such  sources as MM.  Richet and  Bouley.  Both
were at the head of the  service  at the Lourcine, a hospital opposed
to the doctrine of the inoculation of secondary accidents: both have
a reputation for probity, and for intelligence, which cannot be ques-

  * This report, with the exceptions of the conclusion, was  read at the Lourcine
by M. Dubreuil in the presence of the patient of M. Richet, under whose observa-
tion it was made, in the presence of several students of the Lourcine and my intern',
M. Pelifcgot, who accompanied me.
  f Vid. the chapter on Mucous Tubercles. 
SYPHILITIC ERUPTIONS.
363
tioned.  Nothing now is wanting but an admission from Hunter,
from him who promulgated the error which I now combat. Well,
we shall see that Hunter himself has recorded  in his work a con-
clusive example of the inoculation of the secondary accident!   At
page 1524  of his Trade des maladies veneriennes, translated by M.
Richet, first edition (Amer. Ed. of Hunter by Babington, p. 241.—
G. C. B.), are these words which I carefully copy:
  " To ascertain whether her  secondary ulcers were infectious,
that is, whether the matter of them would have the specific effects
of venereal matter, she was inoculated by some matter from one of
her own ulcers, and with some matter from a bubo of another person
where mercury had not been used.  This was done September 18,
1782.  Sept. 19, the puncture where she was inoculated with her
own matter gave her pain three hours from the time of inoculation,
and the day following inflamed a httle.  The other had not  then
inflamed at all.  Sept. 20,  both the punctures had suppurated, and had
the  appearance of a small pox pustule; they spread considerably."
  Here we have two pustules exactly resembling those of variola,
produced one from pus taken from a secondary, the other from that
of a primary accident.  The secondary was therefore inoculated as
well as the primary accident.  This fact is incontestible.  But, then
comes  the  system which, considering  itself greatly compromised,
thinks to save itself by pretending that the two pustules were not
cured by the same means, that they did not terminate at the same
period; Hunter therefore concludes, that secondary accidents can-
not be inoculated.   As if the  pustules produced by inoculation
with the pus of chancre were always cured by the same means,
and always at the  same  time !  I have quoted Hunter, and  have
referred to  the page.  I beg the  reader to peruse the report  from
which  I have given an extract; it is very remarkable on other ac-
counts.  Further, I  shall be  able to show that Hunter frequently
contradicts himself.  This will be done in the approaching  chapter.
We insert in this place one more case reported by M. Rossen, one
of my  former internes :
  B. (Alphonse) set. 17,  carpenter, of a lymphatic  temperament,
constitution not very strong,  admitted at the Hopital du. Midi,
Ward  11, No. 11, March, 1851, and left on the 18th April of the
same year.
  Six  months  before, he had blennorrhagia;  cured in a month
spontaneously.  On the 8th or 9th of March, 1851, the patient
discovered  a syphilitic eruption, for which he entered the hos-
pital on the 17th March.  When  examined,  we found the follow-
ing characters.
  Abdomen and Thorax.—There  are  here  slight red  elevations,
conical-like papules, surrounded at their base by  a red areola,
The summits of some of these are covered by a small purulent
vesicle containing whitish pus.  On several, a small crust  easily
detached covered a small, brownish-red  elevation.   The eruption
is sparse and  scattered, and  the pustules  are irregularly spread
over the surface.                                    .
   Pubes.—On the pubes, in the midst of the hair, are thin, lamel- 
364             VIDAL  OX VENEREAL DISEASES.
lated, yellowish  crusts; some are of a greenish color, others are
soft, others friable.  Among  these crusts  are scattered some acu-
minated, very small, and  prominent  pustules; the base of those
which, from their isolation, permitted the fact to be noticed, was
not  surrounded  by an inflammatory circle.   They contain an
opaque and purulent fluid.
  Left Axilla.—The eruption here presents nearly the  same char-
acters  as on  the pubes ;  the pustules are very numerous,  and at
different points among them,  are seen isolated crusts.  The surface
of the skin covered by the eruption is surrounded by a red circle.
Over the  scapular regions the eruption was of the same nature;
only it is a little more discreet.  Crusts, pustules, &c.
  Right Cheek.—For a space of  about the width  of a five-franc
piece are  yellowish crusts, resulting from the desiccation of the
pustules, which  are  very confluent  at  this point.   They  are
wrinkled, and of a yellowish-green color.  On detaching a portion,
the skin is found  red and  shining,   A  sero-purulent discharge
issues  from the surface covered  by this crust, and permits us to
raise the latter at all points of its circumference.   It seems to ad-
here slightly to the skin.
  On  the  posterior part of the trunk and nates, exist irregularly
scattered pustules.  They have the same character as those on the
thorax, with  the exception of some  which I shall  describe more
particularly.   One of these is on the internal and superior part of
the left nates.   The diameter of  its  base, which is  not indurated,
is somewhat less than that of a half-dime piece; summit a little
elevated, and covered with a  crust not quite so broad as the base,
and appears  as if formed of super-imposed scales; the crust is
somewhat raised by a thin layer of yellowish-green pus, is thick,
and has a coppery-red areola (ecthyma).  The matter from this
pustule was used to inoculate the anterior surface of the right fore-
arm.   Two punctures were made.
  On the external part of the right thigh is another broad circular
elevation, with a prominent  reddish  base.  Around and beneath
this elevation is a feeling of induration,  which seems to extend
through the  subjacent cellular  tissue.  The summit, more acute
than that of the pustule last described, is covered with a yellowish
crust of less thickness, and raised by  a yellowish pus.  Pus from
this pustule was inoculated  on  the left fore-arm.   These inocula-
tions  were performed  in  the presence of MM.  Chaussit, Auzias,
Turenne, and the studeiits in the service;  they were made  on the
9th of April, 1851.  The  punctures were left exposed to the air
during part of the day.
  April 10th.  On the right fore-arm, the punctures are surrounded
by an areola,  the diameter of which is equal to that of a half-dime
piece.  On the left fore-arm  exists a red  point: areola not more
than half so large as in the other puncture.
  11th. On the right fore-arm are two acuminated pustules, of the
size of a lentil seed; areola very red, and of the diameter of a half-
dime piece.  On the left fore-arm the pustule is smaller, and conical
shaped; areola of a rosy hue,  and two or three millimetres in width. 
SYPHILITIC ERUPTIONS.
365
  12th, 13th. No change.
  14th. Patient has  chafed  right fore-arm;  surface reddish,  and
bloody.  On the left fore-arm, the pustule is surrounded by  a
brownish-red areola,  smaller than on the 11th.
  15th. A new pustule has appeared on the right fore-arm, of large
size, and seems formed by the union of the two first.  Areola  of a
brownish red, diameter of a twenty-centime piece;  crust yellow,
slightly adherent, and raised by a thin layer of pus; base not in-
durated.  On the left arm, the inflammation is of a browner color,
and seems to spread.
  16th. The pustule  on right fore-arm presents the same characters
as the first.  That on the left seems as if about to disappear.  Are-
ola brown, and from  two-fifths to four-fifths of a line in diameter;
the epidermis raised by the pus  appears to be in folds.   The crust
covering the right pustule was removed in the presence of MM.
Auzias and  Chausit,  and beneath was  found an ulceration with a
reddish base.  In its centre is a grayish  portion formed by con-
crete pus.
  17th. The crust on the right arm has been reproduced, with the
same characters as the old.  On the left, the  inflammation  seems
to have assumed more activity.   Areola larger -and redder.
  18th. On  the right arm, the diameter of the areola remains the
same, though somewhat browner; in  its centre is  a thin, yellow
crust, formed by solidified pus.   The  pustule on the left arm is
broken; there remains a thin, yellow,  and very broad crust.  The
areola has the same characters as the old.
  The  patient left, on the 18th  of April, to enter the hospital St.
Louis.   He was followed by M.  Chausit, who has sent me the fol-
lowing note:
  " The patient, on  whom M. Vidal  successfully inoculated  two
pustules of secondary ecthyma,  entered the hospital St. Louis the
day after leaving the Midi.  Five days afterwards  the  crusts on
the fore-arms separated and the  ulcerations cicatrized.  I saw him
on the  28th of April; I found a well-marked, depressed cicatrix,
of the  diameter of a lentil seed,  at the point where  the puncture
was made on the left fore-arm; this cicatrix was surrounded  by an
areola of a coppery-red, brownish color, the diameter of which was
about one-third of an inch.  On the  right fore-arm, the cicatrix,
instead of being depressed, projected a little on the  contrary,  like
a tubercle.   Same copper-colored  areola.   Brownish  red  spots
marked the  places occupied by the first pustules, but none of them
presented a  notable cicatrix.  Patient  left the hospital St. Louis on
the  1st of May."

                    SYPHILITIC TUBERCLE.

  The  syphilitic tubercle appears in the form of a small, full, tense
tumor,  containing neither serum nor  pus.  This small  tumor or
tubercle is  more or less  elevated above the level of  the skin.
Sometimes they are scattered in large  numbers over an  extensive
surface, sometimes,  on the contrary,  the number is limited  and 
366
VTDAL ON VENEREAL DISEASES.
confined to  a small portion of the surface; occasionally we find
them in more or less regular groups, whilst in other instances they
are scattered unequally over various portions of the body.  Some-
times they are small as a pea, circular, shining, and of a decided
coppery color, or, on the other hand, they are broad, flat, or spher-
ical, round, or of an oval form.  But, in the latter case, there are
several mucous tubercles, such as I have described at the close of
the first chapter.  Sometimes the tubercles appear as if encased in
the thickness of the tissues, or, again, as if protruding to a trifling
extent.   Under certain circumstances they remain smooth and
shining; in others, they are covered with light scales.  Sometimes
they become ulcerated and  covered with thick crusts.   In some
patients the only trace they leave behind is a  grayish spot, which
at length disappears;  in others, they are replaced by an  indelible
cicatrix, which is more or less irregular, according to the existence
or non-existence of previous ulceration.  Sometimes the syphilitic
tubercle, no matter what ite gravity, passes through aU its  stages,
and commits all its ravages from without inwards over every point
where it is at first established; sometimes, starting from a distant
point it invades very extensive surfaces, destroying the skin more
or less profoundly during its course.
   These tubercles are found at every point of the surface, and even
on certain mucous membranes.  But by a very unfortunate prefer-
ence, they attack especially the face; we find them then on  the
forehead, cheeks, and around the  nose.   Sometimes they appear
in very small numbers; at other times they break out suddenly
and simultaneously wherever they are going to appear.   In some
patients their eruption is precede'd by the syphilitic fever, of which
I have spoken.  Locally, there may be a  certain reaction, a slight
pain, a congestion of the surrounding skin, or, on the other hand,
no change of this portion of the  integument.  According to M.
Cazenave we may always detect some accidental exciting cause.
   Tubercles in Groups.—When tubercles exist in groups they are
generally of small size;  they have but little tendency to ulceration;
and their coppery hue  is  always well  marked.  Sometimes these
groups are regular, more or less numerous, and perfectly circular;
the tubercles are of the size of a pea, prominent, very round, one
by the side of another, forming a  circle;  every patch,  including
both the tubercles and the interspaces by which they are separated,
is of a coppery-red color.  Each tubercle,  besides, is often covered
by small, hard, grayish scales, which do not  completely  cover
their summit.  Generally they do not terminate in ulceration; their
progress is slow; they do not ordinarily produce either a stinging
or an itching sensation.  At length they subside, and resolution,
though tardy, is generally complete; no cicatrix remains.  These
groups of tubercles are found chiefly on the superior extremities,
sometimes on the forehead and neck.  Occasionally, on the other
hand, the tubercles are grouped without any kind of order or regu-
larity, as is represented in plate 6, fig. 4.   Then they are generally
small; but their form  is more globular and circular,  they are
much more easily detached from the surface of the skin, as their 
SYPHILITIC ERUPTIONS.                 367
base is much less broad.  They are, besides, of a shining  color,
and their coppery redness much more distinct.  Sometimes, espe-
cially on the face, this redness extends much beyond the surfaces
which are the seat of the tubercles;  in this case they are also
accompanied with a slight tumefaction.  This is certainly the form
of syphilitic in which the real coppery color is the most decided.
On pressing these tubercles with  the fingers, we feel a resistance
like that  presented  by large pin heads.  They seldom become
ulcerated; it sometimes happens,  however, that  after having re-
mained a  long time  stationary they inflame, the  groups coalesce,
and on the excessively tumefied  surfaces deep  ulcerations  are
established.  What is much  more common, is to see these tuber-
cles, after having been for a long time stationary, diminish in size
and lose their color; the redness  becomes less and less marked,
and resolution, after  various lengths of time, is so complete that
no trace of the tumor remains.   This is the form  most commonly
observed on the face, especially on the cheeks and lips.
  Disseminated Syphilitic Tubercular Eruption.—This form appears
particularly  on the  face;  occasionally  it is observed with  the
grouped variety,  but it is then in the regular groups, those which
form  circles.  Sometimes there  are wide  intervals between  the
tubercles;  the  skin  in the interstices is then faded, and of a dull
color.   They are at first small, but afterwards become larger than
the others.  Their form is most generally irregular, but their base
is broad.   They have a decided  copper color; the skin covering
them seems tense and shining.   They rarely ulcerate, and secrete
no matter.  They are slow, both in their  development and pro-
gress.   At first, as already stated, they are small; they increase in
size, and  attain the volume of an  olive.  Then they become sta-
tionary, and may remain so for a long time.   A change afterwards
occurs, they gradually diminish in size, become flattened, and dis-
appear after  two or three weeks, leaving only a spot which may
remain for a month.   Or, it may leave a smooth, superficial cica-
trix, which has not  been preceded by suppuration, ulceration, or
any solution of continuity.  In rare cases,  the tubercles ulcerate,
and then the cicatrix  is more  profound and irregular.
  Perforating Syphilitic Tubercular Eruption.—The name of this va-
riety indicates its gravity.  The  tubercles are of large size, few in
number, semi-spherical, and elevated at the  summit, and have a
broad base, which seems to penetrate  the dermis, and to be con-
founded with it.  Individuals with a delicate soft skin present the
greatest number of examples of  this variety.  They occur almost
always  on the face,  attacking the nose, lip, and sometimes  the
pavillion of the ear.   Ulceration in these cases is  the rule.  The
tubercles,  indeed, after a certain  period of indolence, inflame and
ulcerate at their summit, in two different manners: 1st. They be-
come softened, slightly painful, and a superficial loss of substance
occurs; they resemble small purulent collections which  have
united and  opened, on which moist and slightly-adherent crusts
form,  and when they fall, leave a cicatrix which  does not exceed
the  area of the tubercle; 2d. The tubercle  becomes tense, redder, 
368
VTDAL OX VENEREAL DISEASES.
painful, and is surrounded by an erythematous patch.   Ulceration
invades ite summit, and  penetrates speedily throughout its entire
thickness ;  a thick and more humid crust forms, which soon falls,
leaving a deep, perpendicular ulcer; another crust forms and falls
again; a new destruction takes place, which is repaired at the
expense of a deep violet-colored cicatrix, often appearing as if cut
out with a punch, and  representing a quarter, or  half a  circle.
This  destruction involves a portion of the cartilage of the ear, or
of the lips, and  especially of the nose.  AVhen new tubercles are
developed after the first,  the ulcerations may become confounded,
producing a hideous mutilation of the face.  It is not uncommon,
then,  to see both alae of the nose destroped, and what remains of
this organ ^is represented by a large red  stump.  In rarer cases,
the tubercles unite,  a considerable tumefaction takes place, and by
an effort of the  organism, or under the influence of rational treat-
ment, the whole gradually disappear without ulceration or suppu-
ration.  But,  unfortunately,  this cure is often only temporary;
from  various causes the tubercles reappear, ulcerate, and the havoc
above mentioned follows; or, on the other hand, reparation be-
comes complete  without  any previous ulceration.
  Serpiginous Syphilitic Tubercular Eruption.—The ulceration is here
more superficial than in  the preceding variety.  Instead of de-
stroying from without inwards, as in the last variety, that is, deeply,
the serpiginous form skims over the surface, as it were, of the skin,
but always invades new  regions.   The furrows have been seen to
cut up almost the whole  surface  of the body.
  This variety of tubercular eruption is observed on all parts of
the body, but more particularly  on the trunk, face, and wherever
hair abounds.  The tubercles, scattered irregularly here and there,
are few in number at first, and of a volume varying from that of a
large  pea to  a walnut.  They are smooth,  shining,  of a decided
coppery tint, remain stationary for some time, after which ulcera-
tion  supervenes; a black crust is formed which falls.  If repara-
tion  is not complete  beneath it, we  find  a  superficial, grayish
ulceration,  which becomes again covered with a crust, but  less
black in color, and of a less compact consistence.
  The ulceration increases by the destruction  of tubercles already
existing, or by those which are  developed in  the situation of the
first, or their vicinity.   The tubercle always precedes the ulcera-
tion, and seems to direct.  It is when a new tubercle appears, and,
as it were, prepares the ground of the ulceration, that we perceive
that reparation at an opposite point has commenced.   At the same
time  we may observe, over a limited extent, 1st, the tubercles
which prepare the ulceration;  2d, the grayish ulceration, with
perpendicular edges;  3d, the points covered with  crusts;  4th,
other points,  the seat of the recently-formed cicatrix.
  These ulcerations generally leave very irregular, violet-colored
cicatrices, perforated by numerous small vessels, and there are
bridles, resembling those resulting from burns of the third degree.
Sometimes nearly the  whole surface of the patient's body is cov-
ered with these  cicatrices, which occasionally degenerate, and as- 
SYPHILITIC ERUPTIONS.
369
sume the characters of keloides.  I have had under my care, in
Ward 10, No. 26, a patient whose  case was remarkable for  the
number and  the aspect of these cicatrices.  He was twenty-three
years of age.  He had ulcerations near the frenum, accompanied
with a very abundant  discharge  between the glans and the pre-
puce ;  at the same time there was  phimosis.  These ulcerations
lasted for about a year, alternately appearing and  disappearing;
they were dressed with  aromatic wine and Goulard's  extract, a
treatment which had been recommended at the Hopital du Midi.
There was no bubo, nor was there any eruption on  the skin.
   One year after these ulcerations were  cured, he had an attack of
pharyngeal angina, and was treated by a  homeopathist, who admin-
istered globules to him for eight months.  Two months afterwards,
that is two years  ago, he had an  eruption on the skin.   Accord-
ing to the statement of the patient, this  eruption commenced by a
red pimple (tubercle) which appeared on  the right leg.  Similar
pimples broke out on the right  thigh, the  hip, and the left nates,
and on the posterior surface of the arm; on the face, they occu-
pied the chin, nose, forehead, and left mastoidean region.  These
pimples exhaled a fluid which formed into  crusts.   The patients
remarked that these crusts were surrounded by a red circle, which,
as it were, marched before  them.  The  affection, in fact, did  not
remain stationary; it extended  from  point to point, disappearing
where first developed, to reappear on the adjacent parts; so that,
the cure preceding, or rather accompanying the ulceration, the lat-
ter never occupied at the same time a space of a larger diameter
than a half-eagle piece.  At the points where the crust had disap-
§ eared, a cicatrix formed, resembling that of a burn of the second
 egree.  This form  of cicatrization  was  not at every  point  the
same; in some regions—on the chin,  nape of the neck, and fore-
head—the patient observed fleshy growths, which attained a large
size.  One of them, situated on the forehead, and of the size of a wal-
nut, was removed by a physician of Nantes, who prescribed a su-
dorific syrup and two hundred pills of the proto-iodide of mercury.
Under this treatment the ulcerations were speedily cured; even the
fleshy tumors, developed on the scars on the face,  seemed to di-
minish in volume.  At present, May 15th, 1851, about three years
since the appearance of the first eruption, the patient has neither
tubercles, crusts, nor ulcerations.   Instead of these, we  find cica-
trices of the  character described; on the legs, thighs, and arms,.
are broad cicatrices of a reddish color, irregular edges, covered by
a thin transparent pellicle, and appearing to be consecutive to  the
ulcerations  of the deeper layers  of  the dermis.  On the face,  the
cicatrices, at  points, are of a dull whitish color, at others they
arc of a bright  or violet red  color, but at certain  points  we
observe something very remarkable, as,  for example, on the cica-
trices covering the  chin and surrounding the mouth,  perpendi-
cular  to  the long diameter of the latter, we observe a kind of
fleshy crest, about one and a half inches  in length, not very thick,
and about a line in height.   This  crest is of a reddish color, and
covered with a thin pellicle, and strongly resembles the bridles re- 
370             VTDAL ON VENEREAL DISEASES.
suiting from burns.  In the left mastoid region is a growth similar
to that on the chin, but of much larger size ;  it appears to be  pro-
duced by a swelling of the subcutaneous cellular tissue, but is ex-
posed by the ulceration of the  dermis;  it is of a red color, of an
irregular form, and projects to the extent of some two lines, and is
two inches in diameter, covered with a well-organized pellicle, the
aspect of which  resembles that  of mucous membranes exposed to
the air.  Around this fleshy growth is seen a whitish cicatrix, on
which this fungous growth is developed.  The patient complained
of no pain in these vicious cicatrices, in  which he felt occasionally
only an itching sensation.  There were no other syphilitic accidents.*

                        Ill—CAUSES.

  In treating in  general of the  consecutive affections, I was com-
pelled to speak of the causes of the syphilitic eruptions, since they
are the accidents of most frequent occurrence.  But, connected with
these cutaneous eruptions, questions have been raised which I can-
not pass in silence.   It has been  asked if blennorrhagia may be
followed by a syphilitic  eruption. ■  Upon this point, in my opin-
ion, there  can be no question, since I have proved that there is a
syphilitic  blennorrhagia.   These blennorrhagia, therefore, may
produce the same effects as chancre.   I  do not believe that one of
the forms  of primary syphilis produces a more intense and speedy
action on the system,  and has a stronger tendency to cause  erup-
tions on the skin than another.   Blennorrhagia, like chancre, may
produce the  syphilitic diathesis; and the  manifestations of this
diathesis depend, not upon the cause, since in both it is identical,
but upon other circumstances, and other influences.   From what I
have stated, my  opinion may be inferred on the question, if there
exist any real connection between certain primitive forms of syphi-
lis and  certain varieties of the  eruptions: in other words, is Car-
michael's doctrine true ?   To this, I reply in the negative.   I do
not believe with the Irish surgeon, that blennorrhagia, or what we
designate as simple chancre, must necessarily produce the papular
eruption ;  that the chancre with elevated edges (ulcus elevatum)  is
foUowed by the  pustules; and that psoriasis depends  upon the
true Hunterian chancre:  I do not believe  in these imaginary de-
pendencies, because I have seen the same chancre, the  indurated
chancre, followed by  every variety of eruption; and I have obr
served  these  same  eruptions  occurring as  primary  affections
(d'emblee),  in  other words, without any  preceding  syphilitic acci-
dent, without a blennorrhagia, or chancre of any  kind.
   [Mr. Liston regarded the scaly eruption as pathognomonic of the
chancrous form of primary sore (the Hunterian chancre).  Although
Mr. Acton believes in the doctrine of  a  simple virus, in a note on
page 285  (2d Am. ed.), he observes: " And here I must  agree
with Mr. Carmichael in his belief, that indurated sores will be fol-
lowed generally by a pecuhar form of secondary accidents.  These
* Reported by my former interne, M. Pellagot. 
SYPHILITIC ERUPTIONS.
371
eruptions are usually found to be scaly, and attended with sequela,
which seems to have a strict relation to induration ;  I believe to
that gentleman we must give the credit of having called public
attention to this view of the subject, which subsequent experience
has confirmed."   The true scaly eruption at the present day, like
the true Hunterian chancre, is rare, and, from what has  come
under our  own observation, we are disposed  to accept Mr. Car-
michael's views—at least, so far as the scaly eruption is concerned.
Doubtless, as suggested by Mr. Egan (op. cit. p. 49), the desquamat-
ing stage in which the majority of eruptions terminates, has led to
confusion on this subject.—G. C. B.]
  The question is of more  importance as regards the influence of
treatment on the development  of these eruptions, and especially
the mercurial treatment.  As soon  as it became established that
mercury is  not indispensable to the reparation of a chancre, it was
also pretended that this same agent did not prevent the appearance
of the consecutive accidents, the syphilitic  eruptions; finally, not
only was ite utility contested, but dangers were attributed to its
use, and it  was accused of causing instead of preventing the  erup-
tion, whilst the more moderate maintained that the eruptions were
less grave when mercury was not administered.
  It is  very true, as  has been  already shown in this work, that
chancre may heal without mercury, and that after the cure of this
primitive accident  no further trouble may be manifested.  But
this fact does not destroy that other fact, also unquestionable, of
the greater  frequency and gravity of the syphilitic eruptions when
the primitive accident has  not been treated;  that is, when  there
has been no specific  treatment", and especially when mercury has
not been employed.  The utility of mercury, therefore, is evident;
it cannot be questioned by any true practitioner.  The value of
this agent, as  a preventive of the syphilitic eruptions, and its
efficacy  as a curative means, is a sufficient reply to those who ac-
cuse mercury of  producing these affections.  There is another ar-
gument of still greater force;  it is based  on the fact, that work-
men,  who  are constantly exposed  to mercurial emanations, and
who suffer  from salivation and mercurial tremors, are never affect-
ed with venereal eruptions.  Biett  attached great  importance to
this fact in his'Cliniques at the hospital St. Louis, where a  large
number of  gilders came under his care.  If to  these workmen we
add those who  have never been  exposed to the influences of mer-
cury,  and who have had chancres followed by the syphilitic  erup-
tions, we shall find that we have  superabundant proof that the
dangers of mercury have  been exaggerated.   To the primary
cause, which  is  the  syphilitic virus,  and  the  other influences
which we  have mentioned, as concerned in the etiology of the
syphilitic eruptions, we must add an occasional cause ; according
to M. Cazenave, who always admite this element, whatever produces
the simple may prove the  occasional cause of the syphilitic eruptions.
This  occasional cause may be a vapor  bath, salt or  fresh water
bathing, excessive drinking, a violation of the laws of hygiene, or
a strong mental  emotion; a wound, an intermittent fever, the 
372
VLDAL ON VEXEREAL DISEASES.
application of a blister, intense cold, excessive fatigue a violent
medicine, &c, may all likewise prove exciting causes.   These can-
not always be detected, but when they do exist may generally be
appreciated.

                      IV.—DIAGNOSIS.

  The diagnosis of the syphilitic eruptions is of great importance.
A mistake here may be the cause of much domestic unhappincss,
and lead to a specific treatment, which is not always free from in-
conveniences ; on the other hand, a disease which unaided by art
is seldom cured, may be abandoned to itself, and the traces  of its
ravages may  be left in mutilations which  might by proper  treat-
ment have been prevented.  To avoid such errors, we must have
recourse to the characters common to all the syphilitic eruptions,
and to those  peculiar to the individual varieties.   I have  entered
into this double study at such lengths  that I may here be  brief.
In  cases of embarrassment, we must rely chiefly  on the  common
characters, such as the color and form.  The antecedents should
be  carefully investigated.  But it should not be forgotten, that the
first infection may have occurred in  a manner unknown to the
patient.  A kiss, which a patient believed to be innocent, may be
the cause  of a  frightful  syphilitic eruption.  The long interval
between the  appearance of the latter and the former act, may have
caused it to be forgotten.  A false  pride  may also induce the pa-
tient to tell a falsehood, and there are certain conditions in private
life into which the scrutiny of the  physician cannot penetrate.
Thus, for several reasons, we may  fail in  our efforts to obtain the
antecedents of the case, which, however,  affords us no excuse for
discarding their value, or neglecting  their search.  To confirm or
destroy the suspicions excited by a knowledge of the antecedents
of  the case, and  to  remove all doubts as to the  character of the
eruptions,  a  special  treatment  has been  proposed, viz.,  the mer-
curial.  It is very true, that in the syphilitic eruptions mercury acts
with power;  but its effecte  are not so certain and so  prompt that
we may avail ourselves of it in forming  our diagnosis, for some
cases of the  nature of which there  could be no question, have re-
sisted every  known mercurial preparation,  and  there are  others
which are  modified by this  agent only after a very protracted ad-
ministration.  Further still, there are eruptions  not  venereal, for
the treatment of which  mercury is of decided efficacy.   It is be-
sides improper to demand light from a source itself requiring  it;
and it is certain that obscurity prevails as to  the modus operandi
pf remedies.   We  must seek  for an exact useful diagnosis  in
another quarter.   We must carefully study the characters  which
distinguish these eruptions on their first appearance, with a view to
their practical appreciation.  First, we must endeavor to establish
the special nature of the disease; we must see whether it presents
the common characters which render venereal  affections  so  re-
markable ; we must consult the syphilitic physiognomy.  I think
that I have sufficiently established these common characters.  There 
SYPHILITIC ERUPTIONS.                 373
is a peculiar color belonging to the eruption itself, and a peculiar
hue  also  of the  sound parts, harmonizing with those which are
diseased ;  a disposition, a plan which seems to belong especially to
them, and which, in connection with the other characters, con-
stitute the  basis  of our  diagnosis.   If we thoroughly  understand
the characters common to all the syphilitic eruptions;  if we have
several  times observed them, they become so familiar, that at the
first glance, and even at a distance, they may be recognized.
   [Mr.  Erasmus Wilson, unquestionably a high authority  in all
matters pertaining  to cutaneous  pathology, thus speaks of the
copper color, the  pathognomonic character of the  syphilitic erup-
tions.   After alluding to the different shades of this copper-color,
according as it is  blended with yellow, brown or red, he  states
that the reddish yellow brown is the true type of the color of the
eruption under consideration.   "The copper color represents, in
fact, a declining stage of the eruption, when the congestion is sub-
siding, and  the yellow stain of the altered fluids of the  skin shines
through the purple of the blood.   The ' copper color,' therefore,
may have a greater or less amount  of red  or yellow in ite com-
position, and be  either a reddish copper color, or a yellowish
copper color."  He remarks that the dull purplish red,  the muddy
red,  and  the yellowish red,  called "copper colored,"  are  by no
means characteristic of the syphilitic eruptions, being commonly
met  with  in chronic eruptions  of other  kinds, as, for example,
acne.  He has seen non-syphilitic  eruptions possessing more of
the dull and muddy hue, supposed to be peculiar to syphilis, than
syphilitic  eruptions themselves;  and "in  selecting  undoubted
syphilitic eruptions in their  earliest and best-developed  stage for
illustration in my 'Portraits of Diseases of the Skin,' I  have some-
times felt a regret that  there was not more of the coppery hue
present.   But to  have obtained 'this ' copper color,' I  must have
waited  until the  eruption was  in its decline.   The color of the
skin must not, therefore,  be relied on as  proof of their syphilitic
nature,  although  it may  be fairly taken as a pathognomonic char-
acter where other symptoms tending to the same "diagnosis are
found to be present."—G. C. B.]
   An early diagnosis is of the highest importance, for by it we
arrive at  a  more accurate knowledge  of the nature and special
form of  the eruption.   These points being ascertained, we endeavor
to determine to what order the eruption belongs.  " Then  it is,"
says M.  Cazenave, " that  we may advantageously apply the method
of Willan ;   then, also, should  we scrupulously aim to avail our-
selves of all the knowledge acquired by observation.  Indeed, £he
diagnosis of the form is often attended with the  greatest difficulties
to be imagined;   and if it be remembered that the progress of
venereal eruptions is essentially  chronic, and that  the  elementary
lesions,  often not  well marked, leave behind other lesions which
may lead to confusion, we may see that for certain forms in par-
ticular,  these lesions are frequently of such a transient  nature that
they cannot  be appreciated;  as, for example, in almost all  the
vesicular,  and in the lenticular pustular eruptions. 
374             VLDAL  ON VEXEREAL DISEASES.

  The diagnosis, then, is chiefly  based on  a knowledge of the
general characters; it may, in many circumstances, be rendered
more easy by other  circumstances,  which,  however,  are  essen-
tiaUy connected with the  eruptions themselves.   Thus we may
be greatly assisted by a knowledge of the accompanying  symp-
toms which  are frequently  observed, and  by that of the pe-
culiar  characters which establish  sufficiently the  existence of
the syphilitic  affection, and which  is  especially manifested by a
tendency to  destruction.  However, we should not attach more
value to these otherwise important signs, than they really merit;
for, if, as already stated, a syphilitic eruption may coexist with a
simple eruption, still more may a special affection coexist with an
extosis, &c.  The concominant symptoms are then but a means of
attaining a diagnosis, but on themselves they are  insufficient to
lead to a positive decision.  On the other  hand, other affections
may leave behind cicatrices, and we should  not be too readily in-
clined to regard them as a proof of the action of syphilis, although
the syphilitic cicatrix has an especial mark;  but the observations
made in reference to accompanying symptoms apply to the cica-
trices.   In doubtful cases, assistance may be  derived by appealing
to the antecedents of the case; but this can never be but an acces-
sory means among others which shall conduct us to the discovery
of the truth.*

                       V—PROGNOSIS.

  The prognosis in the syphilitic eruptions is not generally of it-
self  grave ; the dangers arise from the complications and relapses,
for in  cases of relapse  the skin  is always  affected to a  greater
depth.  These affections, taken together, form  two great groups.
One, which  is the most common, appears shortly after the primi-
tive accidents, and assumes a character comparatively more acute,
and extends over a large portion of the surface; this group I call
superficial, benign; it consists principally  of roseola, papules, and
numerous superficial pustules.  The  other  group  is  of a more
chronic character, supervening upon  the first when the latter has
been badly treated ; in  this group depth, instead of surface, is in-
volved ; compared with the former, it is malign.  The deep-seated
pustules, the pustulo-crustaceous eruptions, those of chronic ecthy-
ma, few in number but profound, which appear  on the extremities
and  legs, and the tubercles which  invade the face; those which
manifest themselves at a somewhat later period, before the osseous
affections, or  at a very  late period,  even after  exostosis, are  of a
very grave character, because they exhaust the patient's strength,
and  leave indelible traces and sometimes mutilations which un-
fortunately occur most  frequently on the  face, rendering the con-
dition  truly hideous.   Add to these  facts the difficulties in the
way of treatment,  much greater  here  than  in the first category,
and it will be evident that the deep-seated  and  chronic forms are
of a more serious character than the superficial and acute.
* Cazenave, Traite des syphilides, p. 554. 
SYPHILITIC ERUPTIONS.
375
  The prognosis depends also upon the treatment.  Now, as it has
been shown that it is by the relapses that the syphilitic eruptions
become more  and more profound,  we should endeavor to prevent
them.  The best means is a methodical treatment, into which mer-
cury should almost always enter.   It is true that  the  most judici-
ous and best-directed treatment does not always prevent a return;
but, as it is also well established that these returns are much more
frequent when the  treatment has  been  improper and  badly
managed, the  eruptions which occur  at first should be thoroughly
treated, or what is still better, the primary accidente should be ac-
tively treated,  so  that eruptions may be prevented, or if they ap-
pear, it shall be in a mild form, and one easy to be cured.


                     VI.—TREATMENT.

  The treatment of the syphilitic eruptions is internal and external.


                 INTERNAL TREATMENT.

  Having treated particularly of the internal treatment of the so-
called consecutive venereal affections,  and the syphilitic eruptions
being among the most frequent of these, I shall here be brief.  I
must, however, repeat, to a certain extent, and add  some  details.
  It is  evident that mercury  should constitute  the  basis  of our
therapeutics.   The form most frequently employed  is the proto-
iodide of mercury.  In my opinion, mercury should never be dis-
carded except when there is a very decided repulsion on the part
of the system,  and even then it should not be wholly thrown aside.
I have seen, indeed, patients at first  decidedly anti-pathic to mer-
cury, and in whom it produced unpleasant effects in the abdomen
and mouth; some of these were debilitated by the smallest doses
of mercury, and  yet  after  having been strengthened by the  pre-
parations of iodine or iron, these same  patients could  take  and
tolerate the mercury, and it finally  became the means of their cure.
I have  already mentioned these practical facts.   I repeat, that I
Srefer to begin with small doses of mercury, for I fear that large
 oses will compel me  to suspend the  treatment, which would be an
unfortunate circumstance, tending to favor the relapses  and to
make the subsequent treatment more difficult.   However, I must
acknowledge that I do sometimes  discontinue the use of mercury
even when it is well borne, but it is only when it has been used for
a long time, as for two months, without  arresting the progress of
the disease.  Then, if the patient retain his strength,  I administer,
every morning, a glass of Seidlitz water or of the citrate of mag-
nesia, and after awhile  resume the use of the mercury,  which, in
the majority of  cases, then advantageously modifies  the eruption,
even in the same doses, which, before the repose, and the repeated
purging, were ineffectual.   When the constitution  is much im-
paired,  instead of purging the patient, I resort to the preparations
of iron, or  the iodide  of iron, or I confine my treatment to substan- 
376
VTDAL ON VENEREAL DISEASES.
tial nourishment, with the view of always resuming the employ-
ment of the mercury.
   The preparations of iodine, especially the iodide of potassium,
should be administered when the eruption is deep-seated, and when
it is complicated with other affections still more profound, a sub-
cutaneous lesion, such as a periostosis or an exostosis.  There are
still many practitioners who conjoin with  these means the use of
sudorifics.   Here, as in the treatment of the primitive accidente, a
question arises which is difficult to decide, viz. that of the duration
of the treatment.  " In general," says M. Cazenave, " in the milder,
recent forms, if the disease disappeared rapidly, in the course of a
month or six weeks, for example, the treatment should be  con-
tinued for a month longer, dividing the time into three portions.
One in which the complete treatment is maintained, and  two
others, in which the  quantity administered is gradually reduced
one-third.  If the treatment has lasted for several months, the
medicine should be discontinued for several days after the cure has
been obtained, and then its employment should be resumed with
the same  decision as during the first  several weeks."  Thus, M.
Cazenave recommences the treatment two or three times, according
to the gravity of the preceding disease.   In  the  severer forms, a
still longer period is insisted upon; and when after a long interval,
the medicine having besides been well tolerated during the whole
duration of the treatment, an intolerance  is manifested, it is with
the physician of the St. Louis hospital the strongest evidence that
the disease is completely cured.


                 EXTERNAL TREATMENT.

   The cure of the syphilitic  eruptions may be  promoted, their
removal hastened, and certain local accidents mitigated by external
means, by topical applications.  Simple general bathing, starched
or gelatinous baths, may prove of service in cases complicated with
inflammation,  and when there is a manifest over-excitement.  In
these cases, emollient, sedative,  and even opiated  fomentations
may be advantageously employed.  M. Cazenave condemns the
use of cataplasms, which have been recommended by several prac-
titioners, especially if applied for the  purpose of promoting the
separation of the crusts of certain syphilitic eruptions.   By exposing
the ulcerations they render them painful; the ulers assume a bad
aspect, enlarge and soon become covered with a new crust.  It is
much better for  the  crust to fall spontaneously, that is, that its
separation should result from a rational treatment, which has pro-
duced a  reparation of the ulcer.  When  the eruptions are not
irritable, baths,  and  simple vapor douches, may prove  of service.
The papular, tubercular, and squamous forms are speedily modified
by these means.   The cure of the syphilitic exanthemata, of lichen,
of impetigo, is expedited by baths of  amidon and gelatine.  M.
Cazenave has a high opinion of alkaline baths in  the majority of
the syphihtic pustular affections, especially when the dry crusts 
SYPHILITIC ERUPTIONS.                 377
seem to indicate that reparation is complete.   He asserts that sul-,
phurous baths are not in these cases particularly indicated.  There
are two kinds of baths still more special than those which have been
mentioned;  these are the corrosive  sublimate  baths, and fumiga-
tions with  cinnabar.  According to M.  Cazenave,  the sublimate
baths are not to be trusted even as auxiliary means, in the treat-
ment of the syphilitic eruptions.  Considered as topical applications,
these baths would be a rational means ;*but they should not be
confided in  alone in our general treatment.  The vapor baths of
cinnabar are, on  the contrary, generally approved.   MM. Ricord
and Cazenave agree on this point.  The cinnabar fumigations mav
be either general or local.  Ointments are but rarely employed.
Those  containing the proto-iodide of mercury are  generally pre-
ferred.  M.  Cazenave adopts the following formula:

           OINTMENT OF  PROTO-IODIDE OF MERCURY.

                 $. Hydrarg. Proto-iodide, grs. xv.
                    Axung. \ i.

   This is used in the dressing of the ulcerations of lupus syphilitica.

   In these  same cases, if we desire to modify more actively the
non-ulcerated tissues, we are to use the following, which is a true
escharotic:

         OINTMENT OF  THE DEUT-IODIDE OF  MERCURY.

                   $.  Hydrarg. Deuto-iodide, gr. i.
                      Axung.  3 i.

   M. Ricord states that he has found benefit in the squamous form
from the use of the ointment of goudron of M. Emery.  This is
the formula:

                   OINTMENT OF GOUDRON.

                       T£. Goudron,  3 iii.
                           Axung.  3 x.

   Cauterizations are generally avoided.   After the crusts in syph-
ilitic rupia have separated, M. Ricord dresses  the ulceration with
charpie steeped in the following solution :

                     SOLUTION OF IODINE.

                    ]£. Aq. dist.  3 vi.
                       Tinct. Iod. 3 iss.
                       Iod. Potass, grs. xv.

   The application of the sparadrap of Vigo cum mercuria cannot be
too highly recommended in the majority of the syphilitic eruptions.
I have already mentioned an excellent example of  the rapid cure 
378
VIDAL ON VENEREAL DISEASES
of several very grave, extensive, and serpiginous ulcerations.  It
is, perhaps, the means which most speedily removes the symptoms.
The value of this plaster is most apparent in the treatment of cer-
tain syphihtic eruptions on the face.
                        SECTION II.

          DISEASES OF THE APPENDAGES OF THE SKIN.

               I.—FALL OF THE EPIDERMIS.

  In the preceding section, when treating of the squamous syphil-
itic eruptions, I alluded  to  an alteration of the epidermis which
becomes of a horny nature on the soles of the feet and the palms
of the hands.   There  are also certain other changes to which the
epidermis is liable, and to which it is well here to  refer.  The
epidermis, indeed, in all the consecutive accidents, becomes some-
what thickened and discolored, of a white, grayish hue, and after-
wards separates by Httle disks, and leaves the papillary substance
covered only by a vejy thin layer of new epidermis.  These phe-
nomena are observed especially on the palms of the hands. When
these patches  multiply and become  united, the epidermis may
separate  to a very great  extent:  the fingers being in some cases
likewise  denuded.  By some writers,  this shedding of the epider-
mis  on the  hands, feet, and other points of the body, has been
called pelade.
  Occasionally the epidermis separates in extremely fine furfura-
ceous desquamations, as,  for example, on the scalp, thus producing
alopecia, though, in some instances, there is no loss of the hair.


                       IL—ALOPECIA.

  Those who have studied the different classifications of  the acci-
dents of syphilis, are aware that one of the  first was made by
Fernel.   According to this eminent physician,  the syphilitic virus
does not invade at once the whole organism ; it penetrates by lay-
ers, proceeding from the epidermis towards the deep-seated parts,
until it reaches the bones.   Adopting this theory, Fernel estab-
lished four degrees of syphilis.   In the first, the virus  becomes
insinuated hke a vapor beneath  the epidermis, producing a loss
of the nails and hair.  Fernel's theory, like all  other theories, may
be discarded, but the facts remain; it  is very true that alopecia is
one of the first manifestations of the syphilitic infection.  Here,
however, we must carefully distinguish partial  alopecia, from gen-
eral, universal  alopecia,  involving the  loss of the hair  throughout
the body. Without this distinction, it is impossible to explain the
differences of opinion which exist in relation to alopecia, or to 
          DISEASES OF THE APPENDAGES OF THE SKIN.      379

commence a serious description of this accident.  Thus it is evident
that if M. Desruelles had  recognized  this distinction, he  never
could  have asserted that this affection has almost entirely disap-
peared,* that it is no longer observed;  and M. Lagneau would
not  have declared that it  is exceedingly rare.   H  these authors
intend their remarks to apply to general alopecia, then they are
correct, but they would completely reject the facte, if they  dis-
puted  the frequency of partial alopecia.'  This phenomenon, in-
deed, is  common  in  the commencement of the diathesis,  when
there are cephalalgia, and  rheumatoid pains.   M.  Baumes, who
agrees with me on this point, states "that this partial loss of the
hair is observed after quite recent attacks of chancre and blennor-
rhagia."f  In such cases there is  sometimes a furfuraceous erup-
tion, a slight  desquamation of the epidermis at the roots of the
hair, and alopecia occurs; but this sometimes takes place  without
any apparent alteration  of the epidermis.  Friction,  a slight trac-
tion, the action of a comb, detach the hair on the scalp ; occasion-
ally the hair on the body is  removed in the same manner, but this
is much more rare.
   In partial alopecia, the  hairy bulbs are not always affected, or
at least, they are not so  much impaired as to  prevent the growth
of the hair.   Such is not the case,  however, with the  hair on
other parts of the  body, proving that in persons thus affected, the
infection is more complete.
   M. Reynaud, of Toulon, has remarked  that in  partial alopecia,
the affection assumes a circular form, and that this tendency which
has been noticed in describing the general characters of the syph-
ilitic eruptions, is manifested even here.  The scalp is thus laid
bare in disks, forming,  as it were, little tonsures.  The same thing
may happen with the beard.  Generally, we do not observe dur-
ing the first stages of syphilitic infection this circular disposition
in the  falling of the hair ; but it is lost at various points;  some-
times so slight is the loss, that it is not noticed. A little is brought
away with the comb, and this is all that arrests the patient's  atten-
tion, and individuals who are negligent of their persons may be
wholly unaware of the  loss they sustain.  It  is owing to this cir-
cumstance, that this phenomenon is rarely noted in the reports of
cases, and that able writers have asserted that alopecia  is  very
rare.
  General, universal alopecia is indeed rare,  for it occurs  only
during the last stages  of the  diathesis, and  frequently when  a
syphilitic cachexia  has  already  formed.  It is this degree of alo-
pecia which, in the  language of Brassavole, " gives to the patient
a ridiculous aspect, for we cannot refrain from laughing when we
see men without beards,  without  eyebrows and eyelashes.";}:  I
have seen ah instance of complete, universal alopecia.  The man
was  examined  by several syphilographers, for he passed from the
care of one to another.   So completely was his system saturated
with syphilis, that the whole habitude of his body was changed;

     *  Page 612.         f T. ii., p. 411.        % De morbo gallico. 
380
VIDAL ON VEXEREAL DISEASES.
   his virility was completely annulled;  and  so  degraded was he,
   that his sex could hardly be recognized.  Brassavole would have
   thought him more than ridiculous.  He had lost all the hair on
   his head and body ;  his eyebrows, beard, the  hair on the pubes,
   and in the  axilla, were all wanting.  The complete report of the
   case has been published by M. de Castelneau in the Annales de la
   syphilis, tome i.
      Mercury is accused of producing alopecia, as it has been of all
   other consecutive accidente.  M. Desruelles  was the most decided
   on this point, and we know that other pupils of Broussais have
   repeated the accusation.  No one acquainted with the dictates, or
   fruits, of a false system, will be surprised at  this.   There has been
   in fact, and  still is, hydrargyrophobia.   But what is surprising, is,
   to see men who were never devoted to Broussais or his school, men
   of true merit, absolve syphilis and attribute the alopecia more  or
   less directly to mercury.   Of this number is M. Gibert.   ( Vid. his
   Manuel, p. 433.)  It may, however, be  easily proved by two cir-
   cumstances  that mercury has been unjustly accused, and that the
   syphilitic virus is the true cause.   In  the first  place, observe the
   workmen who are daily subjected to the influence of mercurial
   emanations,  and there observe  what occurs in patients affected
   with  syphilis, and who are never submitted to mercurial treatment.
   The former, the gilders, for example, have attacks  of stomatitis,
   mercurial tremors, but never alopecia, except it be senile alopecia.
   Patients with the venereal disease,  on the contrary, if the disease
   be left to itself, frequently have partial alopecia,  at first, and if
   the disease  continue to  be neglected, and  the diathesis reach a
   state  of cachexy, the alopecia may become universal, and the pa-
   tients be deprived of all their hair.
      Alopecia, therefore, does actually occur;  it frequently presents
   itself under a mild and partial form,  and is one of the first mani-
   festations of syphilitic infection.   General alopecia  is also some-
   times, though rarely observed, and in the last stages of the diath-
   esis.  Both  forms  are independent  of the effects of  mercury.
   This  agent,  on the contrary, is one of the best  means of prevent-
   ing or of arresting this accident.   When it has  become general, it
   is incurable, that  is, there can be no hope of restoring the  hair.
   When, on the  contrary, it is  partial, and the  diathesis  has  only
   commenced, a complete cure may be obtained.  For this purpose
   a number of lotions and ointments have been invented, which, in
   my opinion, are useless.   I repeat, that we  must  resort to the use
•  of mercury.

                           III.—ONYXIS.

      Under  the  influence of the syphilitic virus, the matrix of the
   nail sometimes  suffers changes,  which depend  upon an inflamma-
   tion  more or less  acute.  There  is, also, often ulceration, but in
   many cases  a vicious secretion only of the matrix is  observed;  oc-
   casionally, but more  rarely, the nail  is lost without any appreci-
   able  alteration of the skin.   The ulcerative inflammation of the 
         DISEASES  OF THE  APPENDAGES OF THE SKIN.      381

matrix of the nails is preceded by a somewhat painful tumefaction
around the nail, but especially around its root.  The skin becomes
alternately of a coppery and of a violet-red  color.   This part of
the integuments, which at first become softened, is excavated by
an ulceration which has a grayish, blenny base, covered  by a san-
ious liquid of a foetid and peculiar odor.  At other times, on the
contrary, the swelling which is round and folded on itself, projects
on each side of the nail, and is separated from it by pus which may
be made to issue on each side by pressing on the tumefied skin. This
pus is often mixed with dark-colored blood.  M. Cazenave states
that he has frequently observed sleeplessness in these cases.  It is
rare that the skin does not at length ulcerate; in which case, the
wound thus made more extensive, exposes a larger portion of the
root of the nail.  Whatever may be the progress of this inflam-
mation, the pus which constantly bathes the  matrix and the nail,
completely detaches the latter, which in its fall, lays bare the ma-
trix, which may not be ulcerated, when the nail will be quickly
reproduced, however  the  disease may progress  towards a  cure.
On the other hand, the matrix becomes ulcerated, and fungous,
surrounded by a prominent swelling, itself  ulcerated throughout
nearly its whole extent, and then  the nail is  not  reproduced; the
syphilitic ulceration is replaced by a furrowed cicatrix and smaU
horny patches of no particular shape.   This variety of onyxis,
which  was well described  by Delpech, is  rare;  it attacks the
fingers and the toes, but more frequently the fingers; it forms one
of the complications of the more or less severe symptoms of syphi-
lis, and especially the syphilitic eruptions.
  The inflammation of the  matrix of the nail does not generally
advance in ulceration.  The skin then remains intact.  Sometimes
there are very severe pains under the nail itself, but there is neither
a tumefaction of the skin, nor purulent discharge.   The secretion
of the horny matter is vicious, and the nail may present a number
of different alterations.
   "Sometimes  it becomes at several points of a gray color, dry
and broken at  ite  free extremity;  sometimes,  independently of
these alterations, it becomes thickened for two-thirds of its extent,
opaque, chaffed, and its exfoliated surface is reddish and unequal;
and what is remarkable, a well-marked line of demarkation sepa-
rates the diseased from the sound parts, ordinarily represented by
a surface beginning a little beyond its lunated portion where the
nail preserves its luster, polish and its color.  In some cases, how-
ever, the alteration of the structure is general, and the nail is con-
verted into a dry,  grayish,  chaffed,  and very friable production.
This form, well known to the ancients, is, I repeat, very common;
it is even rare for syphilis to exist for any length of time without
involving,  to a greater  or  less extent,  the nails.  It  is always
secondary.  Sometimes it is the  only symptom which reveals a
consecutive syphihtic affection."*
  The following is an example of ulceration of the matrix of the
♦Cazenave, Traite dessyphilides, p. 429. 
382            VTDAL ON VENEREAL DISEASES.
nail;  the last figure  in plate 6 was taken from this subject.  The
patient, Teurtrier (Auguste) was twenty-three years of age, a cook
by profession, of a lymphatic temperament, and an impaired con-
stitution.  He was admitted on the 13th Sept., 1851, into Ward 9,
No. 13.
   Sept., 1850.  Blennorrhagia which lasted five weeks, without
complication.   Cured entirely by copaiba.
   Oct. Bubo treated by M. Puche, who has furnished information
of the existence of,  1st, two indolent adenities; 2d, an enlarged
cervical ganglion on the  left side.  He left uncured  on the  1st
November, after having taken three ounces of the bromide of po-
tassium.
   March, 1851. Blennorrhagia which lasted ten days;  there was
a scanty muco-purulent discharge, which ceased completely under
the influence of injections of Goulard's extract.
   June, 1851.  Inguinal bubo on right side, painful, treated  by
antiphlogistics.   At present, no ulceration on the glans or around
the anus.  Five weeks before the appearance of the  bubo, patient
suffered very intense peri-articular pains.
   July, 1851.  Ulceration of the anus.  From this time the patient
commenced to take pills prescribed by a physician in town.  This
ulceration lasted four or five weeks; at the time  of its cicatrization
(August), the right testicle very soon became inflamed, and  pain-
ful ; nevertheless, by the aid of a suspensory bandage he was able
to work.  The left testicle became in like manner speedily attacked.
Towards the end of August, an exanthematous  eruption appeared
on both lower extremities.  At the same time crusts formed at
the roots  of the  hair, and the latter began to  fall; further, the
ulcerations invaded the matrix of the nails of the middle and ring-
finger of the right hand.   Fifteen days afterwards, the patient pre-
sented himself at the Hopital du Midi.  There was no discharge,
nor were there  any traces of ulceration about the anus, which did
not have an infundibul formiappearance.   On the lower extremi-
ties was an eruption of roseola, which at certain points had become
converted into yellowish  patches, and was undergoing a kind of
desquamation.  They were enlarged  cervical and inguinal glands,
but they were  not painful.  Both testicles were enlarged, and the
epididymis was particularly the seat of the engorgement.  The
tunica albuginea  is  not hard to the touch.  The right testicle is
more  engorged than  the left;  both are nearly insensible to pres-
sure.   The nail of the ring-finger is lost, and  the whole matrix
invaded by a grayish ulceration, secreting pus of an offensive odor.
The nail of  the middle finger is  destroyed towards ite root.  The
lunated form is destroyed and the nail distorted, as represented in
plate  6.  The  patient had  suffered at the ends of his fingers, but
at the time of his admission these pains had ceased.
  19th. Was placed under  the influence of iodide of potassium;
forty-five grains in the day.
  25th. The induration of the right testicle has entirely  disap-
peared ; there  remains only a very slight  sensibility  to pressure.
The patient demands his discharge; he would not finish his treat- 
          AFFECTIONS OF THE MUCOUS MEMBRANES.       383

ment at the hospital.  In addition to the fact of the existence of a
remarkable ulceration of the matrix of the nail, we here find both
testicles affected with what is  called syphililic'sarcoceles, and  yet
the epididymi alone were engorged;  even the substance of  the
testicle was intact, which is contrary to the opinion of those who
pretend that syphilitic sarcocele affects exclusively the gland itself.
The general  treatment of onyxis is that  of confirmed syphilis.
However, as it is a symptom of deep infection, and  as it  is often
observed in feeble  subjects, we should not insist too strongly on
the use of mercury alone, but combine it with the iodide of potas-
sium.  It will have been remarked that the subject of the case just
reported had taken the preparations of iodine only; this was owing
to the fact that he was feeble, and that the affection of the testicles
was a proof of confirmed  syphilis.  It was my intention to add the
proto-iodide of mercury when the patient regained  his strength;
but, as has been stated, this patient would leave the hospital  im-
mediately after he began  to improve.
   As to the local treatment, it must vary according to the more or
less acute character of the onyxis, and according to the  pains of
which it may be the seat, and the period of the disease.
   Local emollient baths, to which laudanum may be added, cata-
plasms of the same nature, should be preferred when the inflamma-
tion assumes an acute character, and when the pains are severe.
When the inflammation has been subdued, the local treatment
should be confined to dressings with calomel cerate, apphed after
washing  the part  with  a  dilute  solution of  chlorated  water.
Finally, in case of indolent fungous ulcerations, we  should cauter-
ize gently with the nitrate of silver three times in a  day, and dress
the part with the plaster  of Vigo.
                       SECTION  ILL

      AFFECTIONS  OF THE MUCOUS MEMBRANES.

  The mucous  membranes are too intimately connected with  the
skin not to participate in ite diseases, especially when the essential
cause  of such diseases is a poison.   We see, indeed, in all cuta-
neous affections resulting from morbid poisons, the mucous mem-
branes suffering to a greater or less extent, and, generally, the
manifestations are chiefly apparent in the^ throat, nose, and respira-
tory passages.   Thus,  in scarlatina, there is a characteristic angina;
in rubeola, the lining membranes  of the nose and larynx  are
affected, and every one knows that coryza is not rare in variola;
in miliaria, the fining  membrane of the mouth becomes involved,
as shown  by aptha?, and sometimes there is  an eruption on the
tongue which deprives it of its covering.
  In  the syphilitic eruptions, we also find analogous affections of
the mucous membrane of the throat, and especially that of the 
384             VIDAL OX VENEREAL  DISEASES.
mouth, and, it may be said, that in almost all the external, there
are also internal syphilitic eruptions.  Like  the affections  of the
skin, those of the mucous membranes are often followed by ulcera-
tions, and indeed such a termination is more frequent in the  latter
than the former situation; these solutions of continuity assume an
elongated form, and constitute what  are  called  rhagades.  It  is
observed  particularly at the anus, on  the tongue, and the  corner
of the lips.  The affections of the mucous membranes, moreover,
afford the strongest evidence  of constitutional syphilis,  but, in
general, they are not of a grave character, and speedily disappear
under the mercurial treatment; but these affections are also most
readily  and speedily reproduced, when this  treatment is  neither
methodical nor complete.
  Modern, writers on syphilis are not  content to show the coinci-
dence of  the cutaneous affections and those of the mucous mem-
branes ; some,  as,  for example,  MM.  Babington and Baumes, re-
cognize a repetition in the internal membranes of the forms of
eruptions described in the preceding  section, when the syphilitic
eruptions, properly so called, were discussed.
  In treating of the most important of these affections of the mu-
cous membranes, we shall see whether such an opinion is perfectly
correct.   I shall commence with those of the membrane lining the
buccal cavity, as this is the  most frequent  form of the internal
eruption.

        I.—MUCOUS  MEMBRANE  OF THE MOUTH.

  M. Baumes establishes three forms of this  affection:
  1st. The  angina, corresponding to  the  syphilitic exanthemata,
appears in patches more or less  irregular, of a more or less lively
red color, sometimes whitish at the centre, without tumefaction, or
with a very slight tumefaction of the mucous membrane, occurring
on  the palatine arch, the velum palati,  the pharynx, internal sur-
face of the lips, and cheeks.  These patches  are of short duration;
they  disappear simultaneously with, or even before the cutaneous
eruption.   According to M. Baumes, if this form seems to be un-
common,  it is because the syphilitic exanthemata are themselves
unfrequent, and because, being in themselves of no great  import-
ance, and producing but  little inconvenience throughout their
course, they escape attention.   The last reason  is the best; as to
the first, it does not accord with facts  which  prove that roseola  is
of very common occurrence.
  2d. The form of angina  coinciding with  the papular eruption
consists, in  the first place, of genuine  mucous tubercles, that is,
flat  elevations, of  a circular or oval form, but less prominent and
less distinctly circumscribed than on  the skin.  Their surface has
sometimes a slightly granular aspect.  Their color is a little deeper
than that of the surrounding mucous membrane ;  they inflame but
slightly, and are not more difficult to destroy than  the mucous
tubercles  of the skin.  In speaking in the first section  of the
mucous tubercles,  I »have mentioned these  papules found at the 
           AFFECTIOXS OF THE MUCOUS MEMBRANES.        385

 commissure of the lips, within the lips  and cheeks, on the velum
 and the pillars of the velum palat'i, and even towards the sides of
 the base of the tongue.  Sometimes the papules assume the  form
 of tubercles; in that case they somewhat resemble the papillas on
 the base of the tongue, when  the latter are morbidly developed,
 but, unlike the latter, they are not painful, nor are they seated on
 the edges and even on the point of the  tongue. These elevations
 are  sometimes wrinkled and  elongated, and they speedily termi-
 nate by resolution.  These little tumors do not ulcerate unless irri-
 tated by stimulants, or by rubbing against an adjoining, angular
 and cutting tooth.
 ,  3d.  The third form corresponds with the  squamous variety, not
 in the presence of scales, the  formation and sojourn of which on
 the surface of the lining membrane of the mouth are  not possible,
 but  in the disposition of the patches, the elevation,  tumefaction,
 and redness of the mucous membrane, which, at one point, par-
 ticularly the central portion of these  patches, presents the epider-
 mis raised, of a whitish color, wrinkled, and on its  separation a
 very superficial, grayish ulceration.   It is very probable, says M.
 Baumes, that if the epidermis, raised and constantly macerated by
 the  fluids  which fill the mouth, were not soon detached, a true,
 thin, and very extensive scale would be formed.  This variety is
 met with on the palatine arch, the velum, the pillars of the fauces,
 the tonsils, the internal surface of the lips, and even of the tongue.
 This is of longer duration than the preceding variety.
   4th. According to M. Baumes, there is a pustular form corre-
 sponding to the pustular syphilitic eruption, but as  the  elevated
 epidermis is soon detached, as it  is speedily destroyed, and is re-
 placed by ulceration, it becomes confounded with the following
 variety.
   5th. This fifth form'should  correspond to the ulcerated syphil-
 itic eruption.   It  is, according to M. Baumes, the most common,
 and that which gives  rise to  the most important considerations
 relative to its progress, duration, gravity, and the ravages it  may
 commit in the mouth, and that, in  fine, in which all the others
 terminate, when they become exasperated by any irritating cause.
 There must exist some varieties, but it is not always  an easy mat-
 ter to  distinguish them from ulcers produced by other causes.
 The very  commencement of these  superficial ulcerations, by a
 white  or grayish  surface,  of which  the  circumference,  without
 forming distinct edges, easy to be recognized as in the other ulcers,
 blends insensibly, as by a sort of levelling with the more depressed
 ulcerated part,  occasionally presenting such an appearance as to
 produce the impression that no ulceration exists.
   The circumference of these ulcerations is ordinarily, for a greater
 or less distance, of a deep red color, which contraste with  the dull
 white of the ulcerated surface.  This surrounding redness is par-
 ticularly remarked when the ulcers are seated on the velum palati,
the pillars of the velum, and the tumefied tonsils.  It is often ab-
sent in the ulcers on the Hps, within the hps, and on the  internal
surface of  the  cheeks.  Occasionally the whole bottom of  the
                               2'5 
386
VTDAL ON VENEREAL DISEASES.
mouth is lined  with this kind of ulcerations, which is attended
with a sensation of uneasiness and dryness rather than of pam, and
does not interfere with deglutition  unless deeply seated towards
the base  of the pillars of the velum palati.  From the aspect and
the irregular form of this affection, one  might suppose that the
parts had suffered  from a burn of the first and  second degree.
According to the physician of Lyons, this is the kind of ulceration
which forms the most important part of the constitutional symp-
toms of blennorrhagia.
  In  the second variety, the  chancrous form is more strongly
marked.   The ulcer is  superficial, though it involves the greater
part or the whole of the thickness of the mucous membrane, has a
grayish,  granulated base, its edges  are  irregular, sometimes de-
tached, the circumference but little or  not at all red colored, situ-
ated on the tonsils, the pharynx, the pillars of the velum  palati,
the internal part of the lips and cheeks.   Very frequently the parts
adjacent  to the dentes  sapientiae become invaded, or the points
even  through which  these  teeth protrude  or  are about to pro-
trude ; we  should guard against confounding the ulcers under
consideration with those produced by the cutting of  these teeth,
at which time the  mucous membrane is already disposed to in-
flame and to become tumefied.  In the normal state, this membrane
ordinarily tolerates, without lesion, the pressure of teeth, or frag-
ments  of teeth,  however irregular they may be;  but when it is
irritated  and inflamed, these teeth, or portions of teeth, wound it,
and give rise to ulcerations, which, at first view, might not be
readily distinguished from the  venereal  ulcers in question, even
after inquiring into the antecedent or concomitant circumstances.
The syphilitic ulcer is of long  duration, is  more obstinate, more
difficult  of  cure  than the preceding.   It leaves a cicatrix on the
mucous membrane,  which continues  for  a long time, remaining
smooth, whiter and more brilliant than the adjacent healthy mu-
cous membrane.
  The third variety affects at first and almost exclusively, the ton-
sils.  The ulcer resembles a  primary chancre, and without causing
a previous tumefaction  of the  tonsils, "  digs them  out  as it were
with a punch;" it has a yellowish base, and a circumference of a
deep red color, extending in every direction, sometimes the red-
ness involves the whole  surface of the tonsils and the surrounding
parts, invading at times the orifices of the Eustachian tubes, and
producing deafness  or an alteration of hearing, much  more fre-
quently than the preceding ulceration.  In some instances, this
ulcer, in  the first place, produces neither  pain, inconvenience, nor
impediment in deglutition;  and if the patient's attention be at-
tracted by either of the above  circumstances, he is surprised to
find that the ulcer has already made considerable progress.  The
latter is  generally chronic,  and  attended with but  little gene-
ral  disturbance.   Occasionally, however,  the inflammation is se-
vere.
  In the fourth variety, the progress of the ulcer in its incipient
state, resembles in part that of a phagedenic ulcer, with or without 
           AFFECTIONS OF THE  MUCOUS MEMBRANES.        387

superficial  gangrene.   It is particularly in this variety, that the
ulceration is preceded and accompanied by pains which are some-
times very severe, with febrile reaction, a difficulty or impossibility
of swallowing, a change of voice, as well as of hearing, resulting
from the extension of the ulcer to the uvula, the base and posterior
part of the velum palati, the posterior and superior surface of the
 Eharynx, the posterior and even  superior part of the velum palati,
 ordering on the nasal fossae.   These,  together  with the tonsils,
are  indeed the parts which are the most common seat of these ul-
cerations.   They are, however, likewise observed on the internal
surface of the lips, and the inner and posterior  surfaces  of the
cheeks.   The progress of the phagedenic inflammation is  some-
times so rapid that the osseous tissues of the palate, behind the
pharynx, and the nasal fossae, become involved, in which case mat-
ters assume a more serious character.   The progress of the ulcer-
ation is generally more rapid than- in the preceding variety.
  It is probable that the different forms described by M. Baumes*
correspond to the  cases which he has observed.  But I am of the
opinion, that  both in a theoretical and practical view of the sub-
ject, we must here invoke the aid of synthesis.  I shaU therefore
reduce to two varieties, the different forms of ulcerations in the
buccal cavity; 1st, the superficial variety, which is sometimes lim-
ited to a slight erosion, and  which, in the majority of cases, does
not extend beyond the mucous membrane; it is that which accom-
panies the  syphilitic eruptions, and which, in its course more or
less resembles them;  2d, the other,  deep-seated; destroying the
mucous membrane as well  as the parts beneath,  and the affection
does not generally commence in the mucous but cellular tissue be-
neath, as in the case of syphilitic tubercles, and  it may also com-
mence in parts still more deeply seated.  This form of ulceration
may be observed  in the absence of the eruptions, frequently after
the cutaneous affection has disappeared, and even in the last stages
of syphilis.  It is ordinarily preceded by a tumefaction, partly in-
flammatory and partly oedematous, of the parts about to be affected,
which  tumefaction  impedes both  deglutition  and phonation.
Sometimes an ulceration, the most profound, which  destroys the
uvula, the velum palati, or a tonsil, becomes known to the patient
only by the functional lesions  produced, which are often very
slight, the patient in  this case  reposes in the most  perfect secu-
rity.  But  soon the mucous membrane becomes destroyed to a
greater  or less extent, and then an ulcer with perpendicular edges
appears, its edges are  more or less serrated, and it is surrounded
by a red, oedematous tumefaction, whilst ite base is covered by a
grayish-yellow false membrane.   Occasionally both the uvula and
the velum are destroyed; the progress of the ulceration may be
here very insidious, as it  sometimes commences  on the posterior
surface of the velum.   In other  instances the posterior surface of
the pharynx becomes attacked; then, if the ulceration is not very
extensive, and  is central, we may observe ite yellow base, and
* Baumes, t. ii. 
388
VLDAL OX VEXEREAL DISEASES.
more or less  tumefied borders.   There are cases,  however, in
which we cannot define the limits, for the ulcer cannot be entirely
exposed, neither by depressing the tongue, nor  elevating the ve-
lum to the  utmost possible extent.   When the ulceration is thus
extensive, the tumefaction of the edges is considerable and involves
the Eustachian tube, and produces deafness.  Sometimes both ton-
sils are affected with this deep-seated ulceration, but never to the
same extent.   Sometimes one only becomes excavated,  the other
remaining  sound.   This  ulceration may be observed even on the
tongue, either at ite base or on its borders.  A patient affected
with  these  profound ulcers generally complains of suffering  noc-
turnal pains, and when the pharynx is their seat, there is difficulty
of deglutition  and phonation, with  pain  in moving the neck.
Whatever may be the  form of ulceration, its  depth, or its connec-
tion with other syphilitic accidents,  the sub-maxillary glands may
or may not become enlarged.   •
  There is  a double motive for carefully studying this last form of
ulceration; in the first place, it sometimes progresses with  great
rapidity, and may thus commit the worst ravages in a short time,
and in the  second place, because treatment is here most triumph-
ant; indeed, the iodide of potassium, administered in season and
in large doses, will sometimes cause these ulcers to disappear as if
by magic.
  Inoculation of a Consecutive Ulceration of the Tonsil.—Dr. L. wish-
ing to ascertain if the pus of a secondary accident under the form
of an ulcer could produce a syphilitic accident,  performed an ex-
periment in my amphitheatre, which I have reported to the Socicte
de Chirurgie.   I insert in this place an extract from a report made
by M. Begin, in the name of a Commission, of which M. Ricord
formed a member.
  " For the purpose of giving a greater degree of certainty to a
hygienic measure, proposed in the  treatment of chancres of not
more than  ten days' duration, Dr. L. performed during the  months
of December and  January, 1850-51,  an inoculation with  the pus
of chancre, nearly every  five  days, which were  made to cicatrize
in four days by the application of cold-water lotions.
  " Three  months after this first series of experiments,  on the 2d
of May, a friend of Dr. L. himself a physician, consulted  the Dr.
for an indurated chancre, contracted some seventeen days before,
and which  was seated in the groove at the base of the glands.
After a little more than a month's duration, on the 17th May* the
chancre was cicatrized; the treatment is not mentioned.
  "Twenty-three days afterwards,  a roseola, preceded  by pains,
appeared, and soon become complicated with an enlargement of
the sub-maxillary glands, on both sides, and of the superficial and
deep-seated glands on the right side.  About the same  time, that
is on the seventh day after the appearance of the eruption, a pro-
found ulceration was discovered on each tonsil, with fissures on the

  * I copy literally from the  report published in the  Bulletin de VAcadcmie de
Medecine. 
            AFFECTIOXS OF THE MUCOUS MEMBRANES.        389

tongue.   This organ  together with the whole buccal cavity was
somewhat inflamed.   These  last-developed accidente were  cured
in thirty-four days after the first manifestation of the roseola.
   " At this period, the twenty-second day of the existence of the
chancres  on the tonsils, (expression of M.  Begin; they were not
chancres, for a chancre is a primitive, whilst this was a consecutive
ulceration,) our experimenter resolved to inoculate himself with the
matter which they furnished.   With this  view, two hours after he
had carefully cleaned  the surface of the left tonsil, he collected the
serous,  for  it was  hardly purulent fluid, which was  secreted, and
with a new lancet inserted it  by a  very superficial puncture on the
anterior surface of the left  arm.   For the first ten days after the
inoculation nothing in particular was observed, but on the eleventh,
Dr. L. discovered a small pimple of the size of a pin's head, of a
red color, and remarkable hardness, without an areola, and it was
not painful even when pressed with considerable force.  Towards
the fifteenth day, this  pimple, which had gradully increased in size
until it had attained that of a lentil, became covered with crusts,
which were united into one, and beneath it existed a reddish serous
fluid.   The latter furnished the matter used for  the inoculation,
four of which were repeated every fifth day, for twenty days, some
twenty successive inoculations having  in all been  made."*
   It will be seen, even according  to the  report of M. Begin, that
Dr. L. did really succeed in inoculating a secondary ulceration of
the tonsil.  His friend had had, in  fact, a previous  chancre, roseola,
and afterwards ulcerations of the tonsils.  Add  to this, that the
ulceration resulting from the experiment, occurred after a period
of incubation.  M. Chausit, who published the details of this ex-
periment in the Annates des maladies de la peau  et de la  syphilis,
observes:  "This  case, important  when  regarded  in view of the
object for which  it was undertaken,  and of the  results  already
mentioned, presents,  it must be  acknowledged,  great scientific
interest;  when regarded in reference to syphilization it may shed
a sad but strong light on  this newly-developed principle.!   M.
Vidal (de Cassis) has fully presented this  case in  all its bearings.
The important case, therefore, which is now furnished to science is
at the same time a new proof of the inoculability of  secondary
syphilitic accidents, and in  connection with this subject we must
also notice another very important fact already placed  beyond
question by those furnished by  Wallace  and Waller,  viz. the
period of incubation intervening between the date of the inocula-
tion and the time when the first specific accidents were manifested.

  * The report goes on to expose the experiments  in syphilization.  It was read
on the 21st of January, 1852.
  f M. Chausit here alludes to the exasperation of the eruption, and the aspect of
the chancres, as well as the increased number with which Dr. L. was affected, for
the Dr. was presented to the Surgical Society and to the Academy as a victim of
syphilization.  It was for the purpose of completing the report of the case, and of
turning it to a useful account, that I furnished the Surgical Society with the details
rotative to the inoculation of the  secondary accidents. M. Velpeau did the same
to the Academy, and a committee was appointed to examine the matter both in
reference to syphilization and the transmissibility of secondary accidents. 
390             VEOAL  ON VENEREAL DISEASES.
   " The different inoculations which Dr. L. afterwards made, seem
to  establish, contrary to the doctrine of M. Auzias, and to the
experiments of M. Sperine, that the liability to syphilitic infection
does not  diminish in proportion to the  number of inoculations
performed, and that these inoculations may not contribute to ar-
rest the progress of the pre-existing consecutive symptoms: this
is an important fact, the value of which can be appreciated  by our
readers.   As to the question proposed  by  M. Vidal (de Cassis),
we know  with what kind of a response it will meet at the onset,
but there  is an important matter here to be taken into considera-
tion, for it is connected with the character even of the subject of
this melancholy  case.  The  experimenter was a  physician, and
the friend who voluntarily submitted to this series of experiments,
was likewise a physician, circumstances which do not permit the
intervention of such suppositions as  are usually  urged against
facts of the kind we have mentioned."
   The hypothesis of a chancre has, in fact, been here reproduced,
but, it must be confessed, with still less success than under other
circumstances.  The existence of this chancre could not  be be-
lieved, because, in the first place, a primitive chancre in this situa-
tion has  never been,  and probably never will be, demonstrated.
In the case in question, the subject of the  experiments was  him-
self a physician, who observed for himself, and who is certain that
the virus of a chancre never entered his mouth.  He contracted a
chancre on  the penis, and it was after the cicatrization of this
chancre, that he had constitutional syphilis, of  which the tonsillar
ulceration was an evidence.   The  existence of an  enlarged sub-
maxillary gland has been invoked, as indicating that of a chancre.
But this gland was  enlarged previous to the  appearance of the
ulcerations  in the buccal cavity, and there were others on the
posterior part of the neck.  Glandular enlargement, I repeat, and
will ever repeat, is of no value in the  diagnosis of syphilitic ulcer-
ations in general,  for it may exist in scrofulous  subjects, and may
coincide  both with the primitive and consecutive ulcerations; it
may doubtless exist in constitutional syphilis, yet the system may
be completely infected, and yet  the subject of this infection may
be perfectly free from glandular  enlargement in the neck or other
regions.   At present, there  are  in my service  at the  Hopital du
Midi, two patients who  are  daily exhibited to the students: one
of them, a coachman,  has superficial ulcerations on both tonsils,
which appeared shortly after the cicatrization of a chancre  on the
penis, and in this  patient, the  sub-maxillary glands  are enlarged;
in the second, there are ulcerations on both tonsils,  but they are
more profound, and occurred at a later period;  in this patient, the
sub-maxillary glands are  also enlarged.  The chancre in the latter
patient had existed for a year previously, and was situated  on the
penis.  Both of these patiente were questioned in every possible
manner to ascertain whether direct infection could have occurred.
In both cases, it was positively established that the ulcerations  in
the throat were consecutive.  I retained  these patiente, and par-
ticularly the coachman,  a long  time in the hospital.  We may 
           AFFECTIONS  OF THE  MUCOUS MEMBRANES.        391

therefore, appreciate the value of glandular enlargements- in the
diagnosis of ulcerations.
  Treatment.—Here we must not forget the two principal varieties
which 1 have established; the one, superficial and peculiar to the
first stages of constitutional syphilis; the other profound, and cor-
responding particularly to the last stages of the diathesis.
  1st. The first variety, consisting of superficial ulcerations, and
co-existing with a syphilitic eruption, should be treated with the
proto-iodide of mercury internally, according to the formula men-
tioned while considering the treatment  of the so-called  consecutive
venereal accidents.  We  will here add another for a gargle to the
parte:
                T$. Decoction of Oatmeal,   § iii.
                    Honey,               3 fl-
                    Van Swieten's Licpior,  3 iiss.

  2d. In the second variety, when the ulceration appears late, is
deep-seated, and occurs  after the eruption, co-existing with the
affections of the fibrous and osseous systems, we must employ the
iodide of potassium, according to the formula described in treating
of this therapeutic  agent and ite mode of administration.  At page
312, I have stated that I use one and a half ounces of the iodide
of  potassium to eight ounces of water, thus making fifteen grains
of the iodide to a spoonful of this solution.  Three spoonfuls may
be given in the day; seldom should the dose be increased to six
spoonfuls.  The gargle already mentioned may be  employed, but
instead of the two  and a half drachms of Van Swieten's liquor, we
may substitute  the same quantity of the iodide of potassium.  M.
Ricord frequently  recommends the following gargle:

                      $. Aq. dist.     3 viss.
                         Tinct. Iod. 3 iss.
                         Iod. Potas. grs. xv.

  I have more  than once observed that  this gargle greatly irritates
the throat.  I  therefore prefer  that which does not contain  the
tincture of iodine,  but the iodide of potassium in a somewhat con-
siderable quantity.  We should not always wait for the ulcerations
in the buccal cavity to become profound before we resort to  the
iodide of potassium,  both as an internal remedy  and as a gargle.
In order that the mucous membrane may not  be  destroyed, and
the ulcerations become  chronic, recourse must be  had to this
powerful agent, especially if the subject be debilitated.  In sucB,
mercury should be proscribed.   In other cases,  both  of these
agents may be united, and act conjointly, as I have already shown.
  In  both varieties we  may employ  cauterization with hydro-
chloric acid or  the nitrate of silver.  These means may be adopted
in cases of mucous tubercles; especially  when they cover a portion
of the cheeks, the  internal surface of the lips, and when there is
not great  inflammatory turgeseence.   When the ulcerations are
profound, and  of  late  development, and when they co-exist with 
392
VIDAL ON VENEREAL DISEASES.
affections of the bones, the best remedy is  still the iodide of pot-
assium, both internally and in the form of a gargle, but in large
doses.  Cauterization may be attended with inconveniences during
the first stages of the ulcerations;  it is better then to touch them
with the following mixture, recommended by M. Baumes:

             £.  Mel. Ros.            3 ii.
                 Laud, of Sydenham,    -H. xv.

  When the parts become less sensitive, and the edges of the ul-
ceration less tumefied, less turgid,  they may be touched with

             I).  Mel. Ros.                 3 ii.
                 Hydro. Chlor. Acid.        v\.  xv. a xx.


        IL—MUCOUS MEMBRANE OF THE NOSE.
                                         r
  Frequently after the cure of the  primitive accidents, chancre and
blennorrhagia, and when it is supposed that all is  ended, the pa-
tient experiences a kind of a stuffing, which, unless great care be
taken,  is regarded  as  a catarrh, but which lasts for a long time.
He finds at length that his nose becomes  more and more affected,
and soon  a  thick  yellowish  purulent  matter escapes, and  oc-
casionally with thin black crusts.  The sense of smell becomes im-
paired, and is lost, either on one or  both  sides.  In many cases it
is not until this period that the practitioner is  consulted.   He de-
tects a redness with more or less fungous swelling of the mucous
membrane of the nose, externally  and internally, or on both sides
at once extending to a greater or less  height, so that it can no
longer be perceived by the unassisted eye.   Before this mucous
membrane becomes ulcerated, that of the buccal cavity, together
with the eruption, have preceded  it.   The  affection of the nasal
membrane  is  then regarded as a blennorrhagia,  which existed
previous to the  ulcerations in the mouth.  But  at other times these
ulcerations are speedily reproduced in the nostrils, within the alas
of the  nose;  or they may occur still higher, and penetrate more
deeply to the surface of the inferior turbinated  bones, so as to be
difficult of detection.   These ulcers may  assume a  phagedenic
character, and destroy the different bones entering  into the com-
position of the nose and its cavities,  which may become ulcerated
simultaneously  with the mucous membrane.
  The affection often commences in the bone;   the vertical layer
of the ethmoid, and the  turbinated, may suffer from  necrosis or
caries.  When  those belonging to the cartilages become attacked,
the nose is depressed ; pressure on it produces  a kind of crepita-
tion ; portions of the bone issue with the mucus when the  patient
blows his nose.   Then we have also those, profound ulcers in the
nasal fossae, which corrode the parts with or without caries of tho
bones,  without  much, or even with no  suppuration,  but  with  a
fetid odor,  a  condition known under the name of ozcena.  Ac- 
AFFECTIONS OF THE  MUCOUS MEMBRANES.        393
cording to M. Baumes, vegetations of a more or less fungous char-
acter may form within the nose, under the influence of the sjrphi-
litic diathesis, and more than one vesicular, spongy polypus, of a
more or less vascular nature, may be due to this cause.  This does
not accord with my own experience.
  The consecutive inflammation of the nasal mucous membrane,
often passes unnoticed, either because it ordinarily produces only
an inconvenience and not pain, or because having an analogy to
coryz 1, and because  this annoyance  about the nose may result
from many other causes, the patient attaches but little importance
to it.  In this connection, these phenomena resemble certain others,
such as a sensation of uneasiness, or of stiffness  in the throat, a dis-
charge from the auditory canal,  with or without difficulty in hear-
ing;  a slight smarting in the anus, symptoms which may be due,
as in the first  instance, to  consecutive syphilitic  ulcers in the
throat, in the second, to a consecutiveHalennorrhagia of the mucous
membrane  of the auditory canal, and in the third, to  a rhagade,
and  yet  the patient who suffers but little, or not at all, and who
apparently is in usual health, never attributes these symptoms to
their true cause.  But this  same patient, one  or two years  after
the cure of his primary accidents, consults his physician for symp-
toms which are evidently constitutional.   lie then does not allude
to the phenomena which had previously existed,  because he is far
from supposing that they were syphilitic, and  these symptoms
during perhaps a long interval of time, may alternately have in-
creased, diminished, or have ceased entirely, and been replaced by
other morbid phenomena on the part  of the  nervous system, or
certain of  the viscera.   All these phenomena, however, are evi-
dence of  the long duration of the  syphilitic diathesis, which has
waited a favorable opportunity for a more terrible and manifest
development.  Examine carefully into the antecedent of the  case,
and you will find that these morbid affections, not very grave, yet
truly syphilitic, previously  existed and  even yet exist, having
suffered, in some manner, a transition by which the syphilitic symp-
toms now  apparent have been  produced.  These  things I have
often seen  in my practice, and I doubt not that they have been
observed by many other practitioners; I have also remarked that,
when an individual complains, some three, four, or five years after
this cure of the primitive symptoms, of suffering, for the first time,
from troubles which  are unquestionably syphilitic, it is  very rare •
that phenomena similar to the  preceding have not existed,  some-
times constantly, at others  being  of an intermitted, irregular or
periodical  character, or occurring with  the seasons,  &c.  I have
never seen, for example, the  syphilitic corroding dartre established
on the alao of the nose by tubercles, unless there had previously
existed, for a longer or shorter period, a chronic coryza more or
less obstinate, and which was  produced by the same  syphilitic
diathesis.
  It  is evident here as well as in the buccal cavity, there are two
stages,  two varieties of ulceration:  1st, the more superficial, which
precedes and afterwards accompanies the syphilitic eruptions, and 
394
VTDAL ON VENEREAL DISEASES.
which rarely involves the parts beneath the mucous membrane:
2, that which  occurs  at  a  later period, which belongs to the last
stages of syphilis, is profound, and always compromises the bones
or the cartilages.
  In the treatment we must be governed by the rules already pre-
scribed whilst treating of affections of the throat, that is, we should
administer the proto-iodide of mercury in the first, and the iodide
of potassium in the second variety.  In the case of ozcena, we may
inject the foUowing solution into the nasal fossae.

                      Iji,. Atpdisfc.,     3 x.
                         Sod. Chlorid. 3 iiiss.

  [We have used injections of chloride of zinc, from three to six
grains to the ounce of water, with the happiest effects.—G. C. B.]


 Ill—MUCOUS MEMBRANE OF THE GENITAL  ORGANS.

  Consecutive  syphilis may affect the mucous membrane of the
genital organs,  in  the  same manner as in the primitive accidente.
Thus  consecutive urethral  blennorrhagia has  been observed,  as
has been balano-posthitis; of this a case together with an illustration
may be found  in  the  first section of this word.   In the female,
whose genital mucous  membrane is so extensive, we too frequently
meet with discharges which  are inordinately protracted in conse-
quence of constitutional syphilis, the existence  of which they per-
sist in denying, and  which, consequently, is not subjected to treat-
ment. All the instances of consecutive blennorrhagia, are more
or less chronic in their progress, and are attended with  no marked
excitement; they are in fact more properly cases of blennorrhcea.
  They are not detected, or rather, their nature is not suspected
until long after the occurrence of the primary symptoms,*or when
they accompany some other accident which is decidedly consecutive,
as for example, a syphilitic eruption.   And  yet it is nqt unusual
to attribute the discharge in both instances to a new contagion,
and  which  besides may be  they cause.  Thus, we  see, that the
diagnosis of discharges resulting from constitutional syphilis is not
easy, especially  when we are unable to inspect directly the diseased
mucous surface.  When we have it  in our power to examine it,
we discover that it is not of a very bright redness, and that it has
a tendency to assume the coppery color peculiar to the secondary
affections.  In  plate 1 are two figures:  one representing acute
posthitis entirely primitive;  the other a consecutive and chronic
balano-posthitis.  The redness in the latter is browner and darker
than in the preceding figure.   The consecutive ulcerations of the
genital mucous membrane are generally not so well  defined  as
those which are primitive, hke chancres, and reparation soon takes
place, though the ulceration is speedily reproduced.   These ulcer-
ations occur on the prepuce, the internal surfaces of the labia,
majora and minora. 
AFFECTIONS OF THE MUCOUS MEMBRANES.        395
    It is sometimes difficult to distinguish these consecutive ulcer-
  ations from that  disposition to excoriations which the genital mu-
  cous  membrane manifests when  it has already been the seat of a
  primitive lesion which has lasted for any length of time; thus, we
  frequently observe, after an  indurated  chancre on the  prepuce, a
  disposition to a morbid excitement and ulceration of the mucous
  membrane, which is often mistaken  for a  consecutive affection;
  the inflammation, ulceration, in these cases are liable to reappear,
  hence they are regarded as relapses.  Most generally there is no-
  thing syphilitic in  this condition of  the preputial mucous mem-
  brane, and the patient is more easily cured by topical applications
  and simple measures, than by a mercurial treatment.  The obser-
  vations apply  to the ulcerations of the lining membrane of the
  vulva and of the  whole genital apparatus in the female.
    [Granular erosion of the cervix uteri  is stated by Dr.  Bennet to
  be an exceedingly common  lesion, in females suffering from the
  secondary forms  of syphilis.  He is  inclined to  believe that the
  proportion is as high as three out of four cases, in secondary syph-
  ilis (op. cit, 2d cd.,  pp. 326, 329).  Dr.  Egan's experience  is op-
  posed to that of Mr. Bennet.   " That this condition obtains in the
  most virtuous description of patiente I cannot for  a moment doubt,
  but that prostitutes enjoy a peculiar exemption from this formida-
  ble lesion I am perfectly satisfied.  I have looked for it over and
  over  again, both in individuals subject to discharges, and likewise
  in those affected with the secondary and tertiary form of syphilis;
  and, with the exception of two instances,  I most decidedly  have  never
  encountered ulcerations, properly so called, either  of the exterior or in-
  terior of the uterus"  (Egan, op. cit, pp. 131, 132).  This view of
  the subject is supported by the evidence of Mr.  Acton.  " In
  women who suffer from syphilis in its worst  forms, in all other
  parts of the body, the os uteri is  very seldom  affected,  &c.;  these
  ulcers on the uterus are perfectly  independent of syphilis in
  ninety-nine out of every hundred  cases"  (op. cit. p. 198).  G. C. B.]
    The judicious practitioner, therefore,  will not be in haste to put
  his patient under the influence of mercury or of iodine, especially
  if the first has been administered for any considerable  length of
  time  and in a systematic  manner.  If, however, the ulceration of
  the mucous membranes co-exist with the syphilitic eruptions, or
*  other concomitant  lesions, of which the syphihtic nature  cannot
  be questioned, the practitioner will  then avail himself of  these
  powerful agents.
    I should here speak of the vegetations and the mucous tubercles
  of the genital mucous membrane, but these have already been de-
  scribed in the first part of this work.  The reader will recollect
  that I then insisted on the fact  that these may be both primitive
  and consecutive.
    As to the general treatment, it is the same as that of the syphi-
  litic eruptions.  The local treatment consists principally in isolat-
  ing the inflamed surfaces, and in  the application of astringents. ^ I
  consider that a weak solution of the nitrate of silver  has astrin-
  gent properties. 
396             VIDAL  ON VENEREAL DISEASES
  [We  have frequently employed a solution of the sulphate of
zinc, to which laudanum is added, with beneficial results  The
following formula answers a very good purpose:

                     1J.  Sulph. Zinc,  3 ss.
                         Aq. pur.     3 vi.
                         Tinct. Op.  3 ii. M.
  Apply as a lotion.                                   G. C. B.j

  The local treatment may exert a great influence in affections of
the genital mucous membrane in  the  female.  The observations
which we  have already made on intra-vaginal and intra-uterine in-
jections, should here be reperused.


 IV.—MUCOUS  MEMBRANE  OF THE EPIGLOTTIS  AND
                         LARYNX.

  There are  cases in which the affection of the  fauces and the
pharynx extend more deeply, and involve the epiglottis, producing
serious  impediment in deglutition.   This disease, which  is  gen-
erally in the form  of ulceration, may affect the vocal apparatus,
causing alterations of the voice much more decided, and variable,
according as they involve the superior portion or whether  they
penetrate  into the cavity of the larynx; it may likewise occasion
an oedema of the glottis.*
  When these ulcerations exist independently of an affection of
the buccal cavity, it is often very difficult to detect their nature
and to establish a differential diagnosis. According to M. Reynaud,
who has carefully studied this form of syphilis, the laryngeal ul-
ceration occurs only long after the primitive accidents.   It  may
produce all the symptoms of ordinary diseases of the larynx,  such
as uneasiness, or a fixed pain on a level with the thyroid cartilage,
and its extent may evidently in some cases increase the alterations
of voice, the dyspnoea, the hacking cough and efforts made to ex-
pel the mucosities which obstruct the  glottis, after which  the pa-
tient expectorates a little purulent matter in some cases streaked
with blood.   The malady by becoming  protracted may produce
fever with night sweats, and all the train of symptoms of laryngeal
phthisis.  The firmer portions of the larynx sometimes participate
in the  disease and increase its gravity.  Therefore, even in,the
more fortunate cases, in which we succeed in arresting the progress
of the ulceration, and curing the disease, there generally  remains
aphonia, or  at least profound alterations of the voice.  The seat
of the malady sufficiently indicates its gravity.
   [Mr.  Carmichael, in his Clinical Lectures on Venereal Diseases,
p. 143,  refers to a case in which from  extensive ulceration of the
pharynx,  the Ungual artery gave  way, and the patient  died of

  * The reader may consult on this subject the Traite de Vangine laryngee adema-
teuse, of M. Sestier, p. 88. 
AFFECTIONS OF THE MUCOUS MEMBRANES.        397
hemorrhage before assistance could be had to secure the vessel.
He also  exhibited preparations in his lecture, showing the neces-
sity, in some cases, of resorting to tracheotomy in these distressing
cases.-G. C. B.]   _
   The treament is similar to that of the consecutive  affections of
the buccal cavity; but if the affection continues obstinate, remain-
ing long after the subsidence of the tertiary symptoms, we  must
then resort to the use of iodine.  In some cases even in spite of
this remedy, the disease seems to continue, but it is then main-
tained by a necrosis, the dead portion acting as a foreign substance,
and though the syphilis be cured, the patient is far from being
saved.

         V.—MUCOUS MEMBRANE OF THE EAR.

   The mucous, or rather the semi-mucous lining of the ear, may
become affected by constitutional syphilis.  In treating of mucous
tubercles, I  mentioned a case in which the patient's whole body
was covered;  they occupied both  auditory canals; in one, was
seen the raised papula, accompanied with a slight discharge; in
the other, there were ulceration of a dark brownish  color, and a
true otorrhcea.   Hearing was not impaired.  I have read, however,
and we may find in the work of M. Baume's, that consecutive dis-
charges from the ear coincide almost always with more or less dul-
ness of hearing.  True, the physician of Lyons intends his remarks
to apply  to greenish-yellow  discharges.  Those which  I have ob-
served consisted of a dirty, offensive serum.  Cases have been de-
scribed in which the ulcerations had the character of those belong-
ing to constitutional syphilis; they were seated both at the en-
trance of the  auditory canal, and at a greater depth, the latter
being discovered only by the aid of the speculum auris.  In  such
cases there is necessarily more or less of a discharge.   According
to M. Baume's, during the continuance  of the discharge, soft, fung-
ous, pediculated vegetations are to be seen in the auditory canal.   I
believe that  these are most  commonly mucous tubercles, 'at  least
Buch is the result of my own observation, and that the matter dis-
charged  proceeds from  these tubercles.  I have never seen any-
thing in the ear that could be compared to true pediculated vege-
tations.   Of course, I do not include polypi in these remarks, as
they have nothing in common with syphilis.
   When I have been called upon to treat mucous tubercles of the
auditory  canal, I have  administered the  proto-iodide of mercury
internally, and have confined my topical applications to cleanli-
ness.  Lotions with diluted Goulard s extract, or with  a dilute
solution of the chlorides, and the insertion of cotton  in the canals,
may prove  of service.

VI.—MUCOUS MEMBRANE OF THE  ANUS AND  RECTUM.

  In  speaking of blennorrhagia, in the first part of this work, I
stated that anal discharges were most frequently the result of con- 
398
VTDAL  ON VENEREAL  DISEASES.
secutive affections.  These discharges generally proceed from con-
secutive mucous tubercles; but the most abundant source of the
matter is  particularly the mucous membrane surrounding these
tubercles,  which is the seat of a consecutive blennorrhagic inflam-
mation.  The  vegetations, and especially the mucous membrane
by which  they are surrounded, may also secrete more or less mat-
ter.  These vegetations, in the great majority of cases, are consecu-
tive  affections.   They may invade the mucous membrane to a
much greater height than the mucous tubercles, which are always
developed on the margin of the anus, and rather encroach on  the
nates,  where they spread and multiply.  On the contrary,  the
vegetations form high in the rectum, even on the lining membrane
of this portion of the  intestine, as may be seen by the speculum,
or when the patient makes strong bearing-down efforts, as in going
to stool.
  These ulcerations of  the  rectum, and particularly of the anus,
are of frequent occurrence.   In the majority of cases, they assume
an elongated form, and are known by the name of rhagades.  They
have a grayish-yellow base, with edges more or less indurated and
irregular.   They may be seen  completely when the patient forces
down the  parts, as in going to stool.   They are much less painful
both to the  touch and during  the act of  defecation, than is  the
fissure of the anus, and we do not  observe  that disposition to syn-
cope which is  common to the  latter affection. There is  another
kind of ulceration which is more superficial; it is observed in
blennorrhagia, and is rather  an excoriation, like that of balanitis.
M. Baumes has met with greenish discharges from the anus, con-
joined with other syphilitic symptoms.   He examined  with  the
speoulum, and found  the mucous membrane red and thickened,
and  as if granulated  at certain points, without ulceration.  But
generally, with the puriform discharge there is ulceration, the  lat-
ter may occur without previous engorgement or induration of  the
mucous membrane. According to this writer, they may be found
in large numbers very high in  the rectum.
  The general treatment of the consecutive affections of the anus
is that which has been recommended  for the same morbid condi-
tions in other mucous  membranes.   The local treatment  consists
particularly in the observance  of cleanliness.  Hip-baths should
often be used.   The anus should be filled with charpie or carded
cotton.  That portion  of the mucous membrane which admits of
being exposed, may be  cauterized with the nitrate of silver.  In-
jections of Goulard's lotion,  or a solution of  the nitrate of silver,
may be used when the affection extends to any great height.   We
should avoid injections containing laudanum.   I have seen poison-
ing produced which threatened the most deplorable consequences,
by injecting a solution containing sulphate of zinc and a large
proportion of the Sydenham's laudanum. 
DISEASES OF THE EYES.
399
                        SECTION IV.

                 DISEASES OF THE  EYES.

  In the first part of this work, I have already described a serious
affection of the eyes, which commences in the more external mem-
brane, the conjunctiva; it is one of the so-called primitive venereal
accidents, a form  of conjunctivitis.   A consecutive conjunctivitis
has been mentioned, or rather it has been supposed, for what  has
probably been regarded  as a manifestation of secondary  syphilis
in the ocular mucous membrane, was probably a chronic conjunc-
tivitis succeeding to a blennorrhagic ophthalmia, or it may have
been the latter in a  protracted state, or a conjunctivitis dependent
on some other diathesis which cannot be determined.  As to  the
lesions of the other  tissues of the eye, they are still more problem-
atical, or if they have indeed been observed, it was in severe cases
of iritis  with  extension of the inflammation, or,  more  properly
speaking, in complicated cases. Thus, writers speak of a complete
disorganization of the  globe of the  eye  resulting from syphilitic
iritis.   Mackenzie alludes  to this  accident, and I have now in  my
service, Ward 11, a patient who has passed through all the -stages
and demi-stages of syphilis:  he  has a sunken eye.   It was  not
long after this profound lesion that we saw him, so that we were
able to note the  starting point of the ophthalmic  affection. , We
obtained sufficient proof that he had not blennorrhagia' at the time
when the eye became affected, so that the eye was  not in this case
lost, as is observed in a severe case of blennorrhagic  ophthalmia,
but it was the result of a lesion occurring during the development
of various consecutive accidente, or, probably, of an accident itself
of this nature, but  of a  much more serious character than that
which is most commonly observed, viz., syphilitic iritis.  The  iris
is indeed most commonly affected when the virus has infected  the
whole organism; and this lesion alone is noticed by some writers
on venereal diseases.  I will devote a paragraph to it.


                   SYPHILITIC IRITIS.

  M. Ricord, in his  Notes to  Hunter, thus  remarks:  " There is a
secondary accident  to which  Hunter has not alluded, because it
escaped the laws which he had established, or what is very probable,
because he was ignorant of the disease."  I  quote verbatim.*
  Causes.—Syphilitic  iritis is so  intimately connected with  the
affections of the  skin, it occurs so frequently in their train, that it
may be regarded as  one of the accidente of the syphilitic eruptions.
It is for this reason that I treat of this disease immediately after
the affections of the skin and mucous membranes.
* Hunter, 2d Ed, Note by M. Ricord, p. 648. 
400
VIDAL OX VENEREAL DISEASES.
   Attempts have been made to determine what form of syphilitic
eruption is more frequently followed by syphilitic iritis.  Accord-
ing to M. Legendre, it  is the papular and the pustular varieties,
(Thesis already quoted.)  Mackenzie states  that his experience has
shown that the pustular and squamous eruptions on the face  and
trunk should  take the first rank,  whilst the second should be
assigned to the syphilitic affections of the throat.  " The pustules
on the face,'1 says Mackenzie, " which I have observed to coincide
with  syphilitic iritis, were often voluminous, hard, and penetrated
the skin so deeply that they almost deserved the name of tubercles.
The  squamous eruptions  on the face sometimes resembled  the
areolar form of lepra.   On the body, where the eruption had gene-
rally a more acute character, it appeared under the form of numer-
ous circular elevations, of a brownish-red color, about half the size
of a pea, and terminating by a succession of thin pellicular desqua-
mations of the epidermis.'7*
   M. Ricord admits three degrees of syphilitic iritis.   According
to this writer, if the patient is affected with the syphilitic exanthe-
mata, rubeola,  the iritis coincident with this form of eruption, with
•other things being equal, will be less intense, forming what is
known under the name of erythematous iritis, and which some oph-
thalmologists call serous iritis.  There is another iritis  accompany-
ing the papular form  of eruption;  in this variety, under certain
circumstancas,  vegetations are observed, which Beer has compared
to condylomatous vegetations; but most frequently, says M. Ricord, .
we observe on the iris genuine papules, more or less prominent, of
the size of  a  grain  of millet  seed, and  of a  copper-red color.
Finally, when  the iritis co-exists with a vesicular or a vesieo-papu-
lar eruption,  we discover  on the iris true  vesicles, vesico-pustules,
and we may even say, small ecthymatous pustules.  Each principal
form of cutaneous eruption should therefore have its prototype on
the iris.   Such is the opinion of M. Ricord.  Thus we have  not
only  a syphilitic iritis  but several varieties corresponding to  the
several syphilitic  eruptions.  And  yet M. Ricord concludes by
doubting the existence of syphilitic  iritis; he seems to reject the
disease, as a distinct variety, after having  described three different
forms!  In the same  note, by the same syphilographer, we read
as follows: " In the absence of all pathognomonic signs, we are justi-
fied in asking, as  in  certain cases  of pemphigus in  the  infant,
whether syphilis does not here act like any other common cause."f
So that after all, syphilis in these cases acts like cold, or any other
non-specific exciting cause; and this, too,  for the reason that  this
iritis  has not a specific character by itself.   As if the antecedent?,
the progress of the malady, its relations  with other concomitant
circumstances,  such as the  syphilitic eruptions, and the whole
pathological  history of iritis,  were  not  equal to an  anatomical
character in establishing its nature!


  * Mackenzie,  Maladies des yeux, p. 377, translated into French, by MM. Laugier
and Richelot.
  f Vid. Notes to Hunter, p. 682, 2d ed. 
DISEASES OF THE EYES.
401
  [Among the writers who first describes syphilitic iritis as a dis-
tinct disease, were Prof. Schmidt, of Vienna, and Mr. Saunders, of
London.   Although  the highest authorities of the present day,
such as Messrs. Lawrence,  Jones, Hilton, and Mackenzie, as did
Mr. Carmichael, regard it as a specific affection of the iris, there are
others, as. observed by our  author, who can see in it nothing to
entitle it to such a distinction.  Mr. Porter objects  to the term
iritis, believing, as he does,  that all, or almost all the other  struc-
tures participate in the  disease.   "I have seen patiente  become
blind long after every symptom of the 'iritis' had disappeared,
and I have witnessed the unpleasant situation in which a surgeon
was placed, who had, under such circumstances, pronounced his
patient cured.  I prefer, therefore, that name which tells us and
keeps constantly before us  the fact,  that all the deeper structures
of the eye are engaged—deep-seated syphihtic ophthalmia,"  (Lect.
in Dub. Med. Press., April, 1847.)  Mr.  Morgan believed, and this
is the doctrine, if we mistake not, of Mr. Travers, that the form of
iritis under consideration is due to the conjoint agency of syphilis
and mercury, but Mr. Lawrence has quoted a number of cases in
which  mercury had been given in some quantity, for the cure of
the primary sore, in  about  one-third of the whole number; very
little, in about another third, and no mercury at all in the remain-
ing third, and  yet iritis supervened.   Similar resulte followed
the  non-mercurial  practice  of Messrs.  Rose  and Thompson.—
G. C. B.]
  Symptoms.—Diagnosis.—In the first place, I should remark, that
iritis, whatever  may be its cause and nature, may present the fol-
lowing characters:  1st. A particular vascularity of the opaque
cornea and even of the iris;  2d. A modification in  the motions
and form of the pupils; 3d. A production of lymph, of a more or
less purulent fluid, and adhesions; 4th. Impaired vision and pains
in the eye and around the eye, and even beyond this  region, but
always confined to the head.  Thus, we have what is called Zonu-
lar sclerotitis, that is, very fine vessels, which run Hke rays towards
the margin of the transparent cornea.  The color of the iris is
changed by an abnormal vascular development, or the production
of lymph, in its substance, or on its posterior surface.  If it is
naturally  blue  it becomes green,  and if of  a red disk  color it
changes to brown.   The pupil contracts and its motions  are im-
paired or destroyed.   The lymph of which I have spoken may be
effused in the posterior as well as the anterior chamber of the eye.
This same lymph may become  organized on certain portions of the
membranes, forming bridles and producing adhesions of the margin
of the pupil to the capsule of the  crystalline lens, and sometimes,
though more rarely, to the cornea. These morbid  productions
may assume the form of tubercles, or of pustules; we then have,
in the majority of cases, abscesses in the iris.   Finally, there are
subjective symptoms relating to vision, which is more or less dis-
turbed and sometimes destroyed, and there are circumorbitar pains,
which  may be nocturnal.   These characters are not observed in    »
                          26 
402             VIDAL ON VENEREAL DISEASES.
all cases of iritis, but they may be met with from whatever cause
the disease may occur.*
  The Germans, at the head of whom stands Beer, describe among
the characteristics of a specific iritis, a peculiar distortion of tho
pupil, and the development of what are called condyloma on tho
iris.   The first is produced by a gradual contraction of the pupil
from without inwards; instead, therefore, of being in the centre of
the iris, it is much nearer ite superior internal border, thus causing
a deformity, a  laceration of the pupil, converting  its  grand axis
obliquely from below upwards, and from without inwards.   This
distortion may certainly occur during the existence of syphilitic
iritis, but it is also observed during that of rheumatic iritis.   Fur-
ther still,  by following the different phases  of syphilitic iritis, we
may observe both this distortion and that in the opposite direction.
This character, therefore, is  governed  by no law; it may depend
upon the  adhesions to the crystalline lens and the effecte of bella-
donna so  frequently employed in the  treatment of iritis.  If the
adhesions no longer exist at the  time when  the  belladonna is em-
ployed, the pupil wiU dilate equally in all directions, presenting
not the slightest deformity.  If,  however, adhesions still exist, the
dilatation of the pupil will then  be irregular, and then  only do we
perceive distortions of the pupil; they result from the action of
the belladonna, dilating the portions of the iris free  from adhe-
sions, whilst the position of those which are adherent remains un-
changed ; thence the distortions, which are  not constant, and con-
sequently cannot be regarded  as  pathognomonic.  M. Legendre
has twice seen the contracted and  circular pupils  dilated by the
action of belladonna, and assume an oblique form from below up-
wards, and from within outwards, a direction the opposite of that
which is regarded as pathognomonic; in another  case, the pupil
was vertical and lozenge-shaped; and, finally, in other instances,
it could not be made to assume  any particular figure.  The distor-
tion of the pupil, accidentally produced by the belladonna, is repro-
duced, but in a permanent manner, by the cure of the iritis. Indeed,
when the circular coarctation ceases on the disappearance of the
disease, the pupil has a tendency to  reume its natural shape; but if,
during its contraction, adhesions form, and the unadherent portions
only should become dilated, a permanent distortion then results.
   As to the condylomata, according to some of the best ophthal-
mologists, they are but abscesses which occur more frequently in
syphilitic than in other forms of iritis.   We should therefore take
into consideration the circumstances of  their existence, especially
if they co-exist with a syphilitic cutaneous eruption, as they will
then be of more value in  establishing our diagnosis.
   Mackenzie alludes to a rusty color of the iris near its pupfllary
margin:  a phenomenon, he observes, which is sure to  be met with
in syphihtic iritis.  But M. Desmarres has seen  this color in cases
of iritis, without any special complication.

  * Vid. in my Pathologie externe the different formd and degrees of Iritis, t. iii. p.
18, et suir, 3d ed. 
DISEASES OF THE EYES.
403
   The progress and the character of the pains in syphilitic iritis
deserve the greatest attention.   Ite progress is slower and less acute
than that of traumatic  iritis, which very frequently terminate in
the rapid and  complete obliteration of the pupil.  The cause of
traumatic iritis being entirely local, ite effecte  seem to be Umited
to the eye affected; nothing, on the contrary,  is more common
than to see the other eye attacked in  syphilitic iritis, and scarcely
does the inflammation  subside before it reappears, and so it pro-
ceeds, until' several relapses have occurred.   It is frequently the
case, that  false membranes are  not  formed  until  after several
attacks of inflammation in the same iris, and  they rarely produce
an obliteration  of the pupil, even when the disease is abandoned
to itself.  Disorganizations of the eye, and staphylomas, very sel-
dom result from this specific iritis.
   Pain in syphilitic iritis evidently occurs in paroxysms; these
paroxysms are  nocturnal, and, if pain existe during the day, there
is always an exacerbation at nigh't.  It seldom  occurs before eleven
o'clock at night, and most generally at midnight, or at one o'clock
in the morning.  These pains are seated not only  in the globe of
the eye and orbit, but the corresponding side  of the head; some-
times it extends towards the  occiput.   I am perfectly aware that
other forms of  iritis are attended with nocturnal pains—as,.for ex-
ample, the rheumatic, and even simple iritis; but I believe that
this phenomenon is much more decided in syphilitic iritis.  I attach
much more importance to it than  to condyloma, for these I  have
rarely observed, whilst the nocturnal pains have never been absent
in cases of iritis where the disease has  been at all severe.  I should
add, that the sulphate of quinine exerts a powerful influence over
these pains; the hour of the accession of the paroxysms may,
therefore, be changed, and finally they may be entirely removed
by this potent agent.
   None of the anatomical and physiological  characters of  iritis,
taken separately, can be regarded as proof of its syphilitic nature.
But, united, they possess a real value in forming a diagnosis, and
this is especially true of those relating to ite progress and the na-
ture of the pains.   First of  all, the skin should be examined, if
we would establish  a sure diagnosis.    I have already attempted
to show the  intimate connection existing between the syphilitic
eruptions and iritis.   It is such, that I consider the existence of
syphilitic iritis impossible without the cutaneous eruption. Indeed,
we shall find, almost invariably, some of these  eruptions, or traces
of them, and if not yet developed, it soon wiU be, before the iritis
can have made much progress.   In cases where the skin appears
to be perfectly sound,  we shall  probably find on  the mucous
membranes in  the buccal cavity, the anus and genital organs, le-
sions analogous to the syphilitic eruptions.   Certainty of diagnosis,
therefore, is established by taking into  consideration circumstances
unconnected with the symptomatology of iritis.  But this is no
reason why we  should attach but slight importance to the elements
which the symptomatology may furnish, for they may lead us to 
404             VIDAL ON  VENEREAL DISEASES.
an examination of the cutaneous surface, which might otherwise
have been neglected.
  I shall not here attempt to establish the varieties of syphilitic
iritis.   I have already stated that M. Ricord has assigned a form
of iritis to each variety of the eruption.   He recognizes an ery-
thematous, a papular, and  a pustular  iritis.   The mildest form
should therefore correspond to the milder forms of the eruption,
and vice versa.   I will  only remark, that I have  observed very
slight and perfectly erythematous forms  of iritis, with the graver
forms of the cutaneous eruption.  Thus the subject of the squa-
mous eruption represented in plate 5, fig. 3, was affected with the
mildest form of iritis, which was cured in eight days, and yet the
eruption on this patient was very obstinate ; the testicles became
affected, his constitution deteriorated,  and finally the constitutional
infection was very complete.
  Prognosis.—The gravity of the prognosis does  not depend upon
that of the s}^philitic iritis itself, for, like the inflammation  of the
iris, it is perhaps one of the least compromising as regards  vision.
One circumstance which should render the prognosis  very guard-
ed,  is the  evident  tendency of this  disease to return.   But  the
danger arises principally from the changes produced  in the sys-
tem, by  the establishment of the syphilitic diathesis.   Indeed, the
iritis almost  always  supervening on  constitutional syphilis, and
after other manifestations of the disease, the patient is  generally
debilitated, and consequently intolerant of antiphlogistic,  and other
debilitating remedies  which form the principal  part in the thera-
peutics of iritis.
  Treatment.—Blood-letting is frequently  indicated.  Monteath in-
sists upon the absolute necessity of this measure, especially  in par-
ticular cases; he opposed his experience to those who place all
their confidence in the  use of mercury, to the exclusion of all
other means, such as blood-letting, blisters, &c.   This practitioner
has seen, indeed, syphilitic iritis running  rapidly into  a dangerous
hypopion,  notwithstanding  mercury had produced its complete
effect, and yet ite progress was at once  arrested by repeated vene-
section in the arm, and the application of a blister  to  the nape of
the neck.  Mackenzie, who quotes and coincides with Monteath,
states that he has been obliged several times to repeat venesection
in the arm, besides resorting to the application of leeches, before
he could affect the disease so as to derive advantages from  the
use of mercury.*
  Unfortunately, syphilitic iritis often occurs in subjects whose
constitutions, greatly debilitated, will not tolerate the abstraction
of? blood.  Applications are frequently made to parts adjacent to
the orbit, and  to the eyelids, for  the  purpose of mitigating the
pains, and preventing contraction and obliteration of the pupil,
and they are either of an antiphlogistic character, or have a ten-
dency to overcome the diathesis.  Opiated frictions are commonly
used to reUeve  the nocturnal pains; they should be apphed about
* Maladies des ycux, p. 378, French Translation. 
DISEASES OF THE EYES.
405
an hour before the expected attack.   The eye may afterwards be
covered with a folded compress which has been previously warmed
before  a  fire.  Whenever the  paroxysms threaten to return, and
this generally occurs about midnight, these  frictions with opium
should be renewed.  Opiated  mercurial ointment has  also been
employed, or the  tincture  of  tobacco, according  to the circum-
stances of the case and the judgment of the practitioner.  The ex-
tract of belladonna, in the form of an ointment, is much used ac-
cording to the following formula:

                IJ. Ext. Belladon. grs. xv.
                    Axung. 3  i.

  An application of a mixture of one part of extract of belladonna
and one of mercurial ointment, is also employed ; but precautions
should be taken when belladonna is used in large quantities.  It
is proper here to allude to a phenomenon which has often been
observed, and which is noticed  by M. Velpeau.   The  extract of
belladonna is generally employed for the purpose of preventing
the contraction  of the pupil and promoting the laceration of the
false membranes which may have been developed in ite vicinity.
But it has been remarked, that in cases of intense iritis, the pupil
does not dilate under the  influence of the belladonna; it was only
after  the inflammation had subsided, and the congestion  dimin-
ished, that dilatation was produced, and the laceration and separa-
tion of the very thin grayish newly-formed adhesions were effect-
ed.  This shows the necessity of resorting to antiphlogistics before
we use the belladonna.   Every evening  the belladonna should
be freely rubbed over the eyebrows and on the eyelids.   After the
cessation of the acute symptoms, we may drop several times  in  a
day a filtered aqueous  solution of this substance on the conjunc-
tiva.  The medicine should be used regularly for a month at least
when the pupil has not completely regained ite natural mobility.
  Mercury, however, is the best of all means.  It is on this medi-
cine,  says  Mackenzie, that we should chiefly rely to arrest the
progress  of syphilitic inflammation of the iris, and to remove the
morbid changes which may be produced in this membrane and in
the pupil.  It should  not be  administered in small doses  as an
alterative,  but  the system must be fully impregnated and the
mouth evidently affected.  In  many cases, it is only after a copi-
ous sahvation is established, that any beneficial effect is observed
from its use.
  I employ frictions twice  in the day on the eyelids and the eye-
brows, with  a  pommade composed  of two-thirds of  Neapolitan
ointment, and one-third of the  extract of belladonna; afterwards I
apply the Neapolitan ointment alone under the angles of the max-
illary bones.  In addition  to  the above, I administer internally
two pills of the proto-iodide of mercury, daily.  The mouth soon
becomes  affected, even severely, producing an abundant discharge
of saliva, and a rapid resolution of  the iritis.  I know of no treat-
ment more rapid and effectual. 
406            VIDAL ON VENEREAL DISEASES.
               Mackenzie aUudes  to a case where the medicine was thrown
L^jsrrj^)   aside by the family physician ;  having been recovered, it produced
             but little benefit; the patient,  finally, having fai_:en~ten grains of
             calomel and five of opium, daily, for several successive days, the
             mouth became suddenly affectea, and the iritis disappeared as if
             by magic.  This was  a case of genuine syphilitic  iritis, the pa-
             tient's body being covered with a copper-colored eruption.
               Mackenzie strongly recommends the combination of calomel and
             opium.  A pill composed of one and a half grains of the former,
             and from one-third of a grain  to one or one and one-third grains
             of the latter, may be given morning, noon, and evening, for some
             time, until  the  gums  become decidedly affected;  afterwards two
             pills a day may be continued for awhile, and when the  salivation
             is of longer standing, we may diminish  the quantity to one a day,
             to be taken in the evening.   This combination is  adapted to the
             severer cases, and when we wish to speedily arrest the progress
             of the malady, to prevent the effusion of lymph in the pupil, and
             to produce its absorption when already deposited.  In the milder
             forms,  we may rest  satisfied in  giving,  to begin with, one pill
             morning and evening.
               Mercury, especially the proto-iodide, should be administered for
             a long  time, not only  that  the  iritis  may be checked, and its con-
             sequences removed, but for the  purpose of curing  the  constitu-
             tional  infection, as we cannot infer the  cure of the syphilis from
             the cessation of the iritis, and we should remember that the gene-
             ral disease often appears to be cured, though much still remains to
             be done, particularly with  mercury,  in order that  the eye may be
             thoroughly cured of the iritis and its consecutive effects.
               I come now to speak of a means which has been highly praised,
             viz.,  turpentine.  Carmichael of Dublin has reported cases in his
             memoir, presenting incontestable proof  that this medicine has
             sometimes cured a form of iritis regarded  as syphilitic.   After the
             effusion of  lymph in  the pupil, and the formation of condyloma
             on the surface of the iris, he has succeeded in restoring these parte
             to their natural state.   Carmichael was led to administer turpen-
             tine in  iritis from the known influence of this remedy in cases of
             peritonitis, and the analogy existing  between the morbid products
             in the two diseases, since in  both a serous membrane is  the part
             affected, and in both adhesions  are produced between surfaces
             destined to be separated.  This medicine, which, moreover, I have
             never administered, may be of service in some cases  in which,
             from various circumstances,  mercury cannot be employed.   The
             oil of turpentine is -given  in drachm doses three times in a day.
             Ite disagreeable taste, and the  nausea which it produces, may be
             avoided by taking it in the  form of an emulsion.  If strangury
             supervene, the  medicine should be for awhile suspended, and an
             infusion of flax-seed or camphorated  julep be given.   To prevent
             burning sensations in the stomach, we may add from four to five
             grains of camphor to eight ounces of  the emulsion,  containing one
             ounce of the turpentine.   Conjointly wifh  all these means, and
             even with the opiated  frictions  already mentioned, we should ad- 
DISEASES OF THE TESTICLE.              4Q7
minister the sulphate of quinine, in cases where the nocturnal
pains are severe.  A pill containing  one and a half grains  of the
quinine may be given when the patient retires,  and another one
hour before the expected paroxysm.
                        SECTION V.

              DISEASES OF THE TESTICLE.

  In the first part of this work I have described an affection of
the testicles peculiar to the so-called primitive venereal diseases; this
affection is orchitis, a lesion  which is almost  always of an acute
nature.   The disease now under consideration  follows other syph-
ihtic manifestations; it is one of the most  remarkable forms of
consecutive syphilis; it is the syphilitic sarcocele or the venereal tes-
ticle, a malady essentially chronic.


        SYPHILITIC  SARCOCELE, OR VENEREAL TESTICLE.

  This chronic engorgement of which Astruc had a faint glimmer,
and which Benjamin Bell seems to have in view, was but imper-
fectly known before the investigations of Dupuytren and Sir Astley
Cooper.  It is to modern writers that we must refer for the history
of this affection, and several obscure points yet remain to be eluci-
dated.
  [Among those who have most contributed to promote our knowl-
edge on this subject, by pathological evidence, the names of Cus-
ack of Dublin, and Dr.  John Watson of New York, deserve a con-
spicuous place.  The paper of  Mr. Cusack in the 8th vol. of the
Dublin Jour, of Med. Science, Nov. 1835, though brief, is valuable,
inasmuch as his remarks are based on  the evidence afforded by
eight pathological specimens.   It is strange that neither Sir Astley
Cooper nor Mr. Curling never had an opportunity of dissecting a
syphilitic testicle (Curling on  Testis, Am. Ed., p. 348.)  Sir Ben-
jamin  Brodie refers to  a case in which he examined a testicle
thus affected, but the morbid appearances observed by him did not
differ from those seen in chronic inflammation. (Lond. Med. Gazette,
vol. xiii., p. 379.)  The preparations presented to the Surgical So-
ciety of Ireland by M. Cusack, exhibited the changes produced by
the disease " in all its stages of progress, from a small circumscribed
tubercle in an otherwise sound testis, to the contracted, indurated,
and completely disorganized gland,"  which changes were  analo-
gous to the products of scrofulous disease.  The several examina-
tions made by Dr. Watson led  him to conclude that the primary
seat of the affection is  in the fibrous envelope forming the proper
capsule  of the testis,  which  occasionally be'eomes enormously
thickened, whilst the proper tissue of the testis  remains healthy. 
408             VIDAL  ON VENEREAL DISEASES.
The tubule seminiferi, with their continuous vessels of the epididy-
mis were atrophied, pale, and immersed in serous effusion.  In one
case, there was a deposit of a large yellow mass, irregular in shape,
broadest in front, and  apparently connected with the fibrous en-
velope of the testicle, and extending backwards in the direction of
the corpus highmorianune.  This mass, by its pressure,  produced
atrophy of the tubuli seminiferi.  (Watson on Syph ilis, New York,
Jovrn. of Med. & Collat.  Sciences, Nov., 1845.—G. C. B.]
  As I have already stated, syphilitic sarcocele is one of the most
remarkable forms of consecutive syphilis;  it is also that affection
which at its commencement perhaps furnishes the strongest argu-
ment against the systematic arrangement of the syphilitic accidents
into three divisions. In fact, the same tumor may be a secondary,
a successive, and a tertiary accident; for we see syphilitic sarcocele
developed during the existence of chancre, and the eruption which
is  earliest manifested, or even when  not preceded  by  syphihtic
cutaneous eruption, and again it appears  only in connection with
the more profound and tardy forms  of the eruption; finally, it may
not occur until the last stage of syphilis, with the exostosis; then it
is  tertiary.  I had  in  my wards for a long time three patiente
affected with this disease, and in whom existed these  three connec-
tions with other accidente.
  Symptoms.—If we would remove the obscurities surrounding
the history of venereal engorgements of the testicle, it is necessary
to establish two varieties.
  1st Variety.—A blennorrhagia has existed, and may still exist,
but it is  rarely alone,  the  patient  most  frequently having been
affected with chancres.    The tumor almost always commences in
the epididymis; at a period, generally advanced, of the disease, we
may detect an effusion of greater or less quantity of  serum, in the
tunica vaginahs.   Sometimes the testicle is affected simultaneously
with the epididymis; it may constitute  the largest portion of  the
tumor, which  is generally of considerable size; it  is ordinarily
larger, more unequal and painful than in the second variety.   It
is in this variety especially, that the tumor is the seat of lancinat-
ing pains like those of cancer.  When the disease is of long stand-
ing, we find both sides affected;  then when we imagine that we
are treating  an ordinary orchitis, which shifts from one testicle to
another, as is of frequent occurrence,  we are frequently mistaken,
for  whilst orchitis  ordinarily disappears  on one  side when  the
other testicle becomes affected, we here observe the tumor on  one
side  increasing whilst that of the opposite side does  not  diminish.
This is the engorgement of the testicle which M. de Castelneau re-
gards as a chronic orchitis, and which other writers on  syphilis
consider to  be a syphilitic testicle, and which, in my opinion, is
both.  Perhaps it would be more proper for me to say,  that it is
an orchitis complicated with syphilis, a circumstance which gives
it a decidedly chronic character.   Thus, in this first variety, syph-
ihs invades a testicle already diseased, already inflamed; it attacks
a testicle affected with orchitis.
  2d Variety.—This is  observed in patients who have never been 
DISEASES OF THE TESTICLE.              409
 affected with blennorrhagia, who even have never had any disease
 of the genital organs, since I have seen a case of syphilitic sarco-
 cele  in a patient where the  only antecedent disease had been a
 chancre on the lip.  Generally, there has been a primitive ulcera-
 tion on the penis, and this has been followed by a syphilitic erup-
 tion.  In the majority of  cases,  there are no  premonitory symp-
 toms and it is only by accident that  the  patient discovers that
 there has been  any alteration in his genital organs, or perhaps he
 may feel a sensation of weight, and inconvenience, and of dragging.
 It is rare that a dull pain in the loins, occurring chiefly during the
 night, precedes  or accompanies this variety of syphilitic engorge-
 ment. The tumor is generally smaller than that in the first variety.
 Sometimes the  epididymis is not involved in this augmentation
 of volume; it seems perfectly atrophied by the  compression which
 it suffers from the abnormally-developed testicle.  The gland be-
 comes gradually indurated in patches, in zones; these multiply and
 finally become united, the testicle only, enlarged without being
 sensibly altered in form, is of remarkable  hardness.   Both sides
 are affected more frequently than is imagined, but generally one
 is larger than the other, and this  alone arrests the attention of the
 observer.   If but one testicle is  really affected at first, the other
 soon becomes involved.  According to M. Ricord, the parenchyma
 of the testicle, after having suffered this syphilitic attack, becomes
 transformed into fibrous, cartilaginous, or osseous tissue; it may
 undergo even a malignant degeneration.   Sometimes the tumor
 ulcerates ; according to the same writer, this would then constitute
 a  gummy tumor, which should be opened independently of the
 testicle, it being seated in  the  cellular tissue  of the  scrotum.
 Atrophy may be one of the consequences of this affection of the tes-
 ticle, but  it is not constant.  I have  seen, in more  than one in-
 stance, both testicles which had been completely affected with this
 disease, restored to their normal state and afterwards perfectly fulfil
 their functions.   I have seen it followed even by hypertrophy of
 the testicle; a case came under my observation, where the testicle
 on one side  had been removed, and the other was affected with
 the disease under consideration, and yet this patient  after he was
 cured, indulged to excess in  coition.   I shall refer to this fact in
 another place.
   This second variety, which  affects especially the seminal gland,
 may occur even  where no antecedent chancre  has been observed;
 it may result from syphilitic blennorrhagia.  It is to cases of this
 kind that most of the obscurity connected with  the history of the
 disease in question is to be attributed ; for the advocates of chronic
 orchitis, who almost always reject this second variety,  attach great
 importance to the antecedent blennorrhagia in  establishing this
 same chronic orchitis.
  Generally, the tumors on both  sides are not painful, when they
belong to the first or second variety.  If pressure be made some-
what firmly, it produces the same amount of pain that it would if
made on a sound testicle.  This  pressure may be productive of
no sensation whatever.  When pain does exist, if on one side, it is 
410
VIDAL ON VENEREAL DISEASES.
rather towards the inguinal region, and in the majority of cases,
it is then caused by the weight of the tumor, when the latter is of
large  size.
  As I have  already stated, I am now treating of chronic affec-
tions.  Their progress is slow, and they may continue for several
years. If we observe a certain tendency to assume an acute char-
acter, it is in the first variety, and affects the epididymis.  In tho
great  majority of cases, there is a decided alteration in the func-
tions  of the testicles.  Sexual  desire is diminished, and in some
instances completely destroyed;  erections are then less frequent,
and sexual intercourse, less sought after at first, at length becomes
impossible.  The secretion of semen is lessened, and is proved by
the smaller number of animalculae which is in all cases  observed.
These lesions  in function become much more decided when the
disease involves more particularly the parenchyma of the testicles,
and when both are involved.  The second variety in this respect,
is more grave than the first.   I shall return to this subject when I
come  to speak of the prognosis of the disease.
  Diagnosis.—The diagnosis may be greatly simplified by observ-
ing the general rule  mentioned  in a memoir which I read to the
Academy of Medicine.  I have stated that when there is a chronic
engorgement of both  testicles, the affection is necessarily benign;
it cannot belong to any of the forms of cancer,  nor to the category
of tumors caused by tubercles which are found  at the same time in
the internal organs.  Syphilitic  sarcocele, therefore, can be con-
founded only with the chronic engorgement of the testicles, which
is also regarded as a tubercular affection, but which is of a benign
character as the viscera are sound.  It remains, then, to distinguish
syphilitic sarcocele from this chronic engorgement, or, if it be pre-
ferred, from these  benign tubercular tumors.   Here the  antece-
dents and the  concomitant symptoms afford us  great assistance.
The tumor, besides, in the second variety, is less irregular than in
the strumous  affection,  and the induration involves the  testicle
itself, whilst in the strumous disease the testicle retains its normal
elasticity.   The first variety, that which was first described, may
more  readily be confounded with the engorgement  in  question,
and so much  the  more easily as among  the antecedents of both
tumors a blennorrhagia may be found.   But the strumous tumor
is much more irregular; there are portions of it which frequently
become softened, and suppurate; it is rare  that the patient, at
some  period of the disease, does not experience pain, and pressure,
even when slight,  produces  it.   Syphilitic sarcocele, on the con-
trary, may pass through all its stages, without  ever being the seat
of the least pain, and, in some instances, even pretty strong press-
ure does not excite it.
  Treatment  may throw some Ught on the diagnosis ; the iodide
of potassium, indeed, in large doses, produces a prompt and de-
cided  effect on  the syphilitic tumor, whilst the  same medicine,
administered  in strumous cases, is long in exerting ite influence,
and its action is-felt in the tumor only after the whole system has
been  thoroughly modified by this agent.  True, the prompt  and 
DISEASES OF THE TESTICLE.
411
manifest action of which I have spoken  is produced  only in the
first variety, and it is rare to observe  these effects produced when
the iodide is employed in  the other forms of syphilitic sarcocele.
But this variety is  very favorably influenced by mercury, used
both externally and  internally, while  the effects of this agent are
injurious in the strumous affection.
  Prognosis.—I have already indicated my opinion as to the prog-
nosis in syphilitic sarcocele, when I classed it among the benign
tumors  of  the  scrotum.   The prognosis is  therefore  favorable,
especially since the iodide of potassium  has been introduced into
the therapeutics of certain forms of syphilis.  There is no diversity
of opinion on this  point.   The  patient, then, has nothing to fear
in general; but what effect has the disease on the functions of the
organs ? This is a serious  question, which I have attempted to
discuss in a paper read before the Surgical Society of Paris.
  A testicle affected  with what  is called syphilitic sarcocele doubt-
less suffers profound modifications in ite structure.   I have already
stated, that the organ may become of a  fibrous or a cartilaginous
nature,  or its parenchyma may become the seat of calcareous de-
posits, in which case' it becomes atrophied.  Nutrition in the sub-
stance of the organ  is impaired,  the organ itself  is diminished in
size, and after the cure of this  kind of sarcocele, it remains  more
feeble and of smaller size.   Atrophy of the testicles, therefore, is a
condition so frequently produced by syphilitic sarcocele, that we
are authorized in assigning it a  place among the general  characters
of the disease.   But I believe  that those who regard atrophy as
an inevitable termination of syphilitic sarcocele, entertain an opin-
ion not  warranted by facts, or, more  properly speaking, by well-
authenticated facts.  The consequences of atrophy of the testicles,
as regards their functions, may be imagined, since if it exist to any
great extent, if  it involve the parenchyma  of both  organs, it is
equivalent  to castration.  Unfortunately such a  condition some-
times happens.  Thus, I was  consulted  by one  of my confreres,
who had watched the wasting of  his testicles under the influence
of syphilitic disease; a portion of the epididymis only remained
on either side, and these remnants of the organs were exceedingly
sensitive; impotence in this case was complete.   This was an ex-
ample of atrophy with its  most serious consequences.   The  most
common result of the disease is to diminish the size of the testicle
in its ensemble  only, and  to render it irregular and of unequal
consistence.
  The extent to which virility ig  impaired, does  not appear  to  be
always  in proportion to that of the destruction in the organ pro-
duced by the disease: indeed, we  meet with patients  no longer
capable  of an erection, or in whom the seminal discharge  is  very
diluted,  and small in quantity, and yet who have lost but a small
portion  of the parenchyma of the testicle.  These differences de-
pend upon the age of the patient, the use or abuse he  has made of
his virile powers, and the  state of his mind.  In connection with
the latter point, melancholy cases are sometimes observed;  they
occur in that class of society capable of comprehending  the nature 
412
VIDAL ON VENEREAL DISEASES.
of atrophy of the testicles and its effects on virility.  These un-
fortunate individuals have learned the nature of indurated chancre
and  its consequences, of syphilitic sarcocele and  its results:  they
remain a long time  under the influence of disease; they imagine
an impotence with which they are often not affected;  they are
afraid of marriage, regarding themselves as ruined men,  and they
remain in a state of celibacy the  most melancholy and complete.
If certain considerations, family or self-interest, lead them to con-
tract marriage, at the moment of attempting the conjugal rite, their
courage fails them, and  they sink  into  the deepest  despair.  I
knew a person placed in the  above circumstances, and who after-
wards  became a father, after having  been persuaded that even
when both  testicles are diseased, provided the patient be placed
under proper treatment, virility may be preserved.  This fact of
itself is calculated to impress  upon our minds the importance of
the subject now under consideration.
  [These  remarks of  our author will doubtless recall those made
in another place on Syphilophobia.—G. C. B.]
  For my own part, I believe, not only that  atrophy followed by
impotence  are  not  the inevitable consequences,  even  when what
we  call syphilitic sarcocele  is cured,  but I  am  acquainted with
facts which led me to think that, in certain cases, the testicle thus
affected may, after a well-directed treatment and cure, preserve its
vigor, and be completely restored to its  normal  anatomical and
physiological state.  A rare exception is where the same syphilitic
influence,  exercised on the same  individual, produces  completely
opposite effects in  each testicle; one will become atrophied, the
other hypertrophied.   I  shall soon relate  a case showing this
double effect of the syphilitic action.
  I have already published the details of one of the strongest cases
to show that virility may survive a  profound syphilitic  affection
of the  testicle; this case  is related in my work on surgery, and  I
shall repeat it when I come to the subject of the therapeutics of
this disease.  The patient was a soldier, from whom an army
surgeon removed one testicle, supposing it to be affected with
malignant disease;  in investigating the previous history of the
case  I found that the patient had had symptoms of syphilis.   I
prescribed  the  iodide of potassium in what I call sufficient doses.
The  testicle soon returned to its normal state, with the exception
that  it remained somewhat larger than natural.   I call the atten-
tion of the reader here particularly to the last part of  the report,
which  thus concludes:  " Tliepatient is constantly inclined to sexual
indulgence."   I am convinced of the truth  of this by the fact that I
have been called upon to treat this soldier twice for blennorrhagia
since he left the hospital.   Here we have a patient with only one
testicle, and that affected with what is called sarcocele; the previ-
ous history of the case, the characters of the tumor, the good effecte
of the iodide of potassium, all go to prove the fact; yet this testicle,
after the disease is removed, was not only not atrophied, but seems
to have been hypertrophied; his virility was not destroyed, for he 
DISEASES OF THE TESTICLE.
413
 indulged  in  sexual  excesses,  the penalty of which was repeated
 attacks of blennorrhagia!
   In the  month of August, 1847, there was in my service at the
 Ilnpital du Midi, a carman, who presented an analogous  case to
 that just described.  This patient had never lost a testicle, but one
 was not developed;  it was the right testicle, and was situated near
 the  external opening of the inguinal canal, where  the only trace
 of it to be found was the epididymis, which was scarcely the size of
 a  common bean.  This carman left my service  cured;  he after-
 wards contracted a chancre at a house of prostitution, communi-
 cated it to his wife, who became pregnant and gave birth to a child,
 which died shortly after  its birth, covered with a syphilitic erup-
 tion, similar  to that which I observed on ite unfortunate mother.
 Here, again, was a subject with only one testicle, and that evidently
 syphilitic, and yet his virility was not affected, since it was mani-
 fested both in lawful and illicit  intercourse, and by the birth of a
 child bearing the marks of the paternal disease.
   The following case would seem to prove that a syphilitic affection
 involving both testicles, may produce  atrophy in one alone.  M.
 Ricord asserts that this atrophy is consective to an actual disease
 of the testicle, of the  existence of which we may be ignorant, since
 it does not augment the volume  of the organ.   For my own part,
 I consider it of but little consequence whether the atrophy is primi-
 tive or consecutive; what I maintain is, that there may be atrophy
 of the testicle on one side, and hypertrophy of that on the other.
   On the 19th July, 1845, there was admitted into my  service a
 man named B., aet. 50, a  road-laborer,  and of good constitution.
 Twenty years before he contracted a chancre, which was followed
 by a suppurating bubo in the left groin.  At the end of ten days
 the chancre became cicatrized, but the patient was confined to his
 bed  awaiting the cure of his bubo.   He took pills, but  does  not
 know whether they contained mercury; he never had an eruption
 on his skin, nor sore throat.  Six years since he suffered, without
 any apparent cause, pains in his head, neck, and extremities, which
 lasted only fifteen days.  Three months since he contracted a new
 chancre on the anterior part of the reflection of the prepuce;  the
 only treatment was cauterization, and it cicatrized in the course of
 fifteen da}rs.  This patient never had a blennorrhagia.  Some two
 months before the appearance of the last chancre, the left testicle
 began to enlarge, and this enlargement was unattended with pain.
 It is only during the last month that the patient  has experienced
 shooting pains, which are more frequent during the night than the
 day.  The left testicle at present is of the size of a large hen's egg;
 it is hard, heavy,  of pyriform shape,  and presents slight  inequali-
 ties.   The epididymis cannot be felt, but appears to be confounded
 with the testicle.  The spermatic cord is somewhat larger than
 natural, and the veins of the same side are also unusually developed.
 Pressure produces but little pain.  A month and a half since a
small tumor appeared on the external and superior part of the left
thigh, which  suppurated.   The wound was not completely cica-
trized until about eight days since;  a very large  reddish cicatrix 
414
VIDAL ON VENEREAL DISEASES.
remained, analogous  to  those left by cutaneous tubercles.  The
right testicle is atrophied, being reduced to half ite  size.   This
diminution  in  size was not preceded by any tumefaction, and
occurred about two months after the left began to enlarge, and at
a time when discutient plasters had been applied to the latter, lead-
ing the patient to suppose that the atrophy of the right testicle had
been produced by the plaster.
  July 12th. The iodide of potassium was  administered to  the
extent of half a drachm daily.   Eight days  afterwards the pains
had ceased,  and there was a marked diminution in the  size of the
testicle.
  28th. The left testicle, which was  the largest, is  reduced  to
nearly half  the size it presented on the patient's admission.  In-
durated nuclei are felt much more distinctly when the testicle is
made to glide beneath the skin under the fingers; the  consistence
is less.  The epididymis  is readily distinguished from the rest of
the gland, and  the spermatic cord has regained its normal size.
There is no  longer pain even on pretty firm  pressure.  The nor-
mal sensibility seems to be  diminished.  For some days past the
patient has  been troubled  with dimness  of  vision.  The vessels
radiating from the sclerotic are  slightly injected; there is photo-
phobia, with lachrymation.   The patient also complains of buzzing
in his left ear, but this has  existed for several years.
  Aug. 8th. Vision is now perfect, and the eyes have resumed
their natural appearance.  The buzzing in the ear continues.   The
indurated nuclei in the left testicle are less numerous and  painful.
The consistence still diminishing.
  22d. The left testicle  has regained  its normal shape.  It still
remains larger than natural.  The right is always  small—that is,
it is reduced one-half.  I saw this patient again one month after
his cure; he came to consult  me in  regard to a blennorrhagia
which he had contracted.
  Here, then, we have three cases estabfishing the fact that both
the testicle  and ite functions may be  preserved in their integrity
after the termination and cure of a syphilitic sarcocele.   They jus-
tify me in placing hypertrophy  of the  testicles  in the  same cate-
gory.  I will not conceal the  objections which may be urged
against my  conclusions, objections drawn from the cases them-
selves which I have quoted. In the first place, it may be said, that
hypertrophy of one testicle in  the absence or imperfect develop-
ment of the  other, is a fact in the organo-genesis well known ; that
the hypertrophy preceded the syphilitic infection.  Syphilis, there-
fore, did not give rise to it; it resulted in obedience to  that law of
compensation, by which  the  materials  destined for  the nourish-
ment of an absent or imperfectly-developed organ, are carried  to
its fellow organ, which thus receives an unaccustomed supply.   It
may be  objected, perhaps, that in the cases  above  mentioned,
syphihs has found the testicles hypertrophied, and that if after its
cure, the testicles remain of their natural, or of an unnatural sizo,
if they still  retain their functions, it is no proof that  these organs
have not suffered a certain  degree of atrophy, for an organ which 
DISEASES OF THE TESTICLE.
415
is equal to one and a half may very well suffer a substraction, and
remain still equal, if not a little more larger than the other.  The
case of the carman furnishes the strongest argument in favor of
this view of the subject; he was born with but one perfectly-de-
veloped testicle, whilst the situation of the other was indicated
only by a portion of the  epididymis.   There may therefore be
some ground for  believing the  perfectly-developed testicle, in this
case, had become considerably enlarged before it became diseased.
When attacked by syphilis it became reduced to less than its  na-
tural size: the hypertrophied organ here became atrophied, and
the hypertrophy was at the expense of the cure. These arguments,
to which I cannot refuse a certain value, do not destroy the fact of
one testicle  retaining ite natural  size, with  a volume even more
than natural, preserving its functions,  and  this,  too, after it has
suffered from the disease  called  syphilitic sarcocele..  I do not
know precisely what was the condition  of the left testicle in  the
carman before it became attacked by syphilis; what I affirm fs,
that, after the cure, it was found of larger size than the same organ
in another subject of the age and strength of that patient.  I will
also state, that this carman, who had begotten no child before  his
disease,  did so after his cure.
  The same objections, perhaps, may be advanced against the case
of the soldier in whom one testicle had  been extirpated, and who,
after being cured of syphilitic sarcocele in the other, preserved the
latter in an hypertrophied and very active state, for there was an
interval of two years between  the castration of the one, and the
syphilitic attack in the other.  During this period, it may be said,
tne testicle which was left had the benefit of the  nutritive mate-
rials destined for  the other as well as for itself, and may have thus
become  preternaturally developed: constituting an hypertrophy,
which may have prevented the atrophy from producing ite effects.
To this I will reply, in the first place, that the two years' interval
above mentioned, was too short a period for an organ to  become
so hypertrophied  as to resist the atrophy produced by syphilis.
Further, as  the whole history of this soldier's disease, a history
which may soon be read, proves to me that the amputated testicle
was not cancerous, but syphilitic; and, as it was the same venereal
disease with which the first was affected that invaded the latter, I
submit whether a subject, completely infected with syphilis, under
the influence of a principle the  tendency of which is to  produce
atrophy of the testicle, could, under such circumstances, have one
of these organs hypertrophied.   I believe, further, that the altera-
tions of tissue constituting the tumor, called syphilitic testicle, or
syphilitic sarcocele, may vary, and that  the  mode of reparation is
not always identical;  in proof of this, I will offer the case which I
have fully related.  It shows, indeed, that under the same syphili-
tic  influence, one testicle  becomes atrophied without  becoming
tumefied, while the other tumefies, actually forming a tumor, and
remains, to a certain extent, hypertrophied.  These facts and these
inferences are, in  my opinion, of a nature to merit the attention of
practitioners, for they relate to an important question in pathologi- 
416
VIDAL ON VENEREAL DISEASES.
cal anatomy, and to the question of sterility in the male—questions
of very serious importance, in many points of view.
   Treatment.—The treatment  is the same as in confirmed consti-
tutional syphilis, modified, however,  according to the variety of
the sarcocele and the other circumstances already indicated.   Wo
should remember that syphilitic sarcocele does not always occur
at the same period of syphilis.  I have asserted, at the commence-
ment of this article, that the  tumor may appear shortly after the
first manifestation of syphilis, simultaneously with a premature
eruption on the skin, or without this eruption, that it has  been
observed during the period of transition, and that, in  fine, it  may
occur among the  latest symptoms,  such as  periostosis and the
exostosis.  The practitioner should take these circumstances into
consideration.   The  sarcocele which  appears before this profound
alteration of the organism, which contra-indicates all depletory
treatment,  may be advantageously affected by mercury.   It was
-this variety of sarcocele, which I will call premature, that was cured
with mercury alone, by Dupuytren, Boyer and other practitioners,
who, before they decided to perform castration, subjected to a mer-
curial treatment patients affected with chronic enlargement of the
testicles, which assumed certain of the characters of cancer. Thus,
more recently, with  the  pills of the proto-iodide  of mercury, I
have removed a double syphilitic sarcocele, which had preceded
the squamous  eruption.  Mercury, therefore, and even mercury
alone, may radically cure certain  syphilitic sarcoceles, and I be-
lieve that it is well to commence with it, when we have a concom-
itant superficial  eruption, and the patient still retains his strength,
and his constitution is not profoundly altered.   It is,  in my opin-
ion, the means for preventing relapses.  But it is evident that cer-
tain sarcoceles,  especially those of the second  variety, cannot  be
affected by mercury, no matter how it may be administered.   This
remedy, therefore, may  have its dangers,  and  it  is  principally
when the disease is late in its development, when it occurs in the
last stages of syphilis,  when the syphilitic cachexia is already es-
tablished.   These are  the  sarcoceles which  were  formerly re-
moved  by castration; they were regarded as of a cancerous na-
ture, because they resisted the influence of  mercury.   This period
is not very  remote  from our own,  and I have seen, quite re-
cently, some of  the great  masters whom I have mentioned remove
testicles which  might have been saved by  the iodide of potas-
sium.
   [Dr. John Watson  refers in his Essay to an instance where, in
consultation, he opposed,  but unsuccessfully, the operation of cas-
tration for syphilitic sarcocele !—G. C. B.]
   This, therefore, is  the remedy to be employed in severe cases,
when the constitution  has become  compromised;  in the second
variety, then, it will produce very prompt, and at first, very de-
cided effecte.  Its employment even  need  not be confined to the
latter variety; as a general rule, it should,be associated with mer-
cury in the treatment of the first variety.  The following is  a re-
port of the case to which  I have alluded; it is calculated to make 
DISEASES OF  THE TESTICLE.
417
the surgeon reflect in similar cases, and to cause the surgeon who
performed the operation to regret the deed.
   Great enlargement of the left testicle.   Ablation of the  organ by an
army surgeon who regarded the tumor as a hydro-sarcocele.  Similar
enlargement of the right  testicle.   Cure  by the iodide of potassium.—
B., set. 29, gunsmith, occupying No. 24, Ward 10, admitted 11th
of March.  Not very robust, and of a scrofulous aspect.  He states
that from his childhood he  has  never been ill.   His parents are
healthy, and are very vigorous.  On his neck and face, however,
are cicatrices which  have resulted from  scrofulous  ulcerations.
Six years since, he  had a blennorrhagia, which lasted eighteen
months;  this was never painful, and was cured spontaneously.
Six months afterwards, long after he had indulged in sexual inter-
course, ulcerations  appeared  on the  prepuce  and glans.  The
patient submitted to a mercurial treatment.  After this, he had an
eruption on the skin, which the physician did not regard as syphi-
litic, according to the patient's statement, and there was an enlarge-
ment in the left axilla, without any abrasion or wound of the cor-
responding extremity; perhaps it was a scrofulous bubo,  and it
was treated by maturatives and  an incision.  The  patient states
that there was a syphilitic ulceration in  his mouth, which his
physician repeatedly touched with the nitrate of silver, and which
healed several times only to  break out again.  At length, the left
testicle began to  enlarge (the patient being at this time in service);
in the  course of four months it acquired  an enormous volume;
hard at the commencement, it  became  softer and softer; more or
less frequent shooting pains were felt  in  the tumor, extending
even to the kidneys.  For four  months the patient remained in
military hospital. Finally, in April 1841, the tumor was removed
by operation. The wound, at the  end of six weeks, had completely
cicatrized.   The man resumed his occupation as gunsmith.
   Two years afterwards, the right testicle became enlarged.  In
the month of August, 1843, this enlargement  had acquired the
volume of the two fists.  It was hard, particularly at its inferior
part;  it was the  seat of severe lancinating pains, which deprived
the patient of all repose.  His physician prescribed the repeated
application of a  large number of  leeches to the tumor, frictions
with mercurial ointment, and the plaster of Vigo.   Six weeks af-
terwards  there was a  great improvement; but the patient led  an
irregular life, and was addicted to excesses.  Although deprived
of one testicle, and the other was diseased, he had strong sexual
desires. After his indulgences, his pains returned with still greater
severity.   He then resolved to place himself under my care, and
he was admitted into the Hopital du Midi.   The  tumor was much
larger than the fist;  it was hard at its posterior and lateral  parte;
somewhat soft anteriorly, and there was a  sense of fluctuation for
the extent of about one inch; its shape was oval, its upper extrem-
ity the largest, and it had much the appearance of the swelling in
hydrocele; but it was much heavier  than the latter.   As I have
already stated, this tumor was the seat of severe lancinating pains.
The particular hardness of this tumor, the  nature of the pains, the
                               27 
418
VIDAL ON VENEREAL DISEASES.
circumstance of the ablation of the other testicle, seemed to show
that it was  a  true sarcocele,  a scirrhous or encephaloid tumor
which might lead  to a  fatal termination.  But having  carefully
learned the history of the disease, on his admission, I placed him
under the influence of the iodide of potassium; he had taken only
about two drachms before the  pains had nearly ceased.  At pres-
ent, April 15th, 1844, the tumor  is reduced one half in  size, and
the pain has completely subsided.
  The part of the tumor presenting an obscure fluctuation has not
enlarged, but there is still a sensation of a fluid of this consistence,
as if it might be the product of ramollisement.   On the 2d of May,
1844, the indurated portion had diminished in extent, fluctuation
was more evident, and the whole tumor was less than half its orig-
inal size;  on the 19th of May, it was scarcely double the volume
of arf ordinary testicle.   The administration of the  iodide of potas-
sium was suspended.  Frictions were made on the tumor with an
ointment of the iodide  of lead. Finally, the testicle resumed its
normal state, and the patient left the hospital on the 15th of June.
He is always strongly inclined to sexual indulgence.
  We here see a tumor presenting many of the characters of ence-
phaloid disease; an obscure fluctuation, lancinating pains, debil-
ity, pallor of countenance, one testicle amputated,  a testicle which
was similarly affected, and yet the iodide of potassium in this case
was triumphant!   Did it cure a cancer, or was it a case of benign
tumor, a syphilitic sarcocele ?  The latter appears  to me  the more
rational hypothesis.
SECTION VI.
         DISEASES OF  THE CELLULAR TISSUE.

  In describing the affections of the skin and mucous membranes,
we have frequently alluded to a simultaneous lesion of the cellular
tissue^  Thus, the deep-seated syphilitic eruptions, the tardy lesions
of the velum palati, of the pharynx and tongue, are attended with
more or less congestion of the subjacent cellular tissue, and at the
same time it is observed in the affections of the external and in-
ternal tegumentary coverings.  It is  the diffused  syphilitic indu-
ration of the ceUular tissue ;  it may  occur conjointly with the le-
sions of the skin.  In this case, the cellular tissue seems to become
affected by the extension of the cutaneous lesion, or by that of the
mucous membrane by which it is covered.   At  other times  the
ceUular tissue becomes thickened, and indurated without any pre-
vious affection of the skin,  which may then  remain for a long
time and forever,  in a normal state.
  Instead of this  diffused or vaguely-circumscribed induration,
we  may  observe  partial engorgements, which gradually assume
the form of  a nut, tubercle or knot.  They may be condylomata, 
DISEASES OF  THE CELLULAR  TISSUE.          419
and then they occur especially about the anus; or they have re-
ceived the  names of gumma, nodes, gummy tumors, and are found
beneath  the skin, the  deep cellular tissue, and even in the sub-
stance of certain organs, and  of  muscles.  This affection of the
cellular tissue is observed when constitutional  syphilis has deeply
undermined the system.  The most frequent seat of these tumors
is on the external surface of the extremities, in the subcutaneous
cellular tissue, where it is lamellar and dense;  there they may for
a long time preserve a certain degree of mobility and for a decided
prominence; they have been seen of a pediculated shape.
  These tumors may occur in the cellular tissue of the scrotum;
they may then  be confounded with syphilitic sarcocele,  a mistake
of no  great importance, or they be confounded with genuine can-
cer, an error of much more serious  consequence.   They may also
occur  in the deep-seated cellular tissue, and even in that which
unites, or separates the fibrous or the muscular system.  Thus they
frequently  invade the tongue, which then appears as if covered
with small hazel nuts.  M. Ricord mentions a remarkable case of
the kind.  It is in such cases that it is especially Uable to be con-
founded with cancer.
  Generally, there are several of these tumors, but they are not all
developed  simultaneously.   Months, and  even years, may there-
fore be required to effect their cure, no matter what the treatment
pursued.  At first, they are small, but little sensitive, hard, adhe-
rent to the  skin, but free and movable beneath.  They are slowly
developed,  increase slowly, and are unattended with pain.  Some
little inconvenience in the part, or accident, leads to their discovery
by  the patient.   They vary in size  from that  of a hazelnut to a
walnut.  For a long time hard, they finally yield to pressure, pre-
senting a slight sense of fluctuation, which afterwards becomes
quite evident.   Then, if they are in  the vicinity of the skin or the
mucous membrane, their envelope becomes thin, of a violet reddish-
brown color, and they burst, presenting  perforations similar to
those which follow the opening of an anthrax.  A badly assimi-
lated pus, a kind of gummy matter,  of organic debris, issues by the
openings which become enlarged:  a deep ulceration forms; the
gummy tumor appears to be evacuated, leaving a kind of cavern,
bounded by a shell, or cyst, which must be  destroyed and cast
out, before complete reparation can occur.   The cicatrix that fol-
lows is depressed, and irregular like that succeeding to a deep
burn.
  M. Ricord observes that the ulcerative destruction which suc-
ceeded to the tumors on the tongue, in the case before mentioned,
" was horrible, and to  eyes unaccustomed to such sights these ul-
cers might  have appeared horrible cancers."*
  We  should remember, that all deep-seated syphilitic tumors are
not formed by the cellular tissue,  or at least by this tissue alone.
Thus, in describing the tumors of the muscles, I shall soon speak
of one  formed by a particular degeneration of the muscular fibres
* Traite des Maladies Vcncrienncs, p. 660. 
420            VIDAL ON VENEREAL DISEASES.
themselves.  In complex cases, the tumor may be composed both
of cellular tissue and the parenchyma of organs.
  The affections of the cellular tissue, of whatever form, are neces-
sarily grave, as they occur at a period of syphilitic  infection char-
acterized by a profound alteration of the  organism.   The gravity
of the prognosis, besides, depends upon  the seat of the gummy
tumors.  Thus, those situated beneath the skin on the extremities,
are of a much less serious  character than those which are devel-
oped in the substance of the tongue, or of the velum palati; for
when they ulcerate, they may commit vast  ravages, and compro-
mise important functions.
  The treatment must  be adapted to the nature of the affection,
and the period of syphilis in which it is observed.  Mercury can
seldom be administered with propriety in these  cases, on account
of the profound alteration of the  organism coinciding with these
tumors.  The practitioner should therefore avoid this and all other
hypothenisants, and trust to  tonics, and such other means as may
invigorate the  system.   At  the head of these means, stands the
iodide of potassium.  If the subject tolerate it well, and it be ad-
ministered in due season, we shall see these tumors rapidly disap-
pear.   Some have advised the application of  blisters to these
tumors, and that they should be opened, and even extirpated.  It
is evident that these proceedings cannot be resorted to except in
certain cases, where the situation of the tumors renders them ac-
cessible to the  means indicated.   Cullerier treated these tumors by
blisters dressed  with the bi-chloride of mercury, as is  recom-
mended by M. Malapert in the treatment of buboes.  The opening
of these tumors is but  a palliative remedy, and their extirpation
should not be attempted except when general treatment has been
exhausted, and a satisfactory trial given to the iodide of potassium.
Should, however, we  attempt to extirpate them, we should do it
thoroughly, for the suppuration will be rendered very protracted
if any portion  of the cyst be left behind.   Sometimes the opening
of the tumor, whether spontaneous or made by the surgeon, is fol-
lowed by a very active inflammation.  We must  then resort to
topical emollient applications.   In the majority of cases, dressings
with charpie, steeped in a mixture  of two-thirds water and one-
third  tincture of iodine,  should be preferred.   We may afterwards
employ dressings with the vigo cum mercurio, which will here be
found a very useful application.
                       SECTION  VH.


   AFFECTIONS OF THE MUSCLES, TENDONS, AND APONEUROSES.

  These  organs  of locomotion frequently become affected in the
last stages of syphilis, and yet, until recently, the  study of these
lesions has been  almost entirely neglected.  Astruc merely alludes 
          AFFECTIONS OF TnE MUSCLES,  TENDONS, &c,       421

to this manifestation of syphilis;  according to this writer, when
the substance of the muscles becomes infiltrated with the virus, we
have  ganglions, and hard tumors; he speaks of rheumatic  pains.
Petit  Raael properly characterises it  "a retraction rebellious to
treatment."  M. Lagneau seems to have observed analogous cases,
and he regards the syphilitic contractions as chronic inflammations of
the muscles, arising from the syphilitic infection.   MM. Ph. Boyer
and Ricord have  clearly described  these  contractions, especiaUy
those seated in  the flexor muscles  of the fore-arms; they place
beyond doubt  the  syphilitic nature of this lesion,  and its connec-
tion with the tertiary symptoms.   I have more than once observed
the contraction  of the brachial  biceps,  and have seen a tumor
seated in the rectus femoris.   The particulars of this  case I  will
soon  relate.  Finally,  M.  Bouisson has treated, ex professo,  this
question of the syphilitic tumors of muscles and  their appendages, in
a memoir published in the Gazette Medicate of Paris, 1846.  I have
availed  myself of this memoir in the present article.
   Causes.—The  last effects  of the  diathesis are  manifested by
numerous local affections.  It is  the duty of  the  practitioner to
discover the existence of this diathesis, and to assign to it its  pro-
per place in the etiology of these affections.  Nothing is  better
established than its manifestations in the osseous and  fibrous tis-
sues,  in what is called the tertiary form of syphilis, and these
manifestations are generally produced by the influence of syphilis
alone, without the  intervention of any local or appreciable  exter-
nal cause.   The syphilitic tumors of the  muscles, and tendons,
come under the same category; they become developed in the  sub-
stance of these  organs, independently of any  particular  exciting
cause.
   Symptoms and Pathological Anatomy.—The principal symptoms
are, pain, contraction and tumors.
   1st. Pain.—Pain is more especially observed when the syphilitic
infection is  inveterate, and in patients who have been exposed to
the influences of cold and moisture;  these predisposing causes are
not essential.  This accident  has been described under the name
of syphilitic  rheumatism.   The pain is felt along the course of the
muscles, tendons, and the aponeurosis  of attachment or envelop;
it is of a character similar to  that felt in osteocopes, but is less  pro-
found, and is exasperated by muscular contraction; it differs from
ordinary rheumatic pain by  its  relation to accidents evidently
syphilitic, and it yields to specific treatment.
  2d. Contraction.—The  muscular contraction is  sometimes  the
result of syphilitic rheumatism, of which it is but a higher degree;
at other times, it is slowly manifested, and coincides with a more
or less advanced state of the disease.   The muscles of the superior
extremities,  and more especially the flexors of the fore-arm, are
most frequently affected with this contraction.  M. Bouisson speaks
of a syphilitic contraction of one of the motor muscles of the  eye.
According to this surgeon, if he were to name the seat of election
of these contractions, it would be the sphincters.
  "We know,"  he observes,  "how common are permanent con- 
422             VIDAL ON VENEREAL  DISEASES.
 tractions of the sphincter ani, in subjecte affected with syphilitic
 eruptions in this vicinity, and with fissures of the anus.  We also
 frequently observe active and painful contractions of the vagina,
 in women affected with  ulcerations  in the  vicinity of its vulvar
 opening.   Now, if in certain cases, these spasms are provoked by
 the presence of ulcerations, independently of any specific influence,
 we do not violate  the laws of analogy, in assigning in other cases,
 contraction of  the sphincter  muscles, a place among the accidents
 of confirmed syphilis, and in regarding it as a veritable venereal
 contraction," (loc. cit.)  I know not precisely whether M. Bouisson
 does depart from the laws of analogy, but judging from my own
 observations, he abuses them.
   3d."  Tumors.—Tumors developed in the muscular system and ite
 appendages are deserving especial attention.  I wiU first speak of
 the tumors of the appendages.
   The tendons  and aponeuroses are more frequently the  seat of
 syphilitic tumors than the fleshy part of the muscles.  The tendons,
 like the periosteum, notwithstanding their feeble vascularity, par-
 ticipate in the effects of confirmed syphilis, and are especially liable
 to become the seat of partial thickenings, or of small tumors called
 nodes, which are sometimes hard and filled, sometimes fluctuating.
 The pathological  susceptibility of the aponeuroses, is here less
 marked, but different observations, and particularly those of Hun-
 ter, leave no doubt of the part which they take in this class of
 affections.  It  cannot, however, be denied that all the reports of
 these cases are  brief and  unsatisfactory, and that they merely indi-
 cate their existence without affording  us full details; it  is even
/probable  that in many of the cases where tumors  have formed in
 these tissues from the effecte of syphilis, and which have fallen
 under the notice of different observers, their real nature and causes
 have not been suspected.   M. Bouisson has furnished the details
 and facts, which, as far  as possible,  have rendered the study of
 these affections complete.
   These tumors are sometimes solid, and appear to be produced by
 a circumscribed hypertrophy of the fibrous tissues of the tendons,
 with effusion of a serous  and plastic fluid in their interspaces; they
 are accompanied with pain more  or less acute, which is increased
 during the contraction of the muscle to which the tendon is attached.
 The cadaveric examination exhibits this tendon of ite natural color,
 or presenting only slight traces  of injection; but it is  enlarged
 either by the thickening  of its fibres, or by the addition of an albu-
 minous and demi-solidified matter.  If the affection be long pro-
 tracted, if it does not terminate in suppuration,  ossification occurs,
 and sometimes invades the whole length of the tendon, as was
 observed by M. Bouisson in the tendon of the psoas parvus muscle;
 at other times it is limited to the part diseased, forming a kind of
 sesamoid bone.
   Syphihtic tumors occur both on the surface and in the centre
 of tendons.  The  first is the more common seat;  the tumor then
 forms an abrupt prominence along the course of the tendon, and
 if it terminate  in suppuration the continuity of the fibrous cord is 
          AFFECTIONS OF THE MUSCLES, TENDONS, <fea      423

respected.  When it is situated in the centre of the tendon, the
newly-formed matter separates the fibres of the tendon and causes
the tumor to assume an ovoid or fusiform shape.  M. Bouisson
has given an illustration of a tumor of this kind, taken from  a
preparation  in  the Museum  of Pathological Anatomy of Stras-
burgh;  it was situated in the  substance of the tendon of one of
the flexor muscles of the fingers.  Fluctuation could be detected
through the fibrous envelope, and the tumor presented nearly the
form and size of an almond.
   According to M. Bouisson, the affection described by Lisfranc
under the name of white nodosities of tendons was only a form of the
Byphilitic nodes found on tendons; the case  was thatof a. large
tumor developed in the substance of the tendo-Achilles, in an opera
dancer.   It  resisted every kind of local treatment; but the iodide
of potassium internally administered, aided by compression and
certain  antiphlogistic measures, produced a complete cure.   It is
to be regretted that Lisfranc has not furnished us with the previous
history  of the case; but it is difficult not to  assign this tumor a
place in the category of those produced by syphilis, when we take
into consideration not only the analogy between the situation and
symptoms, but that in  the effects  derived from treatment. _ The
iodide of potassium, the efficacy of which is well established in the
accidente of confirmed syphilis, was  pre-eminently the renledy if
not the exclusive means of effecting a cure in Lisfranc's patient.
   The muscular tumors resemble those of the  tendons. _ The essay
of M. Bouisson contains several interesting facts relative to  these
muscular tumors, which have also come under my own observa-
tion. It is sometimes difficult to determine whether this alteration
has ite  starting point in the muscular fibre, or in the interposed
cellular tissue.  Analogy, observes  the  professor of Montpelier,
 would  lead us to believe that the  cellulo-sclerous  tissue which
 unites  the fleshy fibres, or which forms their sheath, is the part
 first attacked.   But  when  the lesion is advanced,  when it has
 manifested one of ite modes of termination, either in suppuration
 or induration,  all the  anatomical elements would seem  to be in-
 volved, and according  to the more or less advanced state of the
 morbid action, the muscular fibres seem immersed in newly-formed
 matter; or, they become softened or destroyed, or transformed
 into indurated sub-cartilaginous and even osseous tissue.   Such
 are the different conditions in which I at  least have observed
 syphilitic muscular tumors.   M. Ricord has dissected those taken
 from the tibialis posticus and from the ventricles of the heart, and
 in these cases they were evidently formed by the muscular  fibres
 themselves.
   M. Bouisson divides into three degrees the modifications which
 the muscular tumors undergo.  In the first degree the muscle is the
 seat of a circumscribed local tumefaction, of a consistence exceed-
 ing that of oedema.   A section of the diseased part displays some
 discolored muscular fiiscia, surrounded by a plastic effusion of a
 grayish color (a tumor of the gluteus maximus was  of this kind).
 This state may be indicated by a sub-acute  inflammation, which 
424
VTDAL ON VENEREAL DISEASES.
causes the morbid secretion which is to pass through further
transformations.
  In  the  second degree, the  effused matter becomes softened.  If
the inflammation continue with its original chronic character, tho
gradual elaborations of the effused product are transformed into a
thready viscous fluid,  similar to  a solution of gum.   Should an
acute inflammation supervene, or there be a constant pain from the
commencement, with  an increase of the temperature of the part,
true pus has then formed in the centre of the muscle, the softened
fibres are destroyed, or are more or  less considerably shattered.
According to  M. Bouisson, some cases of intra-pelvic abscess,
arising  from psoitis or destructive inflammation of the internal
iliacus, may be the result of a syphilitic inflammation of the mus-
cles in  this region.   In support of his opinion, he mentions the
case of a soldier, affected with an inguinal bubo consecutive to an
indurated chancre.  Whilst in the hospital, this patient was seized
with a chronic inflammation of the psoas and  iliac muscles of the
left side;  a tumor of considerable  size formed in the pelvis, and
protruded on a level with Poupart's ligament, and when opened
by  the  bistoury, it discharges an enormous  quantity of matter.
The patient being subjected to an anti-syphiUtic treatment com-
pletely recovered.
  In the third degree, the non-suppurating syphilitic tumors become
indurated.  By successive stages of organization, they pass through
the sub-cartilaginous, the  cartilaginous, and  osseous  transforma-
tions.  The latter transformation is that which has most arrested
the attention of pathological anatomists.  M. Bouisson has seen in
the Museum of the Faculty of Medicine, of Strasbourgh, an osse-
ous mass of very considerable size, and which was developed in
the body of the quadratus femoris.
  The ossification of the muscles and tendons often coincides with
exostosis in different parte of the body.  Prof. Dubreuil is in  the
possession of the skeleton of an Arab who was affected with syph
ilis.   In addition to numerous exostoses, there is ossification of a
large number of muscles at  their point of insertion.  The osseous
productions on  this skeleton are of a styliform. laminated shape,
or of various other configuration, according to the disposition of
the muscles participating in the  alteration.    The seat of these
muscular  tumors  is very variable.   M. Bouisson has observed
them in the gluteus maximus, the trapezius, the sterno-mastoideus,
vastus externus, and some other muscles of the lower extremity;
he has also seen them in the pectoralis major,  on a subject at  the
same  time affected with a syphilitic perichondritis of the costal
cartilages.  Finally, the same surgeon has observed, in the muscles
of different regions, traces of ossification which might reasonably
be traced to the effecte of syphilis.   I have  already stated that M.
Ricord has met with one of these tumors in the tibialis posticus.
  The following is an example of a muscular tumor, situated in
the rectus femoris. It will be observed that  it appeared after a
deep-seated syphihtic affection of the extremities, with which there
existed an exostosis. 
           AFFECTIONS OF THE  MUSCLES, TENDONS, &c.       425

   July 24th, 1845.  L., set. 38, was admitted into the Hopital du
 Midi.   He was by occupation a groom, and of a sanguine tempera-
 ment.   Six years before,  he contracted a blennorrhagia, which
 lasted nine months.  Three  years and  a half ago, he was under
 the  care of M. Puche, for a left inguinal bubo, which  appeared
 twelve days after a suspicious connexion; he states,  that  on the
 day following this  connexion,  he discovered  a slight  abrasion,
 which disappeared in the course of two or three days.  The bubo
 was very large; it was opened, and suppurated but little.   It  was
 afterwards treated by compression.   The patient was subjected to
 internal treatment,  and  remained two and a half months in the
 hospital.  When he left, the tumor was  very small, and  it finally
 disappeared.  Two months since, no accident had yet manifested
 itself; but at this time, pustules  formed  on the legs, especially on
 the  left;  the  patient states that they were about as large as the
 end of the finger; these soon broke, and from that time there
 were ulcerations at the various points  which  the pustules had
 occupied.  At present these ulcerations are small, round, and ap-
 pear as if cut out with a punch; they are situated on both sides
 of the leg, and  number  some six or eight; the surrounding  skin
 is of a violet-red color.  Some are situated on the  right arm,  on a
 level with the epitrochlea.   At the time of the eruption, the pa-
 tient suffered pains in his limbs,  more particularly in his legs, and
 about fifteen days afterwards, he discovered a prominence  on the
 middle of the crest of the tibia; this became the seat of a  dull
  ain, which was more severe during the  night.   A physician who
  ad probably mistaken these syphilitic for varicose ulcers,  recom-
 mended the use of a laced-stocking;  but  its application produced
 severe and intolerable pain.   At present  the tumor on the tibia is
 of the size of a walnut,  of  the hardness of bone, and painful on
 pressure;  the  skin  covering it is sound.   Since the  patient's ad-'
 mission into the hospital, the pain has completely subsided; and it
 is particularly when he becomes  fatigued that it is rendered more
 intense.
   One day he discovered an indurated tumor on the anterior sur-
 face of the thigh; it was painful on pressure, and when the patient
 extended  his  leg, the pain increased  and  became  immovable.
 This tumor, which was about a quarter of an  inch in diameter,
 could not be attached to the femur, as it was movable, nor to the
 skin, for it glided readily beneath it; it appeared to belong to the
 rectus  femoris, near the  point of its insertion  into  the tendon
 uniting it to the patella.
   On the 26th of July, the  patient was put upon the use of the
 iodide of potassium (half a  drachm  daily).   For four days after
 commencing the use of this remedy, he was troubled with  frequent
 sneezing and a considerable  discharge of mucosities from the nose,
 accompanied with a severe obstruction  of the  passage.  August
 10th, the induration on the thigh had sensibly decreased.  August
 15th, the  ulcerations on the legs, which had been covered with
the plaster of. Vigo, were cicatrized, and the enlargement of the
tibia was diminished one-half.  From this time, forty-five  grains
 
426
VIDAL ON VENEREAL DISEASES
of the iodide were given daily.  August 30th, the  tumor of the
thigh as well as  that of the tibia had disappeared;  the pain had
ceased and the patient left cured.
  When the muscular tumors  are somewhat voluminous, every
contraction  produces pain, and the latter, if it had previously ex-
isted, becomes exasperated.   Sometimes the affected muscle is re-
tracted, as we have seen in the case of the psoas and iliac muscles.
The tumors are movable or fixed, according to the state of relax-
ation or repose of the  affected  muscle.  If in a state of rest, the
tumor may readily be examined; it may be moved in various di-
rections, thus distinguishing it from adherent tumors, and at the
time we may appreciate most of its other physical characters.
When the muscle contracts the tumor immediately becomes fixed,
according to the duration of the contraction, and this  condition
may also affect its degree of resistance and sensibility.
  The consistence  of these tumors varies according to their du-
ration and their mode of termination.  Of a very moderate degree
of hardness during their first stage, they present signs of fluctua-
tion if the matter by which they are formed is converted into pus
or a gummy matter; at length they become  quite  hard, and if
resolution be not effected, they are frequently attacked with a sub-
acute inflammation.  They are ordinarily of a globular form, their
size varying from that of a small nut to that of an orange.  The
color of the skin remains natural, nor does the skin adhere to the
tumor.  There  is no unusual heat, unless inflammatory accidents
are manifested; the lymphatic glands are sometimes enlarged in
the vicinity, as we have seen in cases of tumors of the lips.
  The muscles of the tongue, lips, and of the movable portion of
the palate, are affected with these  tumors; but pathological anatomy
has not yet enabled us to distinguish those produced by a kind of
friuscular degeneration of tubercles which become developed be-
tween, and separate their fibres, tubercles which by their elimina-
tion, leave  profound ulcerations.  The different muscles of the
larnyx itself, so often attacked  in  its mucous and cartilaginous
elements, may likewise become involved.   Finally, says M. Bouis-
son, if it be true that the uterine tissue participate in the characters
of muscular tissue, may we not comprise in the class of tumors
under consideration, certain congestions of its cervix which result
from  the influence of venereal  disease ?  Long ago, I hinted at
the connection existing between the tumors or tumefactions of the
uterus and  confirmed syphilis.  On this subject, the reader may
consult my remarks in my work  on surgery.*
  Finally, the heart may  be  attacked by  tumors  analogous to
those found in the muscles of animal life, at least this may be in-
ferred from the report and illustration  of a case in the Iconographie
of M. Ricord.
  At the autopsy of a  venereal subject who  died suddenly, M.
Ricord discovered in walls of the venticles several points of a tu-
berculiform  alteration consisting  of a hard yellow matter, creaking
* Traite de pathologic externe et de medccine operatoire, t. t. 
         AFFECTIONS  OF TOE  BONES  AND PERIOSTEUM.      427

under the knife, not vascular, of a scirrhous consistence at some
points, at others, analogous to  that of tubercular matter in process
of softening.  In a word, says this writer, we there found the char-
acters of syphilitic nodes or tubercles, tertiary accidents which are
often observed  in the subcutaneous or submucous ceUular tissue.
But in this case even the cardiac fibres were involved.  I shaU re-
fer to this case in describing syphihtic affections of the viscera.
  Treatment.—The affections of the muscular  system and  its ap-
pendages  appear at an advanced stage of syphilis, and as I have
already stated, conjointly with the deeper-seated  cutaneous affec-
tions, and especially with the lesions of the periosteum and  bones,
that is, at  an epoch when, as a general rule, the system is  debili-
tated and but little disposed  to tolerate the  effecte of mercury,
which, besides, in the great majority of cases has been repeatedly
employed.  On this  account we should  discard this agent, or if
we do resort to it, we should administer it cautiously, and carefully
watch  its  effects.  Iodine is the remedy generally indicated, and
of all the preparations the iodide of potassium is to be preferred.
It should be given in  large  doses.  We have already described
the mode of employing  it;  the formulas which have received the
most general approbation.  We may dissolve half an ounce of the
iodide, in  eight  ounces  of water, and  of this,  a spoonful may be
given in a glass of hop tisane twice a day, by which half a drachm
of the iodide will be taken daily.   The quantity may be increased
to six spoonfuls, that is  to one and a half drachms, daily.   But, I
repeat, it is seldom that I exceed forty-five grains in the day. At
the same time, we may  prescribe Bareges' baths, or vapor  baths,
especially the latter, if the patient  is not too feeble.   M. Bouisson
states that he has advantageously employed,  in  some cases, the
preparations of gold.  I should prefer,  in cases of great debility,
and when the iodide  of potassium has  been  administered for a
long time, the  ferruginous  preparations, and afterwards  resort
again to the iodide of potassium, for it is always  the best remedy
in the last stages of syphilis.
  Local treatment is seldom indicated.   Of course, when the mus-
cular tumors are painful, and when  this pain is aggravated by
motion, and muscular contraction, repose should be observed, and
local emollient applications prescribed.  In other  cases, resolution
may be promoted  by applying  flying blisters, which  should be
repeated, and at the same  time we should resort to the use of
iodine ointments.
                       SECTION  vin.

         AFFECTIONS  OF THE BONES AND PERIOSTEUM.

  The bones and periosteum are so  inseparably connected in their
structure and diseases, that I shall consider them both under  the
same  head.  These affections, besides, resemble those of the skel- 
428
VIDAL ON VENEREAL DISEASES,
eton resulting from other causes.  Here, as in all diseases  of the
bones, we have pain, inflammation,  tumors, necrosis, and  caries.
But we most generally observe certain peculiarities in these pains,
and  a certain progress, and consequences of the  inflammation,
which, with other accompanying symptoms, give  them a special
character;  and finally, the effects of our treatment afford us aid in
establishing the  unity of their nature, for the same agent equally
affects each variety.   These shall  be studied separately, and their
treatment described.
                      I—OSTEOCOPES.

  These pains accompany the lesions which I shall soon describe,
but as they do sometimes exist when these lesions are not observed
at the same time, they are separately described  by many authors.
If I conform to this custom,  it is only that this symptom may be
the more  carefully  studied.  I do not,  in fact,  believe that this
modification of sensibility is a separate disease,  independent of
any material lesion. When  there is no external appearance of
this  lesion,  it  is because it  has not yet  completely formed, or
rather that it is developed in  a cavity formed by bone.  Thus, the
syphilitic  disease, instead of being limited to the more superficial
layers of  the bone  and the periosteum, may involve the deeper
layers, the medullary membrane in  the  bones of the  extremities,
and the dura  mater in the bones of the cranium and spine.  In
the latter  case, the bone  may continue for a  long  time, and even
always diseased, without exhibiting any material external mani-
festation ;  and  especially  may this be  the case,  when only the
internal membrane of the bone is affected.   This is proved by the
autopsies,  which expose material alterations- of the dura mater,
exostoses  of the inner table of the skull, without any  external
tumor.  In my work on Surgery, I have given a representation
of the frontal  bone, in which two exostoses  from the inner table
of the skull projected into the cavity of the cranium, without any
external protuberance  whatever.  This is what I call exostosis*
and it is an affection which may produce the most atrocious pains,
and even fatal cerebral compression, without their existence being
suspected, unless the previous history  of the patient be known.
I shall  necessarily  return  to  the consideration of these internal
tumors and their consequences.  When the osteocopes  continue
after the disappearance of the apparent  exostosis, there is reason
to suspect that there has  been, at the same time, an internal and
an external exostosis, and  that the latter alone has disappeared,
while the  first still remains.  I repeat, an osteocope is but a symp-
tom of an affection of the bones, and not a distinct disease.
  [In the  London Journal of Medicine for October, 1852, (vid. also,
Rankings  Abstract, ke., No. 16, p.  128,) Mr. Henry Lee, one of the
* Traite de pathologic externe, 4c., t ii., p. 395. 
         AFFECTICNS OF THE BONES AND PERIOSTEUM.       429

surgeons of the Lock Hospital, London, has published a paper,
showing that long-continued pain in bone may depend, among
other causes, upon the deposition of solid material, arising from
the poison of syphilis.   In the treatment of this affection, he re-
commends the operation of trephining.  This idea was  suggested
to him by a case which occurred at the Lock Hospital during  his
connection with it  as house-surgeon.  A young and delicate woman
died after severe and protracted suffering from pain in the right
thi«h.  On examining  the  bone,  ite cancellated structure was
found occupied at different parte, by a morbid deposit of a light-
brown color, of a moderately firm consistence, and which was dis-
tributed in irregular patches.  The parietes of the bone were
greatly thickened, and a kind of cancellous structure  had been
developed between the original outline of the bone and the newly-
formed portion.   On the 29th of May,  1849,  he operated on a
woman, in whom  the pain and swelling were confined  to the im-
mediate neighborhood of the knee-joint.   As the epiphysis of the
bone appeared to  be the original seat of the disease, he  trephined
at this part.   " As soon  as the outer shell of bone was perforated,
the cancellous structure was felt to give way under the press-
ure of the  instrument, and some  minute and  separate  flakes of
white matter were observed  to escape with the blood by its side.
On the 24th August, her health  was quite restored;  she could
raise her leg without any pain  or  inconvenience, and had expe-
rienced no  return of the ' old pain'  since leaving the  hospital."
On the 19th  October,  1852, Mr. Langston Parker read a paper
before the  Medico-Chirurgical Society of Birmingham, " On the
Nature and Treatment of some painful Affections of Bone."  In this,
he states that the, medullary membrane is  liable to become in-
flamed in the tertiary stages of syphilis, and owing to  the  un-
yielding nature of the  walls by which  it is surrounded, this in-
flammation produces at times the most atrocious pains.  In a case
of this kind, he perforated the medullary cavity with a trephine,
and the hole thus made was kept open by a tent of lint changed
'every morning.  The relief to pam was complete ;  whilst previous
to this operation, it  had resisted all the usual remedies  in such
cases, blisters,  opiates, iodide of potass, &c, and had at times been
so excessive that  she had frequently importuned me to amputate
the limb."  In gratefully acknowledging our obligations to  the
author for a copy of this interesting essay, we would observe that
he recommends the trephine in cases of inflammation of the medul-
lary membrane arising from scrofula, rheumatism, and wounds.—
G.C. B.]
   It is difficult to give a perfect  idea of the character of these
osteocopes.  Sometimes, at the  commencement, they seem to be
wandering, the whole  skeleton being  painful.   They are then
often profound, that is, they come, in the language of the patient,
from the marrow  of the bones.  In the majority of cases, they are
fixed, yet not very clearly seated  at any particular point of the
skeleton.   They are then acute, and  lacerating;  the patient feels
as though the bone were strongly pressed in a very  narrow space, 
430
VTDAL  ON VENEREAL  DISEASES.
and as though it were being  bored.  Pressure in some instances
does not  increase the pain, whilst in  others, it is aggravated by
the slightest contact;  in this case, it is  probable that there is peri-
ostitis, or superficial  ostitis.   The  most remarkable peculiarity of
this pain is its nocturnal  tendency.  Indeed, it  is sometimes com-
pletely absent during the day; at others, it is slight, and wander-
ing, but it becomes  aroused, fixed, and  exasperated with the
twilight,  and is mitigated or subsides with the morn, which brings
sleep to  the sufferer.  The pain is most severe  during the first
three hours of the night, and the paroxysm generally at ite height
about midnight.  As these pains  occur  at the hour for retiring,
and when the patient is warm in bed, this has been regarded as
the exciting cause, and it is said that bakers who turn day into
night, suffer from this pain during  the day,  that is, when  they are
in bed.  But it should be remembered that bakers suffer more
from heat when employed than they do in bed.   Besides, instances
have occurred where venereal patients have awaked, and remained
in the open air, or have  rode in a  carriage  during the  night, and
yet have suffered the same when the fatal hour arrived as when
reposing in their warm couch.
   The diagnosis of these pains may be attended with difficulties. They
are certainly more fixed than those of a rheumatic nature already
described; they return in the same  place at each paroxysm, which
is not the case with those belonging to the earlier stages of syphilis,
and they are ordinarily exasperated by pressure, which generally
relieves rheumatic pain.   But these characters are not always so
well marked, and I have already stated that there are wandering
osteocopes, and some  are not aggravated by pressure.   True, the
latter does not  relieve them  Besides, the patient may have both
rheumatism and osteocopes at the same time, for we know that all
the stages of syphilis are not perfectly distinct, and the accidente
called secondary may occur simultaneously with the tertiary*  It
is not, indeed, very rare to observe a superficial cutaneous eruption,
with an affection of the bone or periosteum.   Still further, it is not
always possible to distinguish syphilitic from rheumatic pains, for"
cases of osteocopes are observed in which the pain is exasperated
during the day, and  relieved during the night,  and  vice versd.
Again, it is not very unusual for a patient to be  affected both with
rheumatism and syphilis, a circumstance which renders the diagnosis
so much the more complex.  Such cases have been observed among
soldiers affected with the venereal disease who have  contracted
rheumatism in bivouac with washerwomen and hosiers.   Thus, we
see that pain alone may  deceive the practitioner.   The value of
this symptom must be duly appreciated, but not exaggerated, and
we must learn the previous history of  the case, and examine the
concomitant symptoms which may exist on the skin and mucous
membranes, for we know  that it is common to observe syphilitic
eruptions or blotches during the existence of osteocopes, and it is
not rare to find ulcerations in the buccal cavity, ulcerations mani-
fested only by functional lesions of but little importance,  and which
may pass unobserved. 
         AFFECTIONS OF THE BONES AND PERIOSTEUM.      431

  I am still compelled to add one vrord in relation to that error
which attributes the osteocopes to mercury.  This error has here
assumed a serious character, for it is true that we may find mer-
cury in the bones, and it is  reported  that M.  Bretonneau has
observed these pains in patients not affected with  the venereal dis-
ease, but whose systems have absorbed much mercury.   As to the
cases of M. Bretonneau, I have been  unable to find them;  I can-
not therefore judge of their value.  Mercury has been discovered
in precisely the bones which have never been the  seat of any pain.
It is known that workmen who are constantly exposed to mercu-
rial emanations, do not suffer from osteocopes, and on the  other
hand, venereal patiente who have abstained from mercury, have
suffered in their bones and have had exostosis. Finally,  these
osseous pains  and lesions have  more than once been cured by
mercury; for before the introduction  of the iodide of potassium, it
was particularly by mercury that  these accidents,  peculiar to
the last stages of syphilis, were combated.  However,  in order to
omit nothing,  I should add, that in a syphilitic  patient who pre-
sented cerebral symptoms, and who died after  having taken much
mercury, this  metal was detected in  the  cerebral substance, (vid.
the work of M. Reynaud, p. 407.)


              II—PERIOSTITIS  AND OSTITIS.

   Periostitis, unaccompanied by ostitis, must be extremely rare if
it does really exist, for the periosteum being but the envelope of the
bone, it is difficult to comprehend how it should not participate in
the affections of the latter.  The same regions, the same portions
of the skeleton,  are most generally affected both by periostitis and
ostitis; thus  the tibia, clavicle, ulna, radius, cranium, sternum,
metacarpal bones, and  the portions of these bones nearest  to the
skin.
   [According to Mr. Stanley, the osseous node does not occur
upon the cranium.  " So far does the pericranium differ from peri-
osteum in its actions under the influence of disease, that under no
circumstances does its tissue become  ossified.  When,  from  syphi-
lis,  isolated portions of the  pericranium inflame, circumscribed
swellings arise, which are hard and painless, when consisting only
of the thickened pericraneum, but soft and tender when produced
by serous or purulent  effusion, either beneath the pericranium or
into the cellular tissue covering it.  In  the latter- case they have
received the expressive designation of soft nodes."  (Stanley on the
Bones, Am. Ed., p. 271.)—G. C. B.]
                       PERIOSTITIS.

  The tumor formed in inflammation of the periosteum, periostosis,
appears simultaneously with the pains already described, sometimes
a few days after their  first  manifestation.  This  tumor,  which 
432             VIDAL OX VENEREAL DISEASES.
grows on the portions of the skeleton just mentioned, is not dis-
tinctly circumscribed; it is rather an engorgement, the most promi-
nent part of which is round, and the  boundaries of which are
insensibly lost in the adjacent tissues.   The color of the skin is at
first unchanged.  Sometimes,  there are several periostosis on a
single bone, on the  tibia or on a  flat bone; they are then smaller,
there is a doughy feel around them, and yet the color of the skin
is unchanged; their progress is ordinarily, but not always, rapid,
and, most generally, the pain which is  severe, is still exasperated
by pressure and by every movement of the corresponding bone.
The tumor or tumors are  much  less distinct,  much more difficult
of diagnosis than when they spring from a bone deeply covered by
muscular layers, as  is the case with the femur.
  If the tumors are more superficial, so that they may be directly
examined, we find them of a doughy feel; then we detect a certain
degree of fluctuation; the skin at first  sound, and movable over
the tumor, finally adheres to it,  becomes changed, and ulcerated
if the disease terminate in suppuration.   But this is far from being
the most frequent result;  periostosis, on the contrary, ma}r termi-
nate in complete resolution; it may also lead to the formation of
exostosis, and this is a frequent result;  this is the variety which I
shall describe under the name of exostosis epiphysaire.
  According to M.  Ricord, periostosis  may  present itself  under
three different forms:
  1st. The first variety, often of a very indolent nature, but rapid
in its development,  is generally of long duration, and terminates
in complete resolution.  The tumor contains a serous, or a sero-
albuminous fluid, resembling,  in some instances, scrofulous pus,
and in others, synovial fluid.
  2d. The  second  variety  pursues the course  of inflammatory
tumors ;  it is acute,  and well marked, or it is sub-acute.   Suppura-
tion sooner or later  occurs, and it is rare then  that subjacent bone
is not primarily or secondarily affected.
  3d. The third variety, of slower development, is, nevertheless,
frequently  very painful on pressure, and  even  when it is not
touched.  The  tumor then  consists of  interlamellar plastic effu-
sions, which may be the  rudiments of exostoses, which we shall
presently consider.
  [The degree of hardness of a node, says  Mr. Stanley, does not
with certainty indicate ite composition.  He states that he has
examined those which, from their  hardness, were supposed to be
osseous,  but found  them  to consist of indurated periosteum.—
G. C. B.]
  I have already spoken of lesions of the periosteum and bone, of
which there are no external signs, and which may produce the
pains which I  have  already described.  These internal tumors,
when developed within the cavity of the cranium, cause disorders
of a still  more serious character, and here the  dura mater, which is
the internal periosteum, may play an important part.   M. Reeve,
in a work entitled, Syphilitic Meningitis, has reported a case which
would seem to belong to this class.  It  is as follows : 
         AFFECTIONS OF THE BONES AND PERIOSTEUM.      433

   " Case.—M. F., in July, 1847, was attended by another surgeon
and myself, for a paralytic  affection: the rapid progress of which,
together with other cerebral disturbances, alarmed the patient.
He was unable to stand on his feet  long enough to remove his
pantaloons.  His articulation was very imperfect, the combination
of his ideas very defective, as well as his memory, and vision  in
both eyes considerably impaired.  Some years before, this patient
had been treated for secondary syphilis, which was manifested  in
the form of obstinate ulcers on the face and extremities.  Shortly
afterwards, he became affected with amaurosis, which continued
to increase  rapidly until it had terminated in the general paralysis,
from which he was suffering when he came under our notice.
   " From an  examination of the patient, and an inquiry into the
previous history of the case, I was led to suppose that the symp-
toms might depend upon a  compression of the brain, produced by
syphilitic tumors developed on the dura mater; but to satisfy my-
self more fully, I concluded to administer mercury in such a man-
ner as to obtain ite prompt and decided action.   I directed  that
the whole scalp should be shaved, and covered with a blister,  to
the surface of which a drachm of strong mercurial ointment was to
be  applied twice a day.  I was, however, alarmed by threatened
coma, and the consequent prospect of a fatal result.
   " Eight days afterwards, I met the surgeon above mentioned; he
informed me  that our patient became rapidly cured, and that he
could now  ascend and descend a very steep flight of stairs.  To
my great surprise, I one day met our patient in the street, in good
health, vision perfect, and it was difficult to believe that it "was the
same person who had consulted me some three weeks before.  He
had completely regained the power of motion, sight, and  articula-
tion, and was in the perfect possession of all his faculties."
  The author expresses the opinion that the preceding case would
certainly have soon terminated in death, had it not been for the
administration of mercury.   Such is his confidence in this agent,
that, in a similar case, he should indulge the strongest hope of suc-
cess, notwithstanding the most decided  exhaustion in the state  of
the patient.  It  is a remarkable case of cure by mercury.  The
editor of the Gazette Medicale, from which journal I have copied
the above report, states, that the preparation of iodine would have
a still more decided effect in cases of this kind.   I do not under-
stand  how such could be  desired.
                          OSTITIS.

  Syphilitic ostitis attacks the bones already mentioned as the seat
of the nocturnal  pains, viz., the tibia, clavicle, sternum, cranium,
ulna, and radius.   I have stated, that it  is difficult to admit the
existence of periostitis without ostitis; indeed, the superficial layer
of bone  is always, or  nearly always, involved in periostitis, and,
most generally, it is the part first affected; an effusion then occurs
between  this layer and the periosteum, by which the latter be-
                              28 
434
VIDAL ON VENEREAL DISEASES.
comes detached, and forms a tumor which may be detected if the
bone be thinly covered.  Instead of invading the superficial por-
tion of the bone, ostisis may attack its parenchyma, and be there-
fore deeply seated; this is particularly the  case, when it has ex-
isted for some time without furnishing any external  indications of
ite presence, of which pain is the only symptom.  Ostitis, whether
involving the external  portion, or  the  parenchyma of the bone,
may be circumscribed—sometimes very limited,  while, in other in-
stances, it may be more extensive, invading the whole or nearly
the entire bone.   The bone, at first, presents here and there stains
of blood, its  vascular canals become developed, and contain red
blood and a transparent fluid,  resembling osseous substance ; fur-
ther, these remarks apply to all cases of incipient ostitis, whatever
may be their nature.  A thicker fluid, resembling that of callus, is
next secreted; sometimes  it is an organizable plastic matter, like
that in certain cases of periostitis.   The tumor, resulting from san-
guineous congestion, and the  products  mentioned, often manifest
themselves after the patient has complained of nocturnal pains;  at
first it is very limited, and diffused;  there is no decided protru-
sion, except in cases of circumscribed ostitis, and when a true ex-
ostitis is about to form.
  Syphylitic ostitis is generally of a slow, chronic progress;  some-
times it assumes a very acute form.
  A word as to the treatment of periostitis and  ostitis.  It is par-
ticularly in cases of the former, of course external periostitis, that
we may resort to  topical applications and  to certain operations.
Thus, there are cases of exostosis  evidently inflammatory, of an
acute nature, and in which the patient  still retains  his strength;
we have then a formal indication  for repeated local depletion by
leeches.  This first indication  having been fulfilled, we may resort
to the use  of blisters.   When the  character of the tumor is less
•decidedly inflammatory, and  the  subject debilitated, the blisters
may be employed without resorting to  the  local  depletion by
leeches. Their surface should  be dressed with mercurial ointment.
Periostitis  may also be treated by incisions.  These, which have
particularly been recommended in acute periostosis, by Crampton,
MM. Velpeau and Maisonneuve, should not be made except when
the tumor  is situated on a superficial bone, and when the  iodide
of potassium  has  been already administered  internally, without
effect.   We may then reasonably infer  that the resistance  offered
by the fibrous tissue to the expansion of the parts affected pro-
duces a kind of strangulation, which may be relieved by the in-
cisions which are then debridements ; but, I repeat that, first of all,
the iodide of potassium should be tried, for in some instances the
relief thus affected is equal to that produced  by  the incisions
themselves.
  The treatment of ostitis, especially of superficial ostitis, does not
differ from that of periostotis above indicated.  Here we must par-
ticularly avoid incisions, until we have administered internally a
means the  efficacy of which is so universally  acknowledged, viz.,
the iodide of potassium. 
         AFFECTIONS OF THE BONES AND PERIOSTEUM.      435

  [The testimony in favor of the iodide of potassium, as remarked
by our author, is indeed universal, especially when the acute stage
of periostitis has  passed.  " It rarely fails," observes Mr. Stanley,
" to stop the progress of the disease, and, in much the largest pro-
portion of cases, completely cures it.   This statement of the reme-
dial agency of iodide of potassium is to be taken in ite most com-
prehensive sense.   Whether it be the inflammation of periosteum
adjacent to an exfoliating bone, or investing an enlarged  bone,  or
that which is the consequence  of scrofula, syphilis or rheumatism,
there has not appeared to me to be any difference in respect to the
influence of this remedy upon the disease.  And, with respect  to
the suitable doses of it, I have but to repeat the statement already
made, that my impression is in favor of administering it in doses
of two or three grains, three times a day, in  either decoction of
sarsaparilla, or a  bitter vegetable infusion, or camphor mixture"
(op. cit. p.  275).  Our own experience would  lead  us  to  rely
rather  on larger doses of the remedy; we do not give less than
five grains three times a day,  and sometimes this quantity is in-
creased to ten and even fifteen grains for a dose.—G. C. B.]
                     III.—EXOSTOSIS.

  A tumor actually exists in periostitis and ostitis, but the term
exostosis is applied especially to the termination of these inflam-
mations in induration.  Indeed, instead of disappearing by reso-
lution, suppuration, or mortification, tho tumor  formed by ostitis
becomes the seat of excessive nutrition, of abnormal ossification.
But periostitis or ostitis is not always necessary to the formation
of an exostosis; sometimes, indeed, We observe hypertrophy in-
dependent  of any previous inflammation;  sometimes a plastic
substance is  deposited throughout the whole osseous substance,
even in the medullary canal, a substance exactly resembling that
mentioned when I was describing  the  syphilitic affections of the
muscles.
   Varieties.—As in other forms of exostosis, the syphilitic may be
divided into two principal varieties;  the parenchymatous, and the
exostosis epiphysaire.
  1.  Parenchymatous Exostosis.—This occurs, especially,  in  cases
of profound ostitis.  The abnormal  ossification  may assume the
character of areola, or of compact tissue.  In the first case, it may
consist of layers, between which are areola, constituting what au-
thors denominate cellular or laminated exostosis. In the second case,
it is the compact tissue, and  according to Albers  of Bonn,  the
cortical substance which constitutes the exostosis.  If the osseous
layers suffer a divarication, an osseous matter without any distinct
organization has been deposited between them, and the volume of
the bone becomes increased, but its weight and density have also
undergone a marked increase.  We  have now the eburnated  exos-
tosis, suitable for making scalpel handles.
  2.  Exostosis Epiphysaire.—This results particularly from perios- 
436
VIDAL ON VENEREAL DISEASES.
titis.  Albers of Bonn, calls cases of this kind osteophytes, that is,
new formations independent of the bone with which they arc con-
nected (at  least for a certain  time), since they can  be removed
without injury to  the bone.  Albcrs mentions an osteophyte (in
the Museum  of Bonn) situated on the middle of the  femur of  an
adult;  it is of an oval  form following the  great diameter of the
bone;  it has a compact envelope,  and internally it is cellular.
These  are  epiphyses, superadded bones, which, like all epiphyses,
finally become incorporated with the bone ;  at first they are sepa-
rated by a  cartilaginous or osseous layer, which disappears when
this abnormal epiphysis becomes incorporated with the body  of
the bone.   We meet with cases, also, in which epiphytal exostoses
are engrafted on those of the first category, on a parenchymatous
exostosis.   According  to M. Rognetta,  the epiphytal exostoses
have a structure similar to that  of velvet, that is, 'they are com-
posed of fibres perpendicular to their surface of implantation.
  Whatever may be the variety of exostosis, its form will be more
or less hemispherical; it may be conical, flattened, elongated,  or
even almost  pediculated; sometimes it is a crest  similar  to that
formed in certain of the annular syphilitic eruptions; an example
of this singular form is represented in the Iconographie of M. Ricord.
The epiphytal exostoses are the best defined, and form the decided
prominences.
  Exostosis, particularly when large, may interfere with the func
tions of surrounding organs ;  and singularly alter their forms.  In
my work on surgery there is a representation of an exostosis of
the superior maxillary bone,  eleven inches in circumference, and
which  rendered the appearance of the patient hideous.*   Some-
times, then, only trouble is in the adjacent organs which may be-
come displaced and atrophied;  thus, the exostosis  of the superior
maxillary bone to which  I have alluded, at first  interfered with
the movements of the lower jaw, and ended in its dislocation. An
exostosis may destroy the regularity in the movement of a limb.
By compressing vessels, it may produce oedema at a greater or less
distance from its seat, and by ite pressure on nerves it may modify
the sensibility of the parts, producing pain which must not be con-
founded with the special pain seated in the exostosis  itself.   The
effects  of this compression are particularly severe, when the ex-
ostosis springs from a bone entering into the formation of a cavity
enclosing organs of great importance, as for example, the cranial
cavity, or spinal canal.   The compression of the nervous  centres
in these cases affects both the general and  special sensibility,  as
well as the powers of  motion, and the intelligence of the patient.
A  cranial  exostosis may  produce  agitation,  somnolency,  para-
lysis, convulsions and delirium.  Amaurosis is sometimes  the re-
sult of an  exostosis of the sphenoid  or some other bone  at the
base of the cranium; this ocular paralysis is not very  uncommon,
and we may remark in passing, that when it  does depend  upon

           * Traite depathologie externe, &c, t. ii., p. 394, 3d ei 
          AFFECTIONS OF THE  BONES AND PERIOSTEUM.      437

 this cause, it generally affects but one eye.   Exostosis of the orb-
 ital cavil)', may produce other ocular paralyses and exophthalmia.
   [In the 28th vol. of the Load. Med. Gazette, p. 45, is a brief no-
 tice of a case of strabismus produced by pressure from  syphilitic
 lesions  in  the  orbital cavity.  The patient was cured by the bi-
 chloride of mercury.—G. C. B.]
   Spinal exostosis is, in my opinion, more common than that of
 the cranium, but it most  frequently remains undetected. I have al-
 ready mentioned my division of exostosis into  internal and external
 exostosis :  now, it is particularly in the former cases that the diag-
 nosis may be obscure, especially if, as I have remarked, we neglect
 to  make ourselves acquainted with the previous history of the
 case.   Thus, we may observe alterations of sensibility and. of mo-
 tion without any apparent  exostosis, nothing on the cranium indi-
 cating the osseous lesion,  for it  may  involve only  the  internal
 table of the bone.   There  are properly no external exostosis on
 the spine, for the osseous  trunk  being in  part  concealed by the
 chest, abdomen, anterior organs of the body,  and in part covered
 by muscular masses, frequently we may be unaware of their exist-
 ence  until they have produced their most disastrous consequences.
 And  yet, even  then, if unacquainted with the antecedent circum-
 stances of the case, we may remain inactive, when had we properly
 inquired into the previous history of the case, we  might  have
 rendered essential  service to the patient.  In  the great majority of
 eases, the  syphilitic  eruptions  may direct  us  in our inquiries.
 Thus we may find one of these eruptions  or  some traces of their
 previous existence, but  it may so happen that the exostosis shall
 precede  the eruption.   Then,  should  they afterwards appear, it
 will shed much light on  the  nature of the case.  M. Debout has
 recently (June 1852) read to the Surgical  Society of Paris an in-
 teresting essay  on  muscular paralysis.  One of the cases reported,
 is that of the paralysis of a part of the superior extremity, the di-
 agnosis of  which had been attended with difficulty.   M. Nelaton,
 who treated the patient, suspected the existence of an exostosis of
 the spine.  It is stated, in the essay of M. Debout, that M. Nelaton
 was confirmed in his suspicions by the appearance of roseola on
 the skin.   Here then the exostosis preceded the  roseola, a second-
 ary accident generally quickly developed following a tertiary ac-
 cident !   This fact greatly compromises the harmony of the syph^
 ilitic triad; but the case was observed by one skilled in the clinique,
 and was fully reported in a serious essay which I heard read.    *
  I am  about to relate the particulars of a case of paralysis of the
 inferior extremities which  I  considered the result of  an affection
 of the bones of the spine, of an exostosis.  I came to this conclu-
 sion by investigating the previous  history of the case,  and by a
 careful examination of the marks upon the skin, showing the an-
 terior existence of a syphilitic eruption of various degrees of depth.
 This case is remarkable not only in a practical, but is  of great im-
 .ortance regarded in a doctrinal point of view.   In fact, I inocu-
 ated the patient by means of a blister with the pus from a mucous
tubercle, and I  produced a specific ulceration, followed by a tu-
 
438
VIDAL ON VENEREAL DISEASES.
bercle of the skin similar to those in  the syphilitic disseminated
tuberclar eruption.   This tubercle disappeared, leaving in ite place
a coppery-red spot, resembling those which continued for a long
time on the patient's skin: so that this experiment, like that of M.
Bourley, proves not only the  inoculabfiity of the secondary acci-
dents, but also the possibility of a second attack of constitutional
syphilis.  The case has been fully and most carefully reported by
my interne, M. Codet.   I have omitted a number of details relating
to the antecedents; and have retained everything which goes to
establish the fact that the subject had had confirmed syphilis, and
that he  was laboring under tertiary accidents at the time of inocu-
lation.  I shall  hereafter profit by this case, and shall there give
its complete details.   This  patient, besides, has several times been
at la Pitie,  where he was treated by two of my colleagues, and he
was a long time in my service where he was observed by several
physicians,  and my students who watched  the progress of  the
different stages of the inoculation.
  M., a3t.  37, admitted to  the  Hopital du Midi, Oct. 6th, 1851.
First infection occurred on  the 13th May, 1847 ; he had chancres
on the penis.  Afterwards was affected with blennorrhagia, orchi-
tis, and disease of the eyes, one of which was lost.  A gleet fol-
lowed, and  mucous  tubercle about the anus.  In June, 1850,  the
patient was in la Pitie, under the care of M. Piedagnel.  At that
time, there was  a deep ulceration, of  the diameter of a five-franc
piece, on the  the  external  surface of the left  thigh.  This was
dressed with diachylon plaster  and calomel in powder, and was
cured in forty days.   The cicatrix left by that ulcer is at present
very distinct, being deep, and of a brownish-red color; there  are
also scafs on the legs, of the same color, but less profound. This  pa-
tient, who had had intense cephalalgia, now suffered somewhat less
from this source, but he was attacked  with pains in his legs.
  During the months of October and November, 1850,  the patient
worked at the leather dressing;  he suffered much from coldness
and  numbness  of the feet.  Walking was very fatiguing;  he
dragged one leg; and felt as though he was walking on cotton; he
became  emaciated.   His appetite was irregular.  He became one
of the watchmen to the Magdalen asylum.  Here, the paralysis of
his lower extremities daily increased.
  On the 10th Feb., 1851, he was again admitted to la Pitie, under
the care of M. Becquerel.   Sulphur baths were  prescribed.  The
lumber  region was cauterized, strychnine was administered, and
electricity employed, but the paralysis constantly increased.  The
testicles became enlarged before he left his bed; they were insensi-
ble.   A deep ulcer on the left leg yielded  only to the application
of the actual cautery; eschars formed on the sacrum, and exposed
the patient to the greatest risks ; he improved but slowly, and left
the hospital but little relieved.  Finally, on the 6th October, 1851,
he entered  the Hopital du Midi, suffering from a relapse. M. Vidal,
having learned the previous history of the case, and struck by the
aspect of the cicatrices, and the nature of the enlargement of the
testicles, came to the conclusion that the paralysis proceeded from 
          AFFECTIONS OF  THE BONES  AND PERIOSTEUM.      439

 an affection of the bones of the spine,  and probably from an exos-
 tosis.  The patient then was placed  under  the influence  of the
 iodide of potassium, taking forty-five grains daily.   At the end of
 two months he was able to rise and walk, though  with difficulty.
 General  condition excellent.   The enlargement of the  testicles,
 which was more marked on the left than the right side, diminished
 considerably under the use of the iodide.  The patient  regained
 his flesh, but wished to remain  awhile in the  hospital,  awaiting
 an appointment  from government.   In  January, 1852, a  small
 blister was applied to each thigh on account of torpor of the blad-
 der ; it was dressed with charpie soaked in the pus from mucous
 tubercles with which the patient was affected.   This was  followed
 by no result.                                                j
   M. Vidal proposes to repeat the inoculation a future time.  *'—
   Indeed,  on the 12th of  April, 1852, the Orient, complaining of
 suffocation, two blisters were applied  to the external and superior
 part of each arm.
   April 13th.  Both blisters were dressed with charpie, moistened
 in the pus of ulcerated mucous tubercles, on another patient.  The
 inoculated subject experienced severe pains during the day.
   15th.  The wound  on each  arm  is  covered by a grayish, very
 adherent, false membrane.   Suppuration is very abundant, and of
 a sickening odor; charpie, steeped in the same pus  as that on the
 13th, is placed 011 the blistered surfaces.
   16th.  The false membrane, at certain points, is wanting; a very
 red and  granulated surface is perceptible, especially on the right
 arm.   Dressings,  soaked with the pus from mucous tubercles on
 another patient in the same ward, are apphed to both blistered sur-
 faces.*
   17th.  The blistered surface on right arm is the reddest, the false
 membrane has disappeared.  No pain.  From that time, both arms
 were dressed with simple cerate only\
   18th.  A grayish  spot, apparently sUghtly  depressed, is discov-
 ered in the middle of the excoriated surface on the  right arm ; on
 the left,  the  surface  is  of a vermilion red color;  a few grayish
 points are here and there hardly perceptible.
   19th.  The small gray spot on the right arm has become slightly
 excavated; on the left the blistered surface is dry.
.  20th.  The whole blistered surface on the right arm is red, with

  * M. Codet has made the following note of the patients from  whom the pus for
 the inoculatidn was taken:
  Ward 11, No. 14.—A., painter, set. 41, admitted April 11th, 1852, left April 19th,
 1852.  This patient  had  an indurated chancre in process of cicatrization.  This
chancre was of from two to two and a half months' duration. Iu addition to this,
the patient discovered mucous tubercles about the anus and the genito-crural fold;
these tubercles were the source of an abundant suppuration.  On the 13th and 15th
April, 1852, the patient in No. 32, Ward 11, was twice inoculated with pus from
tho tubercles about the anus of the patient iu No. 14.
  M., traveller, a_t 45, admitted March  15th,  1852, left Slay 23d, 1852.  Had a
chancre in December, 1851; this cicatrized about the 15th  January, 1852; tuber-
cles appeared about the anus, January 20th, afterwards on the  nose, chin, mouth,
and iu the axilla, &c.  A single inoculation was made with the pus from the tuber-
cles about the anus, on patient in No. 32, Ward  11, April 16th, 1852. 
4-10             VIDAL  ON VENEREAL DISEASES.
the exception of the central part, which is slightly depressed, and
its gray color contrasts with that of the rest of the wound.  The
watch-glasses, which up to this time have been used to protect the
wounds, are now no longer employed.
  21st.  The  suuface  of the small ulcer on  the right  arm  has
changed its color; it is now dotted with red points; there are soft
and fungous fleshy granulations;  in  other respects it has not in-
creased, and has a diameter of about a quarter of an inch in every
direction ;  on  its base,  there is a small elevation reaching nearly
on a level with its edges.  On the left arm, there  remains an unci-
catrized surface of scarcely the diameter of a half-dime piece.
  22d. The small ulcer on the right arm presents  the same appear-
ance, only the red color exceeds the gray.
  23d. The ulcer on right arm seems to have become more regular;
the base is nearly horizontal, the edges well  defined, the color
about the same, the red preponderating.   Left blister completely
healed.
  25th. Instead of the small ulcer on the right arm, there is now a
small hard tubercle, covered by a brownish crust, which remains
in the place of the ulceration.
  26th, 27th, 28th, 29th, 30th;  8th May. The small crust con-
stantly remains; it is removed, and beneath it is found a small
ulceration,  covered with pus; its edges are distinctly defined, and
it has a grayish base.
  9th,  10th, 11th.  The ulcer is slowly cicatrizing.
  14th. The small ulcer is covered with fleshy granulations, and
it is touched with the nitrate of silver.   There are some tubercles
on the neck, about the roots of the hair, and on the upper lip; they
are covered with brownish crusts.
  18th. The little ulcer is on a level with the skin, but in its place
is a small hard brownish red body, which is raised but little above
the level of the skin, and which is felt  in  the surrounding tissues
to be about the size of a pea; it remained for a long time, but at
length disappeared, leaving behind  a  coppery-red blotch  of  the
same color, as the cicatrices on the legs; this spot  still remained in
the early part of June, 1852.
  We here find that the first inoculation on the thighs failed.   At
a subsequent period, both arms were inoculated, but on  one only
were any effects produced.  Had we been satisfied with a single
inoculation, and if the second inoculation had not been  made on
the arms, it might have been maintained, with some show of rea-
son, that he was no longer susceptible to the influence of syphilis.
Again,  this case shows the necessity  before  forming a decided
opinion, of repeating the experiment.   It will be remarked that
the blistered surfaces were  only twice dressed with  the charpie
moistened  with  pus.   The  other dressings consisted of  simple
cerate.
  Second attack of Syphilis.—We know that exostosis has been
placed completely among the last of the accidents  of constitutional
syphilis, that is the most classical expression of the tertiary state,
after which, it is asserted, there can be  no new attack  of the dis- 
         AFFECTIONS OF THE BONES AND PERIOSTEUM.      44J

ease.  Now, the case just ivlated, furnishes another proof that an
individual may have the second attack  of constitutional syphilis.
Indeed, we rind that this patient, after several primitive accidents,
afVr a superficial cutaneous  eruption, for four years, appeared to
be cured—that is,  there was no symptom of syphilis—and then
came an cxtostosis of the tibia, an accident  reputed tertiary, and
simultaneously with this, a deep-seated s3Tphilitic  eruption.  I re-
collect perfectly well this first disease, and I treated  it successfully
with the iodide  of potassium.  But, two months afterwards, the
patient contracted new chancres, which were about two months in
becoming cicatrized, and two years afterwards he had a blennor-
rhagia complicated with orchitis.  Finally, in 1850, a new syphil-
itic eruption appeared on  the right shoulder, arms, and on the
abdomen; at first it presented the squamous form,  then it ulcer-
ated and suppurated profusely; finally, crusts formed, which were
surrounded  by large red patches.   Is this last  eruption to be re-
garded as the effect of the last chancres, or  of the  blennorrhagia
with which he was affected in  1848 ?  Was it not a new attack of
syphilis ?  I am aware that it will be answered, "that it was only a
return of the  eruption with which he had already been affected;
but I would remark, 1st, that this relapse occurred somewhat late,
for it was three years after the former attack ; 2d, that it was more
superficial than  the former, with which the extososis  co-existed.
Indeed, the  cicatrices of both still remain, and may  be compared ;
by which it  will be found that  the last  will be  more superficial.
Now, A\re know that the syphilitic eruptions are more profound as
they occur  late in the disease.  Besides, if the last eruption was
not produced by a second attack of syphilis, then it was a second-
ary, occurring after a tertiary accident.   Bead the following report
of the progress of the case made by my interne, M. Codet:
   L. Christian, set.  35, glazier, of lymphatic temperament, feeble
constitution, admitted June 7th, 1852, Ward 12, No. 10.
   In 1839, this patient contracted a chancre on the glans; he was
imprudent,  and  continued  cohabiting with women.   Soon new
chancres appeared, and for three or four years he had sores on his
penis.   At the same time, there were vegetations on the prepuce
and  glans.   The inguinal glands on both sides became much en-
larged, but never suppurated.   In 1842, he had confirmed syphilis,
crusts in the hair, syphilitic eruptions which  left but superficial
traces behind;  these  accidents disappeared with  scarcely  any
treatment.   Four years afterwards (1816), L. had an exostosis of
the right tibia; at the same time,  there appeared deep ulcerations
on the arm,  legs, and a small portion of the trunk.  The cicatrices
of these are still quite evident.  L., having been admitted to the
Il'pital du J// h' (service of M. Vidal), was placed under the influ-
ence of the iodide of potassium, and left, cured, in about three
months.  Two months after leaving the hospital, he contracted a
new  chancre.  The inguinal glands did not enlarge, according to
the patient's statement, and the chancre became cicatrized, in the
course of two months, no other dressings having been appUed
than diluted Goulard's extract. 
442             VIDAL ON VENEREAL DISEASES.
  Two years later  (1848), he had a blennorrhagia, accompanied
with orchitis on the right side.   This was cured.  The patient
discovered nothing more until 1850.  At this time, there appeared
a broad, red,  shghtly-elevated patch,  on both  shoulders.   The
epidermis soon  became detached in the form of scales ;  the  skin
was red beneath, new scales formed, and in turn separated.  Some
months afterwards,  the  patches presenting an analogous desqua-
mation appeared on the internal  surface of the arm (on a level
with the elbow)  and the lower part of the abdomen (on  the  right
side); these slowly increased for two years, and in the early part
of the  year 1852, a copious suppuration was established  on their
surface.  The  patient was treated by  M. Gibert.   The suppura-
tion  rapidly diminished; and thick crusts formed on the ulcers.
The patient remained in this condition  for some time, and on the
7th of June entered the  Hopital du Midi, service of M. Vid:d.  Ilia
constitution seemed only slightly debilitated.  The cervical glands
were  nearly natural, the inguinal  slightly enlarged.   On 'the
points  mentioned were  ulcerations, some of which  (on the shoul-
ders) were nearly twice as large  as the hand; they involved the
skin; their surface was  covered, at certain points, with thick, red-
dish, and brown crusts.  The surrounding parts were of a charac-
teristic redness.
  On the 8th of June, the  iodide of potassium was prescribed,
half  a drachm to be taken daily.   On the 13th, the coppery hue
and the suppuration  had  already begun to diminish. This effect
of the medicine continued for some days.  On  the 15th,  some
crusts separated; suppuration almost ceased.
  June 20th. There were only some additional crusts,  no  more
suppuration.  Large plasters of  Vigo were applied to all the
points involved  in the eruption.  Under this treatment, the erup-
tions were promptly affected.
  25th. All the  crusts had separated; there remain only red cica-
trices on a surface still humid.
  30th. Patient  is cured.   The parts which were the seat of the
eruption are now covered  with dark red stains.
  Let  us  pass to the treatment  of exostosis.  It does not differ
from that of periostosis,  already described.  As to the internal
treatment, we  should, as far  as possible, resort  to the use of the
iodide  of potassium.   There is less to  be  expected from local,
operative  measures,  in  other words, from the local abstraction of
blood,  blisters, incisions, &c, as, in these cases, a new  bone has
formed, and such superficial measures can, therefore,  be  of no
avail;  but we  must resort to trephining, resections, and amputa-
tions, on which,  however,  we cannot decide until the exostosis, by
its connections and magnitude, compromises very important func-
tions, or the life  of the patient.  These  operations are described in
the works on surgery, to which I would refer the reader.  How-
ever, I must here inculcate certain precepts which are especially
applicable to resections and exostoses.
  There are cases  where the tumor is quite prominent, and ap-
pears to be pediculated; we should then make two  semi-eUiptical 
AFFECTIONS OF THE  BONES AND PERIOSTEUM.
443
incisions, by which  its base, the pedicle, is  exposed, and  with a
saw we  may remove the tumor.  The same incisions should be
employed when the tumor has a broad base,  and when there is an
alteration of  the surrounding soft parts, which should then be
removed with the tumor.  But, in the majority of cases, the cru-
cial incision is to be preferred, for we thus obtain  four flaps, the
methodical dissection of which greatly enlarges the field of opera-
tion, and facilitates the movements of the saws.  These instruments
should vary according to the  form, development, and position of
the exostoses.  In  some cases, we  require  a saw with a flexible
blade, in others a straight and narrow saw mounted on a handle,
or we may employ a circular saw.  This may be the osteotome
of M. Heine, which  is a chain saw, moving on the edge of a large
blade.   We may be compelled to resort to the gouge and  chisel;
the part to be operated on should then be firmly fixed, to guard
against concussions, and these instruments should be made to act
very obliquely, so that they may act as much as possible as cut-
ting instruments.   The rasp and bone-nippers may be used to fin-
ish the operation.  In some instances we may be obUged to resort
to the actual cautery, before it can be terminated.
   When a tumor  is very  voluminous, we may,  so  to  speak,
remove  it piece-meal; we divide it into several portions, which are
afterwards to be separately attacked at several sittings.  This would
bean application of the successive operations (operations en plusieurs
temps) which I have elsewhere advocated.  In cases of epiphytal
exostosis, it has been proposed  to  trust the second stage of the
operation'to nature.  In the first place, the periosteum  covering
the tumor  is to be incised, after  it has been denuded as much as
possible; the exostosis is then  in a condition similar to that of a
sequestrum, the complete elimination "of which is to be confided to
the efforts of nature.  Although an advocate of successive opera-
tions, I  am of the opinion that in these cases the whole should be
removed at the first operation, unless it is likely to be so protracted
as to endanger the life of the patient.

               IV—CARIES AND NECROSIS.

   I regard ulceration and gangrene as the same lesion, for, in both
cases there is mortification; in ulceration it is molecular; whilst
in gangrene it is by small portions (parcellaire).   As there is a
striking analogy between the  two forms of mortification of the soft
parts, and the osseous lesions called caries and necrosis, I shall here
apply the same principle, and consider  the  two last affections as
two forms of the mortification  of  bone.  Those opposed  to  this
view of the subject must admit, at least, that caries and necrosis
often coincide, especially when of syphilitic origin.
   Syphilitic necrosis and caries  are often a direct consequence of
ostitis and of exostosis, which, in this manner,, may be destroyed.
I have therefore  advanced two steps in the inquiry, by the previ-
ous consideration of inflammations of bone, and of osseous tumors.
We have now to glance at the  various portions of the skeleton 
44-1
VIDAL ON VENEREAL DISEASES.
which may become affected with caries or necrosis, and to consider
the effects,  the accidents which these lesions may determine, and
the modifications which,  according to their position, they may
undergo.  I will commence with the bones of the cranium.
  It is particularly in these cases that we observe the combination
of caries and' necrosis.  It is unfortunate that in this situation, that
the efforts of nature are so feeble in the reparation of the  ravages
committed by syphilis, even when the cause no longer exists.  We
find, indeed, that  in  necrosis of the bones of the cranium, the
reparative  action observed in other portions of the skeleton does
not generally precede or follow these lesions,  and yet there  is
nothing in  the structure of the dura mater which seems opposed to
ossification, calcareous formations being in fact of frequent occur-
rence on this membrane.
  Should both tables of the skull become necrosed, as represented
in fig. 140,  of the 11th volume of my Pathologie externe, the case is
one of a very serious  character, and complete reparation is almost
impossible.  If a single table only  be affected, that which remains
suifices to  establish the process of reparation; generally it is the
external table that becomes necrosed.  Then we have the sensible
and insensible exfoliations of which writers speak.
  A necrosis of the cranium always produces more or less irritation
in the vicinity of the brain.  When the  subject is  in ordinary
health, this irritation  is limited to the focus of the mortification;
but indisposition, even when slight, may increase it, causing it  to
extend and to give rise to an encephalitis.  I have seen a woman
succumb, who for a long time had  been affected with a necrosis of
the frontal  bone; the  sequestrum was left to be  separated by the
efforts  of nature, although it was movable;  this woman was seized
with a fit of indigestion, during which the membranes of the brain
became attacked with an inflammation that terminated fatally.  In
such a case the use of the trephine  is indicated; this operation
should be^erformed when the disease has been  of long standing,
and when the effect of the general treatment affords us grounds
for believing that the affection has become localized.   Therefore,
that we may not place too much confidence in the efforts of nature,
let us endeavor to distinguish the cases and localities in which we
may properly rely on these forces, and in which  surgical interfer-
ence should be  preferred.  If in  many cases of necrosis of the
bones of the extremities we should not trephine, does it follow that
the same rule should govern us when the disease involves the
cranium ?   Certainly not.   In necrosis of the  extremity we have
to dread only the exhaustion produced by the protracted suppura-
tion, whilst in the cranium the patient is constantly liable to an
attack of encephalitis, which may be aroused, as already stated, by
the least indisposition.
  In September, 1840, a woman died at the Lourcine; in her case
the whole frontal, and part of the parietal bones, were affected with
necrosis.  Yet this woman did not suffer from the disease; but,
during the  prevalence of an epidemic she was attacked with ery-
sipelas, which destroyed her.   Her cranium presented a  singular 
         AFFECTIONS  OF THE  BONES AND PERIOSTEUM.      445

appearance: 1st.  Simple erosion of the  external table;  2d. De-
struction of the entire thickness of this table;  3d. Also of the
diploe;  and finally perforation.  It  is remarkable that the diploe
was  the only  part in which  reparation had  commenced.  This
woman  always declared that she had never had the venereal dis-
ease.  When she came under my  care her genital organs  were
sound;  but the bones may become diseased long after the primi-
tive accidents have disappeared.
  Caries and necrosis are  rarely met  with deep in  the orbital
cavity ;  when  it is observed here, it is generally from the exten-
sion of  similar lesions in other bones of the cranium.  One of the
consequences of the inflammatory tumefaction characterizing the
commencement of these affections,  is  a compression of the optic
nerve.  Surgical interference is here both difficult and dangerous.
Caries or necrosis may attack the small bones of the ear, and pro-
duce incurable deafness.  In  the commencement, when the pains
are intense, and even at a more  advanced period, it is difficult to
determine what is the malady  which we have to  encounter.  It is
only  by the concomitant symptoms,  especially  their connection
with those of disease of other  parts of the skeleton, that the diag-
nosis can be established.  Thus, if  there exist an exostosis, a ne-
crosis or apparent caries, if in particular there is caries of the mas-
toid process conjoined with the symptoms of disease of the inter-
nal ear, it  is very probable that the impaired hearing is due to a
similar  affection  of the small  bones of the ear.  Surgery, in such
cases, is impotent.  The bones and cartilages of the nose may be
the seat of these lesions.  If the nasal bones become attacked with
caries or necrosis, one of the first  symptoms is pain in the part,
followed by swelling on one side, the color of the skin,  at first,
generally remaining unchanged ; it has rather a puffy feel.   The
skin afterwards becomes red ;  by pressing on the nose we discover
that its  framework is less resisting, and that we occasionally pro-
duce a  crepitus.  Matter, more or less purulent, issues when the
patient  blows his nose, and at  length, small fragments of bone are
expelled with this matter;  the skin, which on the dorsum of the
nose is  red, becomes more inflamed, and sometimes a small abscess
is formed,  which  opens spontaneously;  a fistulous opening exists
for some time.  It is generally  at that point  where the  mucous
membrane is inflamed, more or less thickened and perforated, that
the osseous fragments are detached.   After they have been ex-
pelled,  the skin sinks in proportion to the extent of the loss of
substance ;  the nose remains more or less depressed, with or with-
out a cicatrix, as  there may or may not have existed previous in-
flammation or subcutaneous  suppuration.  If  both bones have
been simultaneously affected,  the depression of the  skin is greater
and the deformity more decided. Should there have been a lesion
of the  lateral cartilages, of those of the alae of  the nose, septum,
sub-septum, aud  the  osseous  plates entering into the composition
of the nose, the deformity will be still more considerable.  In aU
these cases, the skin may have retained its integrity, but when the
affection has commenced under the form of the syphilitic tuber- 
446
VIDAL ON VENEREAL DISEASES.
cular eruption accompanied  with ulceration,  the  destruction of
the skin leaving a part of the interior of the nasal cavity exposed,
the deformity is frightful, and can be  repaired only by a  rhino-
plastic operation.
  The diagnosis is obscure, only when  the nasal  affection is deep-
seated.  But the sanious, fetid suppuration, and  the discharge of
fragments of bone, soon render  the nature of the disease quite
evident.  It is particularly in cases where the posterior part of the
septum is necrosed, carious, and destroyed, that the voice becomes
seriously deranged.
  The surgeon should watch his opportunity for extracting the
sequestra;  these, acting  as foreign bodies, may maintain a sup-
puration that shall  exhaust  the patient's  strength.  Therefore,
with dressing or dissecting forceps, he should occasionally attempt
their removal.   He need not hesitate  to make  incisions  on the
dorsum of the nose, when he can feel the crepitus already men-
tioned.
  Necrosis,  that is,  the mortification of important osseous  struc-
tures, may often involve the palatine vault.   After a fixed but or-
dinarily acute pain, has existed  for awhile in the palatine region,
there supervenes a violet-red,  fungous-like tumefaction of the mu-
cous membrane covering the affected bones ; then, a sanious pus
which sometimes renders the mouth offensive, issues through an
opening caused by the progress of the disease in this small tumor.
A portion of bone becomes detached leaving an opening, causing
a communication between the buccal and the nasal cavities.   If
this loss of substance is not  too great,  it may become completely
closed by granulation.  But  more frequently it remains, though
it is sometimes almost imperceptible.  When the loss of substance
is more considerable, after the edges have  been approximated as
much as  possible by the reparative process, these borders present
a firm cicatrix, resulting from the adhesion of the soft parts to the
circumference of the  osseous plate, and distinctly circumscribing
the fistulous opening, which  is circular, oval, or irregular.  The
patient then suffers all the unpleasant consequences resulting from
this unnatural communication, and an  obturator is the only means
that can afford relief.
  I have very frequently observed necrosis of the superior maxil-
lary bone;  in three cases I early removed  the sequestrum,  which
I always found resting on that part of the alveolar process corre-
sponding with canine and the smaller molar teeth.
  Necrosis of the inferior is generally considered of more common
occurrence than that of the superior maxillary bone.   I have met
with but one case of it at the Maison de Sante of the faubourg St.
Denis; the sequestrum comprised nearly the entire body  of the
bone, which I removed in the presence of M. Morel.
  The cartilages and bones of the larynx  may be the seat of ne-
crosis, and  the dead  portions may be expelled in the efforts to
expectorate.  Here  it is  of immense importance  to remove the
sequestra early in the disease; for they act as foreign substances,
and maintain an irritation and suppuration, and in many cases 
AFFECTIONS OF THE VISCERA.
447
may expose the patient to the dangers of a laryngeal phthisis,
which then actually exists.
  The bones of the vertebras  most frequently affected with caries
and necrosis, are those opposite to  the pharynx; syphilitic caries,
involving different portions of the spinal column, especially the
lumbar region, have been known to produce abscesses by conges-
tion.  M.  Baume's remarks that they  have  occurred when  the
caries affected the lateral or posterior surface, and that when it is
seated in the anterior portion,  an angular curvature is produced by
the sinking of the bodies of the vertebra.
  In the category of the causes of white swellings of the joints,
the syphilitic diathesis is always included;  but the  diagnosis of a
syphilitic white swelling is still to be made; the nocturnal exacer-
bation is the only symptom that can be regarded as characteristic!
The pathological anatomy itself of a syphilitic diseased joint is yet,
and  I think will long remain to  be made, for  those possessing
truly this character are extremely rare.
  I have not referred to the internal treatment of caries and necro-
sis in these cases; it is the same already frequently mentioned in
this article, the iodide of potassium forming the basis of the whole.
Still, as in some instances the  patient may have used this medicine
for a long time, and the bones may be profoundly affected, it will
be well in such cases to try iron alone,  or  combined  with  iodine.
I have  prescribed ferruginous pills, and those of the proto-iodide
of iron, and these have sometimes succeeded when the caries have
been profound, and had reduced the patient to a state of extreme
cachexy.   We may here also administer cod-liver oil,  or  the
iodureted oil, according  to the formula of M. Personne, pharma-
cien  at the Hopital du Midi.
  But the  surgeon should closely watch the progress of the  dis-
ease, so as to embrace the earUest opportunity  of removing  the
sequestrum, or the carious portion of bone.  The  service thus
rendered to the patient cannot be too highly appreciated; for  fre-
quently the syphilitic virus, the primary cause of the disease, no
longer exists, the effects only  remaining, which, in turn,  may pro-
duce'serious consequences, such as exhaustion of the strength of
the patient.

                       SECTION  IX.

             AFFECTIONS OF  THE VISCERA.

  Since the venereal disease has been properly investigated, it has
been admitted  that the syphilitic virus may infect  the blood  and
other fluids of the body.;  the  special lesions of the tissues and or-
gans, and more especially those of the viscera now under consid-
eration, have also been recognized.   At one  period, indeed, syph-
ilis figured  in the whole catalogue of diseases;  it was connected
with them all.   This exaggeration was followed by another,  and
of an opposite  kind, denying  the existence of syphUitic  affections
of the viscera.   The advocates of this doctrine were not sparing in 
448
VIDAL ON VENEREAL DISEASES.
their  sarcasms  against those who entertained  a different belief.
At the present day, the ancient doctrine seems likely to be revived,
but it makes slow progress, as yet it has only probabilities  iu its
support.   As the history of syphilitic affections of the viscera has
yet to be  made, I shall attempt to give merely an outline of the
subject.
  In the first place, it is unnecessary to force analogy in order to
admit syphilis as an occasional cause of certain affections, of which
the germ or predisposition already exists.   Direct  observation
here confirms analogy; indeed, more than one latent phthisis has
been aroused under the  influence of syphilis.   Of this  there can
be no question.   It is not in the thoracic  viscera alone that the
tubercular  element has been  called into action by this influence,
but it has likewise been the cause of similar affections of the lym-
phatic system, and more than one scrofulous bubo has been the
result of this agency.
  But what is most difficult  to be established is the existence of
visceral lesions essentially syphilitic, having anatomical characters
and a symptomatology proving their specific nature.   In analyz-
ing the lesions of the internal organs which have been observed,
I will prove what I have here  asserted, and  at the same time fur-
nish the  young practitioner, anxious to elucidate this point, with
the few materials, or, more properly speaking, the few notes which
I have been able to collect.
               I.—CEREBRAL AFFECTIONS.

  Tubercles resembling the deep-seated tubercles of the  cellular
tissue (gummata) have been observed in the brain.  But can these
tubercles be distinguished anatomically from other tubercles, from
those commonly described in works on pathology, and which pro-
duce such fatal havoc when  seated in the lungs ?  The same ob-
scurity prevails on the symptomatology, for the lesions of sensation,
motion, and intellect, may aU  result from a cerebral affection en-
tirely independent of syphilis.   Still further, the syphilitic diathe-
sis may produce other effects on the cranium,  which may  be con-
founded with the gummata  of the brain, as, for example, tumors
of the dura mater, and exostoses of the cranium.  And  here we
can derive no assistance from treatment in clearing up our diagnosis,
for  the  cranial, like the cerebral lesion, may be equally modified
by  the  same agent, viz., the iodide of  potassium; indeed, under
the influence of this therapeutic agent, the symptoms and accidents
produced by both of these affections may be  made to disappear.
The age, antecedents, and concomitant symptoms, may assist the
practitioner, and conduct him to probabilities  approaching to cer-
tainty.  Thus, what is remarkable, I have observed almost simul-
taneously two  cases of serious encephalic disease,  attended with
symptoms of cerebral disturbance.
  By means which I am about to mention, I was enabled to estab-
lish the probability of the syphUitic  nature of both affections, and 
AFFECTIONS OF THE VISCERA.             449
of their seat.   Both patients  were young,  being scarcely thirty
years of age.   The first had  been attended by a physician who
became confined to his bed.  The young man was attacked with
symptoms of apoplexy.  One oTmy colleagues, M. A. Bobert,* was
called, and not knowing the previous history of the case, treated
the patient for ordinary apoplexy.  The most alarming symptoms
having been removed, the intellectual faculties remained impaired,
memory, especially, being at times lost.  My  coUeague was not
aware that this young  man had had an indurated chancre, and
syphilitic eruptions on the skin, and the patient, who had concealed
his condition  from his family and friends,  was not forward  in
making him a confidant.   Finally a consultation was held; as I
had treated the young man for his syphUitic attack, I was called.
The iodide of potassium was prescribed in large doses; one and a
quarter drachms were given daily.  The intellectual faculties  were
rapidly re-established, and the patient suffered nothing more from
his attack.  Therefore, taking into consideration the age  of the
patient, the syphilitic antecedents, and the rapid effects of the iodide
of potassium, I came to the conclusion that this was not a case of
ordinary apoplexy, but a syphilitic affection of the head.  Were I
to venture on a further expression of my opinion of the nature of
this case, I should say, that it was not  an osseous lesion, an exos-
tosis of the cranium, but an affection of the brain itself, the com-
mencement of plastic deposition, for the effects of an exostosis are
not so speedily removed.  I  acknowledge, however, that  this  is
mere  conjecture> and it will have been  remarked, that the  skUful
surgeon first in attendance discovered nothing peculiar in the first
symptoms, or which might indicate a specific affection.  Here the
knowledge of the previous history of the case, and of the effects of
the iodide of potassium, were wanting in establishing the diagnosis.
  The second patient lived in the suburbs.  He  had hemiplegia,
which was slowly developed.   The antecedents in  his  case  were
chancre, cutaneous eruptions, and syphUitic sarcocele.  I had pre-
viously treated* these affections.  Being  aware, therefore,  of the
previous history of the case, and considering, too, that the patient
was quite young to be attacked with ordinary apoplexy, I thought
it exceedingly probable that this was a syphihtic encephaUc affection.
I went so far even as to presume upon the seat of the disease.  The
slow development of the paralysis, the fact that there existed an
exostosis of the lower jaw, led me to diagnose a cranial exostosis.
In this I was confirmed by the time required to cure the patient
(a year), the same that was required to remove the exostosis of the
lower jaw.   I repeat, that we are here dealing in probabilities, but
in probabilities possessing a value which the most attentive exami-
nation of facts in medicine cannot always impart.  Whatever may
be the scientific bearing of these*two cases, or theoretical interpre-
tation, they remain two instances of cure worthy  of the  practi-
tioner's attention.

 * On account of the standing of the patient, I am compelled to omit the nam©
of the family physician, who^ besides,  will readily recognize whom I mean.
                           *9 
450             VIDAL ON VENEREAL DISEASES.

  [Dr. Budd has reported in the Lond. Med. Gazette, for May, 1842,
three cases in which apoplexy occurred in the advanced stages of
syphilis.   These patients had bee>n for some time  affected with
periostitis, and two of them  had had a syphilitic eruption (rupia).
Dr. B.  says,  it may admit of question,  whether the apoplexy re-
sulted from  the immediate  action of the syphilitic virus on the
brain, or whether it was consequent on syphilitic inflammation of
the bones of the head.  In connection with this subject, we refer,
with much pleasure, to the admirable papers by Dr. John Watson,
of the New York Hospital, " On some of the Remote Effects of Syphi-
lis," which were published in the first and fifth volumes of the New
York Journal of Medicine and the Collateral Sciences, (1843,1845.)  Dr.
W. has reported some eight cases of hemiplegia and epUepsy, result-
ing from syphilitic disease of the cranial bones and envelopes, and
tubercular deposits in the substance of the brain itself.   In one of
these cases, the patient, contrary to the advice of Dr. W., was tre-
phined, his cerebral  symptoms having been attributed  to a blow
on the head received some  two years previously.  He died some
months afterwards; extensive changes were found to have taken
place within the brain and its envelopes,  and the deposits of yel-
lowish dirty-white color in the former, Dr. W. regarded as syphilitic
tubercle.  The cases above mentioned,  together with those men-
tioned by Mr. Inman (Lond.  Med. Gazette,  July, 1843), disprove the
assertion  of Sir Astley Cooper, that the brain,  abdominal,  and
thoracic viscera, are incapable of  being  infected by the  syphUitic
poison.  (On the Testis, 2d  Lond.  Ed., p. 166.) • We regard Dr.
Watson's contributions by far the most valuable yet made on this
subject, for  his remarks  are founded on the autopsies  made by
himself—G. C. B.]

                IL—HEPATIC AFFECTIONS.

  Syphilitic affections of the liver  in the infant have been carefuUy
investigated by M. Gubler.   He has found, as the anatomical lesion,
a fibro-plastic induration, which may be partial or general.  When
I come to treat of infantile  syphilis I shall carefuUy describe this
double lesion.
  In the Iconographie of M. Bicord (pi. 30) is represented a partial
induration,  a very remarkable nucleus  in the  Uver of an adult.
The subject, who had died from  a  deep-seated affection of the
larynx, presented serious  anatomical  alterations of  this organ.
The Uver, of medium  size,  was of the ordinary color  and  con-
sistence;  on the convex surface  of its  lobe was found a tumor,
perfectly round, as large as a walnut,  somewhat prominent, and
involving nearly the whole  substance of the organ.   This tumor,
consisting of two parts, appeared to be surrounded by  a kind of
cyst; it was composed of a hard, dense,  very homogeneous tissue,
crackling a httle under the knife, and offering no traces of vascu-
larity.  It seemed to present a striking analogy with certain tumors
of the cellular tissue,  which are  frequently observed in  tertiary
syphUis.  As to the symptomatology, it  is stated in  the report: 
                 AFFECTIONS  OF THE  VISCERA.             451

" For some months  the patient had suffered from cholicky pains,
which, from his description, resembled those produced by biliary
calculi.   Further, he had had several attacks of jaundice, traces of
which were still apparent on his admission to the Maison de Sante."
  It will be seen that there are no peculiar symptoms of the disease,
and that they might  have been referred to  several different  affec-
tions of the organ.  Besides, in examining the colored plate repre-
senting the above tumor, it is not difficult to recognize a form of
cirrhosis denominated by Laennec, cirrhosis in masses.  Therefore,
the history of syphilitic disease is yet far from being complete;  it
has not even been commenced.

               III.—CARDIAC AFFECTIONS.

  SyphUitic affections of the heart are almost unknown.   In the
Iconographic of M. Bicord, however, is the representation of a lesion
which this physician  regarded as belonging to the class of tumors
caUed gummata.  The subject had had repeated attacks of chancre
on  the penis, accompanied with vegetations;  these  were followed
by mucous tubercles about the anus.  Finally, groups of tubercles,
which ulcerated, appeared on  various  portions of the skin.  He
was treated with the proto-iodide of mercury and the iodide of potas-
sium, for eleven days, when, in going to stool, at seven o'clock in
the morning, he was suddenly attacked with giddiness; he returned
to his ward, threw himself on the bed, and expired in less than five
minutes.   Previous to this fatal event, with the exception of the
accidents mentioned,  "there were no symptoms which could have
led to the suspicion of any deep-seated affection."
  " Before death, the face of the patient became of a violet color,
after which it turned pale; he had to utter these words only: ' I
feel very sick;'  (Je me sens tres mal.)
  "The autopsy, made twenty-four  hours after death,  disclosed
the following appearances:
  u With the exception of the heart and lungs, all the viscera were
sound, but presented very strong marks of congestion.  The heart
was hypertrophied, its cavities were filled with  clots of blood, of
slight consistence.  The endocardium of the  right ventricle exceed-
ed  two-fifths of a line in thickness; it  was  of a dull white color,
and of fibrous consistence.
  " The endocardium of the left ventricle presented nothing abnor-
mal ; but, in that portion of the cavity next the apex, we found an
adherent layer of very friable blood, beneath which was a kind of
apoplectic clot, which occupied the whole thickness of the wall of
the ventricle.  The blood was intimately united with the muscular
substance, the normal consistence of which was  destroyed,  by
which we were  led to infer that the affection was not the result of
an accident; the pericardium  on a level with this clot was puffed
up,  and thickened.  The apex of the  heart was covered externally
by a false membrane, one and one-fifth of a line in thickness.  ^ The
walls of the ventricles at several points presented a tuberculiform
alteration consisting of a firm yellow matter, cracking beneath the 
452
VIDAL ON VENEREAL DISEASES.
V
knife, not vascular, of a schirrous consistence at certain points, and
at others, of an aspect analogous to that of  a tubercular matter in
process of softening.  In a word, we found here the character of the
syphilitic node or tubercle, tertiary accidents which are  frequently
observed in the subcutaneous or sub-mucous cellular tissue.
  " Nq muscular fibres were found compressed by all these morbid
productions, for the degenerated mass was composed of the  mus-
cular fibre itself.   Besides, we vreve able to follow the evolution of
this transformation, which seemed to have commenced by a union
of the blobd with the fleshy fibre.   And, indeed, in this condition
the lesion still existed at several points.  In others, it presented a
yellow color, and  had reached, centrally, a greater  development.
But  at the circumference, the combination  of the blood with the
fleshy fibre Avhich  took place in the commencement  of the affec-
tion, was still evident.  The lungs, perfectly sound at their apex,
presented at their base several tuberculiform transformations as
large as a pea, and precisely similar to those found in the heart."*
  My former friend, Professor  Forget, is disposed to regard these
supposed syphilitic vegetations of the heart  as the  offspring of the
imagination, as well as most of the other  syphilitic lesions which
it has been pretended have been found in  this organ.f


             IV._PULM0NARY AFFECTIONS.

  The lungs and  bronchi have always been regarded as especially
liable to syphilitic lesions.   M. G. S. Lagneau,  son  of  the vener-
able author of the Traite des maladies syphilitiques, has collected all
the recorded facts  which relate  to these affections, and in a rehable
work has attempted  to show  that syphUis  affects the  lungs  and
bronchia:  •
  1st.  By  producing  alterations essentially syphilitic, that is, ac-
knowledging syphilis as the exciting cause.   These alterations he
divides into two  classes, first,  affections generally slight, compris-
ing acute inflammation of the bronchia and the parenchyma oi the
lungs, intermittent bronchial inflammation, or asthma, and chronic
bronchitis.  Secondly, we have more serious disorders, by  most
authors termed phthisis,  comprehending  chronic  bronchitis, with
ulceration, chronic inflammation of the parenchyma and lymphatic
glands, pleuritis, syphilitic tuberculization, or the formation of the
gummy tumors (gummata).
  2d. It may rouse into action tubercles which had existed before
the syphilitic infections, or manifest its effects by exciting the evo-
lution  of tubercles, the progress  of  which it has a tendency to
accelerate.
  According to M. G. S. Lagneau, every organic  lesion found in
individuals affected with  syphilitic pulmonary disease may be re-
ferred  to  one of  these two divisions.   Among  the anatom-patho-

   * Vid. report of the case by M. Gabalda, in the  Iconographie of M. Ricord
   f Precis analytique des maladies du cceur, p. 261. 
AFFECTIONS OF THE  VISCERA.
453
logical conditions peculiar to the first, that is, the lesions essentiaUy
syphilitic, the author specifies the following:
  Chronic Ulcerative Inflammation.'—This consists in small, isolated
or confluent ulcerations, united, occupying the whole or a part of
the bronchi, becoming sometimes very numerous in the minute
ramifications of the bronchi, which are  then fiUed with purulent
matter.
  Inflammation and Ulceration of the Lymphatic Glands, and of the
Pulmonary Parenchyma.—Inflammation of  the pulmonary  tissue
presents numerous degrees, from the simple congestion^ hepati-
zation, and the formation of purulent foci.  These ulcers, and pur-
ulent collections, form especially in the middle lobe; the cavity
containing the pus is surrounded  neither by a membrane, nor  in-
duration; sometimes the lung appears externally sound, and  no
exudation is observed.  In the young infant, we find also abscesses,
indurations, and extensive suppurations; in the recently-born infant
we meet with indurated nuclei,  impermeable to  the  air, friable,
hepatized, occupying, by preference, the apex of the lung.   These
nuclei, of different dimensions, generally numerous, become yellow,
compact, a cavity forms in their centre, it present  walls of greater
or less thickness, infiltrated with pus;  it is filled by a yellow, sero-
purulent fluid.  The microscope detects in this fluid the presence
of pus;  the surface of the lungs is bosselated, arising from these
purulent collections, adhesions exist between the pleural surfaces,
and sometimes  the parenchyma is compact,  yellow, and friable.
At other times the virus exerts  its influence particularly on  the
pulmonary, lymphatic ganglia, which become engorged, indurated,
and terminate in suppuration.  These observations apply particu-
larly to the lesions recently observed  by M. Depaul,  and. which I
6hall describe more fully when I treat of infantile syphilis.
  Pleuritis and Effusion.—The pleura may become raised at various
points in the form of blisters, in patches of from two-thirds of an
inch to two  inches in diameter, by the effusion of a thick, yellow
mellicerous fluid;  sometimes also there may be a more  extensive
effusion
  The gummy  tumors (deep-seated syphilitic tubercles), involve  the
parenchyma; sometimes they are very numerous; and  terminate
slowly in suppuration.   In order to  establish their anatom-pa-
thological ^condition, M.  Lagneau  copies from Astruc, Schrceder,
and Dr. McCarthy. Among other things, he inserts the  following
passage from an article written by M. Foucart, after  a lecture of
M. Ricord:  " According to this physician, one of the  situations
in which the gummy tumors are  developed more frequently than
is generally supposed, and a knowledge of the existence of which
is  most important, is  the pulmonary  tissue."  For several years,
he states, we have had  quite a number of  autopsies  which led us
to the conclusion that there are pulmonary lesions which must of
necessity be referred to syphihtic tubercles.   It pursues the same
course here as in other parts of the body, it is the same form, the
same development, the  same fatal termination  in  suppuration.
The patients expectorate pus  as in the  most advanced, stages of 
454             VIDAL ON VENEREAL  DISEASES.
pulmonary tubercles;  they become emaciated,  feeble, and  death
soon foUows.*
  This extract is from a lecture delivered by Ricord in 1845.   In
his Iconographie, he has been more precise in his anatomy, and less
explicit as regards the nature of the pulmonary affections, for  ho
speaks in presence of the cadaver; for example, in describing the
autopsy of a venereal patient, it is stated  in his work; "Violet-
colored spots were found, beneath which were indurated nuclei,
which, at first view, resembled those found in the lungs of those
who haveWied from pneumonia, the result of purulent absorption.
These nuclei when incised, were found to contain no pus, but pre-
sented a deep red, friable tissue.  In  the left lung were found five
small cavities  half filled with  a whitish viscous matter, together
with a grayish pultaceous matter which  appeared to proceed from
the walls of the cavity, which were  soft and of  a  grayish  color.
The largest of these cavities would have  contained a small nut.
They were situated  near to each  other at the lower portion and
and near the external border of the lung."f   The report is followed
by the following reflections: " These alterations leave us in un-
certainty as regards their nature, and it would be difficult to say
whether they are syphilitic, whether these cavities contained terti-
ary tubercles, which became softened and expelled, or whether
they were the results  of purulent absorption.   M. Ricord here
notices another fact;;{: there can be no doubt that a very considerable
number of autopsies are required to establish the fact, that these pul-
monary lesions are due to syphilitic tubercles.
  It is to be regretted that M. G. Lagneau did not have under his
eyes the version given in the Iconographie, which singularly  modi-
fies the report in the Gazette des Hopitaux.  Doubtless after such
a contrast, M. Lagneau would have been more  reluctant to  admit
these pulmonary lesions to be essentially syphilitic.
  M. Lagneau enters fully into the symptomatology of these affec-
tions.  But, M. Cazenave, who  had reviewed his work,  remarks,
that notwithstanding his attempt to frame a table of symptoms, it
wiU still be very difficult,  even after the  most  careful study, to
select from the group those peculiar to acute or  chronic  bron-
chitis,  ulcerated  or non-ulcerated, to asthma, pleurisy, chronic
pneumonia, and  the tuberculization essentially syphilitic.  In  the
majority of cases, Ukewise, accident or some unexpected revelation
has led to the formation of  a diagnosis rather than any particular
symptomatology. §
  It was accident, as stated by M. Cazenave, that enabled me to
effect a cure in a patient supposed  to be laboring under the  last
stages  of phthisis.   This patient  kept a lodging-house  near the
porte St.  Martin.  He had been treated, and in common language,

  * Vid. Gazette des Hopitaux, 1845, t. vii., p. 610. Reprint of a lecture of M. Ricord
on tertiary accidents.
  f Vid. Iconographie.
  \ Only, it is stated in the report of  the autopsy already quoted, that in a case
of Byphilitic disease of the heart, the lungs presented analogous lesions.
  § Annates des maladies de la peau et de la syphilis, Jan. 1852. 
AFFECTIONS OF THE VISCERA.             455
condemned by a distinguished member of the Academy of Medi-
cine.  This patient was  brought to me by  a friend, and  I was
about to send him to a physician, when he showed me a tumor on
the clavicle.  This discovery led me to examine him more closely,
and to inquire for the previous history of the case.  He had had
chancres on the penis four years before the appearance of his pul-
monary trouble and the tumor on the clavicle.  He coughed much,
especially morning and evening ; he showed me nummular expec-
toration ; he had night sweats; his emaciation was extreme ; and
respiration constantly laborious.  I was wrong in not auscultating
the chest.   But I placed the patient on  the use of the iodide of
potassium : at first, in fifteen-grain doses, which was  increased to
one drachm daily.  In less than a month, he had improved beyond
all expectation, and in less than two months he had  resumed his
occupation.  At present, six weeks from the commencement of the
treatment, the patient is in the enjoyment of most excellent health.
   We may reasonably conclude that syphilis, in this case, exerted
a powerful  influence in the production of the pulmonary disease
which was destroying the patient.  But this opinion I was enabled
to form only from  the concomitant  symptoms of the clavicular
tumor, and the antecedents as manifested in the chancres  on the
penis, and the effects of the iodide  of potassium.  The symptom-
atology, especially as derived from the physical  examination of
the chest, were wanting, and I should not have been warranted in
classing this affection among those essentially syphilitic.
   Such facts are, therefore, insufficient to settle the scientific ques-
tion.  But they possess a real value in a practical point of view.
They teach us to carefully examine  the antecedents of the case,
when there exists chronic pulmonary disease, and not to  decide
upon an anti-venereal treatment, unless the previous history of the
case leads to the suspicion of a syphilitic infection.   The more I
study the chronic aft'ections of the viscera, those called organic, the
more firmly persuaded am I that patients are  allowed to perish by
what is regarded as ordinary tubercular disease, from the want of
an anti-syphilitic treatment.
   The following case, to which M. Lagneau attaches a truly scien-
tific value, is, in my opinion, but the counterpart  of that which I
have minutely detailed.
   "An actor, aet. 46, M., affected with syphilis for more than
twenty years, presented a periostitis on the anterior surface of the
left tibia, and suffered from nocturnal pains in all his limbs.  With
these symptoms were combined  all the  rational signs of the last
stages of phthisis, and there was every reason to  believe that  his
existence would soon be terminated, in the  country, whither he
had been sent to live on ass's milk.   When my father was  called,
together with  M. Andral, to consult with M. Marc, when the pa-
tient made  a temporary visit to Paris, he presented the following
symptoms: cough,  puriform expectoration, sweats, pains  in the
cnest, low fever, prostration, marasmus, and hemoptysis; no phys-
ical  signs were  discovered on auscultation.   The  result oi the
auscultation was, to place the  patient under an anti-syphilitic 
456
VTDAL ON VENEREAL DISEASES.
treatment, which was carried out under the direction of M. Marc,
according to the plan of Scatigna—that is, by the daily application
of half a drachm of the Neapolitan ointment to the axilla?., and the
use of a sudorific tisane with  milk.   On the thirteenth day of
the commencement of this  treatment, the pains in the chest and
limbs, the low fever, prostration and tumefaction of the periosteum,
were already dissipated.  After the thirtieth application of the
ointment, the patient had regained much of his  ordinary embon-
point, and the cough had ceased; on the fortieth day the cure was
complete.   The patient devoted himself for  some time to his pro-
fession, singing, and then  retired into  the  province.   M.  Marc
has learned that he afterwards died—of what malady, however, he
was not informed.*
  The symptomalogy  of these pulmonary  affections,  which M.
Lagneau regards as  essentially syphilitic, not  having been  made
either by this author, or by  other writers on syphilis, we can ap-
preciate the difficulties, I might almost say the impossibility of dis-
tinguishing them  from, for example, the tubercular pulmonary
affections  which had previously  existed, and which have  been
roused into action  by the syphilitic influence, which has hastened
their development and the accidents to which they give rise.
  In  conclusion I would remark, in regard to the knowledge
which we possess  of the syphilitic affections of the viscera: 1st,
that analogy confirms  their existence;  2d, that this analogy is
corroborated by certain facts in pathological anatomy;  3d, that
certain cures of serious chronic pulmonary affections, with their
antecedents or concomitant syphilitic symptoms, that these cures,
being effected by specific treatment after other means have failed,
do not completely disclose the syphilitic nature of these pulmonary
affections, but  should receive great  consideration,  especially  by
the practitioner, who, on the least suspicion of the agency of  syph-
ilis in the disease,  should resort to specific treatment.
   [The attention of  many of the older writers was directed to the
subject of syphilitic  diseases of the lungs, among whom we may
mention Severinus, Sauvage, Portal, Morgagni, Hoffman, Hewson,
and Morton; among the more modern  authors  we may reckon
Drs. Graves, Stokes,  Byrne, Sims, Munk, and John Watson. Dr.
Munk has published two papers upon this subject, in the London
Medical Gazette (vol.  ii., new series, pp. 179, 218), which are wor-
thy of a perusal.  We have  seen cases of pulmonary disease which,
there was  every reason to  suppose, were produced by the action
of the syphUitic virus, yet it is  difficult, if not impossible, to decide
upon  the actual influence  of this cause.  Dr. John Watson has
reported a case, where the patient, just before death, was  seized
with hemoptysis, which was so profuse as to carry him off almost
instantly.  In the examination, a ragged, circular ulcer, nearly as
large  as a cent, with dark, purpled  edges, was found in the left
bronchus, just beyond  the  bifurcation;  this  had perforated the
bronchial tube, communicating with a sort of cavity in the cellu-

  * Des maladies pidmonaires causies ou injluenceet par la syphilis, by G. S. Lagneau. 
                 AFFECTIONS OF THE VISCERA.             457

lar tissue outside of the tube, and thence extending to one of the
left branches of the  bronchial artery, into which it had opened.
There was a second ulcer within the same bronchial tube, about
one inch  and a half or two inches deep, as  large as a half-dime
piece.  This had nearly perforated the bronchial tube, and had an
irregular base, with ragged and uneven edges of the same color as
the other.   Previous to the death of this patient, he had been un-
der the care of Dr. Buck, in the New York Hospital, for a second-
ary ulcer over the parotid region, and there were some spots of
syphilitic rupia in other parts of the body with slight cough. (New
 York Journal of Medicine, July, 1843, p. 57.)—G. C. B.] 
PART  THIRD,
INFANTILE  SYPHILIS.
  The study of infantile syphilis cannot be separated from its
necessary connections with syphilis in the parent, the condition
of the nurse, and the early care which it may receive.  Besides, it
is not syphUis  in the new-born child only that we have here to
consider, but frequently  that of the embryo, the foetus, &c, &c.
In the investigation of. the causes, I shall examine the influence
of the parents and the nurse.  It is obvious how deeply the family,
society, and legal medicine are interested in the questions now to
be discussed, and yet in the most widely-circulated works on ven-
ereal diseases,  this  subject has  received but little attention!  In
the first place,  I shall describe the symptoms and the pathological
anatomy, thus commencing with what admits  of least dispute;
afterwards, I shall enter into the consideration of the causes, under
which head are included the influence of the parents and the nurse
upon  the  child, and vice versa.   Of course,  the question of the
transmissibility of syphilis by the blood, the products of secretion,
and the consecutive accidents, will here be renewed, and its solu-
tion in favor of the contagionists no longer admits of doubt.
  Symptoms.—Infants who have suffered from the syphilitic influ-
ence in utero, are born shriveUed and emaciated; their flesh is soft,
skin of an earthy color, flabby and wrinkled, giving them a senile
appearance. In the language of Doublet,  they are " miniatures of
decrepitude;"  some perish  before any evidence of syphilis  is
manifested; in others, we observe the accidents  and symptoms
which I shall soon describe, and we meet even with vegetations, as
shown by the several cases reported in the work of Bertin.   Such
facts have  therefore  been unjustly denied.  The majority of chU-
dren are born with the appearances of the most perfect health.
Some weeks or months after birth, they present symptoms or acci-
dents of constitutional syphilis.  Bertin  remarks, that according
to his observation,  these symptoms or accidents are developed
from the third to the sixth week; but  he admits that they may
appear before this period.
  The attention  of the nurse is first arrested  by the difficulty of
respiration, and a snuffling noise, especially whilst suckling.   This
is the commencement of the syphilitic cofyza.  The nose is ob-
served soon to become red, and  tumefied;  the no__trils crack, and 
INFANTILE SYPHILIS.                  459
almost constantly discharge a purulent humor mixed with blood.
A portion  of this fluid, as  it becomes dried, forms crusts which
obstruct  the nasal  cavities; the little patient breathes  by  the
mouth only, which is constantly more or  less open.   The lining
membrane of the nose, of a livid red color,  tumefied and softened,
is often  the  seat of superficial  ulcerations, and bleeds from  the
slightest  contact.  Respiration through the nose,  at first embar-
rassed, becomes more difficult;  suction of  the  breast is at length
rendered impossible, and if this  condition be prolonged, the chUd
perishes from inanition.
   When decided inflammation  exists, we should use, at first,
emollient, and afterwards astringent lotions, or cauterization with
the nitrate of silver.
   M. A. Deville has  furnished  M.  Bouchut an account  of four
cases of infantile syphilis in which coryza existed, and all of these
children were born of mothers  affected with syphUis.   Three of
them presented on  their bodies  signs of syphilitic infection.
They were treated with iodide of potassium in doses of from seven
to fifteen grains a day, under which  their condition rapidly im-
proved.  Three were  perfectly  cured; the fourth died from an-
other disease, the small-pox*
   It is generally admitted by writers that  infantile syphilis most
frequently appears under the pustular form.   Bertin,  in his spe-
cial treatise,  observes: " Pustules were symptoms most commonly
observed in infantile syphilis during my connection with the vene-
real  hospital."  We generally  meet  with the mucous tubercle,
such as I have described in the latter part of  the first section of
this work.    In these cases they are found  not only in the regions
 already specified, but wherever  folds in the skin exist, as for ex-
 ample, on the thighs, buttocks, and in  the axUlae. Sometimes they
 occur in patches more or less broad, sometimes the tubercular or
 the lenticular form is most strongly marked.   In  parts where the
 skin becomes heated, these tubercles discharge, even abundantly,
 a matter of an offensive odor, which produces more or less erythe-
 ma or eczema in the vicinity.   At other  times the tubercles are
 dry, and covered with a kind of scaly layer.
   The mucous membrane is also the seat of these tubercles which
 then become complicated with cracks or small fissures.  Thus, at
 the commissure of the lips, at the side of a tubercle, we observe a
 fissure which has a tendency to heal, but which  is overcome by
 the movements required in  suction of the breast, which act is at-
 tended with pain.  On the tongue, we notice Uttle whitish lenticu-
 lar elevations, as if the nitrate of silver had  been  appUed to its
 surface; if possible to open the mouth, we observe  these white
 spots extending towards the throat and pharynx.  The same lesion
 has been  supposed to occur in the  intestinal canal, and to have
 produced bloody mucous stools. The microscope has detected the
 presence of cryptogamia in the  secretions of the lips and mouth.
    The  ecthymatous form of pustule is also  frequent in infantile
• Bouchut, Traite pratique des maladies des nouveaux-nes, p. 869. 
460             VIDAL ON VENEREAL  DISEASES.
syphilis.   " When," says M. Gibert, " we meet with a really syph-
ilitic eruption in the  child, it ordinarily assumes the form  of ec-
thyma.''"'   It is observed even on the palms of the hands, and
the soles of the feet, here replacing the horny squamous syphilitic
eruption which, at this period of  life, is very rare.  Impetigo, es-
pecially facird impetigo, now and then occurs.
  The erythematous form  is common;  children  appear as if
scalded, particularly wherever the parts  are subjected to friction, or
pressure.   The anus, thighs and genital  organs often become red
and sensitive.   This  condition is  then attributed  by the nurse to
teething, even before it is time for the teeth to appear; they are
greatly"in the habit of using, simply, powders which  produce no
effect/ The physician is now consulted.  Whatever may be the
form of the syphilitic eruption, it has a great tendency to ulcerate;
these ulcerations are most frequently observed over the  sacrum,
on the nates, and on  the heels.
  As I have already stated in speaking of the syphilitic bulla in
the adult, M. P. Dubois has described  a syphilitic pemphigus in
the new-born child.  It is generally acute, and the bullae  are as
large as a pea, rarely as large as a small walnut.  They are more
or less numerous;  more than a hundred have been  counted on
one child ;  they are then in close proximity, some of them being
united at their base.   They contain a yellowish, purulent fluid,
which is sometimes fetid, and even mixed with blood.  They may
occur on all parts  of the body.  Most generally they are seen on
the palms  of the hands and the soles of the feet.  The points of
the skin on which the bullae are raised, have a violet or blue tinge,
which contrasts with the rosy hue of the other  portions  of the
skin. Sometimes the dermis is eroded, ulcerated, and covered with
a plastic membranous  deposit.   These ulcerations,  occasionally,
comprehend  the whole thickness  of the  skin, and suppurate
abundantly;  their margins  are sometimes elevated and rounded,
and  at different points they present the appearance of the last
stages of ecthyma (P. Dubois).  Sometimes we do not at  first ob-
serve spots of the  color mentioned ;  afterwards the epidermis be-
comes raised, and the pemphigus is complete.   The bulla, once emp-
tied, the spot is occasionally reproduced as before; there is a relapse.
  Syphilitic  pemphigus may occur in children  who were born
well developed; most generally, however, it is observed in those
which are feeble, and prematurely born.   In all cases, its appear-
ance is ominous, as nearly all die  who are born with it, or on
whom it appears after  birth. It is not unusual to find chUdren
which have died in utero bearing traces of this eruption.  Pemphi-
gus is especially grave when complicated with the affections of the
lungs or thymus gland which I shall presently notice. In speak-
ing of pemphigus in  the adult, I have stated that the syphilitic na-
ture of pemphigus in the new-born child has been called in ques-
tion.  M. Bouchut endeavors to establish a different diagnosis be-
tween specific pemphigus and simple pemphigus.  He observes:
* Manuel des maladies veneriennes, p. 440. 
INFANTILE  SYPHILIS.                  461
" On the one hand, we find the bullae filled with well-formed yel-
lowish pus, whilst  in simple pemphigus they are filled by a clear
or opaline serous fluid. In the one case, the color of the excoriated
skin is  red and livid; in the other, it is of a clear rosy hue,  Iu
the one the skin is eroded and even ulcerated; in simple pem-
phigus it is never ulcerated; in the one case the bullae co-exist with
syphUitic  lesions in the  other  organs,  such  as eruptions on  the
skin or mucous membranes, with abscesses scattered through  the
substance of the thymus gland or lungs, with  fibro-plastic  de-
generation of the liver, onyxis, &c.   In simple pemphigus, on the
contrary, the bullae constitute  the  only symptom.  In  fine,  the
one is -with  difficulty cured, and only by mercury administered to
both chUd and nurse, whilst the  other is cured by simple diluents."*
   I would remark that syphilitic pemphigus  is not always accom-
panied  with other  syphilitic eruptions, and the visceral lesions
mentioned by M. Bouchut are revealed only by an autopsy.
   Besides the eruptions described and which belong to the super-
ficial forms, we may also observe the deeper  seated.  Indeed,  the
child  is sometimes affected with syphilitic ecthymatous pustules
similar to those found on the extremities, especially the legs of the
adult, pustules which are broad, deep, and the ulceration of which
has perpendicular borders.  The child may also present the tuber-
cular form of eruption with an  ulceration as if perforated.  But it
must be admitted these forms are rare.
   [In Dr. Buckley's elaborate paper on Syphilis in Infants (New York
Jour, of Med., Oct. 1840, p. 247), he alludes to the modified appear-
ance of these eruptions and ulcerations as they appear in mulattoes
and blacks, and relates some interesting cases,  showing that in these
they assume a whitish appearance.  The dusky-colored  spots  on
the skin were  surrounded by  whitish  circles, " the color of  the
white being lighter, and that of the dark deeper, than the natural
hue of the skin."  In the article from which we quote, Dr. B. states
that up to that time (1840), he had had under his  immediate care
35 cases of infantUe syphilis, and we have recently been assured
by him, that he has now treated some 60 cases, probably a much
larger  number  than has fallen to the share of any  American prac-
titioner.   We regret that our  limited space  prevents us from no-
ticing this contribution to  the  subject of Infantile syphilis more
fully, but we can only refer the reader to the essay itself, assuring
him that he will here find every point of interest and importance
connected with it, most ably discussed.—G. C. B.]
   In  infantUe  syphilis we seldom find the bones or their append-
ages involved.   Bertin quotes but the following case :
   " Pierre G.,  oet. 35 days, removed from la Maternite to our de-
partment on the 1st Jan., 1809, was attacked with a very severe
blennorrhagic ophthalmia, and tubercular pustules,  over nearly
the whole  surface of the body,  and a tumor the size of a pigeon's
egg over the left great trochanter, and a very considerable perios-
titis on the superior and posterior surfaces of the ulna.   The tumor
* Bouchut, loc. cit. 
462             VIDAL  ON VENEREAL DISEASES.
over the great trochanter continued to increase until the end of
January ; in February it began gradually to diminish, and towards
the end of the month it  had nearly disappeared.  Wishing  to
watch the efforts of nature in this case,  we prescribed no local ap-
plication.   We ordered mercurial frictions  to the nurse  every
second day ;  and on the second of March no' trace of the tumor
remained.  The periostitis in the fore-arm was more obstinate, and
led me to apprehend even an alteration in the bone; the motions of
the arm were very limited;  the child appeared to suffer; the in-
teguments became red; emollient cataplasms were applied, which
subdued the  inflammatory symptoms, but the tumor remained
stationary,  and the pustules disappearing  but slowly, we adminis-
tered during the month of March corrosive sublimate in doses of
one-twelfth of a grain, which remedy was continued for three months.
At the end of this time, the symptoms were all removed."*
   M. Laborie has related  another  case of  osseous disease, with
caries.  M. Bouchut remarks that he has seen many instances of
lesion of bone belonging neither to caries nor to degeneration of
the periosteum; it was characterized by  a premature hardening of
the long bones.  In infants born before  full term, or born dead,
says M. Bouchut, instead of finding the  bones soft, spongy, vascu-
lar, imperfectly developed  and easily cut with the scalpel, I have
seen the middle of the  tibia and the femur solid, compact, ebur-
nated, so as completely to resist the action of a cutting instrument.
He states, that he attaches  no imp6rtance to this modification in
structure, which still possesses sufficient interest to be noted here;
it  seems to indicate in the osseous evolution a degree of abnormal
and premature activity, on the part of the plastic secretions ob-
served in several other organs.  (Bouchut, loc. cit.)  Very possibly
these osseous lesions have no connection with syphUis.
   Chancre is still more rare if indeed it  has been at all observed
in the chUd.   Infantile syphilis, therefore,  is limited to the second-
ary accidents, and to the ophthalmia that I shall presently describe.
Some have established a connection between the form of the acci-
dent manifested in infantile syphilis and  the stage of the disease
present in the parents at the period of conception.   Thus, accord-
ing to this idea, parents affected with  a precocious syphilitic erup-
tion, will beget children with an erythematous eruption;  at a more
advanced period, as about the termination of the second stage of
syphilis, the  children begotten will suffer from the deeper seated
syphUitic eruptions, such as the tuberculata; at a still later stage,
they will produce only scrofulous children.  Observation has not
yet sanctioned this triple hypothesis.
   I cannot conclude my remarks on the symptoms without  notic-
ing purulent ophthalmia in the new-born child.   Certain it is that
this serious affection of the eye may be independent of all venereal
disease, that  it may proceed from atmospheric influences, and un-
fortunate hygienic conditions. But there are cases in which this

  * Bertin, Traite de la maladie venerienne chez les en/ants nouveau-ncs, lea femmea
enceintes, les nourrices. 
INFANTILE SYPHILIS.
463
ophthalmia bears too strong a resemblance to that described as one
of the accidents of blennorrhagia in the adult, to be here passed
over in silence.  Further, during my connection with the Lourcine
(nurse department),  I  constantly observed  this severe form  of
ophthalmia among them.  Now it is well known that the majority
of nurses at the Lourcine are subjects of the venereal disease.
   The symptoms of this ophthalmia resemble those of the blennor-
rhagic ophthalmia already described; tumefaction, redness,  dis-
charge, pain, protophobia, all symptoms common to both.  There
are, however, some slight differences worthy of note.  Thus, War-
drop has observed that the cornea itself is swollen, this membrane
in children being of a very spongy nature, the palpebral conjunc-
tiva is most tumefied and frequently forms a hernial tumor ;  the
tarsal circle, therefore, strangulates this membrane, and we observe
in the eye a phenomenon analogous  to that seen on the penis in
cases  of paraphimosis.   On separating the lids in the morning we
sometimes witness an escape of fluid; so abundant is  it,  and so
speedy its reproduction, that it forms a kind of jet whenever  the
child  cries; this fluid never escapes entirely;  a portion always re-
mains on the globe which can be detached only by injections with
an ear-syringe.
   This ophthalmia  generally appears  about the third day after
birth.  At the commencement of the attack the chUd shuns the
light; on separating the lids, the palpebral fining is observed to
be preternaturally red; it  has a villous appearance;  and on it
there  is formed a thin layer of whitish matter.  As the progress of
this disease is sometimes insidious and very rapid, the closest at-
tention should be given to the symptoms announcing the onset of
so serious an affection, in order that it may be at once arrested.  The
terminations of this malady resemble those of the purulent ophthal-
mia in the adult; with the exception that  death, which  is very
rare at the latter period, is in the child not an unusual result.  The
cornea is liable to be perforated by mortification and by ulceration;
but staphyloma is the lesion most frequently observed.
   Pathological Anatomy.—Under this  head I include the  lesions
which have been observed only on the cadaver.  As yet there are
no particular symptoms by which, during  life, they may be de-
tected.  M. P. Dubois  has  seen  lesions of the thymus gland in
several children born  of parents who themselves  presented  evi-
dences of constitutional syphilis.   Scattered  through the thymus
he detected small foci of inflammation and suppuration.   Exam-
ined under the  microscope, as yet these have presented nothing
unusual.
   In the lungs have been found lobular nodosities, with a grayish
plastic congestion and suppuration.    These nodosities resemble
those  of lobular pneumonia previous to birth, in the fact that they
often  coincide with the existence  of syphilitic pustules.   Ollivier,
Billard, MM. Cruveilhier and Husson  have advanced nothing  fur-
ther in reference to  the connection of these visceral lesions with
syphUis.   But M. Depaul  has gone so far as to assert that these
plastic nuclei were not the result of lobular pneumonia, but that it 
464             VIDAL ON VENEREAL DISEASES.
is  a particular lesion observed  only in Connection  "with other
syphilitic phenomena in the child or parents; in that case, being
a specific alteration  produced by constitutional syphilis. _ The
coincidence of these visceral with external syphilitic lesions in the
chUd, or infection on  the part of the parents, with  M. Depaul is a
sure criterion of their nature.  He has defended this doctrine m an
essay read before the  Academy of Medicine.  M. Caseaux, his  re-
porter, objects to the  conclusions of his colleague, believing that
these alterations  may result from inflammation not specific in its
character, and may therefore be  independent of the influence of
syphilis.  M. Caseaux here shows himself a decided anatomist.
He requires a lesion to prove the nature of its first cause.   M. De-
paul would  establish the fact by the preceding  and concomitant
circumstances of the case, &c.
   M. P. Dubois comes with facts and the weight of his authority
in support of the doctrine of M. Dupaul, who, however, has not
far outstripped the  actual state of the science. _  But, in the mean-
time, a practical question constantly arises, which -cannot be eluded
or postponed in the same manner as an academic question.   I have
stated that in such cases we must appeal to common sense, and
treat the parents as syphilitic, the treatment being attended with
no danger.  In tins manner we shall most generally prevent the
birth of syphilitic children. (Vid. p. 347.)
   We are indebted to M. Gubler for the knowledge we possess on
the subject of hepatic affections in the new-born chUd.  I insert in
this place the substance  of what he has  published on these affec-
tions.
   M. Gubler distinguishes a general and a partial affection of the
liver.  In the first  case, and when the  alteration is carried to its
highest degree, the gland presents a yellow color, quite  different
from that of the liver in its normal  state, and  resembling that of
certain flint-stones.   The natural appearance of the substance of
both lobes is completely lost, with the  exception that on the uni-
form yellow  base, by close  attention,  we  may  discover  a patch
more or less distinct  of opaque white grains, having  the  aspect of
hard grains of wheaten flour, together with dehcate arborizations
produced by the empty blood-vessels.
   " The liver is sensibly hypertrophied, globular, turgid, hard, and
with difficulty divided with the fingers, which tear  it without leav-
ing any impression on its surface.  Such is its elasticity, that, if it
be pressed strongly between the fingers, as  if to crush it, a cunei-
form portion  from its margin escapes,  like a cherry-stone, and re-
bounds on the floor; when cut, it grates beneath the knife like an
 encephaloid mass.  The incisions made into this altered liver are
 very clean, homogenous, and, owing to its  great consistence, very
 thin slices may be removed, possessed of a demi-transparence, which
 is found to a certain  extent in the portions of the  organ  naturally
 thin, as at its margin, and especially the prolongation which ter-
 minates the left lobe.
    " On pressing an incised portion of the liver, no blood escapes ;
 but  from the cut  surfaces there  oozes very abundantly  a limpid, 
INFANTILE  SYPHILIS.
465
slightly yellow-tinged  serum, which escapes equaUy in the end
though no pressure be made.  In  both cases, this tends to render
the organ less turgid and more flaccid, by which we might be de-
ceived if called upon to pronounce on the existence of the lesion.
This serous fluid  coagulates under the same  circumstances as
albuminous solutions, of which I satisfied myself in the following
manner:  having cut a portion of the liver into small pieces, I mac-
erated the  latter for some minutes in water, being careful to stir
it;  the clear liquid thus obtained, being afterwards exposed in a
tube to the heat of an alcoholic lamp, became turgid at the moment
of boiling, with flocculent layers having completely the aspect of
coagulated  albumen.  The fragments, when in turn boUed, became
hard, white, and opaque.
  " In one case where, three days after death, I endeavored to
detect the  presence of the sugar of diabetes, as demonstrated in
the healthy liver by M. C. Bernard, I  did  not succeed with the
double tartrate  of  copper  and potash.   The absence of a normal
product of secretion in an organ so profoundly altered, is not sur-
prising.  It may be objected to the experiment, that  its negative
results was owing to the length of  time which had passed  after
death, and that the saccharine matter that had previously existed
had consequently disappeared.
   " Such arc the  principal characters of the syphUitic alteration
of the liver when carried to  an extreme, such as were observed in
three of  our cases.   But this alteration may not always be so evi-
dent  and  so general; perhaps it  most  generally assumes  other
forms, which we will here consider.  Among these, the most com-
mon  is  distinguished  from the preceding  by  the degree of the
lesion, which besides remains undetermined.   Its characters, al-
ways much  less decided, arc sometimes so little developed, that
until the present  time, it has escaped the  attention of those not
prepared to meet with it,  and in the  future,  it wiU doubtless often
pass unnoticed, on which account it is the more necessary that we
describe the means of detecting it.   The liver, of smaller size than
in  the first variety, may not vary much from that which is natu-
ral ; it is firm,  without presenting the excessive hardness noticed
in the other cases, and it retains in part the color which we have
compared  to that of silex.   This yellow color is observed  more
particularly at  its  circumference, that is, in the  superficial layer of
the hepatic tissue,  and consequently along its anterior border.
The interior of the organ presents rather an indefinite color of a
yellowish  or brownish red tinge, more or less delicate.   No por-
tion of the parenchyma appears  perfectly sound.
   " At the same time, the liver  possesses a certain demi-transpar-
ence, which permits us to distinguish, at a little depth, the  grains
like those  of wheaten flour scattered through its substance.  These
opaque  points are here  much more numerous and firm,  and this
granulated appearance discovered on  attentively examining the
parts, seems to me to  be  one of the best indications of the  patho-
logical alteration, of which the liver is then  the seat.  Indeed,
these  opaque  grains in  the midst of the slightly translucid sub- 
466
VIDAL ON VENEREAL DLSEASES.
stance, reproduces to a certain extent the aspect of both substances
which contribute  to  form the hepatic tissue;  but besides the fact,
these grains are separated by very wide intervals, the surrounding
substance does not much resemble the essentially vascular weft of
the areolar spaces of the sound tissue.   Further, it must not be
forgotten that the Uver  presents very different appearances in in-
fancy and in later periods of life.
  " This gland, excessively developed in proportion to the size of
the chUd, preserves for some time a considerable relative volume,
which  afterwards gradually diminishes,  so  that it  is  actually
smaller at  the  end of the first month than  at the time  of birth.
Thus, in an infant at full term, which had indeed the liver of an
abnormal volume, the transverse diameter of this organ, measured
over the convexity  of its  superior surface, was six  inches; the
antero-posterior  diameter of the right lobe  four  and  one-third
inches; that of the left lobe, three and two-third  inches; whUst in
an infant of one  month, which appeared to me  large when com-
pared with the organ in subjects of that age, the transverse diame-
ter, measured on its plane  surface, was only four and two-third
inches.  The antero-posterior  diameter  of tne left lobe  scarcely
equalled three inches, that of the right lobe shghtly exceeding this
number.
  " At birth, the hepatic tissue  in color resembles  that of the
spleen,  and although its brownish-red  color  gradually  loses  its
intensity, it stiU remains sufficiently deep during  the early months
of extra-uterine life to distinguish  it from the yellowish hue be-
longing to the altered Uver, which, on the contrary, more nearly
resembles the natural color in the adult.   As  to  the transparency,
the reverse is true,  for  the liver of the adult is opaque, even m
thin shoes,  whUst that of the very young child i3 evidently trans-
parent under the  same circumstances, thus diminishing the value
of the character  of  the syphUitic alteration, if  the latter be not
generally accompanied with a transparency much more decided,
together with a more or less yellowish tinge.  This opacity of the
liver in the adult, compared with that of the chUd, seems to me to
depend upon two principal circumstances; first, on the predomi-
nance of the fibrous tissue, second, on the large proportion of fatty
matters accumulated in the proper ceUs.  The difference in the
latter respect is still more striking.
  " The granular aspect, and the appearance of the two substances
which result, are wanting in the Uver of the new-born  child;  but
they exist  in a decided  manner  at the period of life now under
consideration, that is, towards the end of the second  or third
month from birth.   Further, at  this age, the healthy Uver, when
incised  freely, discharges the  blood with which it is filled, a cir-
cumstance  which does noOiappen  in the liver that  has suffered
the morbid alteration alreadyHescribed.  The  anatomical diagnosis
of this  alteration appears to us always possible when the circum-
stances mentioned are taken into consideration.   It is well to be
acquainted with  a last cause of  error, which I proceed to notice.
When we press a portion of healthy liver between the fingers, at 
INFANTILE SYPHILIS.
467
the points where  pressure is made, the blood contained in the
capillary networks is  expelled, thus  causing the substance of the
liver to assume its proper color, which, as aU are aware, is of a
more or less yellowish tinge.  These yeUowish or tawny spots may
be mistaken for diseased portions in the midst of the normal tissue,
if unacquainted with  its true cause; but the hollow imprint left
by the fingers  or  any other  compressing substance, and particu-
larly the absence of a certain transparency, together with the pos-
sibility of causing the blood to return again by pressure, are so
many characters which may lead us to an accurate diagnosis."*
  Causes.—The new-born child may be  infected by the mother,
father, or the nurse.
  1st. Influence of the Mother.—Such are the intimate connections
existing between the mother and the foetus that the poison affecting
the one  must necessarily affect the other.  We have only to con-
sider the circulation of blood existing between the two, to be satis-
fied that the infection must be mutual.  Therefore we here see the
possibihty of transmitting constitutional Syphilis by the blood.
  The mother  may become infected before conception, or during
pregnancy.  In the first case the chUd is almost certain to become
diseased.  If the germ is not altered, the embryo, the foetus becomes
infected.  In the second case, where the infection of the  mother
occurs after conception, it has been asked if that of the foetus may
take place at any period of pregnancy.  To this we may reply,
that the nearer the infection of the mother is to conception, the
more reason will there be to apprehend that of the foetus.  But at
what period of pregnancy may these apprehensions cease ? This
point is  not yet determined.  The infection of the foetus after con-
ception may result from the infidelity of the husband or the wife.
When the husband is guilty there is less difficulty  in ascertaining
the period at which the mother and the child became infected, but
when the infidelity has been on the part of the mother the diffi-
culty is  greatly increased, and if the woman lack sincerity, may be
even insurmountable.
  The question has been asked whether it be possible for the foetus
to become infected during any of the stages of syphilis with which
the mother may be affected.  It is probable that the infection wUl
be more certain, more frequent during the more active stage of the
disease,  as, for example, when eruptions exist together with affec-
tions of the mucous membranes, and that these wUl be  the lesions
communicated to the child.   However, I believe that we are  not
warranted in asserting that a woman affected with  tertiary symp-
toms will not give birth to a syphilitic, but to a scrofulous child.
It is certain that parents laboring under tertiary accidents have
been known to beget perfectly healthy chUdren, as well as those
which were scrofulous, but it  is equally certain  that  they have
begotten those which  were  syphUitic.   Parents with  secondary
symptoms have produced simUar famUies of chUdren, and unfortu-

  * Memoire sur une nouvelle affection dufoie {Gazette Medicate du 24 Mai au 5 Juin,
1851. 
468
VIDAL ON VENEREAL DISEASES.
nately, those perfectly healthy have been known always to procre-
ate scrofulous children, or those whose prospects for life were very
doubtful.
  2d. Influence of the Father.—The question of the transmissibility
of syphilis by the father is involved in the mysteries of conception.
This point is still shrouded in obscurity.   Analogy, however, and
even certain facts, give us some encouragement for  its solution.
Thus, it is evident that the father may exert a very decided influ-
ence on the features, form, and moral disposition of the child; he
may also transmit to it his morbid dispositions, the germ of certain
diseases with which the mother  has never been affected.  We may
therefore suppose that syphilis may be transmitted by the father
to the child, the mother remaining sound, thus implying an altera-
tion of the sperm which vitiates the ovum.  This  supposition is
corrobated by the most authentic facts; they may be found in the
practice of all writers on syphilis, of all accoucheurs.   M. Ricord
himself has  lately stated^ to the  Academy of Medicine, that he has
treated a woman, who in  succession had two  syphilitic children,
although she and her lawful husband had never been diseased.
The  father  alone of these children (the  lover) was syphilitic*
Thus the  sperm was here  altered; it had  vitiated the ovum only,
the mother remaining in perfect health, as  before conception.
  The ovum may be vitiated by the father not only whilst certain
syphilitic accidents are manifest, but even after their disappearance,
at least while there is no external evidence of the existence of the
diathesis.  This fact is admitted by the most reliable practitioners.
It i_? expressed in the following letter in terms which admit of no
question.  Like every intelligent person, M. Lallemand addresses
himself to common sense.   lie thus writes to M. Baumes:
  " I find that you  have been rather too skeptical in reference to
the virus,  or at least, that  you have announced your opinion with
extreme caution.  You have, it is true, very well shown the diffi-
culties encountered in  attempting  to establish  many facts; but
there are still some, of which there can be  no doubt; for example,
when I see a father and a mother in whom no symptoms of syphi-
lis can be  discovered, (the father alone having previously had con-
stitutional syphUis,) begetting  four  children,  which  die, having
pustules and other symptoms of the disease; when I see the fifth
child covered with similar pustules when three or four months old,
and see this  child infect two  nurses; when I cure this child with
baths of corrosive sublimate and a mercurial treatment; in fine,
when after an anti-syphilitic treatment administered to the parents,
I see four other children  enjoy the most perfect health for  more
than ten years,  how is it possible to deny that the virus existed in
the sperm of the father, and that the poison has passed from the
child to the  nurse ?"
  The impression of the  sperm upon the ovaries  may be  such,
that not only wUl the first product be influenced by the sperm,

  * Vid. report of the discussion on  pemphigus of the  new-born child {Gazette
medicate, Sept. 20th, 1851.) 
INFANTILE SYPHILIS.
469
but still other products, and that too after copulation with differ-
ent men.  The following fact, recorded in several works on Syph-
ilis, and which  was observed  during my connection with the
Lourcine, will give my idea on the subject.  It is that of a woman,
whose  first  husband,  had  an obstinate attack  of constitutional
syphilis; from this  union she had one child, that died with the
most  evident signs of syphilis.  This same woman,  after the
death of her husband, was married  again to  a perfectly sound
man; she herself was healthy— that is,  there were no external
signs of disease—yet, four  years after her first marriage, and after
having had  connection with her second  husband, she was deliv-
ered of a child equally syphilitic with her first I
  This case appeared to me inexplicable, unnatural, and I confess
I should strongly have doubted it, had it not come under my own
observation, but  physiology has since taught me that it was in ac-
cordance with natural laws.  I have  learned,  indeed, that certain
females  may bring  forth children bearing a resemblance to the
first male with whom they  had connection, and  this too, when
they have long been separated from that male, and when they have
become impregnated by another male.   Indeed, in  the work of Mr.
Acton I read that a certain lord, residing in India, was desirous
of obtaining a race of horses with a cross of the zebra.  A mare
was covered by a zebra.   The result  was  a colt having very char-
acteristic marks  of  the zebra, among others, the black circles on
the legs and shoulders.
  This mare was afterwards separated from the zebra and covered
by horses; she was  three times with  foal, and each time the foal
bore distinctive  marks of the zebra, from which the  mare had
long been separated.  Thus, by  the act of the  first fecundation,
such had been the impression made on the mare, that not only the
ovum impregnated by the zebra, but the three others by the horse,
resulted in the production of zebras.  We know, besides, how
long a bitch of a good breed, impregnated at first by a dog not of
the same blood, will for two or three successive litters bring forth
a mongrel breed.*
  The following case shows the prolonged influence of syphUitic
infection on  the part of the mother.   It has been  published in a
 Eamphlet by M. Vassal.   The case is  that of a widow, C, who
 iboring under symptoms of syphUis,  was subjected to a thorough
treatment, under the influence of which she seemed to have recov-
ered.  Having married again, some  time afterwards, she had in
succession two chUdren, both of which died with evident symptoms
of syplulis.  The second  husband dying soon afterwards  from
typhoid fever, without having ever suffered from venereal disease.  C.
married for the  third time, and from this union she had twins,
which died  with evident  marks  of  syphilis; she was delivered
again of a fourth child, a male, which soon presented a corona ve-
neris, but which  soon became cured under the influence of a mer-
curial treatment And  yet, says  M.  Vassal, since her treatment,
' Vid. Acton, (op. cit. p. 412). 
470            VIDAL ON VENEREAL DISEASES
the woman C. has not ceased to enjoy good health;  she has had
no new symptom of venereal disease;  has communicated nothing
to the men with whom she has had connection, and yet she has
infected every chUd which she has brought forth.
  M. Cazenave, who has also reported this case,  notes a circum-
stance which can  leave no doubt as to the nature of  the accidents
under which these children labored, viz., the second child infected
its nurse.
  The most striking fact in this part of the etiology,  is that of the
transmissibUity of syphilis to the germ by the semen, that is, by a
product of secretion; a  fact admitted  by a partisan  of the Hun-
terian school, which denies the syphUitic  alteration of the products
of secretion!  Another important  fact is the following, also ad-
mitted M. Bicord, viz.:  the mother who escaped syphilitic infec-
tion after copulation with an individual  laboring under the vene-
real diathesis, this same mother who remained sound  after impreg-
nation, may become infected from  the foetus, the germ of which
has been contaminated by the semen of the same individual.*
  Thus, by an interchange facUitated  by the circulation existing
between the mother and the foetus, when the latter is syphUitic, it
may communicate the disease to the mother, as may the mother to
the foetus, when she herself is infected.  I beg  the reader to pon-
der over this fact of the ovum contaminated by the father, the mo-
ther remaining at first sound, and afterwards to consider the fact
of this mother who receives the infection  from the child she carries
in utero, which child likewise contaminates its nurse;  I beg the
reader to foUow the virus in its course, and afterwards tell me if it
is in accordance with these facts and  their philosophy to  assert
that the virus, when once the primary  accidents have been de-
stroyed, is impotent when removed from  the person infected;  that
when  once admitted to the circulation  it  is no longer  capable of
being transmitted!
  There  is  stUl another question.  Both husbands were sound,
they had never suffered  from syphUis  before the mother became
impregnated, pregnancy existed,  the ovum was sound, now can
this ovum become infected through the influence of the  father
alone, who may have contracted the disease during the pregnancy
of the mother ?  This point has not  yet been  determined.   The
negative may reasonably be inferred, and it is  supposed that for
the contamination of the  ovum, the  mother must  first become
infected.
  [Mr. Porter, in the Lecture from which we have  already quoted,
relates a case (Dub. Med, Press, Feb. 17,1847, p. 100)  which would
seem to settle this question in the affirmative.  The chUd was be-
gotten three months before  the father  contracted  the disease, the
mother was sound, except some spots of button  scurvy, yet the
chUd,  when born,  was syphUitic.—G. C. B.]
  3d.  Influence of the nurse  upon the child, and vice versa, and upon
iliose who have their earliest care.—The new-born  chUd may receive
* Vid. Acton, op. cit. 
INFANTILE SYPHILIS.
4H
from the milk of its nurse poison instead of nourishment, and it is
true it may infect the nurse.  Indeed, nurses  under the influence
of the syphUitic diathesis, and yet having no external evidence of
this diathesis, have communicated syphilis to sound chUdren, born
of sound parents.   In these cases the mUk has been the vehicle of
the poison.
  [Mr. Travers argues that as the  natural secretions, "by a most
happy economy," however they may deviate from a healthy stand-
ard, cannot be the vehicle of the syphihtic poison, so the mUk of a
syphUitic  nurse cannot  affect the  chUd, (Pathology of  Ven. Affec-
tions, Lond. 1830.)  But it is clearly proved, as we have already
shown, by abundant testimony, that contrary to  the opinion of
Mr. Travers, and the disciples of Hunter, the  semen of the syphil-
itic male may infect his paramour;  this law of Hunter  as regards
the natural secretions, can therefore no longer  be maintained.  Dr.
Colics, (op. cit. p. 385,) observes, " I have never seen or  heard of a
single instance in  which a syphUitic infant (although its mouth be
ulcerated) suckled by its own mother, had produced ulceration of
her breasts."  Mr. Egan (op. cit.  p. 317) remarks, that he can safely
vouch for the accuracy of the above statement, and similar testi-
mony is furnished by Mr. Acton, (op. cit. p. 419,) and Mr. Hennen,
(2Iilitary Surgery, p. 558.)—G. C. B.]
  It has been supposed, also,  that chUdren  have infected their
nurse by the saliva which they  have deposited on the nipple dur-
ing the act  of suckling.  Cases, however, tending to  show this
effect, it is well to add, are wanting in those details required to
carry conviction  to  the mind.   Yet they have  analogy in their
support; indeed, it is generally admitted, even by the most de-
cided partisans of the Hunterian school, that syphilis nf&y be com-
municated by the semen; now saliva and mUk are products of
secretion,  and like the semen may therefore become the vehicle of
the syphilitic poison.  I repeat that it is very difficult to establish
cases of infection by the milk and saliva,  independently of all ex-
ternal evidences  of the disease.  It is stiU more difficult to decide
in certain cases, when syphUitic symptoms  appear, whether the
nurse or nursling has communicated the poison.
  As to the infection of the nurse  by the child, presenting exter-
nal evidences of  the disease, nothing is  better proved, and cases
of the kind abound.  Ever}'- physician of much practice, and every
accoucher, especiaUy those who devote especial attention to the
diseases of children, are in  the possession of facts proving this
contagion.   They may be found in the works of writers on syph-
ilis who admit the transmissibility of the secondary accidents, and
even of those who reject this doctrine.  Thus Hunter has recorded
several cases of the kind.  The  following is an  analysis of the
first.  It is  copied from the work of M. Bouchut, who declares
himself a believer in contagion :
  "A chUd was accused of having infected its nurse.   The father
had had gonorrhoea two years before his marriage, and fourteen
years before the  birth of the chUd.  Both the first and second
chUd  were born healthy.  The third died at the end of the fifth 
472
VIDAL ON VENEREAL DISEASES.
month.   The fourth was born at the seventh month, scarcely cov-
ered with epidermis, affected with dysentery) and died almost im-
mediate!}'.  The fifth was born at the eighth month, of wretched
appearance, and in the  course of a  few days, the surface  of its
body, and the  interior of its  mouth, were  covered with vesicles
filled with a clear pus; it  died at the end of the third week; it
had been Tjonfided to the care of a nurse.  The latter, shortly after
the death of the. child, was  affected with ulcers on the nipple, swell-
ings in the axillce, very sore throat, without ulceration, followed by a
cutaneous eruption, with  loss of the  epidermis of the hands and
fingers, and onyxis, with  loss of the finger and  toe-nails."
  Hunter, says M. Bouchut. denies the existence of syphilis, both
in the child and nurse.   He attributes the ulceration of the fingers
and the loss of the nails in the nurse, to the influence of mercury.
But it is worthy of note, that Hunter, in denying the existence of
syphilis, is not  able to pronounce upon the nature of the disease.
But whatever else it may be, in his estimation, it was not syphUis.
  Here  is another case  from  Hunter.   It is taken from a corner
where, says M. Bouchut, it  is  very difficult to  find it; it is dis-
guised under the  title of diseases reovmbling syphilis.  Hunter had
aU the failings of  men bound down to systems, and who discard
whatever perplexes them.   A case is encountered which clashes
with  his theory, it is the case which is wrong, it is an aberration
of nature, according to these masters of nosology.*
   " A woman nursed two children, giving to her own the right,
and the other the left breast; at the end of six weeks the left nipple
ulcerated and was  finally destroyed; the ulcer healed three months
from the commencement of the accident.  Then, the strange child
became affected with shortness of breathing, aphthae in the mouth,
and  died from consumption, its body being covered with ulcers.
Soon afterwards  the nurse  was seized  with lancinating  pains in
different parts of  the body, and patches of eruption appeared on
her arrhs and thighs, several of which became ulcers; she was sub-
jected to a mercurial treatment.
   " Three years afterwards she  had a child, the epidermis of which
was  detached at  several points, the  body presented a squamous
eruption, and which died at  the end of nine weeks.   It had  been
placed under the care of a nurse; the latter, shortly afterwards, had
cephalalgia, pain in the throat, and ulcerations on her breasts ; she
entered a hospital, and* although treated with mercury, she left un-
cured at the end of some months.  The nasal and palatine bones
exfofiated, and some months  afterwards she died from consump-
tion.
   " The mother employed sea-bathing and the  Lisbon tisane.  The
ulcers on her arms and thighs were cured in the course of a month.
A year afterwards, she had  another very feeble child, which died
at the end of one month.  Finally,  ten months  afterwards the


  * I quote II. Bouchut here literally, to show that young and active members of
the profession are opposed to the Hunterian doctrines, for it has been charged that
Buch opposition is confined to those who are behind the age. 
INFANTILE SYPHILIS.                  473
ulcers reappeared, suppurated for a year, and at length disappeared
forever.
  " What," says M. Bouchut, " was this disease that passed from the
child to the Dreast of a woman, infected her  system, produced
lesions of the skin, and caused her to bring forth a child covered
with ulcers, which child infected another nurse, whose breasts,
pharynx, and bones become so deeply affected, that she perished ?
What was it, if it was  not.syphilis or a syphaloid disease, a term
which Hunter has sought without being able to find; for, in speak-
ing of this case, he thought that new poisons were daily formed
strongly resembling the venereal poison;  so that it was  not  from
their points  of resemblance, but dissemblance, that  he formed his
conclusions."*
  As might be supposed, this case of Hunter's, so opposed to his
doctrine, has found other commentators.  Thus, M. Cazenave re-
marks in his journals ;  " if we examine the ensemble of phenomena
in this  case, we see a woman  adopting a strange child to nurse,
and giving it in particular its  left breast.  Now, it was the nipple
of this breast that became the seat of the ulcerations which  com-
pletely destroyed the part affected.  These ulcers were  accompa-
nied with glandular enlargements in the axilla; and to abridge the
first part of  this history, the adopted child died with all the signs
of advanced cachexia.   Subsequently, this same woman brought
forth a second child, and confided it to another  nurse.  The child
died with a squamous eruption, which covered  its whole body.
As to the nurse, her breasts became ulcerated, she had cephalalgia,
necrosis of the nasal and palatine bones, and died cachectic.  Fi-
nally, to conclude this sad  episode, the mother of these two chil-
dren had a third, which also  died at the end of a month, and she
herself was cured only after many relapses, and a great variety of
treatment.   It is difficult not to recognize in this case a new proof
of the possibility of the infection of the nurse by the child, and
the indefinite transmissibility of  syphihs  in this  manner.  Like-
wise, with Babington, we cannot admit the merit  of the negative
argument drawn from the pretended  non-contagion of secondary
accidents.  It is upon the latter point, however, that writers of the
modern school of syphilis found their arguments for  denying
any  kind of infection than that by an unequivocal and primary
chaucre.f
  Babington,  the judicious annotator of Hunter,  admitting the
communication of syphilis from the mother to the chUd, and from
the latter to the nurse, comments, or, more properly speaking,
combats the views of his countryman, and that, too, with a great
number of cases proving this contagion.  He mentions with much
care the syphilitic phenomena observed  in  the new-born child,
infected by its parents, and does not hesitate to admit tlftt persons
thrown  into very intimate contact with a child  affected with this
disease,  may thereby become affected.   This  contagion, in his
* Bouchut, loc. cit.
\ Annates de la syphilis et des maladies de lapeau, No. for August, 1851. 
474             VTDAL ON VENEREAL DISEASES.
opinion, may thus take place to an indefinite extent.   Babington
beUeves (and  this should  be carefully noted), that it is at least
very difficult to deny that cases like those cited, by Hunter are not
the effect of venereal poison, even in admitting that, in children,
the symptoms of syphihs are not precisely the same in their pro-
gress  and aspect as  in the adult.   He believes, in fine, that it is
impossible  to  admit Hunter's argument, that secondary accidents
are not contagious.
  Finally, M. Bicord adds the following to the note of Babington:
  " I coincide completely with the views expressed by Babington;
only I believe that, as yet, we know not how to determine the ab-
solute nature of the accidents which may be transmitted from the
chUd to the nurse; and I believe also  that the accidents  reputed
secondary and transmissible, may at first have been primitive;  as
likewise, in  certain  cases, the nurse who  pretends  to  have been
infected by the chUd, may have otherwise  contracted the disease.
However it may be, in the actual state of the science, if this ex-
planation stUl leaves much to be desired to completely satisfy the
mind, there exists a great number of incontestible cases  of syphilis
transmitted from the child to  the nurse, and vice versa."*
  Of what consequence is  it that the  secondary accident of the
chUd was at first primitive ?  So long as it is actually a secondary
accident that is transmitted, the question is decided in favor of the
contagionists.   What if the nurse does  sometimes  unjustly accuse
the child, when it  is known that she  actually does occasionally
become infected from this source ?   Let us admit that these unfor-
tunate nurses  have  occasionally suffered much both in reputation
and interest from the doctrine laid  down by Hunter.  When they
have presented only secondary accidents, they have been told that
the primary had passed; when, from the  previous history of the
case, and a careful examination of the husband, it  has been  found
that the latter was  never affected with syphilis, then a lover has
been imagined.  All this certainly may be true, and I would not
guarantee neither ftie veracity nor the morality of every nurse.
But it is none the less true,  that some of them have been carefully
inspected before they took  the chUd, and  have  been pronounced
in perfect health, before  it would be  confided to them.   Yet I
have  seen nurses which had been thus examined and declared
sound, become covered with syphilitic pustules,  which they justly
attributed to the child, which had not been examined before quit-
ting its parents.  The foUowing is an instance of this kind that
cannot be questioned:
  " M. P., several days after a suspicious connection, discovered a
chancre on the prepuce.   During the first stages of this chancre, it
being yet undiscovered,  he had intercourse with his  wife, then
seven moflfchs advanced in pregnancy, and  communicated  to her a
simUar chancre.  I  treated both with  Van  Swieten's liquor and
sudorifics.  The husband was cured in twenty-five days ; the ulcer
on  his wife was also readUy cured, but there  followed coppery
* Notes to Hunter, 2d ed., p. 116. 
INFANTILE SYPHILIS.
475
papules on the forehead, and ulcers on the tonsils.   In the mean-
time, she was delivered of a chUd, to all appearance very healthy;
this child was placed under the care of a servant, who had  been
seduced and confined in a maison de sante.  This nurse, having
first been  carefully examined in the genital organs as elsewhere, pre-
sented no evidences of syphilis.   She was  constantly watched, and
went out only in company with the mother of the child. Eighteen
days after the birth of the child, reddish, elevated spots appeared
on  the nates, chest, and  cheeks; in the centre was a pustule; to
the pustule succeeded a roundish, characteristic ulcer; in a word,
they were true pustules of syphilitic ecthyma.  For twelve or fif-
teen days the nurse presented nothing new; but then some ulcera-
tions, with a grayish, irregular, cut out base, appeared  around
both nipples, a similar ulceration invading the commissure of the
lips; around the anus were  mucous tubercles, and there  were
furfuraceous coppery spots over different  portions  of the  skin.
Both were cured, in the course of forty-five days, by the syrup of
Cusinier  and Van Swieten's liquor, given  to  the nurse, and the
application of the sublimate baths to both nurse and child.  As
to the mother of the chUd, she was cured  by a continuation of the
same treatment which was resumed after her confinement."*
  Further, there is a comparison  to be made which seems to me
to settle the question of the transmissibility of secondary accidents
from the child to the nurse.  Even admit the existence of chancre
in the infant, as is maintained by the disciples of Hunter, yet it
must be acknowledged that it is very rare;  so rare, indeed, that it
would  be difficult to assign to it its most frequent seat,  and no
separate  description  of it can be  found.   For my part, says M.
Gibert, I  have never seen primary symptoms in the new-born
child.f  Now, compare the extreme rarity of these symptoms with
the frequency of infection of the nurse by  the chUd, a frequency
admitted even by my opponents,  and it must be  acknowledged
that in this contagion, the so-called secondary syphiUs plays the
principal part, it is that which is  most frequently communicated
to the nurse.
  In spite of these facts, and the admissions of the masters of the
Hunterian school, which  compel them to acknowledge, more or
less completely,  the  contagion of  secondary syphiUs in the child,
there are disciples of this  school who even yet defend the system.
Among these  we  may mention Mr. Acton, in England, and M.
Cullerier, the son, in France, both of whom  have written  against
this double contagion of secondary syphiUs from the  chUd to the
nurse, and vice versa.   The latter has fully expressed  his opinions
in a memoir read before the Academy of Medicine, based  on facts
which  have satisfied him that an infected child  communicates
nothing to its nurse, and that the latter, though fully saturated,
transmits  nothing to the chUd.  But these facts of M. CuUerier,
Uke those of Mr. Acton, have only a negative value; they  avail
* Baumes, t. i., p. 169, et suiv.
\ Manuel des maladies veniriennes, p. 817. 
476            VTDAL ON VENEREAL DISEASES.
nothing against the affirmative facts, which are very numerous.
They both pretend that, under certain circumstances, certain syph-
Uitic  accidents  are not transmitted.  Now, I doubt whether they
find a single person to dispute  this opinion.   In like  manner,
should one assert that, under certain circumstances, certain chan-
cres cannot be inoculated, surely no one would now contradict
him.  But this  does not prove that the same accidents,  under
other circumstances,  are not transmissible.
  M.  Cazenave, who is opposed to Hunter and his followers, men-
tions  in  his journal a  very  remarkable case, in which  a  sound
nurse suckled for three months  an infant likewise sound, after-
wards she received another diseased child to nurse, and, from this
date,  1st, the infection of the first  child removed to  its  mother;
2d, the infection  of this mother; 3d, that of a little  sister; 4th,
finally, the pregnant nurse becomes also diseased, and gives birth
to a child equally infected.
  "Now," observes M. Cazenave, "to this  curious connection of
facts,  to this succession of the phenomena of infection, so rapidly
foUowing the one upon the other, can there be two explanations ?
If we adopt the doctrine of the absolute non-contagion of secondary
accidents, we must accumulate  hypothesis upon hypothesis, com-
mencing with the supposition that  the nurse might have  been in-
fected by a primary ulcer existing in the second chUd, of the ex-
istence of which ulcer we have no  knowledge.   If we take into
consideration the great care with which the details of this curious
history were collected, the repeated  and persevering investigations
to which the infected individuals were subjected, there  remains
but one reasonable explanation.  The second chUd was the start-
ing point, the first chain only remaining unknown, in the  series of
 §henomena which commenced in the infection of the nurse and the
 aughter, 0.  The latter communicated the disease to her  mother,
who in turn gave it to an elder daughter;  finally, the  nurse gave
birth  to a child likewise diseased, even after she had submitted
to treatment, which, it is true, was incomplete.  One of the most
important features in this  curious  case should especially be re-
marked, viz., the identity in the impression of the phenomena in
the different individuals affected;  thus, in none was there  any
trace of chancre, but always, and at  all  points, it was the  mucous
tubercle.  Before dwelling upon this circumstance in detail,  I can-
not refrain from remarking that it is, in this respect, that  the case
differs from that of Hunter, both of which, it is true,  lead to the
possibility of the same fact, viz., contagion, but  under very  differ-
ent circumstances, in virtue of which contagion is necessarily more
constant in one than in the  other, and we shaU hereafter  see that
the explanation of the phenomena detailed in our case does not
conflict so much with the opinion of our opponents, if the latter
were not so fatally bound by their primitive syphilis.
  " FinaUy, we have also been struck with the kind of regularity
in the period of incubation.   Thus, in the nurse,  the syphilitic
symptoms became developed nearly in the same time as in the first 
INFANTILE  SYPHILIS.                  477
child, 0.; and in the latter, the period of incubation was much
about the same as that of the elder child."*
  M. Cullerier, the nephew, the worthy practitioner whom I  suc-
ceeded at the Hopital du Midi, was a contagionist.  He has pub-
lished as follows:
  " But if we mark  the  feeble power of contagion, possessed by
the consecutive accidents of syphilis, we do not pretend that they
are never communicated by  contact.   Well-authenticated  facts
show, on the contrary, that certain of them  may be thus trans-
mitted, and it cannot be absolutely affirmed that this observation
does not apply to others.
  " A genteel married woman presented herself at the venereal  hos-
pital, having a child ten months old, and gave the following state-
ment: I have never had the venereal disease, and my husband is  per-
fectly healthy ; ten months since I gave birth to this child, which
was strong and healthy.   I took a strange chUd to nurse ; it was ex-
tremely emaciated, and its body was covered with  an eruption
such as you now see.   Having no suspicion  of the nature of the
disease, I nursed that child  together  with my own; they  fre-
quently slept together, and wore each  other's garments.   I soon
discovered  that  my child was affected with  a similar eruption to
that on the foster child; and, although the mouth of the latter was
free from sores, yet large scabs  appeared upon  my breast, back,
and chest, some of which  are  still to be  seen.  The foster child
soon afterwards died, and it was  not untU my child  had become
greatly emaciated, that a physician who  was consulted, declared
that both of us had venereal disease.
  " The child was indeed in a deplorable condition, its whole body
being covered with a pustular eruption; the mother was similarly
affected, leaving therefore no doubt as to the nature of the  disease:
the nipple had never been ulcerated."
  Here, then, we have the case  of a chUd communicating syphi-
lis to its nurse and  to another chUd.  In the foUowihg instance
we see the disease still more widely disseminated.
  " Here is another case," says the same writer, " equally  in favor
of the contagion of consecutive accidents.  A woman was admitted
to the hospital, with two chUdren,one aged seven, the other eleven
years.  The following was  her story: I reside in the country, ten
leagues from Paris.   I have four children, all of which together
with their father and myself, have always enjoyed excellent health,
Eight months since, I took a foundUng child to nurse, two  years of
age; it was a wretched-looking  child,  and  had  pimples on its
body  and sore throat.  We permitted it to  take soup with  the
same spoon as ourselves, and to drink from the same glass.  Soon
one of my girls complained of a severe sore throat;  this increased,
and she died in about six weeks; the foundUng also died; soon
after this I began to suffer from an affection of the throat, as did
these two chUdren ;  their father suffered nothing, and to this  day
is perfectly weU.   A physician was called, and suspecting the ex-
* Annates des maladies de la peau et de la syphilis, loc. cit. 
478
VTDAL ON VENEREAL DISEASES.
istence of venereal disease, ordered frictions of mercurial ointment;
but the affection of the throat did not diminish, and I determined
to enter a hospital.
   " These three patients aU had an ulceration of the posterior wall
of the pharynx, supposed to be of syphilitic origin.   After a mer-
curial  treatment  of some months, they left cured;  but the eldest
child soon returned; having a pustular eruption over the whole
body, and was  at last cured by fumigations with cinnabar."
   These  cases  and opinions on the  transmissibUity of secondary
accidents may be found in the work of M. Lucas Championniere,
a work written, so to speak, under the supervision of Cullerier, the
nephew.*
   Analogous cases, I repeat, have likewise  been observed by al-
most every practitioner  of much experience.  I possess several
which are most curious.  The most remarkable, in my opinion, is
that of a little girl  in whom mucous tubercles existed in the
mouth;  she contracted them  from  a nursling which  her mother
had taken. This little girl was placed in one of the weaning houses
in the environs of Paris, where it was almost entirely neglected,
more attention being bestowed on others in consideration of the
remuneration given.   In this weaning establishment there was but
one tin cup for six little girls.  I know not whether she was the
intermediate one, but four of these children who were previously
sound, became  affected with mucous tubercles in the mouth, and
on the genital organs, one month after the arrival  of  the new
boarder,  of the syphilitic nature of whose affection  I had satisfied
myself previous to her departure for the country.
   Diagnosis.—The diagnosis of infantile diseases is  attended with
great difficulties.   The elements  required, indeed, exist not only
in the chUd, but in the mother, father and nurse.  Syphilitic erup-
tions in the child strongly resemble those in the adult.  But there
are some which  are analogous to other eruptions not syphilitic.
Thus,  M. Trousseau is of opinion that the yellow tint  is  more
common to the  eruptions in the child than  the coppery hue.
Those who have followed the discussions on  pemphigus in the
new-born child can appreciate the difficulties in deciding  upon the
nature of that  which is syphiUtic.   Some writers believe, that in
the present state of science, this diagnosis is impossible.  This,
however, I have  attempted to establish in describing this form of
eruption in the child.  According  to  M. Trousseau,  there is one
symptom or accident of great value in  forming the  diagnosis of a
syphUitic disease in the chUd; that is, the chaps or fissures on the
hands and feet.  This symptom  is seldom wanting, but unfortu-
nately it does not always exist.
   Certain affections of the mouth, as aphthae, or thrush, may im-
pose upon us for a syphilitic  affection, especially if accompanied
with a cutaneous eruption.  This mistake is the more Uable to  be

  * This work, indeed, is prefaced with a letter from Cullerier, which thus com-
mences: "The work which you are about to issue is the faithful expression of my
opinions on the nature and treatment of syphilis." 
INFANTILE SYPHILIS.
479
committed,  as certain cases of aphthae, not syphUitic, are conta-
gious.   The eruption must, therefore, be examined with the great-
est care, the parents should also be questioned and examined, so
that erroneous conclusions may be  avoided, which might lead to
the adoption of a mercurial treatment,  a practice in some cases not
unattended with danger.   When  the symptoms presented by the
chUd are doubtful, we should then  look to the suspicious source
of the malady in the parents; both  father and mother should  be
questioned and examined.  But the symptoms in the mother may
not always be evidently syphUitic, but obscure ;  stiU further, she
may be free from all symptoms, and in fact may never have been
infected.  If the accidents on the father have long been healed,
and  have disappeared, the practitioner may be left in the same
perplexity.   He may have an interest in conceahng the truth, and
may deny ever having had the disease.  Finally, a third person
may be the  guUty party, the legal father and mother being both
perfectly sound, and the infection of the child may be  due to this
third person, whom it is difficult to  discover.
  It is evident, therefore, in what obscurity the  questions con-
nected with infantile syphilis are involved.   And yet the physician
may be daily called upon to answer them, in behalf of the parents,
or of justice!
  I certainly do not condemn the conduct of those who require
the elements necessary to-eonviction, and I myself strongly suspect
the veracity and morality of persons, when it is for their interest
to deceive.   Yet, it must be acknowledged, that  in certain cases,
inquiries instituted by men placed  in favorable situations for the
purpose, may furnish results far more important for producing
conviction, than qualified scientific data afforded by a single symp-
tom only.  Thus, there are reputable country practitioners so weU
acquainted with  all that passes in their district, and who know so
well the standing of their families, that their testimony should have
the greatest weight in an affair of damages in which a nurse may
be concerned, especially if their only opponents are writers on
syphilis, who have been long wedded to a system now known to
be false.  Judicial  tribunals begin  to understand the too great
facUity with which nurses may be accused.  Thus, the tribunal of
Meaux  recently gave two hundred francs damages  to  a nurse
infected by her nursling, because two  trusty practitioners of the
county testified to the fact that the famUy of the nurse had received
the poison from the foster chUd, and this judgment was rendered
in spite of a certificate from M. Bicord denying the possibility of
such infection.*
  Prognosis.—The  prognosis in  infantile  syphilis is generally
grave, for a being tainted with  this poison at birth, is one whose
existence is seriously compromised.  But if, aside from the syphi-
lis, the child at birth is strong, and as the saying is, Uvely, if it is
treated early, the prognosis is more favorable, for a cure  is then
not unfrequently obtained; I repeat, if the child be treated early;
• Vid. Gazette des Hopitaux, 1851, and the work of M. Bouchut, p. 894. 
480
VIDAL ON VENEREAL DISEASES.
and I wiU add, well treated.  I should here observe, that the vis me li-
catrix natune in these cases is less powerful than in the adult.   In
the latter, it is not unusual to witness instances of cure which are
entirely due to  this power.  Such, however, is not  the  case with
the child;  a cure  in the case of the latter  without treatment is
exceedingly rare.  When the child at birth presents a miserable
appearance, and the mother is diseased and feeble, and when both
hygiene  and treatment have been  neglected  from  the first, the
prognosis should be very guarded.  These are the  causes of the
frightful mortality among children born with syphilis.
  M. Acton has remarked, in a mortality of three  hundred  and
three children from  this source,  that the most  fatal period  was
during the first ten months of life.  Frequently, if this period be
passed, they gradually waste away and perish before the end of the
year.  If, by the efforts of nature, by well-directed treatment, good
hygiene, the infant fortunately reaches the first  aniversary of its
birth, it will have many chances of being raised.
  Treatment.—In speaking of the treatment of the new-born child,
I cannot refrain from premising a few observations in reference to
that of the parents, for the latter is  sometimes the prophylaxis of
the  child.   During my connection with the Lourcine, and  my
charge of the nurse department  in that hospital, many of them
were pregnant, and these I treated precisely in the  same manner
as those who were not.  In cases of primitive accidents, I adminis-
tered the bi-chloride of mercury, according to  the formula of  Du-
puytren ; in the consecutive accidents, I gave the iodide of mercury,
and this too in the same doses  as to all my patients.  I never
observed that abortions were more common in women thus treated
than in those who refused to take it from fear of producing such a
result.  On the contrary, I am  convinced,  that when properly
treated with mercury in the early period of their pregnancy, they
miscarry less frequently, that their offspring will be less deeply
infected, and that, in  some cases, they wUl be free from syphilis.
Thus, I believe that pregnant women should be treated with mer-
cury as early as possible; it is  even a means of preventing abor-
tion, an accident especially provoked by the diseased state or death
of the foetus.  Now, the sooner the mother is rid of her syphilitic
infection the greater are the chances that the infant will escape,
and consequently that pregnancy will continue until full term.
   [Mr.  Langston  Parker  (op. cit. pp. 192,  193) has some very
judicious remarks on the treatment of syphilitic pregnant women:
" 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
alterative doses of this drug merely, and frictions with small quan-
tities of mercurial ointment every  two or three davs, leaving the
full treatment to be  commenced a month  after delivery."  Mr. 
INFANTILE SYPHILIS.                 481
Acton advises (op. cit. p. 429) that the female, under these circum-
stances, should be treated exactly as if she were in an unimpreg-
nated state.   " Observations on a large scale," he observes, "have
taught me  that the feara of the  surgeon who dreads to give the
pregnant woman  mercury, are chimerical."   Drs. Beatty, Evory,
Kennedy, and Egan, maintain that "abortion may be prevented,
and a healthy child  insured, by a judicious mercurial treatment
during pregnancy."   (Egan, op. cit. p. 291.)—G. C. B.]
  The father should be treated precisely in the same manner, that
is, in  accordance with the principles of therapeutics which I have
laid down.   The question on which writers on syphUis are divided,
is, whether in the absence  of aU evidences of the disease, the father
should be subjected to treatment  simply because the mother may
have miscarried.  It is necessary to distinguish here, if the father
has really had syphilis, if the foetus bears marks of this diathesis,
there  should be no hesitation in submitting the father to treatment;
for we know that the disease may remain for a long time latent, as
is proved by the relapses after long intervals.  Indeed, between
the two manifestations of the disease, we see persons enjoying the
best of health, and bearing on their body no traces of the diathesis;
but the latter does not the less exist; it wUl probably reappear at
a later period on the  same individual, his chUd or his wife.  We
should be guarded when the father assures us that  he has never
been syphilitic, except when we know that he has some particular
object in deceiving us.  In such a  case, the shrewdness of the
physician, and the confidence which  he knows how to  inspire in
the mind of the father, may be of great service to the family. .
   When a  child is born of syphilitic  parents, should the father be
treated ?   No, if there are no marks  upon him of the disease; for
it has been proved that venereal parents have begotten healthy
chUdren, which have been raised, without even showing the least
symptom of syphilis.  But chUdren of such an origin should be
carefully watched, in order that they may be properly treated upon
the very first manifestations of the disease.   They  should not
suckle their mother, for, whatever may be the opinions entertained
as to the alteration of the milk, it is acknowledged that it is better
that they should be nourished by a woman free from  the disease.
Indeed, if the mother's milk is not syphilitic, if it is impossible for
it to infect  the child (which is not established), it may suffer some
other change, from the contamination of the system, so as to afford
imperfect nourishment to the child, or favor the development of a
diathesis, the germ of which might have been destroyed by a more
healthy aliment.  There are  mothers, who, from economy or un-
easiness of their chUd, use the sucking bottle instead of committing
it to the  care of a nurse.   This, especiaUy in cities, is bad practice.
Children, I repeat, of such an origin, should be carefully watched,
and placed in the best possible hygienic conditions.  Now, as ah-
mentation  is here the basis  of hygiene, a  good nurse should be
selected for the chUd.  Should the chUd be born with symptoms
of syphilis, or if these symptoms appear shortly after birth, it must
be subjected to treatment, for, as I have already stated, if we do 
482            VIDAL ON VENEREAL DISEASES.
see adults become rid of unquestionable symptoms of constitutional
syphilis, without  any specific treatment, it is not the case with
children of a tender age.   Under the influence of hygienic care,
the symptoms may completely disappear; but they are certain re-
peatedly to return, after longer or snorter intervals, and with more
or less intensity until a fatal termination, which is then sure to be
the result.  In my opinion, mercury is our proper  remedy,  and it
should be administered directly.  I find that in tliis view of the
subject, M. Cullerier,  the  son, coincides.   This practitioner has
pubhshed an article in the Bulletin  Therapeutique, from which  I
have profited.   But as this mode of administration  is not adopted
by aU practitioners, let us  discuss the advantages of the direct and
the indirect employment of the remedy.
   The indirect treatment, or that through the medium of the nurse,
has been recommended by many writers on syphilis, or accouch-
eurs, who, fearing the effects of mercury on constitutions so  feeble
and delicate as those of infants at the breast, and exaggerating the
gravity of the possible accidents,  beUeve that they can avoid these
effects by medicating the milk of the nurse,  which is thus made to
serve, at the same time, for nourishment  and medicine ; those who
are afraid of the action of mercury on the mother or the nurse who
present no symptoms  requiring its use, cause it to be given to
goats and asses, on the milk of which the  child is fed.   Astruc,
Fabre, Burton,  Rosen, Faguier, Doublet, and Levret, declare them-
selves the advocates of this method of treatment.
   " Seeing," says M. Cullerier, " such great confidence in the in-
direct treatment, it is very natural to  conclude  that it is not the
result of reasoning alone,  but that it is based on researches  show-
ing the presence of mercury in the milk of the females or animals
to which it has been given.  This, however, is not true, and the
theory of the passage of the mercury into the mUk has long been
■regarded as merely an hypothesis, for a truly serious  chemical
analysis has never been made.  Many absurd notions have indeed
been admitted in reference to the action of mercury on the system,
and if it were possible to believe in its presence in different parts
of the system, or in the secretions, we  might, without proof,  admit
of it in the milk.   But let us glance at the  authors who have re-
ported cases of the kind, and see  with what confidence they inspire
us. ^ Thus, Petronius speaks of a syphilitic patient treated by mer-
curial frictions, in whose  urine  numberless globules of mercury
were seen to float;  Mussa-Brassavole having seen a patient on
whose arms and thighs mercurial  frictions had been made, attacked
with vomiting, was astonished at  the weight of the matter rejected,
and, looking in the vessel  with the expectation of finding a collec-
tion of thick phlegm, saw nothing but a large  quantity of mercury
which had been vomited;  Gabriel FaUope, who asserted that mer-
cury is found in quantities in the safiva  of patients affected with
mercurial ptyalism, and declares that  the way to arrest salivation
is to hold a gold ring in the mouth, to draw off the  mercury.
Assertions still more serious have been made,  and authors of some
renown, as, for example, TeUer and Buchener, declare that they 
INFANTILE SYPHILIS.
483
have detected the metal in the bUe,  blood, saUva, and urine of
venereal patients who had been treated with mercury; but these
assertions have been refuted by chemists of equal celebrity.   In
our own day, indeed, we find that M. Colson, in a well-written
memoir, published in the Archives de Medecine, for 1826, assuring
us that he has detected the presence of mercury in the blood of in-
dividuals who had taken it, whilst, on the other hand, an equally
conscientious  and skilful observer, M.  Devergie,  after various
attempts, could not succeed in detecting it." (Med. leg.)
  The question here  rested, and chemical analysis had as yet de-
tected nothing in the mUk, when  M. Peligot commenced  his re-
searches on the subject.   In the Journal des connaissances  medico-
chirurgicales, for November, 1836, he published a  memoir  on the
chemical composition of the ass's  milk, and in a passage where
he is treating of the mercurialization of this milk, he remarks:
"I have made numerous essays for the purpose  of detecting the
presence of mercury at first in the milk of an ass which had taken
five grains of corrosive  sublimate daily,  and afterwards  in the
milk of the goat to which twelve grains were given daily, without
any unpleasant results.   Notwithstanding the utmost care, and the
variety of methods employed, I could not detect the presence of
the mercury.  It cannot, however, be positively affirmed  that  it
may not be found in the milk of these animals; for the best pro-
ceedings for detecting small quantities leave much to be desired."
   M. Cullerier also made experiments, and took; the most favorable
position  for detecting the presence of mercury in the milk of the
female,  and of goats to  which he administered this metal.  He
was aided by druggists,  and  chemists, MM.  Lutz, Reveil, Per-
sonne.  He did not succeed, notwithstanding the utmost persever-
ance, in discovering  but infinitesimal  quantities of mercury, after
analyses made in the best manner possible.
   After these experiments, need we be astonished at the want of
success, and the fickleness of authors, who, at one time have con-
demned  the  direct treatment, preferring  that of the nurse, and
who have subsequently returned  to the former  method.   Thus,
Faguier and Doublet, who at first greatly lauded the indirect treat-
ment, afterwards retracted their praises, and without hesitation ad-
ministered mercury  to  infants.   It should be stated that  these
physicians were at the  head of a hospital established for the ex-
press purpose of carrying out the indirect method of treatment.
It was the Vaugirard, opened in 1780.  At this period, there was
a diversity of opinion in reference to the best mode of treating
children at the breast,  and no doubt was entertained  as to the
transmissibility of secondary accidents from the  nursling to the
nurse.  In this hospital were  admitted only nurses who were in-
fected or pregnant women equally syphUitic who were near their
accouchement; these  women, therefore, could suckle strange  chU-
dren  affected with  the  disease, without  risk, and could supply
them "with milk medicated by means of the treatment which they
themselves were obliged to undergo.
   Bertin, who had charge of the department aUotted to nurses in 
484
VIDAL ON VENEREAL DISEASES.
the Hopital des Capucins, was for a long time inclined to the indi-
rect method  of treatment; but  it is evident that his confidence
sometimes wavered, and he even acknowledges that,  under this
mode, the symptoms were only  mitigated or made to disappear,
with a certainty of reappearing.   He goes so far as to express his
regret that he  had not more frequently resorted to  the direct
treatment, for he had had reason to approve it.   As if completely
to contradict theories  in favor  of the indirect treatment,  some
writers still recommend this method, at the same time that mercury
is administered to the child, as  though such a compromise, says
M. Cullerier,  were not sufficient  to settle the value of this indirect
method.
   As to the treatment with the mercurialized milk of asses or of
goats, which might be  supposed to be more efficacious on account
of the larger quantity of mercury thus  administered at  once to
these animals, the researches of M. Pelligot and of M. Reveil, by
which no traces of it could be detected,  are certainly well calcu-
lated to dissipate such a fallacy (Cullerier).
   For my own part, I have never doubted the passage of  a  small
quantity of mercury into the milk, both of the goat and of the
nurse.  But my reason for rejecting the indirect treatment  is the
impossibility  of regulating the  quantity, or of giving sufficient
doses.   Now, in young infants, the progress of syphilis  is very
rapid.   We see children born of syphUitic mothers, having the
appearance of the most perfect health, in the course of four or six
weeks they are attacked with characteristic symptoms, which, in a
few days, assume a very serious  aspect, and, if the disease be ne-
glected, soon terminate fatally.  What confidence, in such  cases,
could we repose  in the indirect treatment, when the  milk of the
nurse contains  so insignificant a  proportion of mercury, and even
that only some days after its administration.   I repeat, the pro-
gress of the disease is very rapid.  The treatment, therefore, must be
energetic.  The best method  is to give the mercury to the child
itself, without any apprehension  on account of its enfeebled state.
   It may be objected, says M. Cullerier, that the  digestive organs
of these little beings are likely to suffer from the preparations of
mercury, so that their  doses  cannot  be increased.  But then, in-
stead of giving it internally,  it should  be administered according
to  the endermic  method, by  frictions and by  baths.  Mercury,
taken internally,  has rendered great services;  it has  been recom-
mended by practitioners too reputable, and is  stUl thus adminis-
tered by those of too  high standing, not to inspire confidence in
the results they profess to have  obtained; but surely this  method
can be indicated only in cases in which the progress of the malady
is less rapid than usual, and when the constitution is not yet be-
come too far undermined, or when, indeed, the disease, having
been arrested by the endermic  method,  there is some obstacle to
its continuance, the further administration of mercury being still
indispensable.  Corrosive subUmate  is the preparation generally
employed, and it  may be given in milk, 'syrup, or honey, in the
dose of a sixteenth, a twentieth,  or the  twenty-fourth of a grain. 
INFANTILE SYPHILIS.
485
  In the second division of this work, I have already shown how
feeble is the action of mercury on the mouths of children,  either
when administered  internally, or applied to the skin;  but the
chief risk to be apprehended from its internal use, is its deleterious
effect upon the stomach and intestinal canal.  Children have been
seen to  be  attacked with  very obstinate vomiting after  shght
doses, and  what, according to M. Cullerier, is  the predominant
affection, is enteritis, which destroys most of those thus treated.
  The following is the endermic method of employing mercury:
  The infant should be  bathed several times with water, for the
purpose of allaying  any excitement that may exist, and to render
the skin more favorable to  absorption ; fifteen grains of the Nea-
politain ointment is to be rubbed on the sides of the chest, towards
the axilla, the application to  be made on one side to-day, and on
the opposite to-morrow.  These frictions should be gentle, so as
not to irritate the skin; and they should be prolonged for several
minutes.   Twice a week they  should  be suspended, during which
the child  should  take a hot-water bath, to which from half a
drachm to a drachm of corrosive sublimate has been added.
  In children from two months to one year of age, the above treat-
ment is generally sufficient,  though  it  may be  necessary  to in-
crease the  quantity of the mercurial ointment  or  the corrosive
sublimate ; but when they have passed this age, the ointment may
without inconvenience be increased to half a drachm, and that of
the sublimate in the bath to one and a half drachms.
  M. Cullerier has but one objection to these baths,  and this is a
proof of their efficacy, viz., that when daily employed  they cause
the symptoms to disappear too rapidly, and that, both in hospital
and in city practice, the parents seeing no longer any evidence of
disease, are too ready to believe that the  cure is perfect, and they
discontinue all treatment, in spite of the instructions they may re-
ceive.  Well, what  then  happens ?  Why, that in trying to re-
move the symptoms in too great haste, the specific principle is not
destroyed, and we have relapses of a malady, of which, as it were,
we have only skimmed over the surface.
  It is very rare that frictions with the mercurial preparations
above mentioned, give rise to erythema or a vesicular eruption;
besides,  it  is obvious that in making  them on the sides  of the
chest, we  act on  a broad  surface, and  thus avoid the irritation
likely to be produced when made  on  the legs or thighs, with
which urine or fecal matters may come in contact.
  When there are mucous tubercles, or ulcerations secretions copi-
ously on the genital organs, or about the anus, (a circumstance not
unfrequent,) it is well to  touch them  occasionally with a solution
of nitrate  of silver, of the strength of one and one-half or two
drachms to eight  ounces of water.  If the discharge is moderate,
or the tubercles are  dry, lotions with  bran, marsh mallow, or elder
water, will suffice ; we may sprinkle the surface with starch,  farina,
or lycopodium, (club-moss,) and isolate them as much as possible
with dry lint, or charpie.
  When the face is  attacked,  and facial syphihtic impetigo is com- 
486
VLDAL ON VENEREAL DISEASES.
mon, the same lotions should be employed.   The parts being now
exposed to the air, desiccation is rapid, causing very fine  chaps
and fissures, which are very painful when the child cries or nurses,
on which account we should cover them as frequently as possible
with some greasy substance, cucumber ointment, simple cerate, or
cerate containing opium or calomel.
  M. Cullerier thus concludes:
  " The indirect treatment,  or that through the medium of the
nurse, is insufficient, in consequence of the smaU portion  of mer-
cury contained in the mUk, it is dangerous  from the loss of pre-
cious time in a disease of rapid progress, and which may speedily
terminate fatally.
  " The direct treatment only is effectual;  it may consist in the
internal administration of mercury, of frictions, with Neapolitain
ointment, or corrosive'sublimate, baths, means  best suited to the
condition of the digestive organs."
  Since I have described the symptoms of purulent ophthalmia, it
is proper that I should here allude to its treatment.   This does not
differ from that of the same affection in the adult; that is, we must
act directly on the parts, by the most energetic means, such as the
nitrate of sUver in substance.  Before resorting to this powerful
treatment, a great variety of more moderate measures have been
adopted, many of which have been attended with success, thus
showing that there are ophthalmic affections which are not of a very
serious nature.
  As before stated, the nitrate of silver is still the sovereign rem-
edy, if we  really possess a remedy  entitled to  this name, in the
treatment of a malady which is occasionally of a very grave char-
acter, and which terminates in the destruction of the organ.  The
cases reported to the Medical Society of Dublin by Drs. Kennedy
and Ireland, tend to inspire us with stUl greater confidence in this
remedy.  These cases are very numerous, and show that this oph-
thalmia is always cured in two or three days, by the following col-
lyrium, applied three or four times in the day:

                    $.  Nit. Argent. 3 iii.
                        Aq. Kos.    1 viii.

  Antiphlogistics may be employed at the  same time:  thus there
are cases where the active nature of the congestion, and the strength
of the  child, require the application of leeches.  Sometimes one
wiU suffice; if appUed to the upper lid, at  a point where the ves-
sels are much congested, it wUl discharge blood  copiously.
  Hygienic measures should not be neglected, cleanliness being,
in these cases, absolutely essential.  We should frequently inject
water between the lids, for there is nothing more irritating than
the matter  secreted by an inflamed mucous membrane; the contact
of this fluid with the cornea, is one of the most common causes of
its disorganization.  I am convinced, that if we can interpose and
maintain, without inconvenience, some soft substance between the
globe and the eyeUds, we may prevent, in many cases, the destruc- 
                    INFANTILE SYPHILIS.                  487

tion of the eye.   Thus a chUd affected with this disease should be
frequently visited for the purpose of removing  this matter which
tends to adhere to the globe of the eye;  occasionally a hernia forms
in consequence of the tumefaction of the exuberant mucous mem-
brane, and the  wound  is cauterized;  at first  it produces severe
pain, as manifested by the cries of the infant, but it finaUy subsides,
and the inflammation disappears soon after the reduction of this
hernial projection. 
PART  FOURTH.
PROPHYLAXIS  OF  VENEREAL DISEASES.
  I do not think that, at the present day, an author is justified, in
a moral point of view, in teaching the methods of preventing the
contagion of the venereal disease.  On the contrary, he should beg
the indulgence of the reader for the precepts which, under  this
head, he may inculcate.  What, indeed,  does he propose?  To
instruct the reader in the means of preventing infection.   Now, if
we sum up the whole  of our science, disinterestedly, there is but
one advice to give, and that is to avoid the source  of the poison.
It is evident that this advice cannot always be followed. We must
therefore seek other counsel, less certain, but more easy to be ob-
served, and with this view a private and a public prophylaxis have
been instituted.
   As to the  prophylaxis, in general, it may be said that folly, wis-
dom benevolence, and charlatanism have vied with each  other in
the effort.  Some measures may be found which it would be pru-
dent to follow;  others, again, are absurd and useless,^ or even haz-
ardous.  I shall notice only those which possess  some utility;
some there are to which I wiU merely allude, whilst others wiU be
passed in sUence, for I am not writing a satire.
                      CHAPTER,  I.

                PRIVATE PROPHYLAXIS.

  Two persons are here concerned;  one fearing to communicate
the disease, or distrusting himself; the other is exposed to infec-
tion and would prevent it.
  In the first case, that  is, to place such person in circumstances
least favorable to contagion, he should observe the utmost cleanli-
ness.  All the parts should be most carefully washed.  Here, the
chlorides, soaps, in fine every measure capable of acting chemically
or physically in altering or removing the morbid secretions, should
be  employed.  The parts should .be scraped (decaper), to use  an
expression now in vogue in speaking of syphUitic prophylaxis. 
PRIVATE PROPHYLAXIS.
489
  In the second  case, that  is, when a person is about to expose
himself to risk, precautions should vary, before and after the con-
summation  of the  act.
  Before the act, the parts should be minutely examined to ascer-
tain whether there is any solution of continuity.  The least fissure
surprisingly promotes contagion.   Previous to coition repeated
lotions with soap  are injurious, as  they deprive the parts of the
protection of the  smegma and mucosities, and render them com-
pletely naked,  thus placing them in a condition most favorable to
contagion.  Those practitioners who disapprove of these  lotions
before  the  act, do not regard in the same light those made some
time previously with solutions of alum, acetate of  lead, and parti-
cularly with aromatic wine alone or combined with tannin.   These
astringents  are preferable to fatty substances alone,  such as tallow
and  lard, which still  enjoy much reputation with  those who are
much exposed to the chancres of infection.  An intermediate sub-
stance, still more  efficacious, is the  condom already mentioned in
speaking of blennorrhagia; it is a small sack made of gold beater's
skin or the caecum of certain  animals, in which the penis is en-
closed.  It  should be well washed, new, and perfectly sound. The
condom, however, leaves the root of the  penis,  scrotum, genito-
crural  fold, and pubes, exposed, and the  pus of  a chancre may
reach, and  inoculate  these parts;  but it prevents, to a certain ex-
tent, blennorrhagia, and  affections of the glans produced by its
contact with the neck of the uterus, which, in my opinion, is the
most frequent  point of infection in  females.   The condom, there-
fore, is one of  the best measures of prevention; but its cost, and
the calmness  of mind required for its application, are frequent
causes of its neglect.
  Directions have likewise  been given as to the conduct during
coition.  Thus it is recommended that the  act be not  prolonged,
that it be hastened, useless advices  in many cases, for it is not al-
ways easy  to  prolong, and stUl less, to accelerate the act.   Ejacu-
lation has  also been advised, under the idea, that the sudden and
rapid passage  of  the  semen may  carry off the contagious matter.
Such advice, especially that respecting the rapidity of the act and
the ejaculation of the semen, has  been given by practitioners, and
this too without the least idea of the difficulty, in the way of com-
plying with such  directions.
  The precautions after coition  should be prompt and thorough.
It has been advised that the person should void his urine.  True,
when the bladder contains urine, and it is possible to pass  it, it is
a good practice,  for in passing through the canal, it may remove
the infectious  matter from the urethra.  Those who have phimosis,
may close the orifice with two fingers, and fill the preputial cavity
with urine, which as it leaves the urethra washes  the mucous lin-
ing of the glans and its envelope.   But what is of most importance,
is the application of lotions,  to which in the case of a female should
be  added vaginal injections.  These lotions should be  made  to
reach every part  of the mucous membrane;  every fold should be
inspected,  nothing should be  overlooked.   Circumstances  may 
490
VTDAL ON VENEREAL DISEASES.
occur in which it is difficult to carry out the measures here recom-
mended ; thus the necessity of retreating after the act, a false pride,
the fear of wounding the feelings of the person with whom they
have had connection, too  great confidence, or a state of intoxica-
tion, may all cause them to be omitted.  If one is so fortunate as
to be able to put the above plan into execution, there is a strong
probability that  contagion will  be prevented.  The proof of what
I have here asserted, is the immunity enjoyed by prostitutes, who
have already paid the penalty of their neglect by syphilitic infec-
tion.  It does not always depend, as M. de Castelneau has always
supposed, on a kind of syphilitic saturation; but is most frequently
the result of the precautions which these women take both before
and after coition, and the  applications of which they make such
frequent use.  This is one of the reasons why we do not find these
women  returning to special hospitals.  There is also another, and
of that  I speak  in another place; there are  females who though
registered, find the means of treating themselves, or of being treated
in houses of prostitution.
  Acids mixed  with water were  long  since recommended as ex-
cellent  lotions.  Thus, Lanfranc, in 1290, advised that the penis
should  be washed with vinegar and water.   The passage which I
quote from this author is remarkable not only in a hygienic but in
an historical point of  view, for it has been regarded as a proof of
the ancient existence of syphiUs.  It is as follows :  " Si quis vult
membrum ab omni  corruptione  servare  cum recedit a muliere quam
habet suspectam de immundicitia, lavet illud cum aqua aceto mixta:."
  After Lanfranc, Harrison de Gaddesden and Fallopius recom-
mended the use of urine and of wine, which has lately been highly
lauded  by  M.  Bicord, especially  the aromatic wine.  Peyrile
advises  the use of ammoniac, while M.  Malapert praises a solution
of the bi-chloride of mercury.  In England it is a common custom
to wash the parts with water rendered slightly caustic with soap
and  a few grains of fixed alkali, (carbonate of potash.)  Males
inject a  Uttle of  this solution into the urethra, which I consider a
bad practice, for the Uning membrane of the urethra is easUy irri-
tated, and the  injection  may produce an urethritis, which, had it
been emitted, might not have become developed.
  In Belgium, there is a decree  of the burgomaster, requiring a
flask of oU and a bottle of a solution of the sub-carbonate of potash
to be placed in each chamber of a house of prostitution.
  M. Ricord has made experiments to ascertain the action of cer-
tain  substances  on virulent pus.  When he inoculated this  pus
mixed with an alkafi or an acid somewhat concentrated, the results
of the inoculation were  negative.  These substances decomposed
the pus, not as some have supposed, in virtue of any specific prop-
erties, but by their power of destroying matter or organic pro-
ducts indiscriminately.  Sulphuric, nitric, hydro-chloric, and acetic
acids, and pure chlorides mixed with virulent pus  have also pre-
vented the success of its inoculation; whilst the  same subject, on
whom a pustule  was produced by pure pus, that modified by one
of the substances mentioned produced no effect, even though placed 
PRIVATE PROPHYLAXIS.                491
side by side with the first, and under the same conditions for suc-
cess, with the exception of the neutralizing agent.   The  same re-
sults followed the use of the alkaline caustics, such as potash, soda,
volatile alkali, wine, alcohol, and concentrated decoctions of tannin.
  All are aware of the pubhc experiments made by Luna-Calderon,
at the venereal hospital in Paris, for the purpose of showing the
prophylactic power of a substance which he had invented.   This
physician scraped or cut his prepuce, which wound he covered with
virulent pus.  If after this inoculation, his remedy was applied, no
chancre  followed; if not  appUed, the inoculation was followed by
a chancre and sometimes by  bubo.  Luna-Calderon  carried his
secret with him to his grave*
  M. Langlebert was more generous.  He beUeved that he had
invented a prophylactic, and immediately presented it to the pubUc.
It is composed as foUows:

  $.  Alcohol rectified to 40 degrees Cartier, or 95 Gay-Lussac, 3 x.
      Soft soap of potash with excess of base,                3 x«
  Dissolve and filter; then add:
      Essential oil of rectified citron,                       3 v.

  M. Langlebert thus relates his experiments:
  " On  Monday last, July 14th, I took pus from the surface of a
phagedenic chancre, with an indurated base, and immediately in-
oculated the left thigh of M. R.; then, steeping my lancet again in
the same pus, I scraped the right thigh, so as to remove, to a slight
extent, the epidermis and a part of the surface of the dermis.   This
being done, and wishing to place my proceeding under every pos-
sible disadvantage,  to satisfy myself I repeatedly dipped my lancet
in the virulent pus, and deposited it all warm and Uving as it were,
layer after layer, on the wound which I had made.   I then waited
five or six  minutes, when I applied my prophylactic.  The next
day the pus inoculated on the left thigh had produced its customary
effect: an inflamed pimple, already surmounted by a smaU vesicle,
appeared at the punctured point; whilst the  right thigh,  where
everything had been done to favor the action of the virus, there was
nothing but a small scab covering the wound which had been made.
  " This experiment inspired me with so much confidence that I
did not  hesitate to repeat it publicly.   On Friday last, July 18th,
at one of my lectures, I scraped the left arm with a lancet dipped
in the same pus, and the virulence of which I had proved by inocu-
lating a monkey, on which a perfect chancre  was developed.  I
immediately inoculated two  of my  students,  MM. Albanel and
Moreau, at their own request.   At the expiration of six minutes I
applied my prophylactic, and at the present time, July 21st, nothing
has appeared with  the exception of a small dry scab over the parts
scraped."!

  *  Vid. Demonstration pratique de la prophylaxie syphilitique, authentiquement con-
stat'->, by Luna-Calderon.  Paris, 1815.
  f  Vid. Lettre adressie It 22 Juilld, 1851, a VAcademie de medicine, par le docteur
Langlebert. 
492             VIDAL ON VENEREAL DISEASES.

  To form an estimate of the value of the prophylactic measures
indicated, two principal circumstances are required: 1st. When the
pus is deposited only on a sound surface; 2d. When there is a so-
lution of continuity or a local manifestation, an effect of the virus.
  It is evident that, in the former case, the mechanical action may
suffice; thus lotions with simple water may remove the matter and
prevent  contagion.  Everything  depends upon the  speedy and
thorough washing of the parts, in fine, on personal  cleanliness.
Alkaline or acid substances may be added to the water, as has been
already mentioned; or instead of these we may use aromatic  wine;
but I doubt their efficacy when used of feeble strength; they must
possess great  activity to  enable them to decompose the pus and
destroy the virus; they should resemble those which M. Ricord
mixed with the pus which he was about to inoculate, or their effect
will  be reduced to a simply physical action.  Water alone might
then be equally efficacious.
  In the  second case, that is, when there  is a solution of continuity,
and  the virus has already produced some effect, simple washing is
not  sufficient.  Then, the  measures proposed by Luna-Calderon
and  M. Langlebert, offer  the greatest pretensions.  I doubt  their
being true and certain prophylactics, for even if certain substances
can destroy the virulence of pus before it has been inoculated, and
whUe it  remains without the  tissues,  they may not possess this
power when it is inserted beneath  the  skin,  and has  already en-
tered the system.  Having  finished his  experiments on this sub-
ject, M.  Ricord  remarks:  "But if these  substances  may be re-
garded as prophylactics by the effects they produce before inocula-
tion, we  should not forget that it was only when the mixture had
been made at the very moment of inoculation;  for, when pus has
been, as  it were, implanted  in our tissues, and the latter have be-
come infected, unless the parts be destroyed by caustic, to a depth
exceeding that of the tissues contaminated, a chancre will be de-
veloped.   After the rigorous results of inoculation," adds M. Ri-
cord, "we cannot depend on the efficacy of the prophylactic meas-
ures mentioned,  except for  the purpose of destroying virulent pus
that has  been deposited on a sound surface, or temporarily to
destroy a virulent secretion  in an individual who, without it, might
have communicated disease.
  As  to the means proposed  by M. Langlebert, and his experi-
ments already mentioned,  they await the  action of a committee
appointed by the Academy of Medicine; on which account I for-
bear to prejudge them.  But it wUl have been remarked that only
six minutes passed between the inoculation and the application of
the prophylactic.  It is necessary, therefore, that it should be ap-
pUed at  once after contagion, wrhich may occur at the commence-
ment  of coition, and the latter be prolonged for more than six
minutes.   If  the  act is soon accomplished, and the prophylactic
immediately applied, it may then act only physicaUy, in removing
the  virulent matter.
  I should add, besides, that M. Ricord's cauterization is not cal-
culated to inspire great confidence.  In  treating of chancre and its 
            GENERAL  PROPHYLAXIS.—MEDICAL POLICE.       493

 treatment, in the first division of this work, I have shown how
 rapidly the virus may penetrate the system, and have mentioned
 the remarkable case of Professor Dumeril, who, stung by a viper,
 notwithstanding the  immediate suction  and cauterization of the
 wound by his son, suffered the general effects of the poison.   Now,
 it is well known, that the inoculation of the syphilitic poison has
 always been  compared to that of  the viper, the justice of which
 comparison has been particularly acknowledged by M. Ricord.  I
 believe, therefore, that this physician is not warranted in asserting
 that the cauterization of a wound inoculated with syphilitic pus
 will prevent the formation of a chancre ;  and that he is far from
' the truth in stating that this cauterization will prevent constitu-
 tional infection, for  he must have forgotten his observations on the
 rapidity of the penetration of the virus into the system, his general-
 izations upon its effects, and especially the advice that he has given,
 to cauterize to a depth  exceeding that of the parts contaminated, for in
 a moment the whole system is infected.
    We see, therefore, to what private prophylaxis is reduced;  it
 amounts, strictly speaking, to nothing more than an observance of
 personal cleanliness.  It should, likewise,  not  be forgotten  that
 most of the other measures proposed come under the shield of inoc-
 ulation, which itself is worthy  of but little confidence,  especially
 since it has  been clearly proved that the pus of chancre cannot
 always be inoculated,  and that there are individuals who possess
 the power of resisting the action of the most virulent pus.
    I liave nothing here to add in reference to the syphilitic vaccina-
 tion with chancrous pus, as proposed by M. Auzias, nor that re-
 commended by M. Diday, with the blood of an individual affected
 with tertiary symptoms, because I have already devoted sufficient
 space to this subject in my Introductory Remarlcs, and  because I
 have shown, in the second part of this work, that a person  may
 have syphihs several times.   We may have, then, experimental
 inoculation  and physiological  inoculation.   In speaking  of the
 possibility of being  infected with syphilis by inoculation, of course
 my remarks  are intended to apply only to that proposed  by M.
 Auzias, for that of M. Diday has been decided to  be quite harm-
 less ; it can do harm only by inspiring the person vaccinated with
 false security.
                     CHAPTER  II.

           GENERAL PROPHYLAXIS.—MEDICAL POLICE.

  In all ages, the authorities have watched over prostitution; they
have even gone so far as  to regulate it.  We  find  in  ancient
Greece, that at Athens, inspectors wrere appointed,  to examine into
the customs and dresses of the females, not, however, in a hygienic
point of view.   Rome,  which regulated so categorically houses of 
494             VIDAL ON VENEREAL DISEASES
prostitution, and which established a hierarchy among courtezans,
Kome, which  attempted to  repress the disorders produced by de-
bauchery, did nothing in the Avay of instituting a medical police
for prostitutes.
   In the middle ages we find new police regulations;  they are
now more severe, occasionally cruel, and nearly always inefficient;
thus, the whip, the confiscation of goods, and even banishment,
were in  turn  inflicted by Charlemagne, St. Louis, and the parlia-
ments, not only on the prostitutes, but on  the mistresses of the
establishments in which they were received.  It was at this period,
especiaUy during the reign of St. Louis, that the inutility and
even dangers of these measures became again manifested.   It was,
therefore, deemed more expedient to regulate prostitution.   Un-
der these regulations we may include those of the  London police,
by which  women  affected  with a  scalding  were driven  from
houses of prostitution;  regulations followed in Venice, in 1302.
At length those famous statutes of Queen  Jane were passed at
Avignon, statutes which have been  so often  praised, for women
were no longer driven from  their places of  abode, but  weekly
visits were ordered, and a  true  medical  police was  established.
Unfortunately these statutes  are apocryphal, as  shown  by the
researches made at Avignon by Dr. P. Yvaren*
   In 1449, Parliament  began to moderate  its severity; it  no
longer banished persons laboring under venereal disease, but made
an exception  in favor of patients which were poor and had no
home; for them it provided an asylum.  Finally, in 1536, infected
persons were no longer looked upon  as guilty, but as unfortunate
sufferers.  Parliament stUl relented even to such  an extent as to
show more humanity than the administrators of hospitals, the nat-
ural guardians of the sick.   Parliaments, indeed,  struggled with
these administrators for twenty-one  years, trying to obtain the
grant of a small hospital connected with the parish of St. Eustache.
What decrees, what injunctions, what threats were necessary to
procure shelter for a few suffering mortals!   At that time vene-
real patients were obliged to obtain fraudulent admission into the
Hotel Dieu.  Again were they banished.   At last a special estab-
lishment was opened  for them in the rue de Lourcine, and to the
magistracy were they indebted for this act.
   StUl it was was not untU 1684 that the treatment of these crea-
tures was ventured upon in a corner of the  Salpetriere,  at that
time a prison for prostitutes guilty of disorderly conduct.  Those
who were sick then received some attention, but what could they
avail when always preceded by the lash ?  And yet we find un-
fortunate females seeking an arrest with the hope of being sent to
the Salpetriere, and of there obtaining rehef of their sufferings.
The Salpetriere having become crowded, the Bicetre was opened to
venereal patients.  This soon  became as crowded  and unhealthy
as the Salpetriere.   The history  of  this period,  in  reference to

  * Vid. the notes of this physician, appended to his  excellent translation into
French, of the poem of Fracastor. 
           GENERAL PROPHYLAXIS.—MEDICAL POLICE.       495

what was required to  obtain admission, the number of patients
in a ward, the  hygiene of this ward, its mortaUty, is too horri-
ble for my pen, and I forbear; yet aU this happened after 1689,
an epoch most fertile in phUanthropic deeds and in charitable dis-
courses I
  Finally, in 1792, the Capucins were opened to the  unfortunate
subjects of syphUis; this asylum, at present the Hopital du Midi,
which I have seen in a very bad condition, was regarded as a for-
tunate abode, though the mortality was one in forty!   True, at the
Bicetre, it was one in ten!   However, it is from this  period that
the real progress in the treament and  hygiene of venereal patients
begins to date.   First of all, they  must be sought and isolated, so
as to withdraw  from society these  active  agents  of contagion.
Hence the idea of subjecting prostitutes  to a sanitary inspection.
The serious  apphcation of this idea dates from the ordinance of
1G57;  but those women only were  examined who,  detained at
the Salpetriere, had suspicious symptoms of the disease.   It was
necessary  to extend this ordinance so as  to  include prostitutes
at large.   This  project was formed by several lieutenants of the
police in the eighteenth century, but they did not dare to put it
into execution,  lest it  might compromise their authority in the
eyes of the pubfic, by appearing indeed  to favor the vice, by af-
fording  prostitutes the dangerous privilege of a certain security.
Finally, under the prefecture  of Dubois,  in 1800, this project as
well as certain others temporarily  required by the economists, and
always regarded as chimerical,  were actuaUy carried into execu-
tion.  From this time, we  have a  true medical police, since their
authority was not limited to the suppression of the vice, but  in-
cluded likewise sanitary considerations.   Two practitioners, Cou-
lon and Teytaut, were charged to visit periodically houses of pros-
titution, the expense being borne by the prostitutes  themselves,
who paid a monthly tax of three francs.   Even a consulting  hall
was estabhshed,  where females unable to  obtain admission to the
hospital, received advice and medicine gratuitously, thus permit-
ting them to be treated among themselves.   This establishment
received the name of Dispensaire de Salubrite.
  There is at present, in every town in France, a dispensary, but
the ancient  tax imposed on the prostitutes having been abolished
in 1818, the expense is borne  by the municipality.  Were I to
assert that these dispensaries are perfect, I should state that which
is absurd.  At these institutions the visits are generally made. In
Paris the prostitutes, living by themselves, are examined twice  a
month.   In many of the towns  they are visited weekly.  It is
necessary • that this  rule should never be violated, and that they should
never be treated by themselves.   When once it is known that a female is
diseased she should be removed at once to a special hospital, and there re-
main until entirely cured.   I  purposely underline  these remarks.
A number of females, of every occupation, whom poverty or de-
bauchery induce to  lead a life of prostitution, escape the police.
Here is one of the dangers of a medical  police, and yet these are
the women who infect the greatest numer of young men! 
496             VIDAL ON VENEREAL DISEASES.
  Girls in houses of prostitution are visited weekly, and whenever
they change  their residence.  When one is found diseased she
should be actually and immediately conducted to a special hospital,
and not fraudulently to another hospital.  They should never be
treated in these houses under the promise that they will not  have
connection during thci,. treatment.   Experience has  taught  us
what value to place on the promises of the mistresses of these es-
tablishments.  Every girl whose health there is reason to suspect
during the interval between the visits, should at once be taken to
a hospital and examined.
  The inefficacy of the medical police  arises, I repeat, from the
fact that certain girls are treated by themselves  and in  the houses
of prostitution, where they still scatter the disease; another reason
is that the visits are not sufficiently frequent, for the mean period
of incubation is four days; consequently, a woman who shall have
received the germ of the disease on the evening or day before the
visit, will appear to be sound and receive a certificate to  that effect,
and yet she will for seven entire days be capable of communicating
the disease to those who have connection with her.
  At these visits the girls should be examined with the greatest
care.   We should not be satisfied with that of the external organs
alone, but with that of the speculum we should explore  the vagina
and the neck of the  uterus.  The most convenient speculum for
this purpose is the bi-valvular instrument.   In some cases, it may
permit a portion of the mucous  membrane  to  portrude  between
the branches  at the time of their separation, and may sometimes
pinch  this membrane when it is withdrawn.  To obviate this in-
convenience,  it has been proposed to add two other valves, which
are easily united  and separated from it,  thus facilitating its intro-
duction.   -But a Uttle precaution and tact wUl render such  addition
unnecessary.
  The female should be placed upon a table in the same  position
as if to undergo  lithotomy, or she may  sit on an arm-chair, or Ue
on a bed; the legs should be flexed upon the thighs, and the latter
upon  the pelvis.  The speculum, well  oiled, is held in the right
hand; with the left  the operator separates  the  labia majora and
the right labia minora, an assistant separates at the same  time  those
on the left side.   If no  assistant be at hand,  the left middle finger
should be applied over the fourchette, whUst  with the other fingers
the labia are separated; the extremity of the closed instrument is
made to rest  upon the  middle finger in such a manner as not to
press  against the urethra and superior orifice of the vagina.   Dur-
ing the introduction of the instrument we  should be careful to
press  upon the fourchette so  as to efface a  small cul-de-sac which
exists behind it,  for  it  may obstruct the operation, or give rise to
pain if an attempt be made to force the passage of the instrument.
The vulvar ring  having been passed, the instrument is glided on
from below upwards  and from before backwards, and as  it passes
on towards the uterus, we examine the parts exposed.
  The vaginal waUs  applied against  the  instrument form a kind
of rose with an opening at its centre, and at its circumferance the 
GENERAL PROPHYLAXIS.—MEDICAL  POLICE.       497
  natural folds of the canal.  We know that we have reached the
  neck of the uterus by the absence of the folds and a change of
  color  in  the lining membrane, but more  particularly by the ap-
  pearance of the os tineas.  It is sometimes difficult to isolate it with
  the valves of the instrument, either on account of its deviation, or
  the particular position in which the female has been placed.  The
  examination is concluded by slowly withdrawing  the  speculum,
  by which proceeding the whole extent of the vagina is  again
  brought into view.  This second inspection  may sometimes expose
  lesions which escaped notice at the first examination.
    The subject of general  prophylaxis cannot be completed with-
  out referring to the means of preventing the spread of contagion
  by the male.  But if we have  already discovered  the difficulties
  attending the visits of inspection of the female, whom the laws, as
  it were, have placed at our disposal, what can we expect when we
  come to the male, to whom the right of visit does not extend.  In
  the army the case is different; there, discipline and subordination,
  and interests easy to be appreciated, have rendered possible the
  detection  of the malady,  and  the  immediate application of the
  remedy.   In  the first place, the punishment indiscriminately in-
  flicted on soldiers with the venereal  disease, on their  discharge
  from a hospital or infirmary, has been abolished, and thus soldiers
  no longer conceal the existence of affections which they suppose
  to be venereal;  they  can  now seek assistance from the surgeon
  without apprehension ; their cure is therefore more speedy, an ad-
  vantage both as regards their own health, and the propagation of
  the malady.                                         °
    The minister of war has recommended to the commanders in the
  army, and to the heads of the  administration, to unite with the
  civil authorities in opposing, to  every possible extent, the spread
  of a scourge so disastrous  in its effects to the public as well as to
  the army.   These recommendations have produced  beneficial re-
 sults but we could hope for stUl better, if the instructions were de-
 cided, simple and precise, so as to insure their execution
   In Belgium the medical inspector-general of prostitutes is di-
 ^hJnr°   ed+rth the heads of the venereal hospitals, and after
 each admission the name and residence of the person who has com-
 xZTont^TV™ ^  lacir*fr-  the inspector-
 general of the army, bearing date of December 21, 1842 M Vlem-

  e^tionldo fV^^^ ^^^ho^^Sto^
 regulation adopted m the garrison at Liege •                   *
    Every person found diseased, is immediately interrogated bv

 ordef irom^irUeh°ffifCerS  °f ^ ?"*"** ^WSffl £
 ?W.   ■   their/bief; a corporal accompanies  the patient  with
 ThisCOarnTSef t?0hcV0theresidence  &  *« « infaed
 exambS    A    ♦ ♦    dePosltlons>  a™te her, causes  her to be
 aduXl onf+lfBt ft a^PensarJ;  te furnishes the corporal with
 ffi ^°l't f^ ^tx W> the corporal takes fern to the
 In &f the document is delivered in custody to the surgeon
ment ^ T ^ ^dmd^ the health officer of the estaS
ment surrenders him at once to the person in command  No ve- 
498             VIDAL ON VENEREAL DISEASES.
nereal patient can be treated in the barracks.   Soldiers are severely
punished if they fail to make known  their attacks, as are those
who, by false statements, prevent the search for an infected prosti-
tute, but for those only.   The inspector-generals maintain frequent
communication with the physician in charge of the syphilitic wards
for soldiers.
   "Such," says M.  Vleminckz, "are the advantages of these regu-
lations,  that in  1845, out of a force of from  twenty-five to thirty
thousand men,  in the Belgian  army, there were but one  hundred
and fifty affected with  venereal disease, (one patient out of one
hundred and  ninety soldiers.)   There would not,"  he  observes,
"have been one hundred, if the sanitory  police at Gand and at
Namur  had acted efficiently."  M. Bertherand, who mentions with
approbation these regulations, adds: " Now contrast this with what
occurs in France!   At the venereal hospital  in Strasbourgh there
are daUy from one hundred to one hundred and fifty patients; if
we add  to this an  equal number of  cases of urethritis, and the
milder forms of chancre, treated in the regimental  infirmaries, we
find that eight  thousand men in garrison furnish, first, as many
venereal patients as are  found in the whole Belgian force; second.,
the sextuple proportion of one syphilitic patient  to thirty-three
men.  If we consult the table,  at the commencement of this work,
of cases treated in our hospital from 1836 to 1846, calling the price
of one day one franc, we shall find that the mean cost, on the budget
of war, of syphilis,  at Strasbourg, is nearly forty thousand  francs
per annum.
   " Why, in our barracks, is not the  head of department conjointly
responsible, to a certain extent, for the prevention of disease ? The
severe punishment of the venereal soldier  having been abolished,
the deposition of the brigadier or corporal has lost  all its odious
character.  Their repugnances once overcome, it well be easy to
make men of standing, like the  heads of department, understand
that it is as much for the morality and dignity of the  corps to de-
tect a soldier that would conceal the venereal disease, as one affect-
ed with the itch, or any  other contagious malady.
   " With false notions of hygiene, the soldier should no longer be
shut out of pubhc houses, known and examined, and be reduced
to the resources of clandestine prostitution.   Surely it is better to
overlook visits to the former, and redouble our vigilance as regards
these private women, in which all large towns abound.   Females
who are not subjected to examination, who have a thousand plans
for escaping sanitary visits, are the most dangerous  of all pros-
titutes.
   "The measures proposed by the inspector-in-chief of the  health
of the army in Belgium, supposes  perfect harmony and constant
intercourse between the local authorities  and the officers in com-
mand, aided by the army surgeons.   With us, the  number of in-
termediate agents impede the progress of  matters, if they do not
render it impossible by  the obstacles they present, and the disgust
which they inspire.  The distribution of the corps, the  frequent
changes of the health officers,  do not allow them to estabUsh with 
           GENERAL  PROPHYLAXIS.—MEDICAL POLICE.       499

special physicians, the intercourse indispensable to success in pre-
venting the spread of the venereal disease."*
  I here terminate my remarks on  prophylaxis, stating  that the
idea of obtaining from each patient admitted into a hospital, and
every practitioner consulted, the name and residence of the parties
who communicated the disease, and that of granting to every phy-
sician authority immediately to arrest such person—ideas partly
carried into execution in the Belgian army, would, if adopted in
civil life, produce the most happy results.   But I touch here upon
a delicate question, which I propose hereafter to discuss in a man-
tier commensurate with its importance.

      * Bertherand, Precis des maladies veneriennes.  Strasbourgh, 1852.
THE END. 
 
 
 
 
NLM041424069