X^S^ KC3S 2U.A.t..m~,~: W iO ADVltBIl IVNOIIVN 3NOI01W iO A IIV I « I 1 IVNOIIVN 1 N 13 I Q 1 W JO ABVRBI1 IVNOIIVN > io Aivaan ivnoiivn 'mijioiw to Anvaan ivnoiivn inokmw to Aavaan ivnoiivn LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE Y LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE l> dO AaViail IVNOIIVN 1NI3IOIW dO UVmil IVNOIIVN 1NI3IQ1W dO AHVaBII IVNOIIVN 3 pl m. A COMPLETE PRACTICAL TREATISE ON VENEREAL DISEASES, AND THEIR IMMEDIATE AND REMOTE CONSEQUENCES. INCLUDING OBSERVATIONS ON CERTAIN AFFECTIONS OF THE UTERUS, ATTENDED WITH DISCHARGES. BY WILLIAM ACTON, LATE EXTERNE AT THE FEMALE VENEREAL HOSPITAL, PARIS. THIRD AMERICAN EDITION, WITH ADDITIONAL ILLUSTRATIONS AND COLORED PLATES NEW YORK: J. S. REDFIELD, CLINTON HALL, CORNER OF NASSAU AND BEEKMAN STREETS. 1850. YJCft Amc TO PHILIP RICORD, D.M.P. SURGEON TO THE VENEREAL HOSPITAL, PARIS ; LAUREATE OF THE INSTITUTE OF FRANCE, &C, &C, &C. My dear Sir : Europe may admire the genius of the author of the " Traite Pra- tique sur lTnoculation," the British critic may call you the French Hunter, and the Institute may crown you with its laurels ; but the pupil who, for a series of years, has watched you at the bedside, performing the varied experiments which are overturning long-received opinions, and collecting those facts which form the basis of a new school, can alone adequately feel, and sufficiently appreciate, that honest and manly candor which is always ready to acknowledge errors, and that generosity which allows others to participate in opinions still unpublished. To have acquired and still to retain the friendship of such a man, will always be a source of pride and satisfaction—feelings which have been not a little increased by your kindly permitting me to in- scribe this volume to you, and thus affording me an opportunity of stating to my countrymen the friendly relations which subsist be- tween us. Believe me, my dear Sir, To be your grateful friend, WILLIAM ACTON. 5, George Street, Hanover Square, March, 1841. PREFACE. Among the valuable works and monographs which the English language possesses on the subject of this treatise, a surgical lecturer would be embarrassed in selecting or recommending any one book as affording a complete view of Venereal Diseases. Volumes en Stricture, Syphilis, Gonorrhoea, &c, fill his shelves, and each work has its peculiar recommendations ; but, with the exception of Astruc and Hunter, he will in vain inquire for the authors who have treated on Venereal Diseases at length. The pupil who wishes to investigate this subject, is obliged to consult a variety of works, and he soon finds himself embarrassed by the most glaring contradictions between contemporary or preceding writers, and the limited number of cases that come under his obser- vation does not allow him to separate what is truly valuable from among the chaotic mass of authorities. The author has attempted to fill up this blank in medical literature ; he has consulted the principal authors that have written on the sub- ject ; he has retained what is practical, and from the extensive op- portunities of observing the natural history of the disease, and the various plans of treatment in British and Continental hospitals, he hopes to have succeeded in reconciling some of the apparent incon- sistencies of previous writers; and in presenting a body of doctrines compatible with the present advanced state of Pathology. Once for all, he pleads guilty to the charge of introducing some few terms new to English readers, and leaves them, in the words of Johnson, " Candidates or probationers, which must depend for their adoption on the suffrage of futurity." Let the critic suspend his 6 PREFACE. judgment upon them until he be in possession of the reasons which induced the author to attempt to alter the nomenclature of his sub- ject. Although fully aware of the truth of the observation of Hooker, that " change is not made without inconvenience, even from worse to better," still he has not dared to preserve terms sanctioned by their antiquity, " such as hernia humoraiis and condylomata," at the expense of rendering himself unintelligible. The reader will find a very copious Analytical Table of Contents, which, it is hoped, will at once explain the system followed, and enable him to refer to any subject he may wish to investigate. The author can not but refer with pleasure to the illustrations ; and hopes that being the first of the kind that have ever been published in England, they will meet, with the approbation of the profession. The original drawings, he feels confident, bear the stamp of their own value as true copies of nature, and he has only to add that tbey were chosen from among the thousands of cases witnessed at M. Ricord's Clinique, and submitted to his approbation. He has spared no expense in securing the assistance of first-rate artists, as the exe- cution of the plates proves. He would ill requite the favor that has been shown him, did he not publicly acknowledge how much he is indebted to the scientific liberality of the administration of the French hospitals, as well as to the surgeons of the female venereal institutions, in placing the patients at his disposal; thus affording him unexampled opportunities of studying female complaints. How far he has profited by suGh op- portunities the Plates themselves will testify ;—bow deeply he is indebted to the officers of those institutions, no words can express. ANALYTICAL TABLE OF CONTENTS. INTRODUCTION. HISTORY OF VENEREAL DISEASES. Reasons for supposing that venereal diseases were known to the ancients; historical documents cited to prove this position from Leviticus, the Proverbs, Ecclesiastes; quota- tions from Peter Paul Vergerius, Gulielmus de Saliceto, Bartholomew Glanville, Lan- franc of Milan, Bernard Gordon, Petrus de Argeleta ; notices by Beckett in the Philoso- phical Transactions; quotations from John of Gaddesden ; different terms by which the disease was known at the commencement of the sixteenth century ; first called venereal disease by Bethencourtj description of the disease by Fracastorius, as seen in 1530 ; extract from the writings of Fernel in 1548; first methodical account of the effects of the disease given by Astruc ; summary of that author's opinions ; analysis of John Hunter's views; those of Benjamin Bell; opinions of "Broussais; investigations of M. Ricord; divisions of the subject which he adopts. [Page 17. History of the Theories entertained on the Nature and Origin of Vene- real Diseases.—Slight allusions in the sacred writings; opinions of the Greek and Latin authors ; theories of the thirteenth century; origin attributed to sidereal influence toward the fifteenth and sixteenth centuries ; opinion of. Van Helmont; general belief at that time that the venereal disease was unknown previously to the taking of Naples ; opinion of Astruc, Sanchez, Hunter, and Broussais ; belief in the spontaneous origin of venereal disea.ses; opinions of M. Ricord and the author that syphiloid diseases, or non-virulent affections, may arise spontaneously, and that syphilis or the virulent affec- tions never arise spontaneously at the present day ; origin of syphilis not known; similar ignorance as to the origin of other morbid poisons; probable causes of the aggravated forms in which it is generally met with. [p. 23. PART I. SYPHILOID DISEASES. CHAPTER I. BLENNORRHAGIA. Definition of syphiloid diseases ; meaning of the word blennorrhagia ; synonymous terms ; reasons for prefeiring the term blennorrhagia ; observations on blennorrhagia as it occurs on all or any of the mucous membranes ; predisposing causes; age; sex; opinion of M. Lisfranc : influence of temperament; locality; season; hygiene. [p. 27. Exciting Causes.—Various articles of food ; influence of onanism ; local irritation; various eruptions; syphilis (secondary) how fur an exciting cause ; case illustrative of labor; inattention to cleanliness; menstruation; worms. Reflections on the fore- going causes. [p- 30. 8 ANALYTICAL TABLE OF CONTENTS. Contagion: definition of; influence of; habit as a protection against the disease; case illustrative of this view; the medical man must not be too credulous; form of certificate that a surgeon may be called upon to give. [P- 35- Epidemics of Blennorrhagia.—Description of one; how far deserving the name ; on the time that elapses between the action of the cause and the occurrence of the affec- tion ; case cited by Bell; explanation of. [p: 36. Symptoms.—Local symptoms ; characters of the discharge ; course of the affection; may terminate in ; metastasis; resolution; continuation under the chronic form. [p. 37. Pathology of Blennorrhagia.—Simple increased redness; excoriation; granu- lation; ulceration; references to the plates; recurrence of the disease. [p. 39. Complications.—Local swelling; buboes; hemorrhage; chancre; constitutional syphilis; rheumatism. [p. 41. Diagnosis.—Of the position of the affection derived from the secretions; their chymi- cal characters; physical characters; value of blood in the secretion, asR sign of the complication of chancre ; of semen; diagnosis of mind and virulent blennorrhagia; consideration of the previous opinions on thjs subject; buboes ; morality of the female ; color of the discharge ; the duration and acute nature of the complaint; induration; pain, &c, along the canal; M. Ricord's researches on this subject; inoculation the only sure sign ; means of forming a rational diagnosis. fp. 42. Prognosis; dependence upon the mucous membrane affected; influenced by the duration of the complaint; previous attacks; complications, &c. The probability of secondary symptoms ; of swelled testicle occurring after peculiar treatments considered; the circumstances which indicate that the complaint is contagious ; rules to be followed ; line of conduct the surgeon ought to adopt in delicate affairs. [p. 47. Treatment.—History of the various plans that have been recommended ; the opinion of the humoral pathologists; when and why mercury was used; treatment recom- mended by Sydenham; Bell the first to propose a direct treatment; division of the sub- ject of treatment:—1. prophylactic ; 2. abortive ; 3.*curative. [p. 49. Prophylactic Treatment.—Precautions to be taken, 1st, by diseased persons, so that they do not communicate the disease to healthy individuals; 2d, by a sound in- dividual who exposes himself to the contagion. [p. 51. Abortive Treatment.—Reasons for employing it; the objects we wish to attain; general means ; direct or local means. fp. 52. Curative Treatment.—In the acute stage ; remarks on the application of leeches; baths; injections; diluent drinks; in the chronic stage, or blennorrhcea; revulsive general treatment. [p. 54, Copaiba.—Therapeutic effects of; action on the stomach ; intestinal canal; urinary organs ; skin ; nervous system ; the dose of copaiba necessary; administration by the rectum; various forms under which it may be given. The copaiba, capsules; their advantages; preference shown to those of M. Mothes ; dose ; rules to be followed in the administration. [p. 55. Cubebs.—Action on the stomach ; ill effects which sometimes follow its administration; the dose of; manner of administering it; capsules of cubebs; action of cubebs on the urinary organs ; notice of turpentine ; tonics ; blisters. fp 59. Direct Treatment.—Enumeration of the preparations in use. [p. 60. CHAPTER II. observations on blennorrhagia in the male. Section I.—Balanitis.—Synonymous terms; definition ; causes; influence of the prepuce. [p. 61. Symptoms.—Circumstances which may render the diagnosis difficult; course and termination of the complaint; complications; secondary symptoms never follow simple balanitis; causes which have induced authors to form a different opinion. fp. 62. Diagnosis.—Difficulties that may present themselves; importance of inoculation, f p. 64. Prognosis. \p. Si. Treatment.—In simple cases; in inflammatory affections; treatment of the complica- tions ; observations on phymosis ; indications for the employment of cauterization and incision. [p, 64 SECTION II.—Gonorrhoea. Synonymous terms; reasons for retaining the term gonorrhoea. rD gg Cannes.—Individual circumstances which predispose to Konorrhcea; influence of a large meatus urinarius; mechanism of the introduction of the contagious matter- the situation of gonorrhoea. r' 66 ANALYTICAL TABLE OF CONTENTS. 9 Symptoms.--Cause of the dysuria, chordee, &c.; observations on the divisions of gonorrhoea, as described by Bell; reasons for not adopting them. [p. 67. Diagnosis.--Of a simple case ; difficulties that a surgeon may meet with ; means of ascertaining the exact situation of the affection ; importance of becoming acquainted with the exact seat of the disease, as foretelling the probable complications. [p. 68. Complications.—Abscess; inflammation of the prostate ; buboes; balanitis; chancre ; immense practical importance of a knowledge of this complication. [p. 68. Chronic Goxorrhcea or Gleet.—Symptoms.—Nocturnal pollutions; influence on gleet; inflammatory stricture. Impotence—causes of; treatment of nocturnal pollu- tl0?f [p. 69. Ireatment of Gonorrhoea.—The abortive treatment; general and local means; plan of employing injections; position of the patient; sort of instrument; quantity of fluid; consequences which follow injections ; strength of the injection; other plans of employing injections ; method recommended by Mr. Carmichael of Dublin; the reason why they have fallen into disrepute; injections do not occasion strictures; when arose this belief; proof that injections cure stricture. [p. 71. Curative Treatment of the Acute Stage of Gonorrhoea.—General and locai treatment; treatment of complications; chordee; retention of urine; abscess; hemor- rhage ; inflammation of the neck of the bladder ; chancre; buboes. [p. 75. SECTION III.—Epididymitis. Synonymous Terms—from Sir A. Cooper, Sir B. Brodie, Wallace, Rochoux, Ri- cord, &c. [p. 78. Symptoms first met with in the epididymis; condition of the gonorrhoeal discharge; manner in which the other parts contained in the scrotum become successively attacked ; constitutional symptoms. „ [p. 79. Pathological Anatomy.—Cases cited by authors to prove that the affection is principally confined to the epididymis. [p. 80. Causes.—Predisposing ; exciting; period at which the exciting cause acts; the great importance of statistics in a therapeutical point of view. fp. 81. Complications.—Enumeration, and their relative frequency ; rarity of affection of the testis itself. fp. «2. Terminations.—Their importance and relative frequency. [p. 82. Diagnosis.—Cases which present peculiar difficulties; instance of epididymitis occurring when the testis was in the canal; all authors agreed that the epididymis is the first part affected; opinion of Sir A. Cooper, Sir B. Brodie, &c.; M. Velpeau's means of detecting fluid in the tunica vaginalis; diagnosis of affection of the testis itself; eczema and its complications may occasionally simulate epididymitis; characters of abscess of the scrotum. [p. 83. Prognosis.—Generally favorable; chances of the occurrence of complications con- sidered ; will the testis completely recover its functions? means of forming an opinion. [p. 86. Treatment.—Indications for the prevention of the complaint; observations on leeches; puncturing the scrotal veins; treatment necessary for the gonorrhoea; of the com- plications, [p. 87. Method of employing Compression.—Explanation of woodcut; consequences of compression; indications for its employment; counter-indications; modus operandi of compression ; necessity for its reapplication. [p. 88. Treatment of Chronic Stage of Gonorrhoea.—Recommendation of similar plan to that spoken of under the head of Abortive Treatment; treatment of gleet, by cauteri- zation with the instrument of Lallemand ; consequences of this treatment; employment of the proto-ioduret of iron—its doses, &c.; advantage to be expected from the Tent; plan of introducing it; counter-indication to its use ; other plans that have been proposed ; their relative merits alluded to. [p. 90. SECTION IV.—Strictures. Definition.—Division into spasmodic, inflammatory, and organic or permanent, [p. 95. Spasmodic Stricture.—Causes; frequency of attacks, attributed to muscular con- traction. Symptoms; quotation from Sir B. Brodie. Diagnosis; prognosis; treatment, as recommended by Sir B. Brodie. [p. 95. Inflammatory Stricture.—Causes of the affection ; frequent complication of the other forms; treatment should be of an active antiphlogistic nature ; the employment of instruments prejudicial. [p. 97. Permanent Stricture.—Definition; may depend upon—1st, alterations of the sur- face of the mucous membrane; 2dly, alterations of the substance or parietes; 3dly, alterations of surrounding parts. Description of the lesions of the suiface—Ulcers; vegetations; false membranes ; cicatrices ; hujmorrhoidal state of.—Description of the 10 ANALYTICAL TABLE OP CONTENTS. Lesions of the substance or parietes—Simple hypertrophy with softening, or induration ; fungous degeneration; specific induration; various general affections may give-rise to stricture.—Description of the alterations of surrounding Parts—Abscesses, indurations, affections of the prostate, &c. fp- 98. Causes.—Blennorrhagia a frequent one; case showing that other causes produce Btricture ; injections are not a cause ; general situation of; opinion of Hunter, Civiale, Ricord, Crosse, on the number of strictures ; form may be various. fp. 100. Symptoms.—Description of those derived from passing water; other causes than stricture may give rise to them; symptoms derived from ejaculation of the semen; other symptoms ; gleet often a symptom of stricture ; difference of opinion on the part from which it proceeds; these symptoms insufficient to distinguish stricture ; value of the diagnosis derived from an exploration of the canal by instruments; necessary to try to pass various sizes and shapes before coming to an opinion on the existence of stric- ture ; two plans of exploring the canal—1st, from before backward—2d, from behind forward; appreciation of; means of ascertaining the depth of a stricture; exact position and direction of, by means of the porte empreinte ; description of woodcut. [p. 102. Diagnosis.—Of stricture generally, and of the various lesions on which it depends of vegetations; of the oedematous and hoemonhoidal state; cicatrices ; simple callous strictures; specific indurated stricture. [p. 107. Prognosis.—Of stricture depending on vegetations ; hypertrophy, with ramollisse- ment; cicatrices; callous stricture; specific induration; spasmodic stricture. [p. 109. Treatment.—Circumstances which counter indicate any treatment; general reflections on ; division into general and local treatment; notice of constitutional treatment; means of local treatment; injections. fp. 109. Dilatation.—Various means of employing it; 1st, sudden dilatation, or dilatation brusque of M. Ricord ; appreciation of; in what cases useful; in what instances it may be prejudicial; Mr. Mayor's observations on the employment of bougies; 2d, rapid dilatation, or Lallemand's plan ; cases which do not admit of this treatment; reasons for rejecting it; 3d, gradual dilatation ; rules for employing it; period that the bougie should remain in the stricture ; their repetition ; cases unfitted for dilatation in general; cases which will be benefited by it; comparison between permanent and temporary dilatation; observations on permanent ddalation; ill consequences which sometimes follow ; advantages to be expected from. Temporary Dilatation.—Time during which a bougie should be kept in the stricture ; objections to it; M. Ricord's plan ; action of dilatation threefold; 1st, acts by compression; 2d, acts by suppuration; 3d, by ulcera- tion : it should be our object to produce only the effect of compression ; dilatation may act on the face, or on the parietes of the stricture; Dupuytren's treatment; Ducamp's treatment; planof M. Benique ; instruments with which dilatation should be performed ; conical bougies; their advantage : recommended by Dupuytren; advantages of em- ploying the bougie iL ventre; remarks on flexible soft bougies ; Sir B. Brodie's observa- tions on wax bougies; gum elastic bougies the best; inflexible or hard instruments; flexible ivory bougies: whalebone bougies; appreciation of them; observations on maintaining the cure of stricture. [p. m. Cauterization.—History of; this treatment not applicable to all cases; beneficial effect in spasmodic structure; in vegetations, &c, useful in some cases of permanent stricture ; in what cases useless; Hunter's employment of caustic to the face of the stricture; Ducamp to the parietes; rules for the employment of cauterization ; strictures may be cauterized with a variety of substances; preference shown to the nitrate of silver; M. Ricord's plan of cauterization, when he is unable to penetrate the stricture • method of cauterizing the parietes of, or Lallemand's plan of treatment; explanation of wood cuts ; length of time that the caustic remains in contact with the tissues ; ob- servations on its reapplication ; consequences of cauterization; opinion of Sir B. Brodie on the armed bougies. rp n§_ Scarification or Incision.—History; means of employment; puncture; scarifica- tion of ihe parietes; description of M. Ricord's instrument; manner of employing it; notice of other plans ; filing a stricture; employment of the actual cautery. [p. 124! fp. 120. SECTION V.—Affections of the Prostate Gland. Causes.—Enumeration of. Symptoms.—Rarely met with alone ; the more usual train ; symptoms as characterized by the catheter ; stream of urine ; notice of the age and temperament in which the dis- ease occurs; course of the affection ; opinion of Sir A. Cooper. fp. 126 Pathology.—Sir E. Home's opinions. Prognosis. Diagnosis.—Means of forming one. p. 128. p. 129. p 1°9 Treatment in the first stage of the disease ; objections to the use of bougies; observa- tions of Sir E. Home on the use of instruments. [p 129 ANALYTICAL TABLE OF CONTENTS. 11 SECTION VI.—False Passages. Portions of the urethra most subject to; dimensions and directions of; predisposing causes; influence of instruments in occasioning false passages; false passages produced by small instruments, of slight importance; precautions to be taken to avoid ™akuig false passages. LP- },": ' Symptoms.—Notice of the causes of errors. . . LP- X6y- Prognosis.—Circumstances which modify it; necessary to study the direction of. fp. 134. Treatment in recent cases; observations on overcoming the obstacle. IP- 13b. SECTION VII.—Disease of Cowper's Glands. Symptoms may be mistaken for circumscribed abscess of the urethra. [p. 136. Treatment.—Termination in infiltration of urine ; consequences of treatment, fp. 137. SECTION VIII.—Infiltrations of Urine. Causes. Symptoms.—Direction which the urine follows. LP- }37. Treatment.—Importance of free incisions. LP- ■LJ°' SECTION IX.—Fistulous Openings. Their situation ; course ; direction ; consequences of. LP- j1^9 Treatment in simple cases; Mr. Dieffenbach's plan of treating them. LP- 14J- CHAPTER III. BLENNORRHAGIA IN THE FEMALE. Notice of causes which are peculiar to the female genitourinary mucous mem- , [p. 14o. * Morbid Appearances.—Description of the state of the mucous membrane as to color, &c; papular vaginitis; the various characters it may assume; vagina subject to vanous erThe°appearances of the discharges from the female genitourinary organs in the acute and chronic affections; importance to study them as d.agnostic signs. [p. 144 Symptoms.—Similar, though depending upon various causes; usually local; general symptoms often absent; enumeration of local symptoms which are common to all these affections; symptoms of blennorrhagia. Of the Vulva of the tf^Ar*-Means of detecting disease in the urethra; relative frequency of the affect.on. Of the Vagina -Indolent character of symptoms; where to hud traces of a discharge Of he pans. —The discharge is sometimes the only symptom; advantages of employing the sneculum- the bivalve speculum recommended ; description of the instrument; method of Introducing it; indications for finding the neck of the uterus ; counter-indications to the employment of the speculum ; description of the speculum chair. LP- 1fb- ComlliLtions in blennorrhagia of the vulva. Description of, and heir diagnosis; phymosis of the vulva-*/ the urelhra-of tfee urctus. O varite, symptoms, one of the causes of ovarian dropsy ; specific ulcers ; simple ulcers; diagnosis of. lp. 150. OtecrvS on Cordagiou.-The mucous membrane usually diseased when the complaint is contagious; impossibility of distinguishing whites from contagious dis- charges diagnosis of virulent from simple blennorrhagia; form of certificate recom- i i LP- ^•3~. ^ProUwsis.-Ot blennorrhagia of the vulva-o{ the urethra-ot the vagina-ot the O IP* ■*■*}"■ * 'Treatment.-Of blennorrhagia of the vulva; of prevention; abortive treatment not usualy applicable in the acute stage; of the urechra-of the vagina-ol tfie UlVomplications.-netent\on of urine ■, cystitis; stricture; abscess; fistulas; Phy™y i bubo ; nervous complications; ovaritis. LP* 12 ANALYTICAL TABLE OF CONTENTS. CHAPTER IV. FORMS OF BLENNORRHAGIA COMMON TO BOTH SEXES. SECTION I.—Blennorrhagic Oththalmia. Synonymous terms; frequency; situation. [p. 156 Causes.—Difference of opinion upon ; two theories ; description of the first, or sym- pathy ; appreciation of it; reasons for disbelieving it; reasons for believing in the opposite opinion, or in direct contact of the secretion ; considerations on predisposing causes, such as age sex, &c.; deductions. [p. 157. Symptoms.—At an early period; examination of the eye ; state of the secretions; granular condition ; no deduction can be drawn from it; course of the disease ; rapidity in disorganizing the structures of the eye. [p. 158. Diagnosis—No one symptom sufficient; considerations on the intensity of the in- flammation ; coincidence of the blennorrhagia. [p. 159. Prognosis.—Very severe ; recommendation to call in a second opinion ; Dupuytren's practice. _ fp. 160. Treatment.—Lisfranc's opinion; M. Ricord's treatment; leeches, observations on ; the employment of nitrate of silver in substance ; how applied; rules for the reapplica- tion of; on the use of mercury. [p. 160. SECTION II.—Blennorrhagia of the Anus. Does there exist such a disease? Yes. Reasons for supposing it common; no foundation for the opinion. [p. 162. Symptoms.—Description of. [p. 163. Causes.—Direct contact; influence of general causes. fp. 163. Diagnosis.—Always difficult; the value of the funnel-shape of the anus; causes which give rise to it; not always present; color of the discharge; its value as a diagnostic sign ; inoculation, its value ; buboes ; the antecedents of the patients ; no one unequivocal sign ; importance to be placed on a rent of the rectum. [p. 163. Prognosis.—Unfavorable; why. |p. 164. Treatment.—The first indications ; general means ; direct means. [p. 164. SECTION III.—Blennorrhagia of the Mouth, Nose, and Ears. Fabulous. [p. 165. Blennorrhagia of the Umbilicus and Groin.—Causes. Treatment, &.. [p. 165. SECTION IV—Vegetations. Synonymous Terms. fp. 165. Pathology.—Color, stricture, &c. [p. 165. Causes.—Opinion of Sir A. Cooper on their contagion ; case illustrative of the im- portance of a correct opinion of cause. [p. 166. Complications. Diagnosis. Prognosis. [p. 167. Treatment.—Appreciation of the several plans of treatment. [p. 168. SECTION V.—Herpes Prjeputialis. Case from note-book, detailing cause, symptoms, diagnosis, and treatment. [p. 169. SECTION VI.—Eczema. Causes. Symptoms. Treatment. [p. 172, SECTION VII.—Excoriations. Definition. Situations. rp j^ Treatment.—Preventive and curative. |p| 174' ANALYTICAL TABLE OF CONTENTS. 13 PART II. CHAPTER I. PRIMARY SYMPTOMS. Definition of syphilis; division into stages; meaning of first, second, third stages. [p. 175. SECTION I.—Chancre. M. Ricord's Definition. Anatomical Characters.—As proved by inoculation ; natural manner in which chancre may commence; microscopic examination of the secretion of. [p. 176. Varieties of Chancres in the Ulcerative Stage.—1st, Phagedenic chancre; 2d, Diph- theritic phagedenic; 3d, Indurated; 4th, Indurated phagedenic; 5th, Gangrenous chancre. [p. 178. Period of Reparation; Varietiesof; Cause of Chancre.—Meaning of the term cause; traced in the present instance to the secretion of another chancre ; circumstances which compose, form part of, dispose to, prevent the action of,- impossibility of isolating the cause ; influence of chymical agents upon it; reasons for calling it a virus. fp. 180. Origin of the Syphilitic Virus.—Not spontaneous at the present day; hypothesis founded on analogy. Circumstances and conditions necessary for the production of the effects of the Virus. [p. 182. Of the chancre from which the virus is taken. fp. 183. Means and conditions of the agents of transmission ; refutation of received opinions on this subject, practical illustrations of ■which are important to the surgeon. [p. 184. The necessary conditions of the parts about to be contaminated ; destruction of the epidermis necessary; apparent exceptions; explanation of; influence of age; state of the skin; influence of sex; the question, Are there any persons insusceptible of syphilis ? answered in the negative; incubation does not exist; apparent exceptions explained. Is there more than one cause of chancre ? Only one. [p. 187. Causes of the Varieties of Chancre.—Varieties not to be attributable to any one cause; examples, enumeration of the most frequent in cases of the diphtheritic varieties; gangrenous phagedenic; serpiginous; indurated. [p. 191. Diagnosis of Chancre during its ulcerative stage.—The means of forming a rational diagnosis; observations on the appearance as aiding the diagnosis; the situation ; the history; the value of various complications; how far a diagnosis can be formed from the course. [p. 194. Observations on the absolute diagnosis; value of inoculation; cases illustrative of. [p. 196. Diagnosis of the reparative stage of chancre. ~[p. 197. Prognosis of Chancre—Consideration of it as a local disease; usual period of cure; probabi'ity of the occurrence of the varieties supervening on simple chancre, such as diphtheritic ; serpiginous; gangrenous ; indurated. Relative to the probab'e duration of a simple chancre; enumeration of the causes which influence it, such as situation, size, number, constitution ; probable duration of a diphtheritic, serpiginous, gangrenous, indurated chancre. [p. 198. Probability of the occurrence of complications. [p. 200. Prognosis in reference to the probability of successive accidents; meaning of this term ; of chancre (successive); of bubo; circumstances which will tend to modify the prognosis, such as situation, &c.; influence of treatment on prognosis. [p. 202. Prognosis considered in reference to the probability of general and constitutional infection ; the circumstances to be borne in mind ; stage of the sore; duration of the chancre ; number and size; probability derived from the varieties, viz., phagedenic gangrenous ; influence of the indurated ; influence of the complications on the prognosis, such as phymosis ; bubo; prognosis to be derived from the treatment, local and general. [p. 202. 14 ANALYTICAL TABLE OF CONTENTS. Treatment.—Prevention of chancre ; reflections upon ; methods employed in France ; duties of the medical practitioner ; Is it possible to prevent the occurrence of chancre ? Proposed means of preventing the spreading of the affection ; precautions to be taken by the recipient; those recommended to be used by the already infected, to prevent transmission. . [P- ^04. Curative Treatment.—Of the chancre on its first appearance; observations on the employment of lunar caustic; treatment of the variety called phagedenic diphtheritic; indications necessary to be attended to ; gangrenous phagedenic ; serpiginous chancre; observations on the obstinacy of this sore; general and local means ; indurated chancre ; objects the surgeon ought to have in view in treating this form ; local treatment; general treatment; observations on the use of mercury; its dose; preparation; preparatory measures; prejudicial effects of; treatment of; mention made of excision. [p. 208. Treatment of indurated^phagedenic chancre. [p. 209. Treatment of the complications of chancre.—From position; chancres in the urethra; diagnosis of this affection; prognosis; treatment; chancre situated at the fra?num balanitis; phymosis; the indications and method of employing caustic in these last two forms. [p. 216. Operation for phymosis; M. Ricord's plan of circumcision. [p. 219. Paraphymosis; reduction of; operation for relieving. [p. 221. SECTION II.—Bubo. Definition of; meaning of the term venereal bubo; syphilitic bubo; anatomical characters of syphilitic bubo; termination of, in delitescence; resolution; suppuration; in induration. [p. 222. Causes of Syphilitic Bubo.—Remarks on lymphatic vessels ; action of the virus may be twofold, by absorption, by irritation. The predisposing causes—Influence of age, sex, temperament; general condition of the patient; influence from the situation of the chancre; size of; how far the treatment of primary sores may influence buboes, f p. 224. Symptoms of bubo. , [p. 228. Diagnosis of Syphilitic Bubo.—1. Previous to the suppurating stage ; importance to be placed on the antecedents; distinction between syphilitic bubo and bubon d'emblee; description of this last-mentioned form. 2. When suppuration exists; inoculation the only sure guide. fp. 228. Prognosis of Syphilitic Bubo.—Inquiries necessary previous to forming our prognosis; prognosis of bubo depending upon absorption, or upon irritation; the probability of a syphilitic bubo suppurating; the probable duration of a bubo; circumstances which influence the prognosis ; probability of the occurrence of secondary symptoms, [p. 230. Treatment of Syphilitic Bubo.— The Prophylactic Treatment—Indications to be borne in mind, particularly of chancres; treatment of the early stages of bubo ; influence of compression upon ; treatment of the inflammatory stage of bubo ; influence of blisters; observations on the use of caustics; indications for puncturing buboes; method of puncturing ; treatment of suppurating open buboes. fp. 232. CHAPTER II. SECTION I.—Secondary Symptoms. Definition; synonymous terms; history of secondary symptoms; classification of; M. Ricord's and the author's division explained ; general observations on secondary symptoms; are secondary symptoms dependent upon absorption of the virus? reasons for the belief; can they occur without previous chancres ? the chances of error, fp. 239. Predisposing Causes; influence of temperature, food, age, sex, temperament; does absorption of the virus take place by means of the veins or absorbents ? Hypothesis on this subject. fp. 241. Period at which secondary symptoms appear after the occurrence of primary symptoms. rp_ 344. Observations on the average period; exceptional cases. fp] 245' SECTION II.—Secondary Affections on the Skin. Division of, into the following forms; Exanthematous; Papular; Vesicular- Pustu- lar ; Tubercular. ' rp 345 Description of Exanthemata; period of their appearance;' natural course of. [p 247 ANALYTICAL TABLE OF CONTENTS. 15 The Papular.—Parts most liable to; divisions of. Lichen. Psoriasis. Lepra. on the palms of the hands. rp- 347. The Vesicular.—Rarity of the affection. [p.* 249! Pustular.—Course; termination. In Rupia.—Ulcerations; general state of the system; variety of the pustular form. Impetigo. [p. 249. The Tubercular form.—Description of; description of the variety called Condy- lama, and of the French term Mucous Tubercle; situation of; predisposing causes; liability of mistakes; course of the affection; termination of; varieties of Condy- lomata. rp- 250. Complications of Secondary Symptoms above described.—Influence of itch in, as a complication ; existence of eczema ; lepra and various affections of the skin ; primary symptoms, a complication ; importance of the knowledge of this fact; the influence of scrofula, scurvy, as complications. , [p. 253. TJ>£ Diagnosis.—Importance to be placed on the previous history; whether positive or negative ; value of concomitant disease as influencing the diagnosis ; whatdependence . is to be placed on the color of the eruption; how far cau the diagnosis be substantiated by the treatment which has preceded, or that under which the patient recovers, [p. 254. The Prognosis.—Circumstances under which it may be considered favorable ; cir- cumstances which lead to an opposite conclusion. [p. 256. Treatment of Secondary Symptoms.— The Curative Treatment.—Indications to be borne in mind ; general treatment; baths ; importance in the opinion of the author; method of employing baths; on the employment of sarsaparilla; 011 the use of gold, and its preparations; those of silver. On the employment of mercury; on the history of; observations on the doctrines of the mercurialists and non-mercuriulists; author's opinions on the efficacy of mercury; in what cases it should be employed ; manner of employing it; on the action of mercury on secondary symptoms. [p. 259. Salivation.—Predisposing causes of; quantity of mercury necessary to produce it; period of time most to be dreaded, at which it will appear; description, course, and treatment of salivation ; termination of; diagnosis of salivation ; on the employment of mercurial ointment; mercurial plasters ; calomel; fumigations; internal use of mercury; calomel and opium; corrosive sublimate ; proto-ioduret of mercury; local applications to the various syphilitic affections of the skin—as lichen, lepra, psoriasis, mucous tubercle, &c. [p. 263. SECTION III.—Syphilitic Affections of the Mucous Membrane. Mucous membranes that may be the seat of the affection. [p. 270. Syphilitic Affections of the Mouth and Throat.—Division into. [p. 270. Primary Affections.—Causes; other instances cited; anatomical characters of: cause ; reasons for believing it a rare affection ; opinion of Mr. Colles; M. Guersent's opinion; symptoms; diagnosis; cases which present difficulties; means of arriving at a correct opinion ; prognosis ; treatment. [p. 271. Secondary Syphilitic Affections of the Mouth and Throat.—Cases; ana- tomical characters; cases; the predisposing and exciting considered; symptoms; concomitant disease ; diagnosis; prognosis ; treatment. [p. 280. Tertiary Syphilitic Affections of the Mouth and Throat.—Anatomical characters ; sketch of its commencement and progress; history. [p. 288. Diagnosis.—Value of each symptom; inquiry if a strumous sore throat exists ; does a chronic inflammatory affection ever appear? cases; can scorbutic disease of the throat be mistaken for a syphilitic affection 1 the diagnosis of syphilitic affections and cancer considered. [p. 290. Prognosis. Treatment. [p. 296. SECTION IV.—Syphilitic Affections of the Eye. Division of. [p. 298. Secondary Affections.—Quotation from Mr. Lawrence. [p. 299. Syphilitic Iritis.—History; known and described in 1773; symptoms of; Mr. Tyrrell's opinion on; statistics by Mr. Lawrence; showing at what period of life it occurs, &c. fp. 301. Causes.—Predisposing and exciting; probable reason why the disease is rarely met with in Paris; prognosis; diagnosis; value of each symptom individually consider- ed, [p. 302. Treatment.—Employment of mercury. [p. 305. SECTION V.—Syphilitic Affections of the testicle. Synonymous terms; symptoms; pathology; extract from Sir A. Cooper's work; predisposing and exciting causes; diagnosis; prognosis and treatment. [p. 308. 16 ANALYTICAL TABLE OF CONTENTS. CHAPTER III. TERTIARY SYMPTOMS. Definitions; history; Hunter's opinion upon ; cause; predisposing causes; influence of previous disease; influence of treatment of the primary and secondary affections; course of tertiary symptoms ; complications of; prognosis; diagnosis. [p. 309. Description of Tertiary Symptoms affecting the Cellular Tissue.—Tuber- cles of; tertiary affections in the osseous system. [p. 313. Periostitis.—First, second, and third variety. [p 314. Ostitis.—Divisions of; terminations various. [p. 315. Treatment of Tertiary Symptoms.—Indications of treatment; preventive means ; curative means; employment of opium; mercury—observations upon ; on the employ- ment of the hydriodate of potass; dose; manner of increasing it; effects of the salt on the system; treatment of the individual forms of tertiary symptoms ; local treatment of tumors situated in the subcutaneous cellular tissue; treatment of ulcers; observations on the submucous tumors. [p. 316. Treatment of Affections of the Osseous System.—Pains in the bones; treatment of periostitis and its varieties; treatment by means of blisters; local treatment of ostitis; observations on necrosis and caries. [p- 320. CHAPTER IV. syphilis in children. Primary Symptoms considered; ulcerations which may be mistaken for. [p. 321. Secondary Symptoms.—How does the foetus become affected; does the mother infect the child by means of the milk? can the father directly contaminate the fcetus; reasons for our disbelief; allusion to Messrs. Colles' and Carmicheal's opinions; does syphilis cause abortion at the seventh month? reasons for doubting it. fp. 322. Symptoms. Prognosis. Treatment.—Can the child communicate the disease to its nurse ? the conditions under which this may take place; consideration of 6ome errors the surgeon may fall into. [p. 324. INTRODUCTION. HISTORY OF VENEREAL DISEASES. A very superficial consideration of the laws which regulate the animal economy in a state of health and disease, together with the various operations of these laws on the diflerent structures of the human frame, is sufficient, I think, to entitle the pathologist of the present day to infer that various affec- tions, both organic and functional, now recognised as following sexual inter- course, must have existed in all ages and in all climates • these I have included under the collective term of " Venereal Diseases."* Believing, however, that it is not sufficient for the purposes of this work to render such an inference merely probable, I shall in the following pages at- tempt to prove, from authentic historical records, that various diseases answering to this definition were known, and have been described, by persons living in the early ages. These I shall trace down to the present time; but in doing so I shall be as concise as possible, and only dwell upon such points as may be of practical use. An attentive perusal of the twelfth and fifteenth chapters of Leviticus must convince any impartial person that the Jewish lawgiver, in strictly enjoining ablution and separation to women after delivery and menstruation, or, as is said at the eighteenth verse, particularly to "the woman with whom man shall lie with seed of copulation," must have had in view the prevention or cure of affections liable to follow sexual intercourse at that time. This regulation was promulgated about the year 2400 A. M. On referring to the fifth chapter of Proverbs, the reader will find Wisdom ad- monishing her pupil, and desiring him to avoid strange women, lest his flesh and body be consumed. And in Ecclesiastes it is stated, that " whosoever joineth himself to adulterers shall become impudent, and that rottenness and worms shall have him to heritage." Thus we find allusion made to it again about the year 2950 A. M. On the authority of Peter Paul Vergerius the elder, it is stated that "Uber- tinus of Carrara, the seventh of that name, and the third governor of that city, died at Padun, the 29th of March, in the year 1245, of a lingering disease of his private parts, occasioned by too much venery."f * By the term venereal diseases, I mean all those affectionc which are, more or less, di- rectly or indiiectly, the consequence of sexual in'.ercourse, in whatever way effected. t Astruc, p. 58. 2 18 INTRODUCTION. Gulielmus de Saliceto, a physician of Placenza, in 1270, states in his work "De Apostemate in Inguinibus,"* "This disease, called a bubo,dragoncelli, or impostume of the groin, for the most part arises from a cold humor which is expelled from the liver to those places which are weak and empty; it some- times also proceeds from a hot humor, and sometimes it comes from a foulness in the yard (in virgd corruptio), contracted by lying with an unclean woman, or from some other cause. In Astruc's treatise,! it is stated that an eyewitness, Theodoric, a celebrated physician in the year 1290, in his Chirurg., lib. vi., cap. 55, says, that " whoever converses with a woman who has lain with a leper will catch the distemper." Bartholemew Glanville, in his book De Proprietalibus Rerum, translated in 1398 by John Trevesa, speaks of "Unclene spostyd glemy and guyttery, the nosethrilles ben stopyl, the wasen of the voys is rough, and the voyce is hoorse, and the heere falls." This disease of leprosy " comyth of fleshly lying by a woman after that a leprous man hathe laye by her; also it comyth of fader or moder; and so thys contagyon passyth into the chyle, &c. And also when a chylde is fedde wyth corrupte mylke of a leprouse nourryce." In Henry the Eighth's time there were six leprous or lazar houses. Lanfranc of Milan, a pupil of Gulielmus de Saliceto, who consequently lived about the year 1290,}: states, that chancres and ulcers of the penis follow from coition with a foul woman. Bernard Gordon, professor of physic in the Uni- versity of Montpelier in 1300,[| says that "diseases of the yard are numerous, following lying with a woman whose-womb is unclean, full of putrid sanies, virulence," &c. In a manuscript, in Lincoln College, Oxford, cited by Beckett, and corrobo- rated by Dr. Wagstaff, in the thirtieth volume of Phil. Transact., it is stated on the authority of Thomas Gascoigne, chancellor of that university, that " Joan, de Gaunt mortuus est ex tali putrefaciione membrorum genitalium, et corporis sui causatd per frequentionein mulierum." This took place in the year 1399. About the year 1423, Petrus de Argelata, of Bologna,§ says, that the reten- tion of the poisonous matter lodged between the glans and prepuce, after a man has had to do with a foul woman, causes the part to become black, and the sub- stance of the yard mortifies, &c. He likewise speaks of the occurrence of bubo in the groin as a consequence of this affection. In the thirtieth volume of the Philosophical Transactions, page 843, Beckett cites the following passage from a book in the custody of the bishop of Win- chester, supposed to be written in the year 1430, and entitled " De his qui cus- todiunt mulieres habentes vephandam infirmitatem :" " That no stew-holder keep noo woman wythin his house that hath any sycknesse of brenning;1T but that she be putte out, upon the peyne of makeit a fyne unto the Lord of a hundred shylyngs." * Lib. i , cap. 42. t L. c., p. 53. t Tract. 3, Doct. ii., cap. 11. Practicae sen artis completoe, &c. And also in Tract. 3 Doct. hi., cap. 11. De ficu et cancro et ulcere in Virga virili. II Lilii Medicinae Particul, vii., cap. 5. De passionibus virgas. & Chirurgiae, lib. ii., tract. 30, cap. 3. " De pustidis quiz adveniunt virgce propter conversationem cumfad'i muliere, quae albce sunt vel rubra:." H On the authority of a manuscript of John Arden, surgeon to Richard II.,the word bren- ning is thus defined: " A certain heat and excoriation of the urethra." INTRODUCTION. 19 Beckett quotes the following questions as being put to persons who were said to be lepers; he cites them from an ancient book of surgery : " If there were any of his lygnage that he knew to be lazares, and especially their faders and moders, for by any other of their kynred they aught not to be lazares, then aught ye to enquire if he hath had the company of any leprous woman, and if any lazar hath meddled with her afore him; and lately, because of the infect matter and contagious filth that she had received of hym. Also his nosthrills be wide outward, narrow within, and gnawn. Also if his lips and gumms are foul, stynking, and coroded. Also if his voice be hoarse, and as he speaketh in the nose." John of Gadesden* not only alludes to the possibility of contracting the com- plaint from a leprous woman, but mentions the precautions which should be adopted to avoid contagion. " Ille qui concubuit cum muliere cum qua coivit Ieprosus puncturas intra carnem et corium sentit, et aliquando calefactiones in toto corpore. " Primo notandum est ille qui timet et excoriationem et arsura virgae post co- itum statim lavet virgam cum aqua mixta aceto, vel cum urina propria, et nihil mali habebit."f " Si quis vult membrum ab omni corruptione servare, cum recedit a muliere quam suspectam de immunditie, lavet illud cum aqua frigida cum aceto mixta, vel cum urina propria interius vel exterius intra preputium."t. The affections to which we have alluded, and which were described as exist- ing previously to the 15th century, had received no particular name; but after the severe epidemic observed at Naples, and which was so well described by Fracastorius, they became known under the title Morbus Neapolitanus, or Gal- licus, Mai des Francois, and soon after the terms Gore, Grande Gore, Verolle, Grande Verolle, were successively given to them in consequence of the general pustular eruption by which they were attended. Lastly, the affections were described under the title Scorra Pestilentialis, by Sebastian Brant, in 1496, and by Grunpeck, a German physician. Gaspar To- rella writes on the subject a treatise, Contra Pudendagra, in 1498. It was generally known by one or other of these denominations until Jaques de Bethencourt of Rouen called it the Venereal Disease, in a book entitled Nova Pcenitentialis Quadragesima, nee non Purgatorium in Morbum Gallicum, sive Venereum. Paris, 1527. In the year 1530 Fracastorius || writes thus: "When it first broke out among us, it discovered itself by the following symptoms : the patient was low-spirited, complained of weariness, and had a pale look; at last, for the most part, little ulcers appeared about the pudenda, which were extremely obstinate, and, after they were cured in one part, broke out afresh in another. Afterward a kind of crusty pustules appeared upon the skin, beginning in some upon the scalp (which was most frequently the case), and upon other parts in others. At first they were only small, but increased, by degrees, in a short time, to the size of the husk of an acorn, and had a good deal the same appearance, not unlike those scabs which appear on the heads of boys. Of these scabs there werl * Doct. 61. t RosaAnglica. Pavia, 1492. Car. 61. In the library of the College of Surgeons. t Car., 107. II De Morbis Contagiosis. Lib. ii., cap. 2. De Morbo Gallico. 20 INTRODUCTION. several different kinds, some of them small and dry, others large and moist; some of a livid color, some of a palish white, and some hard and reddish. All of them opened in a few days, and discharged a thick foetid matter; nor is it possible to express what the quantity of that matter perpetually discharged was, nor how nasty it was in quality. Afterward the ulcerated parts became eroded in the same manner as those ulcers which are called phagedenic, and sometimes they infected not only the flesh, but likewise the very bones. When it attacked the head chiefly, it produced acrid rheums, which eroded sometimes the palate, sometimes the uvula, sometimes the jaws and tonsils. In some it destroyed the lips, in others the nose, in others the eyes, and in others the whole pudenda. Besides this the limbs in a great many were disfigured with gummy tumors, which frequently grew to the size of an egg, or a small loaf, and, being laid open, dis- charged a white mucilaginous matter. That tough hardness appeared chiefly in the legs and arms, and, sometimes became ulcerated; sometimes it continued entire till death. But, besides all the above-mentioned symptoms, as if they were only trifling, there occurred violent pains of the arms, frequently, together with pustules, sometimes before, sometimes after, very obstinate and lasting, and excessively tormenting. They were most violent in the night, and the pain was not properly in the joints, but in the muscles and nerves. However, there were pustules sometimes without pains; and in some, pains without pustules ; but the greater part was afflicted with both. In the meantime, all the limbs became feeble, the body emaciated, the appetite quite lost; the patient had no sleep, but was either melancholy or very irritable, with a strong inclination to lying in bed. His face and legs swelled; sometimes, though rarely, the disease was attended with a slight fever; some had a pain in the head, which was last- ing, and not to be subdued by any medicines."* During the following years, John de Vigo, Peter Maynard, Nicholas Massa, Fallopius, and others, make mention of the remaining symptoms, which are now universally recognised. Fernel, in 1548, thus writes : " On whatever part of the body the Lues first settles, there fixing itself, it excites a pustule, and soon after a small ulcer. Thence extending further, it fixes its roots, and sensibly penetrates the interior by a forced unceasing action; and in fine, unless you shall have opposed to it some remedial measures, it devastates and commits ravages on the whole by its virulence. From this it is manifest that a certain poison constitutes the essence of the disease, creeping over or insinuating itself into the whole body, in no manner differing from the poison of the rabid dog or scorpion. The signs of it are various, depending on the nature of the parts over which it spreads. When the virus, for the sake of illustration, has its origin in copulation, from the pri- vate parts bedewed with moisture, it determines, first, pustules in those parts which are very obstinate, and then small ulcers which are difficult to treat, and are of rather a bad character. Then the vapor or effusion, creeping inward by * This description of Fracastorius may apply even at the present day. Let any one who is cognizant with large venereal hospitals be asked if he does not often meet with cases of this kind. Females of abandoned lives apply for admission, giving the description here spoken of, viz., laboring under severe secondary symptoms, and do not mention, or altogether deny, the previous existence of primary symptoms. Fracastorius was unaware of the relation be- tween secondary and primary symptoms. There are Fracastorii at the present day, in spito of the progress of surgery. INTRODUCTION. 21 the hollow canal of the pudendum (for it is not credible that any humor or fluid enters it), it impoverishes (labefactat) the blood of the vena cava and the spirit contained in the larger artery, and then the bubo breaks out in the groin. Hence a gonorrhoea manifests itself from the diseased spermatic ducts and kid- neys, by which this most foul virus is ejected as by belching. When this exe- crable disorder has invaded the liver and stomach, a certain slight abdominal dux breaks out, and soon after the blood is infected with the liver, by which all the veins of the body become implicated; and in this manner disseminated in the limbs, muscles, and skin, it having been repulsed, breaks out silently, and worse than before. Livid and reddish pustules occur, ulcers covered with crusts and teters, in some persons excavated and malignant ulcers, and in bil- ious persons phagsedenic and corroding sores ; in the melancholic temperament, cancrous or cancerous ulcers; and in the phlegmatic they are more superficial (leviori), but more foul, and discharging a foetid, mucous humor; and in san- guineous persons they are more thickly set, and resemble carbuncles. All, in- deed, with very hard, indurated, tumid, and inverted edges, which (ulcers) hav- ing eaten the flesh, feed upon the bones themselves ; at first the thin bones (as, for instance, those of the palate and nose), then those of a more solid consist- ence, which, becoming putrid and carious, are thrown off. It follows, as a nat- ural consequence, that when the head is attacked, or the brain is the seat of the disease, many pituitous humors, disproportionate to the condition of the part, collect, which, if shut up in the head, produce a severe and considerable pain; but if they point under the scalp, and should be determined toward the joints and limbs, they excite most dreadful and daily tortures, increased greatly at night; or they excite very hard tophi and scirrhous tumors, by no means free from pain. Although the matter appears pituitous, nevertheless, being im- pregnated with this deadly matter of poison, it partakes of its acrid properties. Thus hiding itself under the periosteum of the bones, it produces pain both by its acrimony and by distension. Penetrating the substance of the bones as it were by minute tubes, it expands them and dilates them into tumors—which (bones) at length being attacked with caries, become putrid. If the matter be- ing less biting and acrid does not destroy the skin, its malignity or noxious va- por, being poured out around the hair, occasions (in the language of Fernel) an effluvium; on which account the greater part appear without hair on the head, eyebrows, or body; but the hair may be reproduced. " But its effects are not confined to the external parts alone; they extend to the internal parts, affecting even the viscera, which are found, as in exanthema- tous diseases, on dissection, covered with pustules and ulcers."* * Joan. Fernelius de Abditis Rerum Causis. Lugduni. Liber ii., cap. xiv. De Morbis Contagiosis, p. 210. Who can deny this accurate description of the ravages of syphilis 1 No author of the pres- ent day can add to the category of the affections successively attacking the various parts of the body, but their relation to primary symptoms was unknown ; this, however, was not sur- prising; at the present day I not unfrequently meet with such cases at St. Bartholomew's Hospital, among the female patients, the genital organs covered with primary sores, the body concealed, as it were, by scabs, the throat and bones suffering simultaneously. Such cases, of course, are contagious, and were arranged under the head of contagious diseases, but no distinctions were made in those days. Fernel, like many modern surgeons, viewed the ulcers as one and the same, and considered them contagious—an error, as will afterward appear. 22 INTRODUCTION. In the year 1736, Astruc, physician to Louis the Fifteenth, wrote his celebra- ted treatise on the Venereal Disease; to him is due the merit of having writ- ten the most learned book of the day, and of having treated the subject in a methodical manner. The work of Astruc is divided into two parts; in the first he describes the first stage, or local venereal diseases; in the second he treats of the second stage, or confirmed pox; in other words, of the venereal disease when it has become universal. Under the first stage he included, 1. Virulent gonorrhoea and all its conse quences. 2. Venereal buboes. 3. Chancres. 4. Verruca? and condylomata Under the second stage, or confirmed pox, he describes successively, 1. Dis eases of the genitals. 2. Diseases of the skin. 3. Diseases of the mouth and nose. 4. Venerea] pains. 5. Diseases of the bones. 6. Glandular and lym- phatic tumors. 7. Diseases of^the eyes. 8. Diseases of the ears. 9. Disor- ders of the functions. Hunter, in 1784, like Astruc, admitted the existence of a venereal virus, and traced an admirable picture of the disease; he, moreover, taught that this virua on which the venereal disease depended, might affect the system in two modes. Primarily or locally, secondarily or constitutionally. By his experiments on inoculation, he proved that these divisions existed, and might easily be distin- guished. The same learned author believed that the primary effect of the venereal virus was twofold. When it came in contact with a mucous surface, a gonor- rhoea resulted; when, on the contrary, it was placed in apposition with the skin, chancres would follow. Hence his classification of gonorrhoea and syphilis as the primary effects of one and the same virus. He called public attention to the induration which he believed always at- tended true primary sores,* and did not consider as syphilitic such primary ul- cerations as presented no such appearance. John Hunter further professed that the venereal virus in either of its two primary forms could give rise to constitutional effects, which he has so ably described in his valuable work, under the term Lues Venerea. In 1782, Benjamin Bell brought forward his experiments and reasons for sep- arating gonorrhoea from syphilis or chancre, and his views were afterward adopted and corroborated, in 1812, by Hernandez of Toulon. In 1815, the celebrated Broussais taught that syphilis is an irritation which affects the exterior of the body as does scrofula; that the physiological school of medicine ought only to note the forms and degree of irritation in the differ- ent organs, and that it should alone occupy itself with means to oppose it. Messrs. Jourdan and Richond, the pupils of Broussais, followed up the doctrine of their teacher, and denied the existence of a virus; " Call it what you will," say they, " but name it not virus." They consequently reject the idea of the constitutional phenomena of poisoning, which they regarded merely sympathetic of local irritation. In 1830, M. Ricord commenced his investigations on the causes and nptural history of venereal diseases. The first result he obtained was to convince him- * De Vigo had long before done this, but Hunter laid stress upon a point which seems to have been generally overlooked. INTRODUCTION. 23 self and the public that a special cause (perfectly independent of the sexual or- gans) gave rise to and occasioned the propagation of syphilis; he moreover attached a strict meaning to each term he employs, instead of that chaos of synonymous terms which existed in the writings of preceding authors. Considering the term " venereal diseases" in its most extended sense, he defines it to be, " all those affections which are more or less, directly or indi- rectly, the consequence of sexual intercourse, in whatever way affected." Venereal diseases thus defined, he arranges in two orders. Order I. contains diseases depending upon common causes, independent of any special agent, reproducing themselves daily, and under all possible condi- tions ; consisting of simple affections, in a word, non-virulent. We call them syphiloid diseases. Order II. contains diseases depending upon a special principle, distinct from all the ordinary morbific causes ; affections which give rise to special effects called virulent. We call them syphilis. This second order has three distinct stages. 1st Stage includes primary symptoms, which are the immediate effect of the morbific cause occurring on the spot where the virulent agent has been depos- ited. Example, chancre. 2d Stage comprehends secondary symptoms, which are the consequence of absorption into the system of this virulent cause. They are hereditary, but not capable of transmission by inoculation. Example, certain affections of the skin and mucous membranes, iritis, &c. 3d Stage comprises tertiary symptoms, not capable of being transmitted by inoculation, nor hereditary, but subject to pathological transformations and alter- ations of the submucous and subcutaneous, or of the fibrous or osseous, tissues. II. HISTORY OF THE THEORIES ENTERTAINED ON THE NATURE AND ORIGIN OF VENEREAL DISEASES. It may be thought by some superfluous to dwell upon these subjects, inas- much as they have been already treated of in the previous part of this historical sketch. The perusal of this section will, however, I trust, prove that such is not the case, as the notice taken of them was only incidental, and they still require further elucidation. In the sacred writings, from the slight allusions made to these affections, no one will be surprised to find that these points are barely dwelt upon; but there is apparently no reason to believe that they were supposed to differ from other diseases, except in consequence of the manner in which they were contracted; in fact, they seem to have consisted of simple inflammatory affections, which yielded to ordinary means. Whether the affections described in the Proverbs were mere inflammatory dis- eases, or maladies of a specific nature, is a question which I shall not now stop to examine. The various affections of the genital organs, of which mention is made by Hippocrates, Celsus, and other ancient writers, as they are not stated to have 24 INTRODUCTION. followed sexual intercourse, can not be noticed here; neither will it be neces- sary to state the various theories which these fathers of physic entertained on their cause—such as too great continence, a dyscrasy of the humors, &c. In the year 437, as mentioned in a former part of this introduction, a disease of the genitals which followed connexion was supposed to depend upon the judgment of Heaven. In the 13th century, as we learn from the writings of Gulielmus de Saliceto and John of Gaddesden, the disease, although attributed to contagion from foul women, was supposed to originate in hot humors, which find their way out of the body through the womb. A little later the disease was stated to have arisen in consequence of persons being affected with the leprosy; and we may offer it as a probable conjecture, that under this term were included affections which would now be called venereal. Such were the opinions entertained regarding the disease we have sketched in the previous pages, up to the end of the fifteenth century; in fact, many authors of great repute believe that, up to this period, no such affections as may be called venereal had existed. Whether these opinions be correct I shall leave to the consideration of my readers, as they are now in possession of the data on which to decide, and I shall at once pass on to the opinions entertained at that period on the nature and origin of venereal affections. Those authors who wrote at the latter end of the fifteenth-and commence- ment of the sixteenth century, were convinced that venereal affections, which at that time assumed such severe forms, owed their origin to the fatal influence of the stars, to the conjunction of Venus and Mars, or of Jupiter and Venus. Among this class may be enumerated the names of Torella, Maynard (Peter), Fracastorius, &c.; and hence we may infer the influence that astrology and the planets were supposed to exercise in producing disease, even by the best-edu- cated physicians of the day. There were, however, others who treated as idle fancies these supposed stories of astrologers, and the malign influence which the air was supposed to produce; thus, the venereal disease being generally ac- knowledged to be a contagious malady, the same causes were stated to develop it as are now considered to give rise to epidemics. These opinions, however, gradually lost ground, and a more special cause was sought after, as the nature of the means and ordinary sources of contagion became more generally known; among others, they (venereal diseases) are again attributed to leprosy, to ulcers in the womb, to poisoned wells, to the use of lime in bread, &c. Van Helmont, in 1640, believed that the disease first sprang from unnatural connexion between a man and a horse laboring under the farcy, which occurred, as he believed, about the time of the siege of Naples. Dr. Linden thought that it had its origin " in sodomy sometimes committed between men and monkeys, or the satyrs of the ancients." Having given the principal hypotheses, I shall pass to the opinions of more modern authors, not, however, omitting to state that the major part of the au- thors believed that the diseases which they described were new, and not known previously to the taking of Naples. That learned and laborious author, Astruc, was of opinion that venereal dis- eases were not known in Europe previously to the year 1493, when, he states, they were brought into Spain by the followers of Columbus, on their return af- ter the discovery of America. The same author quotes various passages from contemporary writers to prove the correctness of his opinion, and states that INTRODUCTION. 25 venereal diseases were endemic in the Antilles, and especially in the island of St. Domingo, whence they were directly imported. In subsequent pages he cites various passage for the purpose of proving that they are of native growth, and that the following places may be considered as so many seed-plots of the venereal venom : viz., the kingdom of Peru; New Spain; Florida; the midland part of Africa under the line; the island of Java; the Molucca islands; the country of China. As to the immediate source of the diseases in these countries, Astruc attribu- ted them to the nature of the diet, to immoderate promiscuous intercourse, and the virulent acrimony of the menstrual flux. Having explained in this manner the original appearance of the venereal dis- ease, Astruc informs us that it was communicated by sexual intercourse to the Spaniards, who imported it into Europe; thence it spread among the Neapoli- tans. Soon afterward he traces it among the French, who contracted it from lying with infected women at the siege of Naples, and it soon afterward spread over the other countries of Europe. In 1752, Sanchez* wrote a book to contradict the opinion which the writings of Astruc had made popular, and came to the following conclusions :— 1st. That the venereal disease was known in France previous the arrival of Columbus. 2d. That the Spanish army could not have given the disease to the French troops, as it did not come in contact with them. 3d. That it commenced in Italy, at the beginning of the year 1493, as an epidemic. Hunter declines giving an opinion on the origin of venereal diseases, as he thinks it could be of little practical benefit. Having previously noticed at length his division of the diseases, and the opinion he entertained on the spe- cific nature of the virus, which caused both gonorrhoea and syphilis, I shall not here allude to them. Broussais and his followers, as I stated before, denied that the venereal dis- ease depended upon a virus. M. Richond, in 1826, published a work, entitled " De la Non-Existence du Virus Vencrien." Practitioners of this school be- lieve that venereal diseases depend upon simple inflammatory affections, result- ing from the mode of the peculiar vitality of the organs primarily affected, and of their sympathetic power over certain parts of the economy. They believe that the diseases in question may arise spontaneously, and in- stances are given by. them in which this is said to have occurred. Having now traced the principal opinions (from the earliest times to the pres- ent day) which have been entertained on the origin and nature of venereal dis- eases, I shall, in as concise a manner as possible, give my own opinions, which I have every reason to believe are those of M. Ricord; but as the professor of the Hopilal du Midi has not yet published on this subject, I am unable to quote his words. Venereal diseases, according to the definition which I have already given of the term, have probably existed from the most remote ages, or at least the non virulent class of such affections. Proof of this has not only been adduced from history, but I have likewise the following reasons for the belief: At the pres- * Sur l'Origine de la Maladie Venerienne. Paris, MDCCLII. 26 INTRODUCTION. ent day we find that all these non-virulenl affections* may be developed sponta- neously, and that we can produce them at will; hence I conclude that it is more than probable that they existed long before they were described, because the same agents were then in action to produce these affections as at present. Thus I admit the spontaneous origin of all non-virulent diseases, and that when once developed they may be propagated by contact, under circumstances which I shall hereafter allude to. In respect to the second order of venereal diseases, or virulent affections,] I can only now assert (and must refer to the subsequent chapters for proof), that we are not acquainted with any cases (nor do any such exist on record) which prove that syphilis, properly so called, can arise spontaneously ; all the experi- ments made to produce it de novo have completely failed; and a careful inves- tigation of the disease proves, on the contrary, that it has been contracted from a person who has himself contracted it of another, and it is in this way that the disease is now propagated. I thus deny most positively the spontaneous origin of this form, or of syphilis, properly so called; the exact laws and periods at which it ceases to be contagious, as far as my observations extend, will be mentioned hereafter. When this disease began (for necessarily it must have had an origin) I, in common with many previous writers, admit my ignorance. I can trace it (as I have done) as far back as the year 1494, and on this point there is little differ- ence of opinion; previously to that year authors ate not agreed: for my own part, I believe that a disease similar to syphilis was known previously to the year 1494, as may be gleaned from the authors I have cited; but I am as firmly induced to believe that the exact date of its outbreak is unknown, and that we are in ignorance of those circumstances which first gave it birth, or in what country it first made its appearance; in this respect the same lack of informa- tion reigns as in a vast number of other diseases, the origin of which we are equally unable at the present day to ascertain. I believe that the disease has had various phases; at one period it has assumed a very mild character, in con- sequence of attention to cleanliness and peace. On the other hand, in time of war and famine, it has assumed aggravated forms depending upon evanescent causes; and the disease, though always smouldering, will break out again, and rival in intensity those forms described by Fernel and Fracastorius, should the world become the scene of that condition of society which existed in the six- teenth century. In proof of this, I need only cite Dr. Ferguson's account of the disease as it attacked our men in the Peninsula, and gained it the name of the Black Lion of Portugal. Having given, then, my own opinions, which will be more fully developed in the succeeding pages, I turn from this theoretical part to describe practically a disease on which the author and reader will more certainly agree. * By the term non-virulent affections I mean diseases, the consequences of sexual inter- course, depending upon common causes, and not on any special one ; as, for example, gon- orrhoea, &c. t By this term are meant those affections which depend on a special principle, distinct from all the ordinary morbific causes. A COMPLETE PRACTICAL TREATISE, &C, &C, &C. PART I. SYPHILOID DISEASES. CHAPTER I. BLENNORRHAGIA. For the purpose of bringing the subject of venereal diseases in a clear and methodical manner before my readers, I shall adopt the arrangement of M. Ricord, pointed out at pages 22, 23, of the Intro- duction. Order I.—Comprehends the non-virulent venereal affections, called syphiloid by M. Ricord. Definition.—By the term syphiloid diseases are meant those af- fections which follow sexual intercourse, reproducing themselves daily, often contagious, but not depending upon a special cause—non- inoculable. Under this order is included blennorrhagia, and its consequences ; excoriations, herpes, eczema, and all other affections the result of sex- ual intercourse, not included under the second order, or virulent affec- tions. Blennorrhagia, from B'Xewa, mucus, and 'Pw, to flow, signifies a discharge from mucous membranes, consistmg usually of mucus, and depending upon inflammation of that membrane, being to the urethra, vagina, or conjunctiva, what bronchitis is to the bronchi, with this difference only, that blennorrhagia most usually depends upon, or is contracted in, sexual intercourse. Gonorrhoea.—The disease here spoken of, under the term blen- 28 BLENNORRHAGIA. norrhagia, has been successively known by a variety of names. Among others, authors have employed the term gonorrhoea, derived from Tovn, semen, and pc us connected with any one lesion or cause more than another. The acute stage, whatever be the particular lesion, causes, at its commencement, a secretion almost wholly serous, or only con- sisting of healthy mucus, more abundant than usual, but becoming opaque, then purulent, or of a darkish yellow color, sometimes green- ish, and at times mixed with blood. The chronic stage often gives rise to a milky secretion of a thickish consistence, similar to that of cheese, or simply to a mucous flux. BLENNORRHAGIA IN THE FEMALE. 145 The chronic discharge may put on a rusty appearance, and become tinged with a larger or smaller quantity of blood. These secretions, whether in an acute or chronic stage, may have no smell; or, on the contrary, have a very unpleasant odor, particularly when the mucous papulae exist. The smell, sui generis, is often so decided, that it is characteristic in a great number of cases : under other circumstances, it resembles the smell of cancer, or that of feculent matter. The only differences which result from the particular seat of the blennorrhagia are, that the secretions which come from the uterus are always more mucous, thready, and collected into flocculi; whereas, those which escape from the urethra, vulva, or vagina, present a less tenacious character than the others. The Symptoms of blennorrhagia in the female do not present dif- ferences which always have a relation to the cause which has pro- duced it; these symptoms are more especially connected with the precise situation, or the degree of severity of the complaint. As the disease is, for the most part, purely local, be its exact seat what it may, we do not find general symptoms present; in a few cases, how- ever, sympathetic or constitutional symptoms accompany the affec- tion, particularly such as depend upon the circulation ; the nervous system may likewise participate, and the digestive organs may suffer. We have seen women affected with both acute and chronic dis- charges, and yet complaining of no pain, and would have been ap- parently unconscious of suffering from a blennorrhagia, were it not for the stains which they were unaccustomed to see on their linen, or in consequence of their husbands contracting the disease. Never- theless, an inconvenient sense of heat of the vulva, accompanied with itching, usually announces the commencement of the disease. To treat, however, the subject systematically, we must describe seriatim the affection as it occurs in the various parts of the genito- urinary mucous membrane. Thus the symptoms of blennorrhagia of the vulva consist in a swelled state and redness of the nymphae, to- gether with a good deal of irritation; on separating the nymphae, the morbid secretion at once appears, which may be confined to the vulva alone, or may escape and become matted and harden on the hair of the external organs, forming thick and offensive crusts, which com- pletely cover the parts. Fat women are more especially subject to it. Patients laboring under this form find a difficulty in walking ; the desire of sexual intercourse is often increased, but it is usually at- 10 146 BLENNORRHAGIA IN THE FEMALE. tended with pain. The discharge renders, of course, the diagnosis easy. In blennorrhagia of the urethra, there is pain in making water, but slighter than in the affection of the male, and in some cases no scalding is felt; therefore, the absence or presence of this symptom is of no great value as a diagnostic sign: dysuria sometimes accompanies the affection ; the introduction of a catheter is, however, seldom called for. The secretion does not at once meet the eye; in order to sat- isfy himself if really any is to be found, the surgeon should take the following precautions : Having introduced the first finger into the vagina, the pulp turned toward the symphysis pubis, let him press somewhat firmly the urethra against the bone, at the same time with- drawing the finger. In this manner, if pus be present in the canal, it will be squeezed out, provided the female has not lately made wa- ter, and she has a blennorrhagia of the urethra. We have by this means detected the presence of a disease that other practitioners have not suspected. M. Ricord estimates that the urethra is affected in eight cases out of every twelve females suffering from discharges of the genital organs. Blennorrhagia of the vagina is attended, in the majority of cases, with little pain : the disease seems to be very indolent, particularly when no foreign substance comes in contact with the mucous mem- brane ; we have, however, been unable to introduce the speculum in some cases without causing pain ; in others, the slightest touch be- comes insupportable, and consequently the act of going to stool is very painful. In cases of this nature, the surgeon will not immedi- ately perceive the discharge, as a narrow vulva may occasion an ac- cumulation of the secretion in the posterior part of the vagina ; large quantities of feculent matter in the rectum, or a full bladder, will tend to the same effect, and thus the discharge escapes only when the pa- tient makes efforts to go to stool or pass urine. The surgeon should be aware that the traces of a discharge are to be looked for, rrot on the front part of the linen, as in the male, but behind ; and if a woman keep herself clean by frequently washing the parts, or retaining a sponge in the vagina, he will with difficulty ascertain whether she be diseased or not. Blennorrhagia of the uterus may be commonly recognised by the usual symptoms attendant on inflammation of that organ, viz., a pain- ful feeling of weight in the pelvis, a distinct sense of heat communi- cated to the finger of the surgeon placed on the neck of the uterus, great pain felt by the patient, when the uterus is pressed upon, from BLENNORRHAGIA IN THE FEMALE. 147 the vagina, as well as from the hypogastrium, a sense of dragging in the iliac region, and derangement of the menstrual function : all these symptoms may, however, be absent, although there is an acute blen- norrhagia and free discharge from the uterus. Such an affection as this, which thus shows itself by a discharge from the external organs, we can not investigate without the aid of the speculum. The same may be said of the deeper lesions of the vagina, or of the neck of the uterus ; it should not be our object alone to ascertain the exact character of the discharge and the complaint which gives rise to it, but likewise to convince ourselves of the con- dition of the mucous membrane, the morbid states of which we have before described. Without any further remarks on the necessity of employing the speculum, as we feel convinced that time will overcome the prejudi- ces which exist in England against its use, more than any argument we can urge in its favor, we shall at once proceed to describe the in- strument that M. Ricord uses, and which, by personal experience, we can recommend to our readers as being of easier application for the surgeon, and less painful to the patient. It consists, as may be seen in the accompanying woodcut, of two valves united at about the mid- (The Speculum.) die point, allowing both extremities to be widely opened ; the narrow- est part is thus placed at the vulva. To each valve a handle is at- tached, by which means space is gained, and the light falls upon the interior uninterruptedly, and pressure on them causes a dilatation of the two extremities, which can be maintained, diminished, or in- creased, by means of a screw. It has the further advantage of being adapted to the young and the old ; one instrument serves alike for all, and the surgeon is not obliged to have a series, as happens when he employs the common speculum. Its employment is very simple, but, like passing a catheter, requires some practice. 148 BLENNORRHAGIA IN THE FEMALE. The patient should be placed on the edge of the speculum-chair, seen in the annexed woodcut, or on a bed, with a pillow under the (Speculum-Chair.*) head and shoulders, the thighs bent on the pelvis, and the legs on the thighs, the feet supported on two chairs. The surgeon should place himself between the lower extremities of his patient, and requires no assistant—an important thing in private practice. The speculum, previously warmed and greased with a white pomatum, is thus to be introduced : Holding the valves of the instrument firmly together with the right hand, the surgeon should separate the nymphae by means of the index and ring fingers, while, by the aid of the middle finger of the left hand, he depresses the lower part of the vulva. This should be done gradually, but gently; at the same time the extremity of the speculum should be introduced, the handles turned toward the left thigh ; the side of one of the extremities of the valve should press upon the middle finger ; the other valve will necessarily * I here introduce to the notice of the profession a ohair which answers admirably for nearly all surgical operations. Its recommendations are its simplicity, firmness, and general application to surgical purposes. It looks like an easy-chair in a library, and may be raised to a sufficient and convenient height. It embraces the latest improve- ments, and is particula-ly distinguished from all others by the inclination of its seat. I can not too strongly recommend to the profession the maker, Mr. Moon of Orange street, who has so ably assisted me in its construction. BLENNORRHAGIA IN THE FEMALE. 149 be applied against the posterior surface of the meatus, along which the surgeon must pass it by depressing the instrument, without tear- ing or excoriating the mucous membrane. As soon as the speculum has/ passed the ring of the vulva, it should be directed in the axis of the pelvis, and the operator should separate the valves ; by this means he is enabled to see the condition of the vagina and uterus, and, finally, the instrument will surround the neck of that organ. It is unnecessary for this purpose to employ a very long instru- ment, or push it on until the neck of the uterus is embraced, as this would expose the organ to laceration, and cause great suffering if the instrument should be caught in the cul de sac of the vagina, as often happens. To avoid this, we recommend that the situation of the neck of the uterus be previously ascertained by the toucher, so that the instrument may fall at once upon it, and the neck of the uterus will be recognised by the smooth condition of the mucous membrane, and by its color, which usually differs from that of the vagina. Use- ful indications for finding it may often be derived from the streaks of white-of-egg-like mucus, which flow from the uterus into the vagina. In spite of these indications and precepts, should the surgeon find the speculum entangled in the cul de sac of the vagina, instead of pushing it onward, let him gradually withdraw the instrument, at the same time that the valves are separated, and the neck of the uterus will at once come into view. This was the method which M. Ricord followed when he formerly had the care of the females, and such is the plan we have adopted when we introduced the speculum at the Hopital de L'Ourcine, and we have never met with any difficulty, although we were often called upon to employ it in cases of various deformities of the osseous system, &c. There are, however, certain counter-indications which should pre- vent the surgeon from introducing the instrument, at least for the mo- ment. These are, first, a severe inflammation of the vulva or vagina ; sec- ondly, the existence of the hymen, which the surgeon ought general- ly to respect; thirdly, the narrowness of the vagina in very young girls; fourthly, the occurrence of various bands of well-organized membranes, which are sometimes met with in women that have had children; fifthly, during the period of menstruation, as it is then use- less. The speculum may be employed, even though a woman be pregnant, provided the surgeon thinks the case requires it, and if the instrument be employed with care. 150 BLENNORRHAGIA IN THE FEMALE. M. Ricord states that the French female in high life is now so reconciled to the use of the speculum, that he often receives notes requesting his attendance, and, in the postscript, a demand that he will bring his speculum. At the hospital, when M. Ricord took the service, in 1S30, a revolution broke out, and a strike against the spec- ulum occurred ; however, a few days of bread and water quieted this revolt of the harem ; and now the women are so convinced of the benefit, that they think no more of its introduction than they do of having a blister dressed. They can, however, appreciate instantly the tact of one surgeon over another in introducing it. The Complications of Blennorrhagia.—We shall now proceed to describe these, more especially as their consideration will lead us in some measure to consider the diagnosis of the various forms we have above detailed. In the affection of the vulva, and as a consequence of want of proper attention to cleanliness, especially in fat women, erythema or eczema may appear on the thighs or external organs, and give rise to a muco-purulent secretion, thus assuming a form of external blennorrhagia, particularly in the groin ; such a state often precedes the breaking out of mucous tubercles. The vulva may like- wise assume an oedematous condition, by which means a species of phymosis of the nymphae occurs, and gangrene arises; this may be followed by an induration, which lasts a longer or shorter time, or an abscess sometimes forms, which, if not opened speedily, may extend to the perinaeum, and produce a fistulous opening, which it is very difficult to treat. Abscesses here often result from cysts, and are lia- ble to return, unless the cyst be entirely cut out. We have, in the Hotel-Dieu, seen a striking example of a frequent return of the com- plaint in consequence of this treatment not being followed. The inflammation of the urethra may extend to the bladder, giving rise to cystitis, retention of urine, dysuria, depending upon spasm or an inflammatory state ; in some rare cases there is haematury. The blennorrhagia of the uterus may be complicated with the vari- ous morbid general sensations we have previously described : to these we shall not now revert; but there is one which we believe is new to English practitioners, at least we do not remember having read of it in English works. We allude to an ovaritis, which bears an analogy with epididymis in the male. Thus a female suffering under uterine blennorrhagia may be seized with shivering and a feverish state of the system; vomiting may come on, together with pain referred to the iliac fossa, where more or less tension may be present (in no way resembling that superficial pain produced by peritonitis); pressure on BLENNORRHAGIA IN THE FEMALE. 151 the os uteri gives no suffering ; but if the finger be carried up the cul de sac of the vagina, and the patient desired to turn upon the opposite side, pain of a most acute kind will be felt. The blennorrhagia may cease for the moment, one ovary may be attacked only, or both simul- taneously, as in epididymitis : revulsion will explain the partial ces- sation of the discharge. Lastly, we believe that a great number of ovarian dropsies may re- sult from a chronic inflammation of that organ, the consequence of such complications. A frequent complication of blennorrhagia of the uterus is the occur- rence of ulcerations. These may be either specific or simple. The specific ulcers may be usually distinguished by being isolated, although they may occupy any portion of the neck of the uterus ; they may be further distinguished by giving rise to the characteristic pustule, when inoculation is tried : the granulations which appear upon their surface rapidly heal, leaving, however, a considerable state of induration. Lastly, secondary symptoms will follow after some time. Simple ulcers arise as a consequence of inflammation ; they are seldom distinct: commencing at the interior of the uterus, they make their way outward, have a great tendency to throw out granulations, but seem little disposed to cicatrize ; by such signs the surgeon will usually be able to diagnose a simple from a specific ulcer. During its progressive stage, or after it has cicatrized, provided no induration follows, it is not easy to form an opinion ; but this is not important, as the treatment will be the same. The consideration of this subject naturally leads me to mention some points which present certain dif- ficulties for the surgeon. The medical adviser is often consulted to know if a blennorrhagia has been transmitted, or is transmissible ; or, in other words, if the disease under which the female labors be con- tagious, has arisen spontaneously, or be the result of a sexual inter- course with a diseased person ? The fact of a blennorrhagia having been contracted by sexual intercourse is, as we have before observed, no proof of the syphilitic or virulent nature of the discharge. On the other hand, a virulent discharge in a female may occasion a mild af- fection in the urethra of the man who has connexion with her, it act- ing not in virtue of its specific influence, but as a simple irritant. M. Ricord, in consequence of the various investigations he has made relative to this subject, is convinced that a female perfectly free from disease herself may communicate either a chancre or gonorrhoea; that is to say, the virulent matter may be deposited in her vagina by 152 BLENNORRHAGIA IN THE FEMALE. one individual, and may be taken up by another in subsequent con- nexion, without her becoming affected by it—she is the reservoir simply; this happens not unfrequently in girls of the town. Admitting, as we do, that various causes may occasion in the fe- male, as in the male, a blennorrhagia which is variously designated by the terms whites, fieurs blanches, still blennorrhagia, depending on these causes, is more uncommon than is generally supposed. In fact, those women who communicate the disease present, on exami- nation, some considerable lesion, such as we have described above ; hence, whenever a patient presents himself, complaining that a woman has infected him, the surgeon, in ninety-nine cases out of a hundred, will be right if he states that the woman with whom he has had con- nexion is herself diseased. Persons having connexion with these women do not, however, necessarily contract the disease, although it is probable that they will do so. Many persons have wished to distinguish the whites, or fieurs blanches, from blennorrhagia. This, however, they have been unable to do ; and it is not surprising that it is difficult to distinguish things which are exactly similar in form, and which only differ, if we may be allowed the expression, by an essence that we can not discover. There is nothing, either in the particular seat of the affection, nei- ther in the appearance of the discharge, nor in the alterations of the tissues, which can distinguish leucorrhoea from simple blennorrhagia. The only possible differential signs, in some few cases, might be drawn from a knowledge of the causes ; thus, in admitting, as some do, that the whites are those discharges which arise from the influ- ence of individual or general causes, then, under the head of blen- norrhagia, we should arrange all other discharges which arise as a consequence of mechanical, chymical, or virulent causes which have acted directly on the organs of generation. Such distinctions are, however, impossible in by far the majority of cases, in consequence of the little degree of confidence the surgeon can place in the stories of patients who deceive themselves, or wish to deceive him. The most important task, then, the surgeon has to perform is to decide whether the blennorrhagia be virulent or not. If a chancre be pres- ent, no doubt can remain in his mind that the disease is a virulent. one, and that it has been contracted from sexual intercourse. In other cases the diagnosis should be very guarded ; care should be taken in the wording of certificates that a medical man may be asked for. " After carefully examining Mrs. ----, I do not find she is la- boring under any syphilitic affection, but is subject to a discharge, FtJI. if s^y :/^— ^ / ^ & 2 BLENNORRHAGIA IN THE FEMALE. 153 which, under the influence of any exciting cause, may become ag- gravated, and thus transmit the disease to persons having connexion with her," is a good form. The Prognosis of a simple blennorrhagia of the vulva is not serious, except in a case of the occurrence of complications which abscess or fistula might give rise to. In urethral blennorrhagia the cure is usually rapid. The disease does not. last so long as in the male. The vaginal blennorrhagia is usually the more difficult to cure, in proportion as the complaint is of old standing. When the disease has extended itself to the posterior portion of the vagina, it is next to impossible to cure ; like the uterine blennorrhagia, it is relieved for the moment only, becoming aggravated at the time of menstruation, and is thus interminable. In this last form women generally are bar- ren, for masses of thick, ropy mucus block up the os uteri, and pre- vent fecundation. Treatment.—With reference to the prevention of the disease, we have nothing to add to what we stated under this head when speak- ing of blennorrhagia in the male. In referring to the curative treat- ment, we shall divide it into the abortive, and the treatment of the acute and chronic stage. Here, as elsewhere, the abortive treatment should be employed ; but women seldom apply in time ; the medical man is never consulted during the first few days : this may be attributed to their modesty, or to a cause which (were I not afraid of maligning the sex) I should attribute to that unaccountable, but no less true statement—want of cleanliness with respect to the genital organs. In the treatment of the acute stage of blennorrhagia of the vulva, great benefit may be derived from warm lotions, containing opium or belladonna. If excoriations similar to those found in balanitis are present, the surgeon will find great benefit from cauterizing the sur- face, and keeping dry lint between the diseased parts. If no excori- ations are present, dry lint alone will usually suffice. When the acute stage has passed, astringent injections may be had recourse to with advantage. Blennorrhagia of the urethra, as it resembles that in the male, re- quires a similar treatment. Blennorrhagia in the vagina.—In addition to the ordinary antiphlo- gistic remedies, it is particularly important to use frequent injections, in order to remove all matter which may stagnate and produce a great source of irritation. These injections are best employed when the 154 BLENNORRHAGIA IN THE FEMALE. patient is in a warm bath. In cases where pain is felt, injection? should not be persisted in. Further benefit may, however, be derived from injections—namely, as astringents. To this effect, the patient should be placed on a bed, the hips raised, and then the injection should be pushed gently, and allowed to remain. The tube of the syringe should be of an elastic substance. When the case is com- plicated with a granular state of the mucous membrane, a ball of lint, moistened with various substances, may be employed, attached by means of a thread which passes out of the vulva, to enable the patient to withdraw it at will. However, the greatest advantage is usually to be derived from slightly touching the parts over with the nitrate of silver. An augmented secretion usually follows this treatment, but soon ceases, and a cure takes place. Injections of nitrate of silver may be employed, but not with the same advantage as the solid sub- stance. When it is impracticable to introduce the speculum, benefit may still be derived from the application of the solid stick of nitrate of silver. In other cases we may derive great benefit from plugging the vagina with dry lint, which should be changed twice a day. Blennorrhagia of the uterus.—In the acute stage of the disease, in- jections into the uterus are dangerous ; leeches, likewise, should never be employed, or placed on the neck of that organ, as has been recommended: when placed on the groin, or opposite the spine, they have as good an effect, and they do not here cause inflammation, or produce virulent sores on the os uteri. In the chronic state, injections of nitrate of silver may be used (two grains to the ounce), and the quantity has been augmented to ten grains. This substance has suc- ceeded better than any other. Since my return to England, my late master (M. Vidal de Cassis) has called the particular attention of the profession to the subject of injections into the uterus ; and as I witnessed many of the cases treated in this manner, I may be allowed to subjoin my own opinion upon the subject, and make a few practical observations which I hope will be found interesting. It is certain that, if fluids be injected into the uterus in abundance, and with considerable force, on the dead subject, some portion of the liquid may pass into the peritonaeum ; this result, however, is by no means certain. When injections are em- ployed on the female during life, some practitioners believe that these same consequences ensue. Such is not, however, my own opinion. I have injected the uterus many times, when at the Female Venereal Hospital, with the happiest results, and have no reason to believe that fluid ever got into the peritonaeum ; immediately after the opera- BLENNORRHAGIA IN THE FEMALE. 155 tion, the patient has occasionally complained of colic and pain in the loins; these symptoms usually disappear in a few hours by warm fo- mentations, therefore I have had no cause to reject on this account a treatment, which has the advantage of curing a very obstinate affec- tion. There are, however, some precautions necessary to be taken. A long tube is to be introduced into the os uteri, and a syringe con- taining a very small quantity of the solution may be firmly attached to it, and the fluid should be pushed on with but little violence ; for it must be borne in mind that the cavity of the unimpregnated uterus is very small, and that large quantities of fluid forcibly impelled might possibly pass into the fallopian tubes, and thus escape into the cavity of the peritonaeum—consequences not very probable, but which might give rise to very unpleasant circumstances. Treatment of the complications.—Retention of urine rarely occurs in the female ; it may, however, demand the use of the catheter. In inflammation of the neck of the bladder, or in cystitis, the usual antiphlogistic means should be used, and great benefit is derived from cold clysters containing laudanum. When the complaint has resisted this treatment, the mucous membrane may be rubbed over slightly with nitrate of silver, by means of the instrument of Lallemand. In the male we have seen this treatment followed by success. Vegetations should be destroyed by excision when possible, but they are very liable to return. Stricture, from the nature of the female genital organs, is very rare ; perhaps it does not occur once in ten thousand cases. When abscesses form in the nymphae, they should at once be opened by large and free incisions, which ought to comprise the whole length and depth of the tissues, and cysts should be removed. Cases of fistula?, which arise previous to the surgeon having been consulted, or which occur in consequence of bad management, must be treated on general principles. Thus, the first object to be attained is. to keep the sides of the fistula in contact, and this may often be attained (provided the fistula be recent) by means of position and pressure. At a later period, when the fistulous opening is lined with an organized false membrane, the solid nitrate of silver may be used in order to destroy the false membrane and produce an eschar; when this fails, pressure should be used on the sides of the fistula. The nitrate of silver may be often replaced with advantage by the nitric acid, particularly when the sides are indurated, or by means of the uretome the callous structure, may be incised. Unfortunately, cases 156 BLENNORRHAGIC OPHTHALMIA. present themselves which resist all treatment, and it only remains for the surgeon to recommend cleanliness. In the oedematous state of the vulva, which we have previously spoken of, instantaneous relief will be procured by dividing the part which may be supposed to form the stricture. Bubo must be treated as in the male. Chancres require the same treatment here as when they occur in other parts. We refer our readers to that subject. The treatment of the various nervous and other complications which occur in uterine blennorrhagia must be conducted on general principles ; but the cure of the local disease will often cause them to disappear. Ovaritis must be treated by our most powerful antiphlogistic reme- dies, otherwise abscesses will form and open either into the vagina, peritonaeum, or rectum. CHAPTER IV. FORMS OF BLENNORRHAGIA COMMON TO BOTH SEXES. Having now described the forms of blennorrhagia which are pe- culiar to either sex, we come, according to the plan we have above laid down, to speak of those forms which are common to the male and female. In the first rank stands blennorrhagic ophthalmia. SECTION I. BLENNORRHAGIC OPHTHALMIA. Blennorrhagic ophthalmia, or what in England is usually term- ed gonorrhceal ophthalmia, is not unfrequently seen ; yet it is a rare affection, in proportion to the vast number of cases of blennorrhagia which we have witnessed. Its exact situation is pretty regular : BLENNORRHAGIC OPHTHALMIA. 157 thus it usually occupies the palpebral surface of the conjunctiva, or the ocular surface may alone be diseased ; however, we most fre- quently find them both affected at the same time. The follicles at the commencement may be the seat of the complaint, or the substance of the conjunctiva, or the sub-mucous cellular tissue. Usually one eye is affected only at a time ; but, in new-born children, both are not unfrequently seen in a morbid condition. Causes.—On this subject there is much difference of opinion, and at the present day two doctrines divide the medical world; one class of practitioners insisting that the disease is a consequence of sympa- thy; another class asserting that it results from the blennorrhagic pus coming in direct contact with the conjunctiva. The supporters of this last opinion reject altogether the doctrine of sympathy ; on the con- trary, the advocates of the first doctrine admit that blennorrhagic oph- thalmia may be produced by direct contact. We shall now consider these opposite opinions, and first of sym- pathy. The authors who take this view of the subject consider that the affection depends upon a sudden suppression of a blennorrhagia, which, not knowing what to do with itself, passes by sympathy to the eye. Such persons have assumed two things as proved which we can not allow : First, that the discharge is suddenly driven into the sys- tem ; secondly, that there exists a sympathy between the eye and the urethra, vagina, &c. Observation proves, constantly, that the blennorrhagia of the genital organs continues, and is not checked at the time the ophthalmia breaks out; therefore there is no metastasis. There are no proofs, either, of sympathy between the eye and the urethra ; we have stated that it is a rare affection in comparison to the number of cases of blennorrhagia ; if it were a sympathetic affec- tion, we should expect it to occur much more frequently. Another reason which makes us believe that it is not a sympathetic affection is, that in women it is a much rarer affection than in men ; now, sympathy is usually supposed to act more powerfully in the former class, or at least equally so. One eye only is affected at a time in by far the majority of cases : how can sympathy explain this ? why does one eye sympathize more than the other with the genital organs 1 These, then, form the reasons which oblige us to reject the doctrine that blennorrhagic ophthalmia is a consequence of metastasis or sym- pathy. 158 BLENNORRHAGIC OPHTHALMIA. We advocate the second opinion, viz., that direct contact of the blennorrhagic discharge is the cause of the ophthalmia, for the fol- lowing reasons : Observation clearly points out that matter directly applied to the conjunctiva will and can produce the ophthalmia; we are well aware that it is not always possible to trace the disease to direct contact, but are we consequently to reject the doctrine, and conclude that none has taken place, simply because we have not traced it ? Certain circumstances, such as the temperature or humid- ity of the air, influence considerably the disease, rendering infection more probable, and aggravating the complaint. Age likewise has its predisposing effect : thus, children born of parents laboring under a blennorrhagic discharge are very liable to be- come infected, in consequence of direct introduction of the matter, and both eyes are usually equally affected. The period of infancy passed, all ages are equally liable. Sex, as we have above stated, has a marked influence in predis- posing individuals. The male is, in a tenfold degree, more liable than the female ; the reason is simple. In making water, the man is obliged to handle the penis ; curiosity also makes him wish to exam- ine the state of the discharge frequently ; thus his hands become soiled with the purulent secretion, which may easily come in contact with the eye. In woman, however, the contrary happens ; her fingers are rarely soiled, for she is lamentably neglectful of the ordinary duties of clean- liness. When one eye is affected, the probability of the other be- coming so likewise will depend upon whether the patient lies on the same side or not, thus favoring the discharge to come in contact with the sound organ. It will be rendered still less probable when the bridge of the nose is high, for the same reasons. Symptoms.—At the commencement, the symptoms are similar to those found in common ophthalmia; the patient feels as if a foreign body intervened between the body and the lid. Should the surgeon be called upon to examine the eye at this period, he will find that the lower eyelid is first attacked ; it is redder than usual, and presents a flocculent, red appearance ; the disease does not remain, however, long confined to this spot, but spreads over the whole surface of the conjunctiva; there is considerable lacrymation, followed speedily by a muco-purulent discharge, which soon assumes a purulent charac- ter ; the follicles participate in the disease ; the mucous membrane assumes a granular appearance, and a sanguineous discharge, or even pure blood, appears on the surface. BLENNORRHAGIC OPHTHALMIA. 159 The secretions now form crusts around the lids, and are often so acrid that they excoriate the cheek and parts which they come in contact with; it, however, does not produce any effect on being inoculated. Granulations are* so common in this affection, that it has been called granular ophthalmia ; this proves that the inflammation has gained the body of the mucous membrane. The symptoms do not, however, stop here ; oedema of the lids takes place to such an extent that the patient loses all power of opening them, and they remain per- manently closed, causing the secretions to be shut up, as in case of abscess. The upper lid, allowing of a greater distension than the lower, covers it, and trichiasis often results ; oedema of the cellular tissue of the conjunctiva occurs, and chemosis follows ; thus the cor- nea is surrounded with a mass of oedematous infiltration. Should phlegmonous inflammation occur, an induration will follow in conse- quence of lymph being thrown out. The other parts of ihe eye become successively attacked ; intoler- ance of light follows ; the cornea becomes clouded, ulcerates, and hypopium succeeds. The ulceration may result from the mere me- chanical effect of the pus, which by its acrid qualities macerates or softens the cornea; or it may ulcerate, from the circulation being in- terrupted ; hence, destruction of the parts follows from insufficient nutrition. These unfavorable symptoms follow one another so rapidly, that in twenty-four hours the eye may be lost. When the disease has ex- isted five days, and the use of the organ is preserved, the surgeon may hope to save it. When the acute stage has passed, the affection may terminate either by resolution, which gradually occurs, leaving a considerable hardness, or cicatrices of the cornea may result, or the iris may become adherent, or be covered with false membranes. Delitescence is a very rare termination. Diagnosis.—In this point of view it is impossible, by any of the signs taken singly, to satisfy one's self of the existence of an oph- thalmia which is the direct effect of gonorrhoea or blennorrhagia. We have before observed that the granular state of the mucous membrane does not prove the specific nature of the complaint, but shows only that the body of the membrane is the seat of the disease. The intensity of this form has been considered as a characteristic symptom, but the practitioner will find he can not. depend solely on it, as other forms of ophthalmia have this sign, in common. 160 BLENNORRHAGIC OPHTHALMIA. The coincidence of blennorrhagia is not conclusive, for any individ- ual may become affected with ophthalmia independently of gonor- rhoea ; the latter complaint does not prevent him from being affected with a simple conjunctivitis; when it occurs, however, it is a sign of importance, but not an unequivocal symptom of a specific disease. However, the coexistence of blennorrhagia of some of the mucous membranes, great intensity of the complaint, together with a granular appearance of the mucous membranes, will usually be sufficient evi- dence that the disease is blennorrhagic ophthalmia. In moist, damp weather, the surgeon should be on the alert to treat actively inflammation of the eyes in persons laboring under blennorrhagic affections. There is still another question which we should not leave unno- ticed. How can we diagnose a virulent from a mild blennorrhagic ophthalmia ? We positively affirm that no case has ever been shown us which we could call virulent; we have inoculated, but no pustule has been produced, and we are not aware of authors having cited ca- ses of it; we therefore believe that there is no virulent form, strictly so called. Prognosis.—There is no form of ophthalmia, the prognosis of which is more unfavorable than the one we are describing; conse- quently, when the surgeon has a case to treat, he should never take the whole responsibility upon himself ; the patient only ob serves the slight redness, and if in twenty-four hours the organ is lost, his treatment will be blamed ; a second opinion should, there- fore, be called in. " To give an idea of the unfavorable nature of the prognosis," says M. Ricord, " when I was Dupuytren's interne, that distinguished pro- fessor never had a case that was perfectly cured, or a patient that re covered his sight completely when once attacked with this complaint, and yet it was not from the fear of taking blood, for six or eight bleed- ings were ordered in as many days." Treatment.—To use the words of Lisfranc, in one of his clinical lectures, " you should tumble upon this complaint, the arm bent, and the mind firmly convinced that it is better for your patient to run the risk of losing all his force than his eye, for one can be recovered, the other is irremediable." But it is at the commencement that we may hope to be of the greatest service ; on the first appearance of redness, let leeches be applied to the temples, and the mastoid process, and let the patient be briskly purged. Should general inflammatory symp- BLENNORRHAGIC OPHTHALMIA. 161 toms be present, general bleeding may be called for. Without wait- ing, however, to allow the disease to gain ground and correct his diagnosis, the surgeon should at once employ the nitrate of silver in substance, not with the intention of its acting like a caustic, but sim- ply to change the character of inflammation ; for, as we have fre- quently had occasion to observe, this substance is endowed with anti- phlogistic properties. To apply it properly, the eyelids should be everted, and then the solid stick of nitrate of silver should be rapidly passed over the surface, so as to whiten it slightly ; immediately in- ject cold water under the eyelids, and by this means the nitrate of silver will not touch the cornea. This treatment should be accompanied by that above mentioned, together with poppy-head fomentations, and great relief may be de- rived from belladonna placed in the nostril of the affected side. At a later period the surgeon will do well to prescribe a seton in the neck; by such means nature seems as if taken by surprise, and frequently the eye is at once relieved. The patient's head should be raised and turned to the affected side, to prevent the secretion coming in contact with the sound organ. When chemosis is present, the surgeon should not hesitate to cau- terize it, or, in case of that treatment not succeeding, he may readily, hv means of scissors, cut off the swollen and oedematous cellular tis- sue. This will tend materially to unload the vessels of the part. When the chemosis is indurated, cauterization may be tried; when, however, the circulation of the cornea is interfered with, the surgeon will do well to scarify it (the chemosis), as recommended by Scarpa. Supposing that the first cauterization does not succeed, it is by no means a reason for discontinuing it; in its reapplication, the surgeon should bear in mind the following rules : Cauterization is usually succeeded by a sanguinolent secretion ; this lasts some few hours ; if, at the end of that time, it does not return to its purulent state, if the eye becomes redder than before, the surgeon may with advantage reapply the caustic. M. Ricord has reapplied it four or five times under these circumstances. When, however, the secretion becomes purulent, and then serous, and the other symptoms of inflammation abate, no further application of the caustic is required ; it is now worse than useless, and will tend only to excite the inflammation afresh. This constitutes the treatment which we have seen employed with the greatest success ; we shall not, however, quit the subjec 11 162 BLENNORRHAGIA IN THE ANUS. without saying a few words on some other remedies which have been used. M. Ricord is opposed to the use of mercury, as it often causes sal- ivation ; for, although the ptyalism might act as a counter-irritant, it is too near the seat of the affection, and causes only another disease, instead of curing one. Our opinion, from what we have seen of mercury in other affections of the eye, &c, differs greatly from that of our learned master, and in spite of his objections, we should feel called upon to use it in certain cases, and under certain restrictions. As regards the propriety of reproducing the original blennorrhagia, we have nothing further to add to what we stated in our general ob- servations on blennorrhagia, except to repeat that, though recom- mended by Baron Boyer, it is very dangerous, and does not produce the results he anticipates. SECTION II. BLENNORRHAGIA IN THE ANUS. It may be asked, Is there such a disease as this ? We answer, Yes. Nevertheless, it is very rare ; but in large hospitals, set apart for diseases of the genital organs, it is occasionally met with. We have seen some cases—one lately, which was clearly proved, as a police officer was witness of the unnatural crime, and the boy entered the hospital suffering greatly from blennorrhagia of the rectum, and presented the following symptoms. How far it may be common, it is not here for us to decide, but as a consequence of direct infection we believe it an unfrequent disease ; the error of thinking it so de- pends upon the following circumstance. A secondary symptom, which we call mucous tubercle, and which very often follows an in- durated chancre, is very common in the hospital: we have given a very good plate of it. (See Plate V., fig. 4, and PI. 7.)' Hence M. Ricord interrogates the patient on this score, and exam- ines the anus frequently. Now, as the mucous tubercle gives rise frequently to a discharge, a superficial observer might suppose that the disease has been contracted by direct contact, particularly when the tubercles are ulcerated. After a careful examination of these BLENNORRHAGIA IN THE ANUS. 163 cases, and after inoculation of the secretion, &c, we have satisfied ourselves that we have only had to treat a secondary symptom. The symptoms of blennorrhagia of the anus are but slightly alluded to by authors, and yet they are of great importance, more especially in medico-legal inquiries, as we have more than once stated. Symptoms.—Pain and difficulty in going to stool usually accompa- ny the disease ; however, such symptoms exist equally in haemor- rhoids and other affections of the rectum ; a discharge from the gut takes place, resembling that from the urethra. The lesions of the intestines may be similar to those we described in speaking of the vagina, and the pain is very often intense, in consequence^ the faecal matter passing over the excoriated and inflamed gut, thus forming a severe complication ; chancres may occur, which, if accompanied, as they sometimes are, by a spasmodic action of the intestine, render defecation very difficult, or even impossible. The disease may assume either a chronic or acute character. When acute, the circumstances and complications render it very se- vere ; when it takes on the chronic form, the position and difficulty of local treatment render the cure very tedious. Buboes seldom fol- low, but abscess at the margin of the anus is not unfrequent; it does not, however, necessarily form a communication with the intestine, though fissures of the rectum may frequently result. The affection is usually seated just within the sphincter, and does not extend beyond the second curvature of the rectum. The cause is, as we have stated above, the effect of direct contact of the blennorrhagic secretion ; it can not be produced by swallow- ing the secretion, as some authors have pretended. The other gen- eral causes of blennorrhagia might give rise to the disease, but sel- dom do so. Diagnosis.—This is by no means easy, for we occasionally see blenno'rrhoid discharges from the rectum, and to distinguish such from blennorrhagia is usually impossible. Notwithstanding, the medical man is sometimes called upon to give evidence ; it is therefore of the greatest importance that he fully understand this subject, as the life and rpputation of several individuals may depend upon his opinion ; and for these reasons we purpose examining some of the signs which have been given in books. M. Cullerier, one of the surgeons of the Venereal hospital, states, in an article he has written on this subject, that an opinion may be formed from the funnel-shaped appearance of the rectum. The case which we lately saw proved completely that this funnel-shaped ap- 164 BLENNORRHAGIA IN THE ANUS. pearance of the anus does not necessarily follow the commission of an unnatural crime; no such appearance was there present. Those who have dissected phthisical patients must be likewise aware that this appearance will be often found, as it depends upon the absorption of the fat; an inflammatory affection may cause a swelling of the parts around the anus, and give the opening a funnel- shaped appearance ; hence, then, we infer that the crime may have been committed without this pretended sign being present; and if it does exist, there is no reason to suppose that the crime has been per- petrated. Our readers will, therefore, appreciate the value of such a symptom. The color of the discharge has been cited as assisting the diagno- sis ; but taken alone this is of no use, for it gives the surgeon no in- formation as to the cause. In simple blennorrhagia of the rectum inoculation affords no assist- ance ; if, however, chancre be present, inoculation will then satisfac- torily prove that the complaint has been caught in an unnatural man- ner. The occurrence of buboes will not assist the diagnosis, as some have supposed ; observation clearly shows that they are often pro- duced by simple irritation. The antecedents of the patient seldom aid the diagnosis, as he rarely acknowledges that he has been guilty of such a crime. In fine, when no chancre exists, there is no one unequivocal sign that the complaint, which the surgeon is called to pronounce uppn, depends on a disease contracted in unnatural connexion ; there is, however, a circumstance on which M. Ricord lays great stress ; we refer to a rent or tearing of the margin opposite the coccyx and peri- neum, which he has never found in persons unaccustomed to the crime. He further states, when this condition has been observed, that the patients, on being pressed, have avowed and confessed the manner in which the disease had been contracted. Prognosis.—This must be always unfavorable, as, during the acute stage, the passage of the faeces irritates the membrane, and may give rise to abscesses. In the chronic stage, if the disease have reached the deep parts of the rectum, we can have no hopes of speedily curing it, as it is difficult to apply local treatment. Treatment.—The first indication we have to fulfil is to empty the rectum, and to prevent constipation as much as possible ; this is best done by lavements. When, however, fissures of the rectum exist, the introduction of the clyster-pipe is difficult, and should not be contin- ued ; laxatives only should be used. Cubebs and copaiba are not VEGETATIONS. 165 only useless, but highly prejudicial, as they tend to irritate the rec- tum, and have no effect in checking the discharge. The direct means consist in keeping the parts perfectly clean, in employing injections of nitrate of silver of the usual strength, and, m some cases, advantage may be derived from the use of the tent. SECTION III. BLENNORRHAGIA OF THE MOUTH, NOSE, AND EARS. M. Ricord, in his immense practice, has never seen any disease or discharge which could be classed under this head ; he is therefore disposed to treat such descriptions as fabulous, and to attribute them to simple catarrhal affections. In the umbilicus, and in the fold of the groin, discharges may appear as the consequence of dirt, or the development of mucous tubercles ; the treatment must, of course, be founded on general principles and consideration of the cause. SECTION IV. VEGETATIONS. Under the general term of non-virulent affections I place vegeta- tions, which, though not necessarily, are frequently a consequence of sexual intercourse, and must therefore be considered. Vegetations are generally designated by the terms, warts, cauliflower excrescences, cockscombs, See (PI. VI.) Pathology.—In color vegetations differ considerably; sometimes they are of a very vivid red or scarlet; this happens particularly when they are seated on the glans penis at the entrance of the ure- thra in the male or female, on the inner margin of a narrow prepuce, and, generally speaking, when they are not constantly exposed to the air.' When seated on the skin they are much paler, and by exposure become even quite black. Their consistence and sensibility differ considerably : they may be quite horny, very little if at all sensible, and quite dry ; or they may 166 VEGETATIONS. be moist, secreting a dirty and offensive fluid, flaccid, and sensible to the ordinary stimuli. Sometimes they are attached to the skin by a sort of pedicle ; at others, they have a broad base, and are flattened. In number and size the same variety occurs ; we meet often with one or two, very small and pointed ; in other instances, the male or female organ3 may be completely covered with them. They are more frequently situated on the mucous membrane than on the skin, although they are met with on the thighs ; still, however, they are found on those parts of the skin which are more closely allied to mucous membrane. Their growth depends apparently on the little pressure and the moisture which surround them ; for, if pressure be made, and if artificial means be employed to keep the parts dry, their growth is retarded. Their structure is very peculiar : a cluster of vegetations is com- posed of a number of granular bodies connected by a common base ; the size of the granules differs greatly, usually that of a small pin's head ; these granulations are more or less conical ; when not com- pressed, they are covered by epidermis or epithelium, which often becomes horny in exposed situations ; if a section be made of this cluster, it seems to consist of an hypertrophied dermis, which is much thicker here than elsewhere. Some authors believe vegetations to consist of the papillae of the skin, which from some cause are hyper- trophied, and lift up the epidermis covering them. Others believe them to depend upon an hypertrophy of the crypts, which form the exhalents on the skin, having assumed a conical appearance. What- ever views my readers may have upon the subject, let them be as- sured that their origin is deeper than is imagined; hence arises the difficulty of removing them, and the necessity of taking certain pre- cautions if we wish to cure them radically. They are plentifully supplied with blood-vessels, bleeding freely when cut; their sensi- bility differs greatly ; in some cases vegetations are nearly destitute of sensation ; when they have been much irritated, they become ex- ceedingly sensitive, and the secretion they give rise to seems to in- crease that sensibility. The causes appear to arise from irritation ; some persons believe them to be the consequence of venereal disease, and pretend to speak of syphilitic vegetations as distinguished from others. Observation leads me to the following conclusions : Any secretion which will oc- casion irritation of a surface for a prolonged period may produce vege- tations. We have often seen them in boys and adults affected with natural phymosis, or who pay no attention to cleanliness; in such VEGETATIONS. 167 cases, it is the secretion of the glandulae odoriferae which produce the disease, for connexion has never been indulged in. Sir A. Cooper, in his valuable Lectures on Surgery, states two causes which prove that the secretion of warts is contagious, and he does not think that the blood of these bodies can become the infectious agent. I have met with similar cases, but I am not prepared to say that the matter they secrete is of any peculiar property, acting otherwise than as a simple irritant, which, as I have said, is alone sufficient to produce warts. In females they depend upon gonorrhoea or irritating discharges ; the secretion of chancres often produces them, not, I believe, in virtue of any specific action, but from its irritating qualities, and modern authors no longer consider them a secondary symptom. It is of no great importance in medical jurisprudence that these points should be properly appreciated. I may here mention an instance. A late interne at St. Louis' hospital was shown a child with these vegetations completely encircling the genital organs, which he in- stantly pronounced to be syphilitic ; and the mother immediately sus- pected an old man who was in the habit of playing with the child, who lived in the same house with her; and the answers of the child appeared to corroborate these suspicions, or they were (as often hap- pens) tortured into an acknowledgment. The authorities were ap- prized, but did not think it necessary to take any measures. I ex- amined the child, and found that the vegetations existed in great numbers, of a dark and horny consistence ; there was a considerable quantity of serous discharge from the vagina. The child was puny, lymphatic ; and I could detect no marks of violence on its person. This circumstance induced me to tell the interne that he had come rather hastily to a conclusion on the nature of the vegetations. Their pale, horny, dark character showed that they had existed a long time, notwithstanding any statement of the mother, who seemed at all risks to tax the old man with rape. The discharge from the vagina, as I assured him, was often pres- ent in scrofulous children ; it existed in this instance, and its serous character showed that it did not depend upon recent infection. Now these appearances did not tally with the commission of rape, or the idea of infection contracted a few days before. I believed the man innocent; and I mention the case here, as the circumstances which attend it are peculiar, and I believe it be an instructive one. Complications.—Vegetations may exist alone, or be complicated with a variety of other affections : in the female we often find dis- 168 VEGETATIONS. charges which produce, keep up, and aggravate the complaint. Excoriation of the surrounding tissues is often likewise a complica- tion. Ulcerations, both of a simple and specific nature, frequently attend the complaint, and render it more difficult of cure. But by far the most frequent in the London hospitals is condylomata, and hence these two affections are often confounded together, and attributed to the same cause. In the female, the situation of vegetations often gives rise to a complication, particularly when they are of a very vascular kind and occupy the meatus, causing that affection which has been described by Sir C. M. Clarke and Sir B. Brodie. In the male, vegetations co-exist with balanitis, chancres, paraphimosis, phymosis, complications which are often severer than the original af- fection, and which it is necessary to remedy previous to treating the vegetations. The diagnosis of vegetations is generally easy; there is, however, one affection with which they may be confounded ; I allude to con- dylomata. The practised eye will, in such cases, however, rarely be deceived. The former affection is pedunculated, the granules small, covered with epidermis ; their color is florid. The history of the case, and the existence of some irritation, help the diagnosis. In the latter affection the bases of the condylomata are large, the granular patch is flat, apparently destitute of epidermis, and covered with a whitish or yellow secretion, rarely occurring without other traces of secondary symptoms, probably the patchy excoriation of the tonsils, or a papular'eruption on the body. When vegetations and condylomata occur together, the local characters I have above mentioned aid the diagnosis. The prognosis is favorable, although the patient should be made aware that, when destroyed, vegetations are very liable to recur. If not removed, however, they may create great local irritation, and produce very intractable sores, although possessing nothing specific. In some few cases I have witnessed, when vegetations are very ex- tensive, no sooner does the surgeon get rid of one crop than another appears ; the disease is hydra-headed; but under the treatment which I shall immediately recommend, this rarely occurs. Treatment.—When these bodies are few in number, it is only ne- cessary to remove the cause which keeps up the irritation, and they will disappear of themselves. Ablution with tepid water, or an astringent wash, will often suffice, provided dry lint be used to pre- vent the vegetations coming in contact with one another. They shrivel up and soon fall away, and are not reproduced. In such PLY. VA-**3 HERPES PRAEPUTIALIS. 169 cases as these, any dry powder may be employed, and, as far as my experience goes, the simpler it is the better; and I should recom- mend hair-powder in preference to those stimulating ones in use, which, however, are not without their danger. I have often had oc- casion to witness vegetations surrounded with a hard crust composed of some powder mixed with the secretion, and producing an augmen- tation of suffering; hence I do not recommend them. When the patient will submit to the use of instruments, nothing succeeds so well as excision of the vegetations with a pair of curved scissors, taking care to cut them as close as possible to their roots. The incised parts bleed freely ; but this should not deter the surgeon from cutting off as many as possible, placing dry lint upon them when the bleeding has ceased; the coagula and lint should be re- moved by the use of the warm bath,.and the greatest attention paid to cleanliness, at the same time that means should be taken to check any discharge which may run over the affected part. If powders be used, the part should be carefully washed and dried previous to any more powder being applied. When these means fail, caustics may be employed, but the surgeon will find them very inefficacious compared to the other means. Nitrate of silver produces but little effect; its action is superficial, and it forms a hard cake on the vege- tation, which is irritating and does not fall off for some days, when the vegetations are often as large as before. The caustic potash is a very unmanageable preparation ; it extends further than is wished, and the black and decomposed substance is very irritating. How- ever, as an adjunct to excision, the employment of the solid nitrate of silver is beneficial; but the surgeon should not employ it to the bleeding surfaces : when the excised parts have ceased to pour out blood, and the part is washed, let the stick of nitrate of silver be applied to the centre, and the vegetations will not reappear. Gener- al means are of no benefit, unless they tend to check any discharge which keeps up the irritation. SECTION V. HERPES PRAEPUTIALIS. Among non-virulent affections is a complaint which pathologists have agreed to call herpes praeputialis. Willan and Bateman have 170 HERPES PRAEPUTIALIS. classed it among vesicular diseases. It commences by a cluster of small vesicles, seated on a patch of inflamed skin : the vesicles may become ruptured, and the secretion of the part may cause ulceration, and little sores are thus produced. The reader who is not familiar with this disease, will gain a very good idea of its characters by examining Plate III., fig. 3: the affection is there seen in all Us stages. I think I can not do better than extract the following case from my note-book, together with the observations which I made upon it, as they comprehend whatever is known upon the disease. August 15, 1839.—My friend Dr. Fisher, of the Place Vendome, directed A. G-----to call upon me, and ask my opinion upon a sore on the penis, this morning. On the prepuce and glans there are several ulcerations presenting the following appearance : one is a small distinct ulcer, covered with a whitish secretion, the base is red, and gradually lost in the surrounding tissue; close to it is a distinct vesicle filled with a limpid fluid ; there are various others, which more or lc?.~ resemble the two spoken of. On the right buttock there is a patch of vesicles of the size of a five-s'iilling piece, the base of each being as large as a pin's head; some are filled with a serous, others with a yellowish fluid. Close to the anus is another patch, which is completely covered with a yellowish crust, such as is"seen on the face of children. The History the patient gives of himself is the following: he left England in consequence of bad health and indigestion, and is now returning from Geneva. On Thursday last, the 8th instant, having been three days in a diligence, he felt a singular pricking near the anus, and at that period the sore on the penis first appeared, but hae made no progress since. Being interrogated on the subject of ex- posure to contagion, he states that he has not had connexion more than twice, the last one dated two years back. As to the probability of having contracted it on a water-closet, he states that he did sit down on one which was very dirty, a short time since. He adds, that had he reason to attribute the affection to contagion, he would willingly avow it, having no motive for concealing the truth. On again questioning him, he states that he is very subject to in- digestion and to eruptions ; lately he has been particularly inattentive to diet, eating at a table d'hote, &c. Such is the history of the case given by a very intelligent young man, who can have no reason for concealing anything, as he is very anxious to pursue his journey. He naturally asked me for an opin- ion on the sore, and this leads me to consider the diagnosis. The HERPES PRAEPUTIALIS. 171 circumstance of an ulceration on the penis, presenting the characters above noticed, in a young man of twenty, is very strong prima facie evidence that a chancre exists ; but we are aware that the presence of a sore on the penis does not prove that it is a chancre, for other sores may appear on the penis, and chancres may appear on any part of the body. As to the characters of chancres, we have stated them to be those attending other ulcerations, and that other sores may put on the character of chancre. In young men, suspicion is excited because they are more exposed ; but any age is necessarily liable. Thus, then, as far as we have yet seen, the present case has as many cir- cumstances for supposing it to be one of chancre as not. Now if it be not a chancre, what is it ? The prepuce is liable to other vesicular diseases. Thus, in addition to chancre, eczema and herpes praeputialis are not unfrequently seen on that part. Can the present complaint be any of these 1 It presents a vesicle of a con- siderable size, seated on an elevated patch: these, we see at once, are not the characters of eczema, for by referring to this latter affec- tion it will be found that eczema presents a very small vesicle, in great quantities, thickly and irregularly sprinkled over an inflamed and reddened skin. Herpes praeputialis, like herpes labialis, usually appears in distinct patches of about some ten or twelve large vesicles on a red base, which, at the end of a few days, fade away and dry up of themselves, or, if the irritation continue, form little ulcers. They generally depend, not upon local irritation, but upon disorder of the digestive organs ; on the contrary, eczema usually accompa- nies, and is produced by, local irritation. So far, then, it will at once be perceived that we are in doubt whether this case be due to a specific cause or not. If it be a sim- ple affection of the skin, it can be only herpes praeputialis, and we exclude eczema, and come to the conclusion that it is either a chan- cre or herpes. As to the probability of its being a chancre, we should add, that our patient has not been exposed to contagion, and unless we allow that a chancre arise spontaneously, the present case does not depend upon a specific contagion. Is it probable that the present case is an herpetic affection ? We find on studying herpes, on the lips and prepuce, that it is usually preceded by general disturbance of the digestive organs ; that it occurs in persons possessing a delicate skin, and such as are subject 172 ECZEMA. to skin diseases ; that it never exists except in patches, and that these patches may be numerous. Now these circumstances are all present in the case before us : the vesicles are not only present on the penis, but likewise on the buttocks, where there has never been an abrasion of surface ; hence inoculation could not have acted here, although it may on the sound surface of the mucous membrane. For these reasons, then, we have diagnosed the case to be one of herpes praeputialis, which from the moisture of the part has ulcerated. The prognosis is favorable, inasmuch as the course of an herpetic affection, when properly treated, is excessively simple ; we therefore gave our patient every reason to suppose that he would be perfectly well in a few days. The treatment we recommended, was particular attention to diet, advising him to live upon milk and vegetables, with meat and wine in moderation, avoiding all heating dishes. We prescribed aperients and bitters, and a local application of lint dipped in aromatic wine. August 18. This patient left Paris quite well. SECTION VI. ECZEMA. The surgeon is occasionally consulted on account of a severe affection of the genital organs which pathologists call eczema. This disease is generally spoken of only in treatises on skin diseases ; however, as it occasionally is a consequence of sexual intercourse, I have thought proper to allude to it, and accompany the description with a plate which the reader will find in Plate IV., fig. 3. Causes.—Eczema can generally be traced to the application of some irritating substance to the skin. In cases which we are about to treat of, the blennorrhagic discharge is the usual exciting cause, together with inattention to cleanliness : hence we very frequently witness cases of the affection in prostitutes. In men, however, who work in a business where much powder or dust is disengaged, this affection of the genital organs is not uncommon, and of course quite independent of any venereal complaint. The surgeon should not forget that mere friction of the trousers will produce it; by itself it EXCORIATIONS. 173 is no sign of venereal disease. I have found it more frequently in persons who have red or auburn hair than in other individuals. Symptoms.—Eczema is characterized at its commencement by a feeling of itching, heat, and redness ; the parts become swollen, and these symptoms are followed by an eruption of small vesicles scat- tered over the surface : when scratched, a serous fluid exudes, form- ing little scales on the skin, and increases the irritation. The disease may assume the chronic form ; in this state the drawing was taken : the skin is red and swollen ; the surface covered with the secretion above mentioned, which is hardened by exposure, and crevices arc seen running between the little lamellae: from these issues, at first, a clear, and in the more advanced stages a sero-purulent secretion, giving rise to larger and firmer scales, and the disease is then called eczema impetiginodes. The diagnosis is easy, and does not require further allusion. The prognosis, in simple cases, is favorable, but in the severer forms no prospect of an early or speedy cure can be given, as this affection is one of the most obstinate. Treatment.—Great, attention to cleanliness is frequently sufficient to cure the patient, at the same time that all exciting causes are carefully avoided. In the more advanced stages, local bleeding will be called for, and some emollient application, such as bran-water, goulard-water, poultices, particularly those made of potato-starch ; linseed-meal, by its rancidity, often exaggerates the complaint. When these means fail, it may be found advantageous to stimulate the part by rubbing the organ with nitrate of silver, when all irrita- tion has ceased, and employing dry lint to prevent friction. SECTION VII. EXCORIATIONS. Definition.—By the term excoriation, I here mean abrasion of the epidermis or epithelium, the result of sexual intercourse. We meet, in practice, with some few individuals who can not in- dulge in sexual intercourse without being subject to excoriations; such persons are not observed to have a particularly fine or clear skin : we have met with the affection in patients who on other parts of the body have a thicker cuticle than usual, and yet are very sub- 174 EXCORIATIONS. ject to abrasions in connexion. Excoriations, however, are more frequently met with in persons who naturally have a long and nar- row prepuce, and pay little attention to cleanliness. The number and position of excoriations differ greatly, but it is in the neighborhood of the fraenum that they are most frequently seen, and they often occur upon the patches of the glandule odorifera at the base of the glans penis. They may rapidly heal, or, if neglected, ulcerations may follow, and be kept up by the secretions of the part; these sores, as far as physical characters go, we are unable to dis- tinguish from chancres, to which thev bear a strong resemblance in situation, size, &c. The treatment is the simplest possible : washing the penis several times in the day with a little goulard-water, and when dried placing a small strip of lint between the glans and prepuce, will rapidly cause these excoriations to heal. When this object is gained, the surgeon, to prevent a repetition of the annoyance, may recommend some astringent wash, and engage his patient to partially uncover the glands ; by such means, together with strict attention to cleanli- ness, or washing the part daily with a little spirit, the abrasions of the skin will not reoccur, and the patient will be relieved from much annoyance and danger in promiscuous intercourse. PART II. SYPHILIS. CHAPTER I. PRIMARY SYMPTOMS. In the introduction it has been stated that venereal diseases may be naturally distinguished into two orders : to the first of these I have already sufficiently directed the attention of my readers. There, how- ever, remains the second division, no less important, if considered in relation to the primary symptoms it gives rise to, or to those general or constitutional results which modern surgeons believe to be a direct consequence of the primary. This second order, the description of which will form the subject of this part, has been styled— Syphilis.—Syphilis is a virulent affection, the essential character of which is its dependence upon a special cause, or a distinct virus. The term syphilis is derived, according to Fallopius and Swediaur, from <™"i with, and i£', to love. Modern authors have subdivided syphilis, as above defined, into separate stages, and this arrangement I shall follow, believing it the most natural ; and I, moreover, consider it a plan fraught with the advantage of placing the symptoms which successively arise in a clear methodical manner before my readers. The first stage includes primary symptoms, or the immediate effects of the specific cause, occurring on the spot where the special virus or virulent matter has been deposited. Example, chancre. The second stave embraces secondary symptoms, which follow as a consequence of absorption of the virus ; these may be hereditary, but 176 CHANCRE. are not capable of transmission by inoculation. Example, various affections of the skin and mucous membranes. The third stage comprehends tertiary symptoms, which are not ca- pable of being transmitted by inoculation, and are not hereditary, but manifest themselves by certain pathological alterations of the submu- cous and subcutaneous tissues, as well as morbid appearances in the fibrous and osseous structures. We shall, in the present, chapter, describe the first stage, or primary symptoms, commencing with chancre. SECTION I. CHANCRE. Definition.—Chancre (says M. Ricord), or syphilitic ulcer, is a specific ulceration depending upon a special and identical cause, al- ways similar in its nature, under whatever form it presents itself, and derived from an ulcer similar to itself, which it reproduces during a certain period of its existence, and which, constituting a local disease at its commencement, gives rise, under circumstances we can often appreciate, to symptoms of general poisoning, known by the term sec- ondary symptoms. Anatomical characters of chancre at its commencement.—The best means of studying these characters is to observe them in cases of ar- tificial chancre produced by inoculation, as we can here examine them at our leisure. They are well delineated in Plate IV. If the pus be taken from a chancre during its ulcerating period, and introduced, by means of a lancet, under the epidermis of the in- ner part of the thigh, or any other part of the body, the following re- sults will be obtained. During twenty-four hours succeeding the operation the inoculated point becomes red, fig. 1, a; in the course of the second and third days the surrounding parts are slightly swollen, and assume a papu- lar appearance, or already traces of a vesicle are seen on the summit, fig. 1, b, c; on the third or fourth day a fluid, which is more or less transparent, is observed beneath the epidermis, and a distinct vesicle becomes apparent, where the papula previously existed, and a dark dot is seen in the centre, owing to the coagulation of the blood which had escaped through the puncture of the lancet, fig. 1, c, d ; from the PI It. *< «>w*&* ■ ■ '-■ d 9 f k 2 CHANCRE. 177 fourth to the fifth day the vesicle assumes a pustular character, and a distinct depression is seen in the centre, so that it represents very distinctly at this period the small-pox pustule, fig. 1, d. e. The red areola, which has been hitherto gradually augmenting in intensity, now as gradually fades away, and the cellular tissue, which was slightly oedematous, becomes infiltrated with plastic lymph. On the sixth or seventh day the pustule is observed to be wrinkled, in con- sequence of the contents becoming thicker, and ultimately a crust takes the place of the pustule, fig. l,f,g. If not interfered with, this crust assumes a conical appearance, increasing always at its base ; it ultimately falls of, leaving an ulcer seated on a slightly indurated base, in depth equal to the thickness of the skin : the bottom of the ulcer is covered with a whitish pulpy substance or false membrane, which adheres so firmly, that it is with difficulty wiped or washed off. The ulcer is generally circular, and appears as if made with a punch, fig. 1, h. The margin, if viewed by means of a microscope, will be found dentated and covered with a secretion similar to that seen at the bot- tom of the ulcer. The border is slightly oedematous, or indurated, and the areola around it of a browner tint than at the previous stages ; this oedematous condition of the border occasions a slight eversion of the edges, and hence the ulcer may assume a somewhat infundi- buliform appearance.* The surgeon, however, must not expect that the course of every chancre he meets with in practice will be similar to this artificial sore. Observation teaches us that primary sores may commence in either of the following ways. The matter from an already infected individual may introduce itself into the follicles which exist in such numbers on the glans penis, and as the opening closes, little ab- scesses or pustules form, which then go through the stages mention- ed in the preceding paragraph ; and a good idea of this form of chancre may be obtained from PI. IV., fig. 2. More frequently, however, the matter comes in contact with an abraded surface, together with mucus or some secretion which forms a sort of crust, and then the chancre is in the same condition as seen in PL IV., fig. \,g ; provided no mucus be present, the abraded sur- face does not become dry, but presents the appearance seen in Plate * Provided the patient keeps his 'bed, is in a good state of health, and commits no excesses of any kind, the course of a chancre produced in the artificial manner above- described will pass through these regular phases, but under opposite circumstances the artificial sore may take on any of the varieties hereafter to be mentioned. 12 178 CHANCRE. IV.,fig.l.g-. Chancres may commence in any of these ways, or the matter may be introduced under the epidermis or epithelium, by leech- bites, punctured wounds, &c. ; they will then follow the course of follicular or artificial chancres. Lastly, the absorbents may carry the matter along a lymphatic vessel, cause the ulceration of it, or of a lymphatic gland, and thus the chancre appears as a little abscess in the course of the vessel, presenting, when the scale falls off, the appearance seen in Plate V., fig. 2. If the pus of a chancre, such as we have described it, be examin- ed by the microscope, it will be often found to contain animalcules, particularly the vibrio lineola of Miiller. The experiments of M. Donne have likewise proved that it may present either alkaline or acid properties, circumstances depending upon its situation, &c. It varies in consistence, but is usually of a thin, serous, and san- guineous character ; however, the peculiar pathognomonic character of the pus is the action which it has on the animal economy when inoculated ; for I may here state that no other secretion with which we are acquainted, or which I have seen employed, will produce similar effects. This pus will produce no such specific effects on animals, not- withstanding all the attempts which M. Ricord and others have made to inoculate them ; hence, as far as experiments can prove it, its effects seem to be confined to the human species. Progress of Artificial Chancre.—If the sore be kept clean, it shows very little tendency to increase, and may remain a considerable time in statu quo, provided no excesses are committed ; the disease has a very mild character, quite at variance with those symptoms usually attributed to it. Weeks may pass, and the chancre not be larger than a split pea, although the areola may become somewhat more livid. The anatomical characters of the ulcerative period are not, however, always so simple as we have above described them ; in consequence of circumstances to be mentioned hereafter, the chancre may assume various appearances, which are considered by M. Ricord sufficiently distinct and characteristic to deserve particular attention. I shall consider these varieties under the following heads. 1st Variety, or Phagedenic Chancre.—Every chancre may be strictly said to be phagedenic, that is to say, it destroys the tissues which are in contact with it, but in simple, uncomplicated cases, its progress soon becomes checked and limited by the infiltration of lymph which sometimes surrounds it, and which Hunter considered CHANCRE. 179 as one of the features of a genuine chancre. When there is an ab- sence of this induration, which, when occurring in a slight degree, I shall call healthy, we may observe the 2d variety of chancre, which I shall call Diphtheritic Phagedenic. Chancre, an example of which is given in Plate V., figure 1.* Its form may be various; it has a ten- dency to extend rather in breadth than in depth, in consequence of the skin or mucous membrane offering but little resistance to it. The surrounding parts are but slightly swollen, or if any swelling be pres- ent, it has rather an oedematous or phlegmonous character than the specific induration ; in size such ulcerations cover a large surface, and secrete a thin, darkish colored, acrid pus. 3d Variety: Indurated Chancre.—I have not thought it neces- sary to give a drawing of the indurated chancre, a form which Hun- ter described ; it is rarely met with either in London or Paris. The cases which I believe Hunter meant, were chancres as seen in Plate IV., figure 1, h, provided they had an indurated base and sides, or what I should now describe as a simple chancre on an in- durated base. This sore and the following is the one spoken of by Mr. Carmichael as giving rise to the scaly venereal disease. 4th Variety : Indurated Phagedenic Chancre.—The simple super- ficial sore will occasionally become indurated to a considerable ex- tent, and plastic lymph be deposited in the cellular tissue around and beneath it in large quantities. In these cases the centre of the in- duration is observed to assume a dark appearance, and what M. Ri- cord calls an interstitial gangrene results, which gains by degrees the whole surface ; commencing at the centre, it reaches the circum- ference, and then becomes limited; it seems as if this gangrene re- sulted in consequence of insufficient nutrition from compression ex- ercised by the induration upon the vessels. A good idea may be formed of this chancre from Plate V., fig. 2. I have lately seen under Mr. Lawrence's care at St. Bartholomew's hospital several cases of this description. The cicatrix of a previous sore became cartilaginous and quite transparent; in a few days red streaks were observed running through it; these became darker until the whole indurated mass lost its transparency, and assumed the peculiar char- acter seen in Plate V., fig. 2. 5th Variety : Gangrenous Chancre.—In addition to the form of phagedenic chancre last mentioned, the result of excessive indura- ration, there is likewise another, the consequence of excessive inflam- * This is the form of chancre which Mr. Carmichael considers as giving rise to the phagedenic venereal disease, and lias by him been named acute phagedena. 180 CHANCRE. mation, which I shall call gangrenous chancre. Violent inflamma- tion may attack any simple chancre as it does other parts of the body, and gangrene of the chancre follows, succeeded by a grayish or blackish slough, which, on falling off, leaves the surrounding tissues in an infiltrated state, but no induration remains. The secretion ap- pears of a very acrid, irritating character, and consists rather of liquid tissues destroyed by the gangrene, than of pus or any secre- tion from the blood. (See Plate V., fig-. 3.*) ' Period of Reparation.—Under whichever of the forms above de- scribed chancre may have first appeared, the reparative process is ushered in by the appearance of healthy granulations on the surface of the sore, the margin, which was slightly elevated, becomes on a level with the ulcerating surface. The cicatrix extends from the cir- cumference toward the centre ; finally, the indurated base becomes absorbed, and a perfect cicatrization, level with the surrounding skin, occurs. When the chancre has existed on the skin or mucous mem- brane, a slight cicatrix only will remain ; but on parts where the cellular tissue is not in abundance and lax, as on the glans penis, or neck of the uterus, a depression will often result. A stain long re- mains on the spot where the chancre has existed ; at first of a livid hue, it gradually grows paler, until the cicatrized point ultimately be- comes whiter than the surrounding skin. The reparative stage, like the ulcerative, has its varieties. Thus, instead of healing rapidly, and from the circumference toward the centre, various points on the surface begin to cicatrize, or on one side only of the chancre. In other cases the sore cicatrizes, but no sooner does this happen than it begins again to ulcerate, or as the cicatrix commences on one side the ulcer enlarges on the other; thus we have a chancre lasting an indefinite length of time. The granulations may likewise be slightly or very much raised above the level of the surface ; in the latter case forming the ulcus elevatum of some writers. Such a sore, however, has usually lost its specific properties, and the secretion it furnishes is no longer inoculable. In some cases the ulceration in cicatrizing becomes indurated; instead of forming a healthy cicatrix, we observe a callous thickening, which, on the slightest cause, breaks out again into an ulcer of a very un- healthy character, as occurred in Plate V., fig. 3. Lastly, a chancre will become changed into what I shall hereafter describe as a mucous tubercle. In this case, instead of being gradually covered by a * Different varieties of chancre, and their different positions are shown in Plate IX. CHANCRE. 181 healthy cicatrix, there will be observed upon it an hypertrophy of the tissue, of a softish texture-like mucus, but lobulated, as represented in Plate VI.* Cause of Chancre.—" Cause," observes M. Andral, in his valuable Lectures on General Pathology, " is a term which, in the natural sciences, may be employed in two senses. " 1st. It refers to, or represents, a force or power susceptible in itself of impressing a change on matter; as matter is inert, every change which it undergoes must be the result of a. force which phi- losophers have agreed to call cause. " 2d. The word cause is employed in speaking of a fact which has preceded another fact, and which is associated with it; and we apply the term to the phenomenon, upon the manifestation of which another phenomenon depends." Barthez calls this an experimental fact, and it is in this sense that I intend using the word cause in the following pages. The cause of chancre I have, in the preceding section, traced to the secretion of another chancre, for we found that, when introduced under the epidermis, it constantly produced a peculiar series of phenomena. Let us now, then, see how far observation can enable the surgeon to study or explain the circumstances which constitute, form part of, dispose to, prevent, &c, the action of this cause. In tracing chancre to the secretion of another chancre, the quantity of which, although very minute, will constantly produce its effects, M. Ricord was necessarily led to push his investigations further ; but neither the microscope, physics, nor chymistry, have enabled him to isolate the cause : all his endeavors have hitherto failed in separa- ting it from the other component parts of the secretion of the sore, and whether it exists as an entity, or in combination with the globules, or the fluid part of the pus, or whether these serve only as a vehicle for it, we are unable to say, nor do we venture even an hypothesis upon the subject, so few are our data for forming an opinion. We are equally ignorant of the exact parts of the sore which se- crete it. We find it on the surface of the ulcer; washing or wiping it away only removes it for the moment—it becomes secreted afresh directly afterward ; but, as in the case of other secretions, we are in- * These varieties in what I call the reparative process have formed the basis of a division of chancres described by Mr. Evans, and more lately laid stress upon by Mr. Skey. This reparative stage of chancre is, I believe, the one which, according to Mr. Carmichael, gives rise to the papular eruption, and hence forms the papular variety: that gentleman not taking his divisions from the primary sores, but from the eruptions which he believes to follow them. I shall have again occasion to allude to this opinion. 182 CHANCRE. capable of discovering the molecular action, but it would seem to be a vital one, and does not resemble that peculiar action of leven—a term applied to it by ancient authors. This secretion, removed from the surface of the chancre, and kept in close bottles during seven days, will produce at the end of that period all its effects, proving that the vitality of the part is not ne- cessary for the preservation of its peculiar effects. Once secreted, it becomes independent of its source, resembling the virus of cow- pock, small-pox, &c. Various chymical agents have the property of neutralizing or destroy- ing it; thus, if the alkalis or acids be mixed with it, and inoculation afterward attempted, no effects will follow; these same substances will likewise destroy the property which inoculation has invested the sore with, of producing an analogous secretion, provided they be employed at an early stage. Simple substances, or ointments, will have no influence either in destroying or aiding the effects of the secretion. We shall then, in accordance with the usual custom of authors, call this peculiar secretion, which is the cause of chancre, a virus— not that we have been able to show its separate existence, but simply because the word secretion is too vague. We shall combine it with the word syphilitic, as this term distinguishes it from all other morbid agents, and treat of the cause under the denomination of syphilitic virus. Origin of Syphilitic Virus.—We have just traced syphilitic virus to the secretion of a particular sore which secretes it, generated by the virus of a similar ulcer produced in the same way ; at least we can affirm, that at the present day there exists no well-authenticated observation in the annals of science, which proves the spontaneous origin of syphilis. Undoubtedly (observes M. Ricord), we daily meet with cases which it is difficult to explain; but when we consider the many sources of error liable to occur, and that our patients have an inter- est to deceive us ; when we reflect that the disease is contracted under illicit circumstances, we should remain convinced that the one exceptional case in a thousand ought to be attributed to the same cause as the nine hundred and ninety-nine, the origin of which is regular and constant; and as long as it can not be shown that other agents, as well as the secretion of a chancre, will produce syphilis (as we understand the term), we shall not be convinced that it can arise from the operation of any other agent. CHANCRE. 183 Allowing that in the present day chancre can .not be traced to a spontaneous origin, still, say some authors, it is no less certain that this affection must have commenced somewhere and on some one. We fully agree in this, and we frankly state, that in the present state of science it is impossible to determine where, when, or under what circumstances, it first appeared ; in this respect, however, the origin of the virus is concealed from us, as is that of many other material objects ; but although the origin of a thousand facts be concealed, the existence of these facts is incontrovertible. If we may be permitted (says M. Ricord) to proceed by analogy, we shall see in the history of the vaccine matter several curious and important inductions. The transmission from the cow to the human species has not always been so well known, yet it must have always occurred. Suppose, then, that at the present time we were ignorant of its origin, it would be no less incontestable that the vaccine matter is not of spontaneous origin in the human race, and that it becomes developed as a consequence of inoculation, or by means of the spe- cific matter taken from an affected person, and applied to a healthy individual. Is it not possible that an analogous source, in the first instance foreign to the human species, may have furnished the first germ of syphilis, which, when once engrafted, has propagated and maintained itself, as the vaccine matter, which, like it, was at first foreign to the human species ? It is certain that true chancre has never been seen on any animal with which we are acquainted, despite the researches which surgeons of the present and past ages have made ; and it is no less certain that, notwithstanding my experi- ments at the venereal hospitals, 1 have been unable to inoculate any animal with chancre, so as to produce its effects ; but who can say that we shall not discover to-morrow what we were unable to find yesterday, or what we are in search of to-day ? Leaving, then, this interesting but speculative field of inquiry, we turn to the consideration of those accessory circumstances and con- ditions which are necessary for the production of the special effects of the virus. These we propose describing under three heads. 1 st. Necessary conditions of the chancre from which the virus is taken. 2d. The means and conditions of the agents of transmission. 3d. The necessary conditions of the parts about to be contami- nated. Necessary conditions of the chancre from which the virus is taken.— In the first place, it must itself have been derived from another 184 CHANCRE. chancre, which must be at the period we have called specific or pro- gressive, for we have already remarked that it is during this first period of the existence of the chancre that the peculiar virus is se- creted. Provided the chancre be thus derived, and presents the ulcerating stage, notwithstanding the length of time it has existed, be the physical characters well marked, the shape circular or oval, the situation on the genital organs, arms, mouth, &c, still the virus will produce its effects if the other conditions be present. We have just stated a general law, namely, that, certain condi- tions of the sore, from which the virus is taken, are indispensable to the production of chancre. Yet to this law there are apparent ex- ceptions ;—a man has connexion with a prostitute, and chancres appear on the penis ; the external and internal genital organs of the girl are examined, and no chancre is found. Here is the virus act- ing, and yet, say some people, it does not come from an ulceration Such cases in practice are not uncommon, but they in no respect in- validate our position, for there is every probability that the virus has been recently deposited from an ulcer of a third individual on the vagina, which being covered with mucus prevents its local action on that membrane, and thus the vagina merely serves as a vehicle for the virus, as any one of the means we are about to speak of. The means and conditions of the agents of transmission.—The fact that the virus is capable of being separated during a space of seven days, from the ulcer which has produced it, without, losing its con- tagious properties, has been already mentioned ; at the end of that period, if still in a liquid state, or, if dried, provided it be only moist- ened, the virus may be transmitted in a variety of ways, of which we may enumerate some of the most frequent. Lancets or other cutting instruments may accidentally become soil- ed with the virus, and thus the surgeon may unconsciously inoculate an incised wound. We have been witness of a case of this kind: venesection was ordered and performed in the usual way ; a few days after, the patient drew the attention of M. Ricord to the point in the arm, which assumed all the characters of chancre, and was very dif- ficult to cure, as induration followed. Such a case shows the neces- sity of great caution in the employment of instruments which may have been soiled with the virus. The Penis may serve as an agent of transmission of the virus, as in cases like the following: A young man had connexion with a prostitute ; in the course of the same day he had connexion with a female who previously had been free from disease ; in a short time CHANCRE. 185 chancres appeared on the second female, although the young man never presented any symptoms whatever of syphilis. Here, then, the penis was a simple agent of transmission, as the lancet was in the last case. The vagina may become a means of transmission of the virus ; this frequently happens in prostitutes. An individual suffering under chancres has connexion with a girl ; a quantity of virus is left in the vagina, but produces no action, as the mucous membrane is covered with a secretion. Should a second individual have connexion with this female under these circumstances, the virus may affect him, and no local disease be discovered on her genital organs, even after the most minute examination. Such cases are not unfrequent. Here the penis has performed the part of a sponge, and completely cleaned the vagina, which was simply a passive agent of transmission. Various secretions have been often accused of causing or trans- mitting the virus. The semen is spoken of as among the most frequent. That this may occur is undoubted; when a urethral chancre exists, the semen may, in passing over it, carry along the virus which is placed on the surface ; in a similar manner the milk may become a vehicle for it, provided a chancre exists on the nipple. The saliva may become charged with the virus, if a primary sore exists on the mouth, of which we shall hereafter give instances. At the 'present day we are little disposed to give credence to stories of chancre transmitted by means of the breath; and in the nineteenth century a minister of the crown is not likely to be accused of communicating the affection to his royal master by means of whispers. We now-a-days attribute a chancre rather to the company a man keeps than to the air he breathes. Various articles have the character of transmitting chancre ; thus, Mr. Colles believes that in Ireland the inmates of a cottage have become infected by the use of the sole spoon that a peasant family possesses. M. Cullerier mentions that at the venereal hospital chancres may be transmitted from one individual to another by means of tobacco- pipes, drinking-glasses, &c. The employment of chamber-pots, and sitting on water-closets, have been successively invoked to explain various difficult cases. Believing that such means of transmission are possible, we maintain that they are not probable, and the medical man should be very cautious how he admits them : patients will be always disposed to conceal the true source of disease, if illicit prac- tices have been indulged in ; and in affections of the mouth it is very 186 CHANCRE. difficult to distinguish primary syphilitic sores from various aphthous ulcerations which are epidemic, and run through whole families, in consequence of similarity of diet, clothing, low, unhealthy situ- ations, &c. Sheets have been believed capable of transmitting the virus; patients affected with simple eruptions on the skin have slept in sheets on which the secretion of chancres has fallen, and the simple sores have been converted into characteristic chancres. I witnessed a case where this was possible, in a patient of M. Puche, who pre- sented chancres on the penis ; he stated that he was taken up in consequence of the riots of May, and put in a prison where prosti- tutes had been previously kept; about two months afterward chancres appeared on the penis. Now here we might suppose that this was the source of the affection ; but when we state that the prisons of Paris are the scenes of unnatural crimes, we should rather conclude this to be the source of the sores, and not the sheets. Hildanus has given rather an odd story of a young lady affected with chancres, who could in no way account for their origin ; she at length remembered having disguised herself in man's apparel, some short time previously, and danced the whole night at a public masked ball; it was then found that a young man, who was at the time suf- fering under chancre, had worn the trousers previously, and conse- quently it was believed that the said pair of pantaloons had trans- mitted the disease. In such cases, when the medical man has to decide about a young woman, a masked ball, and a pair of soiled inexpressibles, with a youth in the distance, we may excuse him if he is lenient to the fair sex. Various articles used in dressing wounds may accidentally become the means of transmitting the virus, particularly sponges, lint, &c. During the last winter, M. Ricord removed a portion of diseased bone from the orbit in a patient laboring under tertiary symptoms ; the wound took on a peculiar appearance some few days afterward, and inoculation of the secretion at once showed that this wound had, through the intermedium of lint, or the water, or sponge (it was impossible to say which), become inoculated with virus from another source, for the patient himself presented no primary affection ; in this case the instruments could not have been the source, as they were new, and had not been pre- viously used. This case should put the surgeon on his guard ; and in venereal hospitals the greatest attention should be paid to cleanliness ; this, CHANCRE. 187 however, is not always possible, in consequence of the habitual care- lessness of the attendants. The necessary conditions of the parts about to be contaminated.— For the production of artificial chancre on the skin, we have already stated that it is necessary to introduce the virus beneath the epidermis, and we may add that an abrasion of that structure is always neces- sary for the action of the virus. In practice, we find that chancre follows abrasions, excoriations, fissures, incisions, leech-bites, wounds, scratches, &c. ; hence results that variety in shape which the sore may assume ; around the rectum we observe those ragged fissures which have no analogy with the circular chancre described by Hunter. We have lately seen a chancre on the thumb of an individual, having the shape of an ordinary small incised wound ; he stated, that in following his occupation as a tanner, he cut his hand ; he slept soon afterward with a prostitute ; the cut surface became inflamed, and he was unable to cure it with the usual remedy, namely, bathing the hand in the tan-pits. He left the hospital cured of the chancre by the usual treatment. The previous considerations will at once explain why the animal economy is more liable to chancre at one period of life than another ; thus the delicate skin of the infant, as well as its greater vitality, render infection {ceteris paribus) more probable than at any other period of life ; on the contrary, the dry and shrivelled condition of the tegumentary covering at the decline of life, causes chancres to be comparatively rare. We find, moreover, that absorption is slug- gish, and the chances of exposure to the virus are less than at the age of puberty, when the passions of youth and a forgetfulness of consequences lead to such frequent exposure. We may mention the influence of sex as a predisposing cause. The female exposes herself less than the male, consequently is less frequently the subject of syphilis ; but when, as in the case of pros- titutes, she exposes herself to contagion, we nevertheless do not find chancre so frequent; this depends upon the structure of the female genital organs, which are not so liable to abrasions as the male. In Paris, the frequency of the fieurs blanches may be mentioned as a cause of this species of exemption, as it shields the parts from the action of the virus. For the production of chancre on mucous membranes, the same principle holds good ; there must be a lesion of continuity of the epithelium, otherwise the virus will have no effect. There is an apparent exception to this law, but. closer observation shows that it is 188 CHANCRE. not a real one. The virus may insinuate itself into a mucous or sebaceous follicle, and having destroyed its lining by a species of irritation, comes in contact with the cellular tissue, and then a pus- tule or abscess is formed. When situated in a little mucous follicle, the virus may remain inactive some days in consequence of the cyst, as the virus is in the same condition as when enclosed in bottles ; the cyst being destroyed, the virus acts directly. This was probably the case in the instance of Mr. H.,* and explains some cases of supposed incubation. * On the 24th of September, A. H., a young surgeon, twenty-five years of age, had connexion for the last time with a woman of the town. He observed at the time that she suffered under a discharge. Immediately after connexion he washed himself care- fully with cold water. Suspicious of the consequences, he paid great attention to clean- liness, and took care to wash and examine the penis daily. On the 6th of October—that is, twelve days after connexion—while in a warm bath, he observed two small but suspicions spots on the glans penis. In the course of the same day he asked the opinion of a young medical friend, but on examining the glans no trace of them was apparent; he took a long walk, and in the evening a small swel- ling appeared in the right groin. On the morning of the 7th he observed these spots again very apparent, and employed some sulphate of zinc as a local application. On the 8th they assumed a vesicular character. October 9th. Mr. H. consulted me to-day; on the glans penis there are two ulcerated points, which present all the character of follicular chancres delineated in plate IV., fig. 2, with this difference, that they have been ruptured. In accordance with my views of syphilis, I felt called upon to cauterize them with a pointed pencil of nitrate of silver, and ordered the part to be constantly washed with lint soaked in aro- matic wine. On the 10th, a superficial sore appeared near the fraanum, which was cauterized, aa well as the sores on the glans penis ; the glands in the groin remain stationary. October 11th. During the course of the last night, a superficial sore appeared on the lining of the prepuce, which I cauterized this morning, thus making four sores at present existing. Nitrate of silver was applied freely to the other three, and the aro- matic wine aud lint ordered. There is no inflammation present; of course the nitrate of silver has somewhat increased the ulcerating surfaces. October 12th. The caustic was again applied. 13th. The sores are going on so well that Mr. H. would not submit to a further appli- cation of the caustic, and took a very long walk. To continue the aromatic wine. 15th. The two sores on the glans penis are completely healed. The ulceration on the prepuce is becoming somewhat indurated, but is nearly healed. The sore on the franum discharges considerably. 17th. All the sores are now completely healed; induration of that one on the prepuce and some redness alone remaining to show where the disease has existed. As I thought a continuance of the aromatic wine and lint could serve only as an irritant, I desired the patient to leave them off. 18th. The induration and hardness of the prepuce remain, accompanied with some redness. I therefore requested M. Ricord to look at it. He, however, would not give an opinion, as he was uncertain if the induration depended upon a specific disease or npon imtation, the consequence of cauterization: he, however, leaned to the latter opinion, from the antecedent history of the case, <5cc.; he recommended that the aro- matic wine be continued, and to watch the result. CHANCRE. 189 In our investigations we have not met with a single case which would seem to contradict the general law we have attempted to establish, namely, that abrasion of the epithelium or epidermis is necessary for the action of the virus ; some authors differ in this opinion, considering that simple contact of the skin and virus is alone sufficient for the development of a chancre. In these last cases, the virus might probably act as an irritant or escharotic, and destroy the surface ; the virus would then come in contact with the cellular tissue, and such cases, far from contradicting, prove the prop- osition we have above laid down. There are other cases which, interpreted in a different manner, might lead to the supposition that syphilis may be introduced into the system without any abrasion of surface. Chancre may heal in a few days, as we have elsewhere stated ; the virus may introduce itself into a follicle or point of the skin, and the follicle may become closed, or the point by which it was introduced perfectly heal in a short time ; in none of these cases abrasion of surface will be apparent, yet chancre will become devel- oped, giving rise to the opinion that lesion of continuity is not necessary. We think we may with advantage here inquire, if there are any per- 23d. The indurated point has been slightly ulcerating the last few days, and now presents an excoriated surface; on the glans there is likewise an excoriated point, which is distinct from the situation of the former chancres. M. Ricord saw Mr. H., and at once declared the sores to be specific. They were of a secondary nature, he believed, and would not inoculate or reproduce the disease. Ordered to wash with the aromatic wine, apply an ointment of calomel and opium, friction with a drachm of blue oint- ment, and bathe on alternate days. A mild diet was ordered. 24th. During the last twenty-four hours, the point which had completely healed at the frsnum has again broken out; the surface is excoriated; there is a point of the same nature on the prepuce. M. Ricord's bandage and an emplastrum vigo on the bubo. Continue the treatment. 25th. The indurated sore on the prepuce has not increased in size, and is nearly dry, being covered with a yellowish crust; that at the fraenum is in the same state as yester- day. The fresh ulceration on the prepuce bleeds on uncovering the glans, which was very painful yesterday; the pain was much alleviated by soaking the penis in water; the aromatic wine causes great pain. Continue the treatment, and observe a horizontal position, was my prescription to-day. P. S. The bandage remains well on, and is not tiresome. The frictions have occa- sioned an eczematous eruption on each thigh where the ointment has been applied. November 4th. The sore on the prepuce has now completely cicatrized; the treat- ment has been carefully followed; but Mr. H. is a determined smoker; in other respects he has committed no excess. 7th. The induration of the sore still remains, though it is much diminished in extent; there is a slight mercurial footor of the breath, and a somewhat red state of the gums. M. Ricord saw the patient to-day, and desired friction every third day, taking care against cold. This patient left soon after for England. 190 CHANCRE. sons non-susceptible of chancre ? If we choose to depend upon the word of some authors, as well as some men of the world, there exist certain privileged beings who are not susceptible of syphilis. It is a fact, founded on experience, that some few persons pass through life without contracting chancre, although they have exposed themselves to contagion. Such persons do not present the accessory conditions we have just spoken of; thus the virus did not remain long enough on the epidermis to destroy it and act on the cellular tissue below. If it be the case of a female, the vagina was proba- bly coated with thick mucus, which prevented the contact of the virus, or it was inflamed ; and experience shows that an inflamed and secreting surface will take on with difficulty the specific action of chancre ; the same occurs on a blistered surface, the secretion ap- pears to wash the virus away. If, then, any part covered with a perfectly healthy and compact epidermis be exposed to contagion, we are not surprised at seeing no effects result; this fact also proves the correctness of our opinion. But we can not agree with those who believe that there are individuals who resist the action of chan- cre ; we are certain that we can produce a genuine chancre on any individual who will submit to inoculation : the privileged few will then find that they have previously escaped contagion from one of the circumstances above mentioned. When the virus is taken from a sore under conditions before de- scribed, and transmitted by means of any of the agents mentioned, and lastly, brought in contact with the tissues in certain conditions, the effects will be regular and constant, and the point of the skin with which the virus comes in contact will be the seat of the chancre ; its development will, moreover, as seen in Plate IV., fig. 1, a, b, c, begin immediately, so that no incubation can be said to occur. In practice, however, cases happen which apparently contradict these statements, and which are believed by some persons to prove the ex- istence of incubation. Patients sometimes state that a chancre has only existed a week, and yet they have not exposed themselves to contagion for a month previously. Here the patient makes a wrong statement, although without any intention of deceiving the surgeon ; for on closer examination it will be often found that he has, from inadvert- ence or other cause, never examined the affected part since the time of exposure to contagion and the period that pain or some other symptom first called his attention to the chancre, which he observed a week ago ; in such a case, it would be correct to say that he observed the chancre a week ago, but not that it has only existed for that period. CHANCRE. 191 How often have we not been called to treat bubo, or even secondary symptoms, when interrogating the patient he affirms he has never had primary sores ; yet, on uncovering the glans, we have shown him sores which he had never observed, and was not cognizant of, inasmuch as they had given rise to no inconvenience ? There are, however, other cases which are brought forward to prove, and which at first sight seem to indicate, incubation ; the case of Mr. H. is a good instance. Persons expose themselves to conta- gion ; they wash carefully the parts exposed ; they examine day by day to see if chancres are produced ; when several days have elapsed, they observe certain suspicious-looking pimples ; here, however, we may naturally suppose that the virus has entered, during coition, the mucous or sebaceous follicles, and lies inert, until, by the irritation it produces, destruction of the lining membrane takes place ; it is then placed under conditions most favorable for its development. That this is not mere supposition, the case of Mr. II. proves ; most probably this always occurs in urethral chancre, as experience shows that a secretion from the canal rarely occurs before the fifteenth day, and this fact has been dwelt upon by M. Puche, who wishes to form a diagnosis by this means between gonorrhoea, the consequence of simple inflammation, and urethral chancre. We shall again have occasion to mention and discuss these points. Such cases as we have described, if they do not explain our views, at least must tend to shake confidence in the supposed theory of incubation. Is there more than one cause of chancre? We have, in the prece- ding sections, spoken of one cause alone, and we have studied the conditions necessary for the action of that cause ; we have spoken of it as constant in its effects when placed under the necessary con- ditions for its development; thus far we have seen no reason for supposing that there exists a second or third virus. Authors have not always been of this opinion, and persons have counted as many as five viruses ; they have founded this opinion upon the number of primitive sores, or secondary eruptions ; however, fewmen>of the present day admit more than one, which may, according to circum- stances we are about to mention, give rise to any of the variety of primary sores we have spoken of under the head of the anatomical characters of chancre. To the consideration of the causes of the varieties we beg now to call the attention of our readers. Causes of the Varieties of Chancre.—On examining fig. 4, a, b, plate IV., the reader will observe what, surgeons are otherwise well 192 CHANCRE aware of, namely, that chancres on the same individual usually present similar physical characters : thus, an indurated and a phagedenic sore are not met with on the same patient: but if several chancres exist, they are usually simple, indurated, phagedenic, &c. Inocula- tion of a great many sores proves, likewise, that chancre will gener- ally assume the same characters on the same individual—we say usually, for when the situation of a sore causes it to put on a peculiar aspect, of course the inoculated point on the thigh, not influenced by similar causes, will not exactly resemble the sore whence it was derived. The knowledge of this fact, viz., that all sores have a tendency to take on the same characters in the same persons, is of use, inasmuch as it should deter practitioners from employing inocu- lation in gangrenous or phagedenic sores ; an evil which we have dwelt upon elsewhere,* and the non-observance of which we con- sider liable to bring inoculation into disrepute.f Scruples which can not be too much admired, have prevented M. Ricord from inoculating one person with the secretion of a sore from another; we have been thus unable, by direct experiment, to show that an indurated sore will not produce its fellow, or that a phagedenic sore will not cause a phagedenic ulcer on another con- stitution ; but although we have been unable to solve this question by direct experiment, observation has satisfactorily shown that the char- acters of sores do not depend upon the source from which the virus is derived. Need we cite the celebrated case, detailed by Dr. Fer- gusson, of several English officers who were attacked each by a variety of sore, contracted by connexion with the same female, a Portuguese opera-dancer 1 We are acquainted with three students who had connexion with the same grisette during one evening ; one was affected with a phagedenic sore ; the other was a long time recovering from an indurated chancre ; the third had a simple exco- riation, which was slighter than that which we witnessed on the genital organs of the female, whom we examined a few days after the debauch. If the source of the varieties does not exist in the nature of the chancre from which it was derived, as the preceding cases and thou- sands of others clearly prove, we must look for them elsewhere. Our belief is, that no one cause can be assigned for the varieties; chancre, like other diseases, may be modified by a variety of circum- * See Lancet, vol. 1, 1839-MO, pages 354, 533, &c. t Since the above was -written, I have had occasion to witness the deplorable effects which injudicious inoculation may produce. Phagedena of the thigh has succeeded to a most fearful extent in one case, and the life of the patient was despaired of. J Pl.i. 3 CHANCRE. 193 stances; thus, climate, constitution, age, plethora, debility, bad air, insufficient clothing, &c, are so many causes which will tend to pro- duce the varieties of chancre. An attentive examination of the varieties of chancre has enabled us to enumerate some of the causes which appear to give rise to them; thus, bad food, insufficient clothing, intemperate habits, expo- sure to cold, local stimulating applications, are a few of the causes which make a simple chancre take on the diptheritic character. Young plethoric persons, who use great exertion, or who are addicted to the abuse of spirituous liquors, at the same time that they expose themselves to vicissitudes of the weather, or who change suddenly their diet or climate—such, we say, run a great risk of the chancre assuming that variety which we have called gangrenous pha- gedenic. Scrofulous individuals, or old men who have led a dissipated life, or men subject to the diseases of hot climates, persons with skin dis- eases, and constitutional complaints, whose health has been ruined by several courses of mercury, as well as those whose chancres have been treated injudiciously, will be found to present the serpiginous variety of chancre. Lastly, we arrive at the indurated variety. Here the cause is by no means clear, yet it is the one which we are most interested in dis- covering. The indurated chancre may appear in a variety of con- stitutions. The one delineated in plate V., fig. 2, occurred on the penis of a young man of a clear, transparent complexion, of short stature, but who could not be said to present very evident marks of scrofula. In the case of Mr. H., detailed at page 188, the constitu- tion was good, though somewhat lymphatic, and he was subject to hypochondriasis. Sex seems to have some influence; it is most common in males, yet we have seen various cases in women. Situation apparently interferes but little, as chancre may, in any situation, take on this character, although an ulcer situated on the prepuce is most frequently indurated. We have been unable to connect induration with any peculiar mode of local treatment ; we have seen persons affected with the most obstinate forms of indurated chancre, who had not been treated either locally or generally ; on the other hand, the most simple and judicious local management of a sore, immediately after its commencement, has not always prevented the occurrence of this character, which deserves so much attention from the practitioner, as it betokens a 13 196 CHANCRE. The history, then, like the situation, aspect, 6fc, is, alone, insuffi- cient to found a diagnosis on ; but if it is deceitful when the patient is desirous of telling the truth, how often may the surgeon be misled when the patient has reason for concealing his antecedents. In the female it is next to impossible ever to attain the truth. The irritation of the menses, or some other cause, is alleged to explain the ulcer- ations about the genital organs. We have mentioned elsewhere* the case of a female who suffered under ulcerations around the rectum, yet at first strenuously denied that they could possibly be syphilitic; although, at last, she was obliged to admit the fact. We might cite numerous cases to prove that an absolute reliance can not be placed on the history of patients. 4. Various Complications.—It is certain that buboes occurring with sores are prima facie evidence of their being syphilitic. But. we should recollect that any simple irritation in scrofulous habits will give rise to them, and perhaps such buboes are more difficult to treat than any others. Similar observations may be made on other com- plications. In fine, we may state, that these circumstances, when present, can only furnish a rational diagnosis. 5. The Course.—It is very true that chancre frequently has little tendency to heal, but on the contrary, gradually progresses; these are, however, characters not peculiar to chancres. There are various sores, which, in scrofulous and scorbutic constitutions, spread and heal very slowly. On the other hand, some true syphilitic sores heal in twenty-four hours ; but it is no less certain, that although such exist, they are of rare occurrence. When these characters are absent, it by no means follows that the sores are not syphilitic, and it is frpm the ensemble, and the greater or less probability, that our diagnosis (a rational one) must be formed. The Absolute Diagnosis.—In obscure cases, and when it is abso- lutely necessary to decide upon the nature of a sore, more especially in medico-legal inquiries, evidence such as we have mentioned would be insufficient. There remains, then, inoculation, which, although one of its greatest advocates, I would not unnecessarily employ ; it will, however, at once decide upon the nature of a sore. -Here, neither ignorance nor deception on the part of the patient, nor want of experience or observation and deduction on the surgeon's part, will interfere with the conclusion. The accu- racy of the test, the certainty of arriving at the truth, and the * Lancet, Nov., 1839, page 354. CHANCRE. 197 reputation of the surgeon, will counterbalance all objections to the operation.* Diagnosis of the Reparative Stage of Chancre.—The surgeon is not only called upon to give an opinion during the ulcerative stage, but he may be consulted at a later period, when the sore is healing, or when induration alone remains ; or lastly, when all traces have * The following cases, taken from a paper I read before the Parisian Medical Society, show the utility of inoculation:— " In the bed of No. 10, in the second ward of the venereal hospital, lies a patient, thirty-two years of age, a shoemaker by trade, of fair complexion. He states that from the age of thirteen till his eighteenth year, he was liable to ulcers on various parts of his body, the cicatrices of which are still visible; from the last mentioned period he has enjoyed good health. About fifteen months since a bubo appeared, which suppurated and healed in about six weeks. " About five weeks ago the patient observed a chancre on the prepuce, four days after connexion ; soon afterward several chancres appeared around the corona glandis, and he consulted M. Ricord as an out patient. During the time he was following the treatment prescribed, a vesicular eruption made its appearance on the inner part of the left leg, which he distinctly remembers having scratched, and from that moment, the sores began, and increased in size. " Present state—Chancres still exist on the penis, which discharge freely; on the inner part of the left leg there are twelve ulcerations of different sizes, but assuming all the characters of primitive syphilitic sores. Inoculation with the pus of these sores was made, and the characteristic pustule was produced. See plate IV., fig. 3 a. " This, then, instead of being a case of secondary syphilis, which was inoculable, is simply an eczema which was inoculated by the nails of the patient, soiled with the secretion of the primitive sore on the peuis. " On the 27th of February, 1838, a man presented himself at the out-patient room, complaining of chancre at the root of the penis, and accidentally, as it were, showed M. Ricord a sore on the frenum of the tongue. The characters of it were sufficient at once to arouse some suspicion as to its nature, and this patient was immediately admitted. Inoculation of the secretion on the sore in the mouth was made, and a characteristic pustule followed. All doubt was now removed, and the avowal of the man additionally proved that this was a primitive syphilitic ulceration. " A boy, fifteen years of age, of pony stature, lymphatic temperament, and not, apparently, arrived at the age of puberty, so slightly were the organs of generation developed, entered the seventh ward, snffering under an ulceration of a suspicious character, in the left groin. He gave the following account of himself:— "Had never had connexion with any females, or frequented their society; about three weeks previously the sore appeared on the groin, but it could not be ascertained if it commenced as a bubo or a sore. "As this sore presented all the character of chancre, except as to its history, inoculation of the secretion was performed, and a well-marked characteristic pustule followed. On these data the boy was interrogated more closely, and M. Ricord then found that he was in the habit of sleeping with a fellow-workman who presented chancres on the penis, which had existed some weeks. Both parties denied any unnatural practices; and whether the virus dropping on the sheets inoculated the scratch previously existing, or whether a scrofulous bubo preceded, which was caught by contact of the contagious principle, it is not here my object to inquire ; but I cite this case, to prove that without inoculation the case would have remained very obscure."—Lancet, 1. c. pp. 354, 533. 198 CHANCRE. passed away. In the first and last cases it can be of little conse- quence to ascertain the nature of the affection ; if it should be, particular caution must be used, and a rational diagnosis is still more difficult than in the first stage. Called upon to give an opinion when induration alone remains, the surgeon whose eye and touch are accus- tomed to syphilitic induration, will rarely fail to decide upon the specific and peculiar cartilaginous feel, particularly when seated in loose cellular tissue, as on the prepuce ; in other situations it will be very difficult to decide upon it, particularly when placed in the deeper portions of the canal, &c. But we shall return again to this subject. In these last instances we must wait patiently for the results, for, if the induration be specific, secondary symptoms will inevitably appear in a short time, and thus clear up any doubt. Prognosis of Chancre.—In the definition of chancre, we have stated that at its commencement it is a local disease, and that it gives rise, under circumstances we can often appreciate, to symptoms of general infection. We shall, then, in the following pages, con- sider the prognosis under two heads :— I. The prognosis of chancre as a local disease. II. The prognosis considered in reference to the probability of general and constitutional infection or secondary symptoms occurring. I. Prognosis of Chancre as a local disease.—In describing simple or artificial chancre, we have mentioned that in a good constitution it has a regular and constant course ; beginning as a pustule, abscess, or excoriation, it becomes an ulcer; granulations are produced; cicatrization follows, and it heals perfectly, without treatment, in a space of time which varies between three and five weeks; therefore we may unhesitatingly state that the prognosis of simple chancre is favorable. In a practical treatise, however, it is not sufficient to state this; the surgeon should consider the prognosis under a variety of points of view, for in practice he is daily called upon to decide on the prog- nosis of this or that form of chancre. It is to facilitate this often difficult task that we propose devoting the following pages, founded on the strict observation of a number of cases. What probability is there of a chancre, which is simple at its com- mencement, assuming one of the varieties which we have described ?— On this subject the surgeon can only be guided by a knowledge of those circumstances which seem to dispose to their production, viz. : If the patient has been exposed to bad or insufficient nourishment, has resided in an unhealthy situation, or has led a dissipated life, it is CHANCRE. 199 probable that the chancre will assume a diptheritic phagedenic char- acter. If the digestive organs be disordered, or provided irritating substances are, or have been, applied locally, particularly in scrofu- lous subjects, a serpiginous sore will possibly result. Should the chancre occur in young plethoric persons addicted to excesses of any kind, particularly to the use of spiritous liquors, at the same time that they employ much the part affected, we may anticipate the occurrence of the gangrenous phagedenic sore. Lastly, as to the probability of a sore assuming an indurated appearance, we must acknowledge our ignorance, for, although we have witnessed it in persons of lax fibre, or in others of clear com- plexion, still we can give no indications, as hitherto we have been unable to associate it with any one temperament or constitution. What will be the probable duration of the chancre ?—Simple chancre, when left alone, usually heals in a space of time varying from three to five weeks ; when properly treated, perfect cicatrization may be obtained in from eight to ten days ; there are, however, circum- stances which have great influence in retarding the cure—among others we may mention the situation; thus a chancre situated on the fraenum, or margin of the prepuce, when a natural phymosis exists, will be prevented from healing by the rupture of the cicatrix when erection occurs. Chancres in the urethra, bathed as they con- stantly are by the urine, or when situated at the margin of the anus, or within it, will be so irritated by the distension of the gut, during the passing of faeces, that cicatrization will be often unusually retarded. Other instances might be given to show that the situation of simple chancre must influence the prognosis. The size of simple chancre must necessarily modify our prognosis, as to its duration ; for a large surface generally requires a longer time to cicatrize than a small one ; yet large ulcerations sometimes heal as quickly as small. The number of chancres might be supposed to influence the prognosis, yet practice teaches the contrary. Patients presenting several chancres are as speedily cured as those who have but one sore : cicatrization going on with equal rapidity in all. The duration of a diptheritic chancre can never be foretold, yet we may be guided, in some respects, by the state of the constitution, for, in proportion as it improves, we observe the sore to present a more favorable aspect. When we are called upon to give an opinion on the probable dura- tion of a Serpiginous Sore, we can not be too guarded ; it is true that, 200 CHANCRE. by rest and proper treatment, many such sores will speedily assume a healthy appearance ; but others resist, and require years to cure, and, when on the point of cicatrizing, again resume all their former virulence. In respect to the gangrenous phagedenic chancre, we may be more confident, as, by judicious treatment, the gangrene may be confined to the parts it has already attacked, and a speedy cicatrization be expected. Lastly, the indurated sore will, if left to nature, remain in statu quo, or, if it cicatrizes, a cartilaginous nodule will remain, unless general and local treatment be employed, and even then it will dis- appear very gradually. What probability is there of any of the affections termed complications occurring ? Did we enter on this subject, we should only repeat what we stated when treating of the complications ; we therefore refer our readers to that section. In diptheritic chancre, we should remember that haemorrhage is often to be dreaded, as well as fistulae, their situation depending upon the tissues and parts affected. In gangrenous chancre a large and rapid loss of parts is always to be apprehended ; but although deformity results, it is not so great as the state of the sore would lead the surgeon at first to suppose. In respect to complications, the serpiginous and indurated sores present nothing remarkable. What renders the occurrence of successive accidents* probable? —" Successive accidents," says M. Ricord, in his Treatise on Inoculation, " are a consequence of the extension of the disease {de proche en proche), or a simple extension of the primitive local symptom, as, for instance, the production of new chancres, simple or virulent abscesses, virulent or simple adenitis, &c. Is a bubo likely to follow? This is a question which the patient suffering from a chancre often asks. Without entering, however, at length, into a discussion of all the causes which occasion the develop- * By successive accidents, we mean such affections as are only a gradual continuation of the same disease, for instance, the production of new chancres, the development of sympathetic buboes or abscesses, from extension of inflammation ; and the occurrence of symptomatic buboes produced by the transport of the syphilitic virus. Whenevei, then, the secretion of a chancre is retained in contact with the tissues which secrete it, or comes in contact with such portions of the body as are susceptible of inoculation, we have reason to dread the formation of successive chancres; hence, chancres of the anus, of the prepuce where a natural phymosis exists, or of the four- chette in the female, often produce successive accidents. Besides, whenever a solution of continuity in the neighborhood of a chancre exists, subsequent sores are probable, from contact with the virulent secretion. CHANCRE. 201 ment of buboes, we shall here mention such as refer particularly to chancre. The mere existence of a simple chancre does not neces- sarily cause bubo ; in the female, for instance, bubo is rare. We have never seen artificial chancres on the thigh, of the male or female, followed by them. But if chancres on particular parts are seldom followed by buboes, there are likewise other situations which exercise the greatest influence on their formation : it will be found that in every one hundred men suffering under bubo, at least eighty have presented chancres around the fraenum or inferior part of the glans or prepuce. When bubo occurs in the female, the chancre will be found most probably at or around the meatus. This fact, of the situation of the chancre and occurrence of bubo, may be reasonably explained by the connexion which exists between the part primarily affected and the gland, by means of a lymphatic vessel which carries the virus directly to it. And it also proves that the theory of exclu- sive venous absorption is not tenable : but it seems in accordance with the doctrine of imbibition. In answer to our patient, we must be guided principally by the situation, not the size or the variety of the chancre; but we shall re- turn to this subject under the head of bubo. The fact of the tendency which buboes have to follow chancres situated on the fraenum, further shows the surgeon how cautious he should be in attributing buboes to this or that treatment; in all such calculations, we should take into consideration the position of the sore. We may here add, that bubo rarely follows any of the varieties of chancres, unless they be situated in one of these particular spots.* Does the treatment alter the prognosis ? In the preceding pages this question has been already answered : but to resume. A simple uncomplicated chancre will heal without, treatment in about from three to five weeks, when properly treated in eight or ten days—the varieties, by judicious management, in longer or shorter periods, de- pending upon the causes which give rise to them. Is the chancre or sore contagious ? To this the medical man should answer peremptorily, yes or no. By allowing connexion, let the practitioner remember he is an accomplice, be it through ignorance of the consequences, or out of deference to his patient. Let him re- member that, a sore which is about to heal, or which has just cicatri- zed, is very liable, under the slightest irritation, to inflame, ulcerate, and present any or all the varieties above described: thus, the patient * See Ricord's edition of Hunter. 202 CHANCRE. may by ignorance or imprudence lose the organ. On the other hand, who will state that a sore which is not perfectly cicatrized is incapa- ble of transmitting the infection ? It should not be forgotten that it is impossible to say how little virus is sufficient to infect an individual ; the edge of a sore which is still unhealed may contain the quantum, and such a permission of the surgeon may lead to the greatest afflic- tions in more than one family, and the innocent child may suffer for its parents' credulity, or from the surgeon's ignorance of the laws which regulate the secretion of the virus.* II. Prognosis considered in reference to the probability of general and constitutional infection, or secondary symptoms. It is not our intention here to trespass upon the interesting subject of secondary symptoms, as we shall hereafter treat of them at great length ; but there are some considerations which so directly relate to chancre and its prognosis, that we shall here consider them. If it be an undoubted fact that secondary symptoms are a direct consequence of chancre, it is no less certain that they do not in every case ensue. The following facts, drawn from observation, may per- haps assist the practitioner in giving an opinion on the greater or less probability of their occurrence. 1. Stage of the Sore.—When the chancre has proceeded beyond the vesicular form seen on the third day, we can never guaranty an absolute indemnity from secondary syphilis ; the symptoms may ap- pear during the ulcerative or reparative stages, provided these are retarded by any circumstance. 2. Duration of the Chancre.—As secondary symptoms are the consequence of chancre, it might be reasonably supposed that the longer it lasts, the more subject is the individual to their occurrence. * The importance of the great discretion which it is necessary for the surgeon to show, has been lately impressed upon me by the following case : An old fellow-pupil of mine at St. Bartholomew's hospital, now established in a distant part of the country, treated a young man for some venereal affection and secondary symptoms ; when he was nearly well, this patient asked the sanction of my friend to a marriage which he was about to contract. The penis was free from disease, as my friend believed, no sore being apparent, though a few blotches remained on the trunk. On such authority the marriage was solemnized, and in a few months the disease broke out again in both parties, and presented the well-marked coppery blotches. On interrogating my friend, he assured me of the correctness of the statements of both parties, and their honorable conduct; but in the conversation he accidentally alluded to a stricture of a very obsti- nate nature which his patient had previous to marriage. The views of M. Ricord on the existence of chancres in the urethra were unknown to him, and he agreed with nxi in the possibility of such an occurrence, and no longer admitted that secondary symptoms were transmissible, which opinion this isolated case had induced him to believe, con- trary to his views. CHANCRE. 203 This, absolutely speaking, is true, and is a reason for locally destroy- ing the virus, which is a constant secreting focus ; but the practitioner will be wrong to suppose that secondary symptoms only follow chancres which have existed a long time. Experience proves that they follow a chancre which has healed without treatment, in a few days ; and we have witnessed cases of chancres which have existed eighteen months and two years, without producing these consequences. 3. The Number and Size.—The preceding observations apply equally to these circumstances ; it is not on such data as these that we can alone found our appreciation of the prognosis. 4. Situation of Chancres.—Chancres on any part of the body, viz., on the mouth, finger, penis, or anus, &c, will be followed in an equal proportion by secondary symptoms. If, however, secondary importance can only be placed on the stage, duration, size, number, and situation of primary sores in forming an opinion on the probable occurrence of general infection, the same does not hold good in reference to the varieties. Daily experience teaches us that the serpiginous and gangrenous sore is rarely followed by con- stitutional symptoms ; the phagedenic diptheritic occasionally gives rise to them ; the indurated almost always. It is well known that Hunter was so imbued with this opinion, that he denied a sore to be syphilitic, unless it presented an indurated base. M. Ricord lays so much stress upon it, that when a patient enters his wards, presenting an indurated chancre of six weeks' duration, and when no secondary symptoms have yet appeared, he puts him on a " traitement ex- pectant," and few days pass before the occurrence of the well-known characteristic symptoms of general infection. M. Ricord never al- lows a patient to leave his hospital when the slightest induration even of the cicatrix exists ; should he, in spite of admonition, quit, he is told that secondary symptoms will result, and the prediction is found to be too true. Let us now inquire how far the complications can assist our prog- nosis in reference to the occurrence of secondary symptoms. We may erase from the list, gonorrhoea, paraphymosis, and phymosis, as they can have little direct influence in disposing to constitutional syphilis. The circumstance of the existence of bubo demands a separate consideration. A-priori reasoning would lead to the supposition, that when a bubo co-exists, there would be a greater probability of constitutional syphilis following, than when chancre alone appears. Experience on a large scale, however, contradicts such an opinion; 204 CHANCRE. bubo, as we shall hereafter find, is but an internal chancre, and by no means proves that the virus has entered the system ; and we do not find that absorption takes place more rapidly from this chancre in the gland than from an open chancre. This circumstance, more- over, seems to prove that the venous system plays an important part in occasioning the general infection. Lastly, we shall speak of the local treatment of chancre, in as far as it may lead to the probability of the occurrence of secondary symptoms. In the first place, let us again repeat that secondary symptoms will follow when no treatment is employed; they may (though in a far less proportion) succeed the most judicious local treatment. On the other hand, secondary symptoms may not occur, although the chancre be allowed to proceed without treatment. Secondary symptoms do not necessarily follow, although the local treatment of the chancre has been injudicious. In respect to general treatment, the same observations hold good. Secondary symptoms do not necessarily follow when general treat- ment has been neglected. The best and longest-continued plan of general treatment will not, in all cases, insure your patient against their occurrence. These facts at once show the absurdity of some persons' reasoning, who attribute to the effect of treatment what in fact is only the natural course of the disease ; it is from want of acquaintance with the natural history of the complaint, that unjust blame or injudicious encomiums are heaped upon so many therapeutic agents. Preventive Treatment.—The legislature of France, finding venereal affections very common and very severe, in 1498 and the following years, proposed means of checking them, by confining those that were diseased in a species of prison or hospital in the faubourg St. Germain and at Bicetre, flogging them very severely before and after incarceration. We find, however that these coercive measures were soon relaxed, and the law became a dead letter, inasmuch as its execution was, generally speaking, impossible ; secondly, the per- sons affected with the disease were too highly connected, and the disease, notwithstanding the punishment, had increased, and become aggravated to such an extent, owing to the concealment of the primary symptoms, and the impossibility of receiving so many patients, that it was ultimately given up; and who that calmly con- siders the subject can be surprised, or would propose such a punish- ment, or cause the infraction of the liberty of the subject at the CHANCRE. 205 present day? Our modern legislators have, I think; fallen into the opposite error. They imagine that the odium tacitly attached to the disease by society, will suffice to deter persons from exposing themselves to contagion, and that government ought not to interfere, or take any steps to check it, as it would be encouraging vice, appa- rently forgetting that neither religion, nor the laws, nor a knowledge of the consequences, will deter men from exposing themselves to syphilis. Is the medical man to remain a silent spectator of the ravages of the disease, as some sensible but short-sighted individuals are inclined to wish him to do, because any success which attends the precautions he recommends will tend to act as a premium upon dissipation ? Were it proved that this apathy of the surgeon was attended with a moral effect on the community, the question might bear a different complexion ; but daily experience and the history of the past prove the contrary. Let no one accuse the medical practitioner of immorality, if, in the discharge of the duties of his profession, he can suggest any preven- tive means against a disease which is frightful in itself and in its consequences ; for the surgeon well knows that immunity from dis- ease does not any more lead a libertine to continue his dissipated habits, than do successive syphilitic diseases check those propen- sities. On the other hand, a first fault may, by the non-observance of those precautions, render a whole family miserable, and entail disease which it may be impossible to cure. Guided by these principles, which we trust will not be misinter- preted, we shall now consider if there be any means of prevention of chancre. Is it possible to prevent the occurrence of chancre ? If chancres do not arise spontaneously, and we trust we have convinced our- readers that at least at the present day they do not, then we think we are justified in stating that we can protect an individual from them ; but if it be possible, what means "can we recommend for this purpose? In other words, what is the prophylactic treatment of chancre ? Syphilis at the present day is widely diffused ; although it no longer presents the dreadful appearance that it did in the last centu- ries, still it exists, and is liable again to break out with redoubled violence, if the circumstances which favor its development occur. It becomes, then, the legislature to put a check to it as far as it lies in its power; and we are of those who think it possible that it might be effectually destroyed, although we feel convinced that this will not 206 CHANCRE. occur, as the disease must be better and more generally understood before such a universal extinction can take place. The French, more than any nation, are advancing in the way which is most likely to eradicate it. Who has not. read the work of Parent Duchatelet ?* Who is not aware that this distinguished phy- sician and philanthropist has, during a long life, done more perhaps than any other individual to check syphilis? He has given us the natural history of prostitutes ; he has pointed out the means of legis- lating for these unhappy creatures, who form, in fact, the focus of chancre ; and until means be taken in other countries to subject this class to some sort of control, it will be in vain for us to hope, for a diminution of the evil; not that we pretend to say that even in France all has been done which might or should be attempted, although we do not mean here to criticise French treatment. Did other countries follow in their steps, Europe would have cause to rejoice. As general prophylactic means, the institution of hospitals and dispensaries for the gratuitous treatment of these complaints, is of the highest importance ; and M. Ricord thinks it would not be use- less to make the following preservative means known wherever a man exposes himself to contagion ; he has likewise suggested that a capable person be attached to each brothel, so that both males and females who expose themselves might be examined. This measure, bv no means impracticable, would tend greatly to diminish the fre- quency of the disease. These are a few of the general prophylactic means which would tend to the object a community has in view. We shall not stop here to examine the feasibility or legality of them, as these subjects have so fully been discussed by Parent Duchatelet, but proceed to speak of the Direct Prophylactic Treatment of Individuals.—The surgeon may be consulted under two circumstances : 1st, by a female or prostitute who runs the risk of communicating the disease. In this case an examination of the external organs is not alone sufficient; the employment of the speculum is of the greatest aid in discovering the existence of internal disease. The practitioner should likewise recommend frequent, ablution, as, without producing the disease, the virus may be contained in the vagina, but not act in consequence of a layer of mucus ; hence the recommendation of the use of injections after connexion. " If women," says M. Ricord, " were only more attentive to cleanliness, * See his book, " Prostitution in Paris," translated from the French—Otis, Broaders, & Co., publishers, Boston. CHANCRE. 207 and took more care of themselves, venereal complaints would be less common." If consulted in the case of a person who is afraid of transmitting the disease, or when connexion is dangerous on account of a sup- posed infection, the chlorine washes, soaps, and the other means of more effectually cleansing, disinfecting, or cbymically acting upon the morbid secretions, ought to be employed ; the more the parts are rendered clean, the less we have to dread infection. The preceding observations relate particularly to those women of the town who are constantly exposing themselves to the virus. 2d. The surgeon may be consulted by a person who wishes to know what precautions he should take if he exposes himself to con- tagion. From the previous description of the accessory conditions of the tissues which are necessary to the action of the virus, the reader may at once infer the necessary general prophylactic means • however, there are several points which deserve a separate consider- ation. Thus, frequent washing the parts liable to be exposed to the virus, with astringent substances, will, as it were, tan the parts, and be a, powerful means of prevention of the disease. But if this plan be advisable, the use of alkaline or chlorine washes immediately previous to connexion is very prejudicial, as removing any mucus or smegma which might serve as a defence against actual contact, of the virus; a person should carefully examine and guard against any abrasion, and, if any such exist, connexion should not take place. The observance of the few preceding recommendations would pre- vent, we are sure, a multitude of diseases. " There is," says M. Ricord, " a means, which the final cause of all sexual intercourse rejects, which morality has always blamed, but which necessity and certain circumstances may occasionally tolerate —I mean the condom." The condom, which permits only mediate sexual intercourse, is frequently, as Astruc has so well remarked, only an illusive guarantee ; it is sometimes torn ; in other cases, the substance of which it is made is pervious ; or, again, in consequence of having been previously used and not properly washed, it may be contaminated ; lastly, though it be made of good materials,.and remain perfect, it only pro- tects those parts which it directly covers ; the root of the penis, the angle of the scrotum, as well as the groin, remain exposed. In con- clusion, the condom, even under the most favorable circumstances, can only guarantee an individual from contracting a gonorrhoea. Coition should not be prolonged, and ejaculation should take place, 208 CHANCRE. as this will frequently prevent the occurrence of urethral chancre, the sperm acting as a cleanser of the canal. Some persons believe that infection is more likely to occur after ejaculation ; this we see no reason at all for believing. After coition, the greatest care should be taken in washing the exposed parts ; for this purpose, alkaline and weak chlorine solutions are preferable, as they have the property of cleansing and decompo- sing any contagious matter, without producing local irritation. Any abrasion or lesion of continuity should be immediately cauterized; and it is useless to hesitate or attempt a diagnosis between the con- sequences of friction and that of the virus : it is better to cauterize unnecessarily than to expose the patient to the chances of infection. Curative Treatment.—In spite of these precautionary measures, or in consequence of no attention being paid to them, a chancre may become developed in a follicle, an ulceration or abrasion of the sur- face may appear, or an abscess or pustule follow. 1. When a pustule is formed, or when a mucous or sebaceous follicle is observed through the skin, filled with pus, as may be well seen in Plate IV., fig. 2, it should be opened, and a stick of nitrate of silver, cut to a fine point, introduced and passed around the little ulcerated base and sides ; we prefer this to the plan of excision with scissors, which may be employed when the pustule is seated on the prepuce ; but as patients do not like a surgeon to employ instruments, and as we have more reliance on the nitrate of silver than on ex- cision, we recommend its general adoption. 2. In cases of abrasions or ulcerations, the stick of nitrate of silver should be passed slightly over the surface, our object being to destroy only the surface. From ignorance of the reasons of employ- ing the caustic, we have seen the local irritation increased, and con- siderable escars form from the profuse employment of this substance, a plan that can not be too much condemned. In the first instances, it is very often unnecessary to reapply the caustic ; usually, however, the parts should be cauterized as often as the eschars fall off, and the ulcerated surface does not put on a healthy, granulating appearance ; when this commences, the granula- ting portions of the sore should be left to themselves ; but whenever the surgeon suspects that the sore, or any part of it, secretes the virus, he should continue the application of the nitrate of silver. It is, however, not only necessary to destroy the virus which is secreted, as well as the parts which give origin to it, but the practitioner should endeavor to check as much as possible its CHANCRE. 209 secretion ; this is best done by employing the aromatic wine,* which experience shows to have that property, as well as the no less advantageous one of hardening the surrounding tissues, thus preventing them becoming inoculated, and increasing the size of the sore. Let the patient wash the sore four or five times during the day with this wine ; a small piece of lint soaked in it may be laid upon the sore, and the whole may be covered with a piece of oiled silk ; thus the lint is kept constantly moist ; it will be found well to wet again the parts before removing the lint, as it might become ad- herent, and cause the sore to bleed if detached with any violence. The patient must keep quiet, but it is by no means necessary to maintain the horizontal posture, or be confined to his bed ; his diet should be light, but nutritious. When perfect cicatrization has been obtained, and no local disease remains, the patient may be allowed to resume his usual occupations, and sexual intercourse may be permitted. Under this treatment, simple, uncomplicated chancre will be cured in a very short space of time, and may be considered as a purely local disease, requiring no general treatment, and followed by no secondary symptoms. Let us, however, now turn the attention of our readers to the treatment of the varieties of chancre above spoken of under the term of anatomical characters. 1st. Treatment of Phagedenic Diptheritic Chancre.—As this variety of chancre depends upon certain peculiarities of constitution, or general causes, such as bad living, low unwholesome situations, and frequently a disordered state of the digestive organs, the first duty of the surgeon should be to remove them, and he will place the patient in the best condition for recovery. A good nutritious diet, and change from the close confined air of a damp house, to the well-ventilated ward of an hospital, have been often sufficient to change the aspect of very unhealthy sores. We have frequently seen a warm bed and a stimulating purgative, or an astringent wash, cause, in a few days, the most aggravated forms of the complaint to take on an improved appearance ; sores which were locally irritated by stimulating prep- arations have, under the influence of opiates, become quite healthy; the same sores, previously treated by mercury, have become healthy when that substance has been left off: hence we can lay down no general law; we must attempt to discover the cause of the variety, * This is a preparation of the French pharmacopoeia, composed of species aromatica\ ?iv., vinum rubrum lb. ij., alcoolatum vulni rariuin ?ij. As a less expensive wash 1 use Decot. Querc. ?viij. Tinct. Catech. ?ss. 14 210 CHANCRE. and remove it if possible ; this being done, the greatest benefit may be derived from employing lint dipped in a concentrated aqueous solution of opium, which should be kept constantly applied on the sore, covered by oiled silk ; the sore should not be dressed too often, as it is liable to irritate it: this form of dressing must be continued for some time, and absolute quietude should be enjoined ; the diet should be nutritious, and wine or beer may be allowed if the patient's general health does not counter-indicate them, or if he be in the habit of drinking to excess. The use of opium at bed-time may be attend- ed with the best results, when there is a good deal of local or general irritability. Constipation or diarrhoea should be treated on general principles, and tonics may be given with advantage. The use of ointments of all kinds will be usually found prejudicial, more especially as these sores secrete a great quantity of pus ; and the greasy substances rarely come in contact with the diseased surface. When, under the treatment recommended above, the chancre is getting better, the aromatic wine maybe employed, and any superabundant granulations should be cauterized, and the.edges of the ulcer, if very thin, or if undermined, may be excised with instruments, or destroyed by caustics ; but it will always be advisable to wait until all inflamma- tion has subsided before this is attempted. The use of local bleed- ing we have not seen followed by good effects, although it might, in some cases, be found beneficial, as well as general depletion : such cases we believe to be rare. 2d. The gangrenous phagedenic sore, the result of acute inflamma- tion which has terminated in gangrene, can seldom be checked at once, occurring as it does in young persons addicted to drinking; here, bleeding, either local or general, is exceedingly prejudicial: in the early stages these means are very useful in checking the prog- ress of the inflammation ; but when the gangrene has commenced, and the parts are struck with death, it is useless to suppose that bleeding will restore vitality, or will check the ravages of the disease. Instead, then, of venesection, let your patient keep his bed, attend to the state of the bowels, let his diet be of the mildest kind, and let lint dipped in the aqueous solution of opium be constantly applied to the gangrenous part; cooling drinks may be given, particularly lemonade. The gangrene will, in spite of this treatment, destroy the parts which are most acutely inflamed, but it will not extend further ; consequent- ly, during the few following days, a serous looking ichorous dis- charge of a very offensive smell cornes away, mixed with the detritus CHANCRE. 211 of the tissues ; this gradually diminishes in quantity until it subsides altogether, and the surgeon is surprised at seeing but a slight, deformi- ty result, comparatively to the severity of the disease ; a simple sore follows, which should be treated in the usual manner, and the sur- rounding oedema which occasionally remains may be advantageously combated by compression with strips of adhesive plaster. If, in this or the preceding sores, any fistulous openings follow in consequence of the disease extending any depth, care should be taken that the escape of fluid be favored by position, otherwise, if it stag- nate, it may considerably aggravate the disease ; it will be, there- fore, well to employ a small syringe to cleanse the part. 3d. The Serpiginous Variety of Chancre.—We have already spoken of several indications which should incline the surgeon to prefer this or that local treatment; in this variety, however, we are obliged to admit, that we can give hardly any rules. Having observed every possible treatment employed that the experience of M. Ricord has suggested, we have seen cases continue in statu quo, and, after months have elapsed, get well by the unaided powers of nature. On the contrary, we have seen cases get well under a line of treatment which a month previously aggravated the disease, and yet the sore apparently presented the same characters. Such being the case, the surgeon should be careful how he attributes the cure of this variety to any local or general application; let him not be too sanguine ; we have been witnesses of cases like the following, under the influence of some simple or complicated treatment; a serpiginous chancre is rapidly getting well, when, without any assignable cause, the granula- tions disappear in a few hours ; the cicatrix, which was nearly per- fect, is destroyed ; and the sore recovers its original size, or even augments, then returns to its chronic state, and defies all means of treatment, when we are suddenly surprised at the promising aspect it assumes, which, perhaps, is only deceptive. Notwithstanding, it must be allowed that few sores present this character ; usually, if the state of the bowels be attended to, if the diet be changed, if the local treatment be guided by general indications, a cure may often be attained ; thus, cauterization may be attempted, or general stimulants be employed, provided the sore assumes a chronic form ; should the serpiginous character seem to depend upon the stimulating local treat- ment, an opposite one may be often tried with advantage. We have lately seen such sores benefited by employing compression with straps of the emplastrum vigo, not in all its stages, but when granulations appear; but if this practice has succeeded in some cases, it has 212 CHANCRE. signally failed in others, particularly when no granulations exist. Among other treatment, the sore has been sprinkled with starch, a layer of tallow has been laid upon it, as it was supposed that the action of the air had an injurious effect upon it; but if successful in some cases, in others it has only aggravated the disease. In hospital practice it is impossible to recommend change of air, but we feel convinced that a better diet, in a warmer climate, to- gether with tonics and sea-bathing, by improving the health gene- rally, would be more advantageous than any local treatment we could prescribe. 4th. The Indurated Variety of Chancre.—Unacquainted with the causes which give rise to indurated chancre, we are unable to prevent its occurrence, or to avoid those circumstances which predispose to, or keep it up: but, as we stated under the head of Prognosis, it is a very unfavorable circumstance, and one which we should attempt to remove as speedily and effectually as possible. In the first place, it predisposes to molecular gangrene, giving rise to the variety of chancre so well drawn in Plate IV., fig. 6, which extends in propor- tion to the quantity of induration. In the second place, it is of very serious consequence, as showing that the system is already, or is about to be, constitutionally affected. Experience has enabled M. Ricord to state, that secondary symptoms will follow indurated chancre in eighty-six out of every hundred cases. We have hitherto spoken of chancre as a local disease, and have not recommended any peculiar general treatment, further than such as was necessary for improving the general health, or treating any peculiar symptom ; we shall now, however, speak of the general treatment, which we shall show to be as advantageous, in this varietyi as we think it to be prejudicial in the last. Local Treatment of Simple Indurated Chancre.—If, in spite of cauter- ization and the employment of aromatic wine, a chancre becomes in- durated, the first means should be laid aside ; or if consulted for an indurated chancre, cauterization should not be attempted, as the very fact of the occurrence of the induration shows that the disease is no longer the simple local affection above spoken of. If we even destroy the local disease, we have every probability of a constitutional infec- tion ; cauterization is, therefore, not only useless, but we run the risk of being accused of causing secondary symptoms by our treat- ment. When, however, induration follows the cauterization of a chancre, and did not exist previously, the surgeon should not too hastily sup- CHANCRE. 213 pose that the induration is of the specific nature above spoken of, inasmuch as cauterization will, in some constitutions, give rise to it. An experienced eye or finger will, however, usually distinguish one from the other, and a few days' quietude will prove whether it depend upon syphilis or not, as the real induration as gradually increases as the false one diminishes. (See Case, note p. 188.) If the indurated chancre suppurate freely, it may be washed several times a day with the aromatic wine : this is not unfrequently attended with some pain, which soon, however, passes away ; the sore should then be wiped dry, and a piece of lint, spread with an ointment com- posed of Calomel, gr. xxiv. Pulv. opii, ?j. Adipis suis scrofae ^j. This should be changed twice a day, and the sore may then be washed with the aromatic wine ; care should be taken in removing the dressing, otherwise bleeding is likely to occur from the wound. Under this treatment the chancre will usually heal; but as the in- duration remains, the sore is very liable to break out again on the slightest cause, and assume the phagedenic form we shall presently speak of. At other times perfect cicatrization takes place, but a cartilaginous nodule is left, which remains in statu quo, or, increasing in size, ruptures the cicatrix and gives rise to an unhealthy ulcer, which is not inoculable, but is most intractable. Indurated chancre, then, will heal without any general treatment. The employment of mercury is not absolutely necessary, but, if not had recourse to, we run the risk of a simple indurated chancre as- suming a phagedenic appearance. M. Ricord, at page 234 of his Re- searches {Doane's translation), states, " If, like the physiological school, we date the cure of a chancre from the period at which the ulcer is cicatrized, without regarding the consequences, the cure will appa- rently be more rapid under simple treatment: and in hospitals the patients are less time under treatment. But if, in order to call a patient cured, we wait until all hardness has disappeared, we shall find an enormous difference in favor of a mercurial treatment. " The induration remains in the first case a long time, even up to the period of the appearance of the secondary symptoms, which are of such frequent occurrence. For myself," continues M. Ricord, " while I allow that other remedies, besides mercury, possess curative properties ; yet, as one of the most powerful and the most, sure, I have recourse to a mercurial treatment whenever a certain degree of 214 CHANCRE, induration accompanies a chancre, prevents its cicatrization, or remains after its superficial healing, and more especially when by its excess it gives rise to phagedena." When it has been decided, then, that mercury snould be used, a no less important question arises, as to the preparation, the dose, the period required for saturating the system, the indications for leaving it off, &c. There is no subject on which so much difference of opinion exists, perhaps, as on this. In the following pages we shall be guided by what we have seen, rather than by what we have read ; but for further information we refer our readers to the treatment of secondary symptoms, where we shall dwell more at length on the action of mercury. In indurated chancre we prefer a preparation which unites the good effects of iodine and mercury, known under the name of proto-ioduret of mercury. M. Ricord usually gives it in combination with henbane, and orders it in one-grain doses, in form of a pill, to be taken every night, five hours after the last meal. The effects are not at first apparent; it does not produce colic, like corro- sive sublimate, nor does it purge like calomel; at the end of a week or ten days he increases the dose, and orders a pill to be taken night and morning. The first visible effect of this remedy is observed on the induration, which diminishes in size and hardness: the surface becomes healthy and covered with granulations, and a cicatrix fol- lows. Provided these favorable results continue, it is not necessary to augment the dose, and the sore usually heals, and all traces of in- duration disappear. The pills should not, however, be immediately left off; let them be gradually discontinued. However, it is always well to continue their use some time after the disappearance of the induration ; no general rule can be laid down, for the surgeon must be guided by the circumstances of each case. We do not recollect having seen a patient salivated in order to cure an indurated chancre, which is one of the greatest recommendations of this preparation. Far from thinking it necessary to produce salivation, we purposely avoid it; and those who are familiar with the practice at the Venereal hospital will agree with us in stating that salivation is of a very rare occurrence ; if it should happen, ushered in as it is by an unpleasant taste in the mouth in the morning, a red and puffy state of the gums, with an increased flow of saliva, a fetid breath, a loaded tongue, disordered bowels, loss of appetite, and general feverish state, the mercury must be immediately left off; quiet and repose ordered, with a light and nutritious diet; and a gargle containing muriatic acid will, usually, soon put a stop to all local and general symptoms ; or CHANCRE. 215 if the state of the gums require it, they may be brushed over with a little muriatic acid, by means of a piece of lint. When all the symptoms of salivation have passed, the use of mercury may be again resorted to. It will at once be seen how different is the treat- ment we recommend to that usually followed. Strongly opposed to the general or indiscriminate use of mercury, we highly approve of it in indurated chancre ; but we do not recommend a certain dose, which every person should take, be his complaiht cured or aggrava- ted ; neither do we think that the mercury should be continued until the constitution shows signs of becoming affected by soreness of the gums. We, consequently, can not agree with those who believe that salivation should be kept up several weeks ; on the contrary we are guided by the state of the induration and the appearance of the sore, considering them to be the only sure guide : after the experience we have had on this subject, we may say that this is the only criterion by which the surgeon can judge. Such treatment will not only cure the local disease, causing the chancre and induration to disappear gradually, but will likewise, in the great majority of cases, guaranty the patient from secondary symptoms—we say in the generality of cases, for we do not put this treatment forward as an absolute protection, believing that no method, however long continued, will absolutely protect, the constitution from secondary symptoms. The mild and rational one we have recom- mended has, however, this decided advantage, that if secondary symptoms follow, they will be of a mild form ; the constitution, not being injured by mercury, will bear it a second time ; but of this we shall again speak, when treating of constitutional syphilis. Excision of the indurated chancre has been recommended ; but when it is remembered that this is often impossible from the situation of the parts ; that it is usually impracticable to remove the whole, for, if the smallest quantity of the virus be left, the whole wound assumes the character of a large chancre ; when, moreover, it is recollected that it has already ceased to be a local disease, and lastly, that if it were possible to remove the induration, the surgeon would lose one of the best guides for the administration of mercury—we reject the plan as prejudicial and useless. The Treatment of Indurated Phagedenic Chancre.—As the phage- dena in these cases depends upon an excessive induration, the most rational treatment consists in curing the induration which gives rise to it. This is best done by employing the treatment above recom- mended ; not that we think mercury good in phagedenic sores gen- 216 CHANCRE. erally, but only in such as depend upon induration; here, sublala causa tollilur effectus; it is from not paying sufficient attention to these different species of phagedena that so much difference of opinion has existed on the use of mercury in these affections—we trust we have in some measure reconciled them. It is upon general treatment alone that we must, depend, as the sore is often very irri- table, and there is a good deal of general nervous excitement; the use of the opium solution locally, as well as the internal employment of morphia at bedtime, are often very beneficial. These compre- hend the principal means in use for the treatment of indurated chancres, as well as the other varieties; we shall therefore now pass to The Treatment of the Varieties of the Reparative Stage.—When the chancre remains, as it occasionally does, in a statu quo, any stimulating ointment may be employed ; but, above all things, rest and quietude on a bed or sofa will be of great service ; this alone will be sufficient to attain our object. When an irregular cicatrization occurs, or when the borders of the ulcerations are livid, thin, and bleed on the slightest pressure, great advantage may be derived from destroying them with caustics, or they may be removed with scissors; a considerable haemorrhage results, but the chancre will assume a healthy character ; the cicatrization will commence and proceed from the circumference, and the ulceration completely dis- appear. When cicatrization appears in various detached points, it will be well to touch the sore with nitrate of silver ; when the gran- ulations are large, soft, and bleed on the slightest cause, a superficial cauterization will cause them to take on a healthy action. When the chancre puts on the appearance of the ulcus elevatum, and the gran- ulations are exuberant, and very red, let the parts be fairly cauter- ized, and when this has been repeated once or twice, cicatrization will commence. In these various varieties we have found the greatest success attend compression by means of strips of diachylon, which may be changed every other day, if there be but little suppu- ration ; or applied daily, when the sore discharges freely. Such local treatment, combined with a tonic and nutritious diet, will usually cure these sometimes troublesome cases. Treatment of the Complications of Chancre.—We have hitherto spoken of the treatment of simple chancre, or of its varieties ; we now turn to that of the complications, which may demand a special treatment, not in respect of syphilis, but in consequence of situation, or the co-existence of some other disease, which marks or changes CHANCRE. 217 the primary affection, or induces the surgeon to modify the treatment above spoken of. The existence of chancre of the urethra is now put beyond doubt ; we give an example of it situated at the meatus in the annexed wood- cut ; it likewise shows that chancre may occur along the whole course of the canal, which becomes the seat, of an irregular ulcera- tion, secreting the virus and extending rapidly. The case is described at page 274 of M. Ricord's work on inoculation. (Chancres in the Urethra.) The symptoms are the following: During the few days following exposure to contagion, no unusual phenomena occur, but some irri- tation is soon felt at the entrance of the urethra, for it is this point which is usually the seat of the affection, followed by a slight dis- charge of a purulent character, tinged with blood, particularly when the canal is pressed ; the urine in its passage occasions some pain, but this at first is slight; pressure, however, on parts of the canal causes suffering, and induration occasionally is felt, confined to a par- ticular point. On separating the lips of the meatus, a chancre may be perceived, presenting all the characters above given, and the secre- tion of which produces, on inoculation, the characteristic pustule. Should it occur in an irritable, bad constitution, the chancre may increase in size, gain the orifice, or destroy the surrounding cellular tissue, form abscesses, or, at a later period, fistula, giving rise to all the unpleasant consequences which usually result; or the chancre may, by the irritation of the passage of the urine, become phage- denic, gain the deeper parts of the canal, form abscesses in the pros- tate, and even reach the bladder, which may be destroyed. Such a condition of the parts can not occur without acting on the system ; marasmus and a hectic state ensue from the local disease ; infiltra- tion of urine takes place ; haemorrhage occurs from vessels which the gangrene has opened, and the patient sinks. In other cases, and 218 CHANCRE. these, happily, are the most frequent, the secretion diminishes by de°rees, and the chancre heals altogether, or leaves an indurated point, which causes a diminution in the calibre of the canal, forming one of the varieties of stricture which is followed in from six to eight weeks by the occurrence of secondary symptoms. Hence gon- orrhoea has been accused of causing constitutional syphilis, whereas, in fact, the patient has never had aught but chancre in the canal, the secretion of which has been mistaken for that of gonorrhoea. The diagnosis of this complication may be founded on the follow- ing considerations. The chancre in the urethra may be often detected by the eye ; it usually gives rise to a secretion from the canal on the sixth, eighth, and even twelfth day after connexion ; it has a sanious appearance, and inoculation produces the pustule ; pain is felt at a particular portion of the canal, usually close to the meatus. When induration exists, it is likewise confined to a point, is well defined, and cartilaginous. In gonorrhoea, redness is merely observed at the meatus ; the dis- charge from the canal usually follows exposure to contagion imme- diately ; serous at first, it becomes purulent, but rarely sanguinolent, and when blood is found in it, it is rather bloody than streaked, as in chancre. Pain, at first confined to a point, extends along the canal; there is scalding and chordee, the induration which may follow is not distinctly limited, but occupies any part of the canal, particularly the deeper portions, and is deficient in the cartilaginous feel so characteristic of chancre. The prognosis is usually favorable, except when the sore assumes a phagedenic form; it is then one of the severest diseases the sur- geon is called upon to treat. The treatment consists in depriving the urine of its irritating prop- erties, by ordering abundance of liquids; subduing any local irrita- tion by rest and antiphlogistic means ; introducing a pencil of nitrate of silver into the canal to cauterize the sore ; recommending injec- tions of aromatic wine, and the nightly employment of camphor in form of pills, to prevent the occurrence of erections. These will be sufficient to cure the majority of cases. When abscesses form, they should be at once opened, as fistulae are less likely to result, and cauterization be had recourse to immediately; if fistulous openings occur, they maybe treated in the manner recommended at page 140. Induration will be best combated by general treatment; but, above all things, let the surgeon be careful how he employs bougies, as they only tend to irritate the canal, and have no effect in removino- the CHANCRE. 219 stricture. We believe that such cases have been the cause of odium being thrown on dilatation by some authors. Chancre situated on the frenum is frequently a complication, as in erection any cicatrix is burst, and it is difficult to cauterize the part; consequently it is better to divide the fraenum, if the chancre has not already done it, and treat the sore in the usual manner. Balanitis is another complication, a disease which is well shown in plate II., fig. 1 ; when it occurs in persons who have a wide pre- puce, enabling the surgeon to uncover the glans easily, and treat at once the chancre and the balanitis, it is of little importance ; but should a chancre occur on the inner portion of the prepuce, and be attended with balanitis, at the same time that, a narrow opening pre- vents us from exposing the glans and treating directly the disease, the case assumes quite a different aspect; the secretion of the chancre, thus confined in the species of sac formed by the prepuce, causes inflammation, additional chancres ensue, so that the lining of the prepuce may become an ulcerating, virulent surface; the loose cellular tissue of the prepuce becomes oedematous and inflamed; a phlegmonous or an erysipelatous state succeeds, which often termi- nates in gangrene ; a dark spot appears on the prepuce, usually on the upper part; an eschar forms, falls off, and the glans is observed appearing through the ulcerated opening ; a fetid discharge oozes out, composed of the detritus of the gangrenous tissues. In some cases destruction of the prepuce only occurs ; in others the glans partici- pates, and a great portion may be destroyed ; the vessels of the sur- rounding parts are exposed, ruptured, and haemorrhage follows, which it is often difficult to check. Such are some of the consequences of this complication, the treatment of which we have already described under the head of balanitis. When there is a natural phymosis, and the surgeon is consulted at a late period, swelling, redness, and oedema having occurred, the same treatment may be pursued, and the patient usually recovers, but the phymosis remains ; it then becomes a question whether an oper- ation should be performed or not. If the surgeon be consulted at a later period, and gangrene be inevitable, we have seen a director passed between the glans and prepuce, and the parts slit up with a bistoury ; considerable haemor- rhage follows, which seems to unload the vessels ; but this does not always check the gangrene, which destroys a greater portion of the prepuce. When a case presents itself, in which the prepuce is already destroyed, and the glans exposed, M. Ricord is in the habit 220 CHANCRE. of applying the opium solution, and letting the disease take its course ; a gangrene usually performs the part of the knife, and a complete circumcision results. He considers that an incision can not be of service, as no part is strictured, and the tissues divided present a puffy, lardaceous character ; he therefore prefers waiting till all inflammatory symptoms have passed away, and then removes by the knife any portions which inconvenience the patient. There is a complication of chancre depending upon its being seated at the opening of a narrow prepuce ; here the chancres assume a linear form, like fissures, or chaps, and are very difficult of cure, in consequence of the cicatrix being torn asunder during erec- tion, and from the urine excoriating them ; quietude, cleanliness, and the use of an ointment of calomel and opium, are very beneficial. Having cured the local disease, the next question is to treat the phy- mosis, provided it be permanent. (Circumcision, as performed by M. Ricord.) If the patient will submit to an operation, the following mode, as delineated in the annexed woodcut, in our opinion, is the best one, Without employing any traction, we trace in ink a line on the pre- puce, which follows the circumference of the base of the glans, and is a little in front of it. This being done, the prepuce should be drawn forward and fixed between the blades of the forceps placed in front of the glans, and behind the line of ink traced on the prepuce ; let the forceps be then held in this position by an assistant. Let that portion of the prepuce which is in front of the forceps be now drawn forward by the left hand of the surgeon, while, at the same time, he with the right divides it in the oblique direction of the for- CHANCRE. 221 ceps, which thus protects the glans. In this operation the skin alone is removed ; the mucous membrane is not drawn forward with the prepuce and remains intact; if we do not wish to see a phymosis recur, this portion of mucous membrane must be removed. To effect this, M. Ricord employs a pair of scissors, slitting up the thin layer of mucous tissue as far as the base of the glans ; the two portions should then be successively held apart by a pair of forceps, and removed by dividing them at the base of the glans, as far as the fraenum, which is divided the last. M. Ricord prefers the employ- ment of torsion in these cases to check the bleeding ; lint dipped in cold water is then applied, and it may be advisable to administer an enema containing opium in the evening, or to prescribe camphor pills to prevent erections. A perfect cure takes place about the twentieth day, and the result is very satisfactory ; there is no deformity, nor have we to dread a consecutive paraphymosis. Paraphymosis is another complication which the surgeon is often called upon to treat. Many patients have an idea that chancres of the glans and pre- puce should be exposed ; hence they keep the glans uncovered for a long time, and employ force in doing so. Should there be much inflammation, an oedematous and swollen state of the prepuce follows, and the patient is incapable of reducing the paraphymosis. When the surgeon is consulted at an early period, applying cold to the penis, and the employment of gentle pressure, are sufficient to reduce the parts to their normal position ; but if, as often happens, there is not only paraphymosis, but ulceration, and the stricture of the glans is considerable, when there is risk of gangrene coming on, or when a paraphymosis has succeeded a natural phymosis, M. Ricord is not in the habit of attempting reduction, which is always attended with great pain, is often impossible, and if effecfed would only convert a paraphymosis into a phymosis. He passes a narrow-bladed knife underneath the portion of the prepuce which forms the stricture, and slits it up full an inch beyond the glans ; should- there remain any bands which keep up the stricture, they should be successively divided, as well as the oedematous fold of mucous membrane in front of the strangulated parts ; cold may then be applied, and the patient will soon recover, but flaps of the prepuce may remain, which it will be well to remove at a later period, as they greatly inconvenience the patient. The surgeon must not be surprised at. seeing the incised wound take on a chancrous appearance, which, however, must be treated on the principles of chancre in general. In thefemale,ihe situation of chancre may form a serious complication. 222 BUBO. SECTION II. BUBO. M. Ricord has divided the first stage of syphilis into two parts ; in the former he describes the primary, in the second the successive symptoms. The meaning of the former term has been already dwelt upon; by the latter denomination, or successive symptoms, I mean those which are the extension of primary symptoms by continuity of surface (de proche en proche) or a simple extension of the primary locaf symptom. Under this head I might consider fresh chancres, inflammatory or virulent abscesses and buboes. As the former sub- jects have been already described, it remains for me now to speak of bubo, which I consider as the type of the successive affections, to the description of which this section will be devoted. Definition of Bubo.—In the following pages we shall imply, by the term bubo, a circumscribed swelling of a lymphatic vessel or gland, with or without suppuration. By the term venereal bubo, we understand a bubo which follows sexual intercourse. Syphilitic bubo is a term applied to those swellings which are the consequence of primary symptoms, or may arise from constitutional disease, generally termed lues venerea. In the present section we shall treat more especially of syphilitic buboes following primary symptoms ; the other forms will be only allu- ded to here, inasmuch as they tend to the illustration and diagnosis of syphilitic ones, and as appropriate sections will be devoted to their further description. Anatomical Characters of Syphilitic Buboes.—The first appearance BUBO. 223 of the affection is frequently the occurrence of an inflamed lymphatic vessel, commencing at the chancre, and extending itself along the trunk of the vessel, attended with swelling, and presenting to the finger the sensation of a chord ; this is seen in the annexed cut. In other instances, there is no swelling of the lymphatic vessel, but the lymphatic gland, which is connected with the chancre, becomes swollen and red, and increases gradually in size ; at first it is per- fectly moveable, and unconnected with the surrounding tissues ; soon, however, the tumor is found to be attached to the deep-seated parts ; at a still later period the skin becomes connected with the tumor, forming, together with the superficial an 1 deep-seated glans, one uni- form swelling. Among the working classes it is at this period that attention is first paid to the affection, from the pain and inconvenience felt. In consequence of the enlargement of the gland, the circula- tion may be impeded, and a varicose state of the limb result, or oedema may come on, and cause great alarm to the patient. The termination of the disease may be various ; among the rarest we may mention delitescence; in such case, the swelling and other symptoms abate, the parts take on their accustomed function, and are restored to their original state. Resolution, again, is one of the terminations ; in this case the tumor becomes moveable on the surrounding parts, and slowly assumes its natural size and form. Suppuration often occurs ; this stage of the affection is announced by shivering, by the sense of fluctuation detectable by the finger, when the pus is seated in a superficial ganglion, although, when it occurs in a deep-seated gland, fluctuation is very difficult, if not impossible to be detected. Many young surgeons may be deceived in the sensation of fluctuation, the elasticity of a swollen gland being liable to be mistaken for fluctuation ; on the other hand, when pus is bound down by a hard mass of condensed cellular tissue, fluctuation is very obscure. In such cases it is useless to attempt to discover its presence by pressing from before backward ; the surgeon should press horizontally, or from without inward, and by this means a more accurate opinion may be arrived at. ShoHld the abscess be left to itself, the skin covering it becomes oedematous, discolored, gangre- nous at one point, and the pus escapes by a fistulous opening; the surrounding skin assumes a livid hue ; is thin, and detached to a considerable extent, or is perforated with several fistulous openings. In other cases, the bubo, when formed, does not proceed to suppu- ration, but takes on an indolent character, becomes indurated, and is 224 BUBO. unattended with pain ; it interferes, however, with the functions of the part, and may terminate in scirrhous degeneration, provided there is any predisposition on the part of the individual. Syphilitic buboes may likewise become scrofulous, or be complicated with scorbutic affections, or attended with haemorrhage, hospital gangrene, or present ulcerations in every respect similar to the varieties of chancre which we shall not here stop to describe, for bubo is but a chancre of the lymphatic vessel, or gland, as we have above stated; consequently, its secretion, parietes, &c, resemble those of chancre, and are regulated by the same laws. On the other hand, a syphilitic bubo, commencing as above stated, may enlarge to a certain extent, and then gradually subside, and ulti- mately disappear; or it may suppurate, and like any simple abscess, go through the different phases of suppuration, ulceration, and cica- trization, and present none of the characters which we have termed virulent when speaking of chancre, from which it differs in its essen- tial feature. Causes of Syphilitic Bubo.—In our definition of syphilitic bubo, we stated it to be a consequence of a primary symptom or chancre ; let us now inquire how this cause produces bubo. To do this, how- ever, let us recall to the attention of our readers the anatomical struc- tures uhich are implicated. M. Cruveilhier found that the lymphatic vessels commence on free surfaces by a sort of excessively fine net-work. Their connexion with each other is seen in the annexed cut. His investigations, confirmed by the experiments of M. Panizza of Pavia, as well as those of M. Fohman, show the distribution of vessels on the sur- faces exposed to chancre. These experiments also prove that the lymphatic vessels, when injected with mercury, proceed onward to the glands, accompanying the superficial veins, anastomosing one with another, but not increasing in volume. Having reached the lymphatic glands, the vessels are lost in the substance of that organ. Each lymphatic vessel is composed of a lining membrane, which BUBO. 225 bears a close analogy to that of the veins, and an outer one which is said to be fibrous, and gives the vessel a great power of resistance. From the experiments of Abernethy on the larger animals, the lymphatic glands are found to be composed of a spongy cellular tis- sue, in which the lymphatics dilate as they enter, and again pass out at the other side of the gland, to assume the same character and size which they had on entering them. Of course it is not here our object to show that these vessels are endowed with absorbing powers ; of this there can be no question; but as to the properties these vessels have of selecting the substances they take up, we must be silent, being completely unenlightened at present on the intimate nature of the function of secretion or absorp- tion ; but it is not a mere hypothesis to state that the absorbents do not, during life, take up indiscriminately all substances, and it would seem pretty well established that the lymphatic vessels often absorb the elements of substances rather than the substances themselves, although, under certain circumstances, it seems that they absorb sub- stances which at other times they appear to have a repugnance to. It is on such a supposition as this, that modern authors have attempted to explain why pus is often absorbed without any unpleasant consequences, whereas, in other instances, the absorption of a little pus gives rise to such fatal effects. To return, however, to the subject of this chapter—it would seem proved that syphilitic virus, on an ulcerated surface, does not neces- sarily give rise to successive phenomena, for the occurrence of bubo is rare in proportion to the number of chancres the surgeon is called upon to treat; hence, we shall presently consider the circumstances which favor or prevent the occurrence of bubo. When, however, the syphilitic virus gives rise to bubo, the investi- gations of M. Ricord induce us to believe that it may act in one of two ways. 1st. By absorption. 2d. By irritation. In the former case the virus is directly taken up by the lymphatic vessels, and carried along them, and, under some influence with which we are unacquainted, deposited on the sides of the lymphatic vessel, which it destroys ; it then acts on the cellular tissue in the same way as when introduced into a follicle, and produces a chancre, which causes destruction of the tissues, until it appears at. the sur face, or, if unchecked, it may be carried along the whole course of the vessel, until it reaches the gland ; here it becomes developed, 15 226 BUBO. destroying the surrounding parts, and eventually appearing at the surface, as above described. 2d. The syphilitic virus may not be absorbed, but give rise to an irritation and inflammation of a simple kind, as any other irritant may, not acting in a specific manner. This irritation may extend along the whole course of the lymphatic vessel, until it reaches the gland, giving rise to the chord above spoken of; or, by a sympathetic action which the extremities of canals have, the intervening portion of the lymphatic may apparently be free from disease, and the simple irritation of the surface be communicated to the gland, on the same principle that in cases of stone in the bladder no pain is felt along the urethra, but the irritation at the neck is accompanied with severe suffering and irritation at the glans penis. We well know, likewise, that tickling the palate causes vomiting. These various ways in which the syphilitic virus may act, do not rest upon hypothesis. Inoculation of the secretion of bubo has clearly proved that a great many buboes exist which secrete the syphilitic virus ; thus proving that absorption must have taken place, and that it has been brought in contact with the gland. A case illus- trative of this is related in M. Ricord's work, at page 143 :— " A patient presented himself, suffering under syphilitic bubo, attended with considerable suppuration. I opened the abscess, but after the pus had been evacuated from the cellular tissue, I found in the middle of the abscess a lymphatic ganglion of considerable volume, and presenting the feeling of fluctuation in the centre. I punctured it, and inoculated the patient with the pus which it con- tained, at the same time that I inoculated likewise with the pus taken from the surrounding parts. While the pus taken from the ganglion produced a characteristic pustule, that from the cellular tissue remained without any effect. I made, in consequence of this case, a series of experiments which no longer left any doubt on the results of inoculation." Predisposing Causes of Bubo.—If chancre be the cause of syphi- litic bubo, it is a fact admitted by all observers, that it is only the direct or exciting cause ; in order that bubo follow, there must be some predisposing influence, otherwise bubo would be more frequent than it is in proportion to the number of chancres. We therefore propose now to speak of those circumstances which appear to pre- dispose to bubo. Age has an influence in producing bubo. Infancy is comparatively free from their occurrence ; we have not witnessed any cases, but BUBO. 227 M. Ricord has mentioned one in a child of a month old; in spite of this exceptional instance, we may say that the quiet life and light nourishment of children predispose very little to the occurrence of buboes. Old age predisposes but little to buboes, in consequence of less exposure of the subject, and sluggish absorption ; but it is by no means exempt. We have witnessed buboes occurring in old people, and we have at present under our care a female, of a very advanced age, suffering under a severe form of syphilitic bubo. It is at the adult age that the lymphatic system seems most liable to absorption, and as exposure to the chances of contagion are at this period most common, we do not feel surprised that there exists a greater liability to buboes. The sex appears to play an important part in predisposing to bubo. Statistics show that the male is more susceptible of bubo than the female. It might be imagined that this circumstance depends upon the greater fatigue to which the male is exposed, compared to that undergone by the female ; such an opinion, however, is not true, for experience proves that women employed at the public markets, and who carry great burdens, are rarely affected with bubo, and in a far less proportion than in males who, from their social position, do not exert themselves. There would seem to exist some other circum- stance beyond that, of occupation, to explain the greater frequency of bubo in the male. Temperament may be considered as a predisposing cause. The lymphatic temperament appears to be more liable to bubo than any other, inasmuch as it predisposes to absorption ; we have not been able to connect the more frequent occurrence of bubo with the other temperaments. The hygienic conditions of the patient, particularly fatigue, irrita- tion of the part, &c, predispose to the occurrence of bubo more than any other circumstances. The situation of chancre in predisposing to bubo must never be lost sight of by the surgeon ; while the artificial chancre on the thigh has never, in the numerous experiments we have witnessed and made, been followed by bubo, chancre situated around the fraenum, meatus of the female, or at the ischium, is seldom unattended by bubo. Whatever be the explanation of the fact, there can be no doubt that in the last-named situation bubo follows very frequently. The size of the chancre does not seem to have the same influ- ence ; we have seen very large chancres existing during a long 228 BUBO. period of time, and yet unattended with bubo ; on the contrary, a small chancre, if situated at the fraenum, is very often followed by bubo. Treatment of primary sores has been repeatedly stated to predis- pose to bubo, many surgeons believing that, by locally treating the chancre, the virus is driven into the system. There is not in surgery a more incorrect opinion than this, and we feel disposed to lay down the contrary principle, namely, that the more speedily and effectually a chancre is destroyed, the less will be the probability of the occur- rence of bubo. It is true that irritation of a chancre predisposes to bubo, but as the nitrate of silver does not irritate, but, on the con- trary, acts as an antiphlogistic agent, its use can not be said to pre- dispose to bubo. However, we do not pretend to state that the use of the caustic will always prevent the occurrence of buboes ; but though it will not, in all cases, succeed in preventing them, it will nevertheless render their occurrence less probable ; and when bubo follows the employment of the caustic, it is usually not virulent, and yields readily under proper treatment. The idea that when a primary sore is treated by mercury, there is less disposition to the occurrence of bubo, has of late years fallen into disrepute, as it has been found that buboes occur during and after the use of mercury; and even Hunter states that mercury sometimes occasions bubo. It is our opinion that mercury has no effect either in preventing or predisposing to the complaint. Symptoms of Bubo.—The earliest symptoms usually show them- selves during the second week of the existence of chancre ; we have rarely met with them during the week following contagion. They are often ushered in by shivering, or the first indication of a bubo is afforded by a pain in the part, attended by heat and swelling, increased by motion ; there is occasionally fever, and the affection may take on an acute character, presenting all the local appearances described under the head of anatomical characters ; or it may assume a chronic form, arid become of a very indolent nature. Diagnosis of Syphilitic Bubo.—Did the limits of the present work permit, we would treat of the diagnosis of bubo from aneurism, ex- ostosis, and the affections which may be confounded with bubo, as well as from hernia, when the tumor is situated in the groin ; but we are obliged to pass over this very interesting inquiry, and to call the attention of our readers to the diagnosis of syphilitic from the other forms of buboes.' The opinion of a surgeon may be asked previous to or during the BUBO. 229 suppurative state; we shall, therefore, consider the points on which the diagnosis, may be founded in these two stages. 1st. Diagnosis of Syphilitic Bubo, previous to Suppuration.—In such a case the surgeon can only arrive at a rational diagnosis, as it is impossible, before suppuration to give a decided opinion upon a point which, though of great importance, has hitherto puzzled the most celebrated authors. When a bubo appears during the second or third week of chancre, or during the period of cicatrization, particularly if the ulceration be seated at the fraenum, at the meatus urinarius, or on the ischium in the female—if it be confined to a superficial gland—if, moreover, it rapidly goes on to suppurate—the surgeon will be usually correct in calling it syphilitic, particularly if all these characters are present in one individual. The diagnosis is not always easy ; there are many conflicting opinions, so that it is difficult to decide upon the true nature of the case. Some have advanced that your diagnosis should be based on the antecedent history of the case, so that when a patient has exposed himself by sexual intercourse with a prostitute, and a bubo follows, it must necessarily be syphilitic ; in this opinion we can not agree, for, as we stated in speaking of chancre, every ulceration which follows promiscuous intercourse is not necessarily syphilitic, for the same reason every bubo is not syphilitic ; although, then, we may rationally consider a bubo syphilitic which follows a sore contracted in promiscuous intercourse, we should not so stigmatize every bubo which follows connexion, unaccompanied by chancre. This brings us to the consideration of a point of great importance, viz., what is the nature of a bubo following connexion, though not preceded by chancre ? Observation of a great number of such cases leads us to the following conclusion—that impure connexion may produce inflammation of the glans or prepuce, causing gonorrhoea praeputialis, excoriations, or gonorrhoea, and will subsequently pro- duce venereal non-syphilitic buboes, which, consequently, may be readily distinguished from the virulent forms. There are, however, cases in which it is sometimes difficult to distinguish syphilitic buboes from what the French call bubon d'emblee. Patients present themselves suffering under bubo, yet denying they have had chancres, or any affection of the genital organs, this is what is called d'emblee. Now, in the majority of such cases on carefully examining the vagina, neck of the uterus, rectum, glans, or urethra, a chancre, or traces of it, will be observed, clearly 230 BUBO. proving that the bubo is a syphilitic one ; but if this happen in the majority of instances, it is no less certain that there are cases which seem to merit the term d'emblee; thus buboes occur in persons who have neither object nor wish to deceive, without our being able to trace them to chancre, or any local affection. Are we justified in calling them dfemblee ? We think not, as the following case proves : M. Ricord inoculated from a superficial chancre, and on the following morning the characteristic pustule was evident, but the chancre from which the pus was taken he found completely cured ; now had a bubo followed, it would have been called d'emblee, as no traces of existing disease would have been found ; yet we see how incorrect this conclusion would have been. The few remaining cases of bubo d'emblee, may, we think, justly be attributed to scrofulous enlarge- ments of lymphatic glands, produced by any local excitement, as connexion, &c. That this is the case, is further rendered probable by the constitution of the individuals, by the indolent character of the swelling, and by its rarely suppurating ; further, by several glands being the seat of the disease, and by their never having fur- nished inoculable pus, although the experiment of inoculation has been often repeated. It is on a consideration of the circumstance relative to each case that the diagnosis must be founded ; but if the preceding observations are borne in mind, the surgeon will not often fall into error. Diagnosis of Syphilitic Bubo in the Stage of Suppuration.—We have stated that an open bubo is in every respect analogous to chancre ; hence, it would be useless to repeat what we said upon the diagnosis of chancre, and we refer our readers to that chapter. It is only when a syphilitic bubo suppurates that we can decide if the bubo has been produced by the absorption of the virus, or by irritation. Prognosis of Syphilitic Bubo.—Many surgeons believe that the mere existence of bubo is a very unfavorable occurrence, as show- ing that the disease had made great inroads on the system ; but our readers will at once observe, that the prognosis of bubo may depend upon a variety of circumstances ; the mere existence will not throw any light on the prognosis ; and our opinion must be founded on other data. To this subject we demand the especial attention of our readers. In forming a prognosis, we must first decide whether a sore exists which may have caused the bubo ; if so, we should ascertain if it be a chancre ; on the other hand, if the patient has suffered or is suffering under gonorrhoea, or any simple non-virulent affection, then BUBO. 231 the prognosis will be always favorable ; but if we have reason to believe that the bubo is a syphilitic and not a sympathetic one, the next question to decide is, if it be a virulent bubo, or merely a con- sequence of irritation ; until this has been decided, it is impossible to form a prognosis. The prognosis of bubo, however, is favorable, inasmuch as it is found by statistics, that in every hundred cases twenty only are syphilitic, and that only a portion of these will suppurate. The prognosis of bubo, preceded by or accompanied with chancre, is, generally speaking, unfavorable, inasmuch as it is probable that the bubo is a virulent one ; but let it not be supposed that other bu- boes are not likewise very unfavorable as to their prognosis, particu- larly scrofulous ones, which are extremely indolent. A bubo, how- ever, which is a consequence of gonorrhoea or simple wound, usually soon disappears. The surgeon will therefore see how necessary it is, on the subject of prognosis, to arrive at an accurate diagnosis of the disease which has preceded the bubo, as well as of its nature ; for he will thus be able, not only to allay the fears of his patient, but save his reputa- tion, by predicting whether a bubo will suppurate or not. The probability of the suppuration of a syphilitic bubo will depend upon the period at which the surgeon is consulted. If at a late pe- riod, when the skin is red and inflamed, and the bubo assumes an acute character, whatever may be the treatment employed, suppura- tion may be expected. In a good constitution, when treatment has been employed early, although a chancre has preceded the bubo, great hopes may be entertained of preventing suppuration. The opinion of the surgeon is often asked upon the probable dura- tion of a bubo. Any opinion that may be given should be very guarded, and must depend upon a mature consideration of the cir- cumstances which have preceded. Thus, every prospect of a speedy cure may be held out by the surgeon, when called in early, when there are no acute local symptoms, in a good constitution ; but when the bubo is suppurating, and you have reason to consider it a virulent sore, or when it occurs in a bad constitution, it is impossible to pre- dict the period of the cure. On this subject, however, we must refer our readers to the prognosis of chancre, as it is rather the latter com- plaint that we have to consider. The termination of bubo in induration depends, in a great measure, on the nature of the primary sore ; thus, if it be already cartilagi- nous, the bubo will probably become likewise indurated. Should a 232 BUBO. bubo occur in a lymphatic individual, our prognosis will be always very unfavorable, more especially if the bubo is indolent, for we have always equally to dread the consequences of a very acute or chronic bubo. With reference to the probability of the occurrence of secondary symptoms after bubo, we must repeat, that as the tumor is only syphilitic twenty times in every hundred cases, secondary symptoms could follow bubo only in the same proportion ; experience proves, moreover, that secondary symptoms do not even occur in that pro- portion, thus showing what is well known with respect to primary sores, viz., that every chancre is not followed by them. Observation on a large number of cases has likewise shown that virulent bubo, unattended with induration, is not followed more frequently by sec- ondary symptoms than is simple chancre ; a virulent bubo, however, attended with induration, like indurated chancre, is almost invariably followed by secondary symptoms ; consequently, in the prognosis the surgeon must be guided by the same principles that were laid down under the head of indurated chancre; constitutional infection being observed as frequently in cases of external as of internal chancres. Treatment of Syphilitic Bubo.—The prophylactic treatment, or the means of preventing the occurrence of bubo, merits our first atten- tion. This is best accomplished by considering the causes, both direct and indirect, which lead to bubo. As speedy a cure as possi- ble of the primary sore is of the utmost importance ; for although, as we stated above, bubo does not always occur, although a primary sore may exist several months, nor after the existence of large sores, still, as bubo is a direct consequence of chancre, it should be our object to cure the latter as soon as possible, as no individual can be guarantied from bubo as long as a chancre exists ; and our readers, we hope, are convinced that the speedily curing chancre by local means does not render the occurrence of bubo more imminent. But the surgeon must not depend alone upon a speedy cure of the primary sore; he should consider and choose that treatment which is least likely to irritate it, and this is undoubtedly the use of the caustic in cases of simple chancre. To persons unacquainted with the action of nitrate of silver, it might seem paradoxical to state that its action is antiphlogistic, but we have already, we hope, proved that this is its true mode of action. On the contrary, we should avoid all stimulating applications, or lay them aside if they have been used; absolute repose should be recommended, or if the patient's occupa- tions do not permit this, we must enjoin him to use as little exercise BUBO. 233 as possible, recommend a suspensory bandage if the sore be on the penis, and use the other means recommended against the occurrence of the complications of chancre. If, in spite of these precautionary measures, or if the surgeon be called to treat a bubo at its com- mencement, it is indifferent at this stage, as far as the treatment is concerned, to diagnose accurately the nature of the bubo ; cold water, ice, repose on a sofa or bed, with slight clothing, are among the most potent means for bringing about delitescence of the swelling which has lately commenced; cold applications, however, should not be persisted in, provided they cause pain, or when, as in some few cases, they tend to augment the swelling. Under these circum- stances, or if an individual will not submit to any restraint, the best means of treatment is the employment of compression, either by means of graduated compresses of linen, fixed in their proper posi- tion by the figure-of-8 bandage, or a bandage or truss of an oval shape, which was invented by a pupil of M. Ricord's, and which he constantly employs with the most signal success. (Truss for compressing Buboes.) It consists, as seen in the woodcut, of a pad of an oval form; to the inner part of this oval pad is fixed a strap, which passes around the thigh, and then goes through a pulley on the external edge of the pad ; it is then brought back and passed around the loins, and having 234 BUBO. gained the front of the abdomen, and then the groin, is ultimately attached by means of a buckle to the pad, thus enabling the surgeon to employ compression to any extent. The application of the bandage will be readily understood with the aid of the accompanying woodcut. Employed at an early period, and in the way above recommended, compression will be found a very advantageous treatment, and will often occasion the disappearance of these swellings, or effect what the French call their abortion. Abortive Treatment.—The surgeon, however, is often consulted when the bubo has already made considerable progress ; there is red- ness of the skin, considerable heat and swelling, but no inflamma- tion is perceptible ; at this period the usual antiphlogistic means must be employed and vigorously followed up, viz., general bleeding, the use of tartar emetic internally, the local application of leeches, the employment of cold washes or ice, &c. If fomentations be em- ployed, they should be continually changed, and thus warmth and moisture constantly maintained ; in place of poultices of linseed meal, the common arrowroot made from the potato, and prepared as a poultice by the addition of boiling water, is far preferable ; it is not liable to become rancid and thus irritate the skin, it never becomes hard, and has the further advantage of causing continually an oozing of moisture ; during the night it is particularly advantageous ; during the day we prefer lint dipped in warm water, and laid on the bubo, taking care to cover it with oiled silk, and to change the lint every hour ; by these means we have obtained the happiest results in speed- ily and effectually relieving all local inflammation. It nevertheless happens that although the acute symptoms are removed, a sub-acute state continues, or the surgeon is called to treat an indolent bubo ; in the practice of the venereal hospitals we have met with many such cases, and we have seen the following treatment followed by success : During the daytime, let the swelling be covered with an emplastrum vigo cum mercurio and compression by means of the truss be made, as recommended in the preceding pages; in the evening let the bandage and plaster be removed, and let a drachm of blue ointment be carefully rubbed on the swelling before a fire during a quarter of an hour, and place an arrowroot poultice over it; on the following day the compression and frictions may be repeated, until all swelling has subsided. In case of the failure of these means, recourse must be had to a more vigorous treatment. It is at this stage that we have seen much benefit derived from covering the tumor with a blister, and BUBO. 235 when the epidermis has been thus removed, gently placing the blue ointment on the parts, which may be covered with a poultice ; when the blistered surface has healed, a second and third blister may be applied, and the same dressing repeated. The mercury, in all these cases, is employed rather as a local resolutive application than as a specific remedy, consequently it is our object rather to place the ointment on the tumor than to occasion its absorption from the chancre, and thus make it pass through the affected gland—the point that Hunter seems to have had in view; of course, should salivation ensue, the employment of mercury should be instantly laid aside, and the usual means of treating ptyalism be had recourse to. In all the plans previously recommended, it will, we hope, have become apparent that it is our object to cause the resolution of the tumor by absorption, and prevent suppuration ; experience, however, proves that these much-wished-for ends can not always be attained. When bubo follows a chancre, and when, consequently, we have every reason to suppose that absorption of the virus has taken place, and has been carried into a ganglion, all our endeavors to promote resolution will too frequently fail; still, under such circumstances, it is better to act as if the bubo were caused by irritation, and not de- spair of dissipating the swelling, for we are no longer living in the good old days of humorism, when it was supposed that that surgeon was the best, who by all the means in his power would assist nature in chasing all the peccant humors from the body. For this purpose, in place of dressing a blistered surface with the blue ointment, let a piece of lint dipped in a solution containing twenty grains of corro- sive sublimate to one ounce of water be applied, and kept on the de- nuded skin for two hours, or a shorter time if it cause great suffering to the patient (a circumstance almost constant); let a poultice on which some laudanum is poured, be applied and frequently changed ; in consequence of this caustic application an eschar will be formed, and when it falls off, the caustic may be again employed according to circumstances. Under this treatment, indolent buboes will get rap- idly well. When employed in virulent swellings, the pus is often seen oozing through the cauterized part, and on the separation of the eschar the true nature of the virulent bubo is at once seen, forming, in fact, a chancre which is brought into view by the destruction of the walls of the abscess. Blisters, then, and caustics, may be said either to promote absorption, if that be possible, or to hasten the opening of a virulent abscess, before it has had time to undermine the surrounding structures. There is, however, a great objection to 236 BUBO. the use of the blister and the corrosive sublimate; they cause great pain in their application, and leave considerable cicatrices, which arer indelible marks of the disease ; consequently, the surgeon should use them with discrimination, and only in cases where all other means have failed. When a patient presents all the signs of fluctuation in the swel- ling—when the skin is thin, livid, &c.—the methods recommended above are worse than useless, by the loss of time occupied in their employment; the virus within extends itself on all sides, and, when opened, the abscess will be found very extensive. To avoid these consequences, the surgeon should open the abscess on the very first symptoms of the occurrence »f pus ; provided the case be virulent, an opening should be made, for it would be useless to expect absorp- tion. The incision should be made in the direction of the greatest diameter of the tumor. In the inguino-crural region, it is in the direction of the inguino-crural fold ; in the case of suppuration of the vertical glands of the thigh, it is in the direction of the axis of the limb that the incision should be made. Incisions on these principles do not expose the patient so much to subsequent burrowing or secon- dary abscesses, or cause crucial incisions to become necessary at a later period. If it be an important question to decide on the proper direction of the incision, it becomes a no less one to consider its length; in small abscesses, a simple puncture is usually sufficient, particularly if there be no reason for supposing that it is not a virulent bubo ; in such cases a large incision is unnecessary, but when there is a large quan- tity of matter, when the skin over the abscess is livid, blue, and thin, when we suspect its virulent nature, and that it has undermined to a considerable extent the surrounding parts, a free incision is absolutely requisite; for in such cases we can not expect that the skin will become attached to the parts below. The same principle holds good, likewise, in cases of fistulous openings which extend on either side ; they should be freely opened, for unless this is done, cicatrization will not take place. It is quite unnecessary to press out the pus ; such pressure gives rise to pain, and the use of the tent is only requisite in cases of non-virulent buboes, as in others the virus will inoculate the cut surfaces, and prevent closure of the opening. Treatment of Suppurating Syphilitic Bubo.—When the surgeon is consulted at this period, or when a bubo has been opened, the treat- ment must vary with the circumstances of the case. In the majority of instances, the treatment is similar to that recommended for chancre BUBO. 237 and its complications. Should inflammation, phagedena, or gangrene, be present, the specific nature of the bubo should be lost sight of, and the usual treatment of those affections employed ; this having been effected, we should turn to the treatment of the specific disease ; care should be taken that the virus does not remain in contact with the surfaces which secrete it; this is avoided by the use of baths, washing the part often, and the employment of the aromatic wine ; position may often be useful in allowing the secretions to pass away. Such treatment, combined with cauterization of the abscess, will usually succeed in bringing it to a happy termination, and cicatriza- tion will follow, healthy granulations filling up the cavity of the abscess. This, however, will occasionally be retarded by an indolent state of the bubo, by the skin presenting livid, thin edges, or being under- mined by the disease ; in the latter cases it is useless to expect that granulation will spring up as long as these portions of the skin remain around the abscess ; their removal is therefore indispensable. This may be effected by snipping them off with a strong pair of curved scissors. Patients have often a great objection to the use of instruments, and they may be very reasonably replaced by employ- ing the Vienna paste,* which, by virtue of its caustic properties, not only removes the superfluous portions of skin, but likewise causes the surrounding parts to take on a healthy action. When the edges of the suppurating bubo ulcerate, when it extends daily, or remains stationary, M. Ricord fills the abscess with the powder of cantharides, and orders a blister on the bubo ; the follow- ing morning, if induration exists, the edges of the blistered surfaces are dressed with lint, on which mercurial ointment is spread, and the abscess is washed with aromatic wine; should it be a simple bubo, common dressing or applications of white wash to the blistered sur- face, and the aromatic wine to the abscess, are sufficient. This treatment, with the powder of cantharides, is not so painful as might be imagined ; healthy granulations spring up, and the whole character of the sore is changed, and it will be often necessary to check the exuberance by the nitrate of silver ; in consequence of the extent of the disease, cicatrization will often take place imperfectly or irregularly ; the usual means of lightly passing the caustic over the surfaces will be found advantageous ; when the cicatrix is livid and indurated, it should be destroyed by repeated and partial applica- * The Pate de Vienne is composed of five parts of caustic lime, and six of caustic potash, with sufficient spirit to make a paste. 238 BUBO. tions of the Vienna paste, and a more healthy surface will be the result. Should induration of a specific kind follow a bubo, the general con- stitutional treatment with mercury must be had recourse to, and be guided by the same principles as were laid down in speaking of indu- rated chancre. In scrofulous constitutions, the tonic and general treatment must be had recourse to. Change of air, a nutritious diet, tonic medicines, particularly the various preparations of iron, together with local stim- ulants, should successively or conjointly be had recourse to. Lastly, in chronic indolent swellings of the superficial or deep- seated glands, neither local nor general treatment will suffice to remove the swollen state, or to remedy the various obstructions to the venous and absorbent system. In such cases recourse must be had to the pate de Vienne; a superficial layer is laid on, and when the eschar falls off, another and another may succeed ; replace it, until at length the whole mass of enlarged glands has disappeared. This process is often indispensable, although very painful, and is far preferable to excision, as recommended by some authors To maintain poultices or dressing on the bubo, or even to employ compression by means of lint, I can strongly recommend a bandage, invented, I believe, by Messrs. Evans and Perkins, of Mortimer street, London ; its application is well seen in the annexed woodcut. (Inguinal Bandage.) SECONDARY SYMPTOMS. 239 CHAPTER II. SECTION I. SECONDARY SYMPTOMS. Definition.—Under this term we comprehend those various morbid phenomena which appear on the skin, mucous membranes, or in the eye and testicle, the consequence of absorption into the circulation of syphilitic virus, giving rise to a constitutional affec- tion which is hereditary, or, in other words, capable of transmission from the mother to the child, but incapable of inoculation. Synonymous Terms.—Secondary symptoms have been variously designated by different authors. Some writers group under the term syphilis, not only what we now understand as primary, but likewise secondary symptoms, without distinguishing them either from one another, or from other diseases. This is not surprising when the difficulties attending the subject are considered, or when the erroneous notions then entertained upon medicine are weighed. The same observations apply to syphilitic affections, a term which includes indiscriminately everything which resembles the disease we are describing, and one which, as at the present day, has often no very definite meaning. Morbus pustularum, la verole, la grosse verole, are likewise sy- nonymous terms ; more modern writers have spoken of lues, constitu- tional syphilis, accidents secondaires, or constitutionnels, as distinguish- ed from the local, primary effects of syphilis. We shall employ the term secondary symptoms, as it enables us at once to classify the various effects which we are about to describe ; and it has the ad- ditional advantage of being generally accepted. We shall, however, attempt to give a more distinct character to the affection we are about to treat of, and avoid that vagueness of expression which has dis- tinguished some writers on this interesting division of syphilis. 240 SECONDARY SYMPTOMS. History of Secondary Symptoms.—If we admit that primary symptoms were described and known to authors long before the dis- covery of America, &c. (as we have elsewhere wished to prove), we might naturally expect that secondary symptoms likewise existed ; and from the description in the Bible, as well as in the Arabian, Greek, and Roman authors, little doubt remains that they formed the major part of the diseases of the skin then so prevalent; we may, however, add that they do not seem to have been attributed or be- lieved to bear any relation to primary symptoms ; or, if known, they were confounded together in an unintelligible manner. It was toward the close of the fifteenth century that we find second- ary symptoms described as depending upon syphilis ; the light at once thrown upon the diseases in question may be accounted for by the existence of predisposing causes, which, as at the present day, are found not only to aggravate, but change altogether the physiog- nomy of the disease. We owe to Fernel, however, in 1556, the first accurate description of secondary symptoms : he first pointed out the relation that second- ary symptoms bore to the primary, and it is this distinction which has so greatly assisted and contributed to an accurate knowledge of the former. In 1784, Hunter, adopting the classification of Fernel, further sub- divided secondary symptoms into sympathetic and virulent: The virulent he again classed under two heads. 1. Those which appear during the early period of the constitutional infection. 2. Those which are observed at a much later period. In the former he placed eruptions on the skin and affections of the mucous membrane ; in the latter, diseases of the periosteum and of the bones. It is, however, M. Ricord who has recently introduced a classifica- tion of constitutional syphilitic affections, which we are confident our readers will consider the most perfect, hitherto proposed. Following Fernel, he has separated primary from secondary symptoms, and has shown us how to distinguish them ; adopting also the views of Hunter in some points, he has differed from and improved upon that eminent surgeon's classification, and the second division of Hunter he has preferred to place in a separate order, and called them ter- tiary symptoms. The reasons for this deviation from the doctrines of our great master will be given in their proper place. General Observations on Secondary Symptoms.—Previous SECONDARY SYMPTOMS. 241 to describing secondary symptoms, it will be wed to devote a few pages to some general considerations. In our definition we have stated them to be the consequence of absorption into the circulation of the syphilitic virus, or to depend upon a poisoning of the animal economy by the virus, which we have described in the first chapter of this part. It might appear that this opinion, now generally received, is capa- ble of demonstration. Such, however, is not the case ; no one, to our knowledge, has ever attempted to inject the virus into the circula- tion. The probable consequences of such an experiment would be so severe that no medical man would undertake it, nor would any one be justified in thus experimenting upon his fellow-creatures ; and as the syphilitic virus has no perceptible effects on animals, we are deprived of two of the most valuable adjuncts in our investigations. Medical men have been content to collect such observations as daily experience furnish, to prove that secondary symptoms are the result of absorption of the virus into the general system. A long-continued observation, and accurate inquiry, in a large hospital, as well as extensive private practice, lead M. Ricord to state that a case of secondary symptoms, d'emblee, never occurs. The excep- tional cases depend upon hereditary infection, or from inattention on the part of the patient to his antecedent history, or to his ignorance of what chancres are, &c. In every case in which he has been con- sulted, chancre either existed, or some traces of it could be seen ; in fact, the exceptional instances may be reasonably accounted for, as in the bubon d'emblee. This is now so generally admitted, that we shall not stop to prove it further, but take it for granted that secondary symptoms are always preceded by a chancre situated in some part of the body. It is no less true, however, that every chancre is not fol- lowed by secondary symptoms ; were this not happily the case, they would be still infinitely more common than they are. Predisposing Causes of Secondary Symptoms generally.—Observa- tion of many thousands of cases shows that these consist in circum- stances not immediately connected with the individual, or apparently dependent on his constitution. It can not have escaped the observation of those of my readers who have seen much of syphilis, that the temperature of the air has a con- siderable influence on the production of secondary symptoms. Rapid changes from heat to cold, as witnessed in persons leaving the warm wards of hospitals for their own damp cold dwellings, place this be- yond doubt. Travellers state that the passing from cold to warm, 242 SECONDARY SYMPTOMS. and from warm to cold climates, produces a great disposition to the same effect. Clothino-, particularly such as is slight and insufficient to maintain an equable temperature, has been accused, with reason, of predispo- sing to secondary symptoms. The use of spirituous liquors, highly savored or insufficient food, excitement of all kinds, moral or physical, are some of the most fre- quent predisposing causes. Among the circumstances appertaining to the individual, we may first speak of age. It rarely happens that a child is born of a mother suffering under secondary symptoms, without becoming affected at birth, or soon after, particularly if exposed to cold. When the pe- riod of infancy has passed, as the child is seldom exposed to conta- gion, the occurrence of secondary symptoms is very rare. From similar circumstances, and the torpid state of the lymphatic system, they are rarely met with at an advanced period of life. Sex.—It is hardly necessary to say that men are more liable than wo- men, in consequence of the former exposing themselves to the chances of contagion more frequently; but we think the statement is no less true, that if the same risks were run by the two sexes, the female is less predisposed than the male. This assertion is supported by the cases we have observed in the Parisian institutions. In the male hospital, cases of secondary syphilis are very common ; in the hos- pital of l'Oursine (the female one), during our duties there, out of four hundred in-patients, we observed few cases of secondary affec- tions. The same remark we made in visiting the foul wards at St. Lazare, devoted to the treatment of the prostitutes of Paris. The reason, we think, is the following : the female, though frequently the subject of chancre, is yet, from her sedentary and quiet life, less ex- posed than the male to the causes mentioned above. We are further borne out by the fact, that common prostitutes are much more fre- quently attacked with secondary symptoms, than that large class of unfortunate females, consisting of poor married women, to be found at l'Oursine. Temperament.—Its influence, as a predisposing cause, is very evi- dent, and some authors state that the lymphatic is the one which most particularly disposes to them. That this is often the case is true, but those who have attended to the subject must be aware, that the same individual, in the course of the year, may contract chancres ; the first will pass away, the second may be often attended with sec- ondary symptoms, or vice versa. Again, how often do we see the SECONDARY SYMPTOMS. 243 (strongest men attacked, and the feeblest escape ; it must, however, be allowed that a great portion of secondary symptons occurs in per- sons who have been reduced by illness, or some other cause. Sur- geons who are called upon to treat secondary symptoms can not but have remarked the number of their patients presenting that clear complexion which has been attributed to scrofulous subjects. I do not, however, assert that secondary symptoms are confined to such individuals ; but on being consulted for primary sores by patients with dark hair, clear brown complexions, or that beautiful transpa- rency of skin, I have too often predicted the occurrence of indura- tion, and the subsequent train of secondary affections. The reader will not forget, that in speaking of the various anatom- ical characters of chancre, and of their prognosis, we stated that the simple chancre, as well as the gangrenous and phagadenic ones, were rarely followed by secondary syphilis ; on the contrary, that the indurated chancre would be attended by it in ninety-nine cases out of one hundred. We stated, however, that the virus being always the same, the difference in the form of the chancre must depend upon the nature of the constitution. What this may be, we are unable to say; observation alone shows that the constitution or condition of surrounding tissues, or the unknown element which causes indu- ration, is analogous to that which subsequently produces secondary symptoms. The importance of this, as indicating a line of treatment, has been already noticed, and further researches, it is to be hoped, will clear up these doubts. In the absence of anything certain, we will not speak of the conjectures which the subject has given rise to. If secondary syphilis, in consequence of the predisposing causes above referred to, arise from absorption of the virus, by what system of vessels does the process take place ? To this question we think observation may furnish a satisfactory reply. When the virus is taken up by the lymphatic vessels, as we remarked under the head of bubo, it is either carried along the vessel into the first lymphatic gland, or, being checked in its course, it occasions the development of a lym- phatic or glandular bubo. We stated, moreover, that under either of these circumstances, the virus remained unchanged, as is proved by inoculation. What prevents its further progress ? Why can it not pass beyond the first gland, and what decomposition or change does the virus then undergo ? We are at a loss to decide, unless, as some have advanced, the elements of, and not the virus is absorbed. This view is not improbable, but is a simple hypothesis ; nor shall we in- quire if a bubo be the means of expelling from the system the peccant 244 SECONDARY SYMPTOMS. virus. One thing is certain, that bubo in no way betokens the prob- able occurrence of secondary syphilis. Often have we observed persons afflicted with the largest, most acute, or chronic buboes, without ever after being subject to secondary symptoms. On the other hand, we daily witness secondary syphilis coming on in per- sons who, we are certain, have never had buboes. It is true that the secondary disease often comes on during the existence or after the cure of bubo. In such cases, we think we are far from justified in attributing them to the bubo, as observation on a large scale shows that there is no direct relation between them. If, then, our opinion be correct, that the lymphatic system does not absorb the virus, and carry it into the economy, we necessarily must suppose that absorption is effected by the veins. The experiments of physiological writers have clearly proved these vessels to be endowed with the function of absorption: veins, we believe, have no power of selection (if we may be allowed the expression), as the absorbents have, nor do they tend to alter the qualities of substances, as the lymphatics evidently do. Lastly, the effects produced on the system by the absorption of the virus bear a great analogy to the deleterious effects produced by the injection of poisons into the veins. At the present day the comparison is feeble, but in the fifteenth cen- tury, when that famous epidemic reigned, we learn that livid patches appeared, that the ulcers on the skin were haemorrhagic ; everything in fact bespoke a liquefaction of the blood, such as is occasionally witnessed even at the present day. In the absence of experiments, all must be conjectural as to the quantity, quality, and period neces- sary to produce the contamination of the system above alluded to. The period at which secondary symptoms appear after the occurrence of the primary ones, deserves to arrest our attention. It is impossible to limit exactly this period. The earliest period at which they may occur, is eight days after the appearance of primary sores. M. Ri- cord relates such a case. It happened in a tailor, who, at the end of the week after the occurrence of chancre, had well-marked second- ary symptoms. M. Cullerier has likewise mentioned a similar case. Excepting, however, such instances, which are rarely met with at the present time, although we believe them to have been very com- mon in the fifteenth century, secondary symptoms usually show them- selves about six weeks or two months after the appearance of the primary sore. Of the importance of knowing this fact we have been more than once convinced : patients come into hospital six weeks after the occurrence of an indurated sore; mercury is given, and in SECONDARY SYMPTOMS. 245 a few days a brilliant display of secondary symptoms breaks out, oc- casioned, as some think, by giving mercury. M. Ricord has often shown us the natural course of the disease by abstaining from any treatment, and the well-known secondary affections soon appear. Can this period be delayed ? It can, as we have had ample oppor- tunities of observing. When due precautions are taken, no excesses or exposure to cold submitted to, weeks may pass over, and no second- ary symptoms appear; but, under the influence of predisposing causes, they suddenly break out. The employment of mercury in insufficient or injudicious doses appears to have the same effect; the disease is retarded, and we have seen it appear some months later, and have been unable to attribute it to any other cause. It results from the preceding observations, that the absorption of the syphilitic virus induces a syphilitic temperament, a peculiar state of system which care holds in abeyance ; the germ exists, but some extraneous cause develops it, and must call it into action ; as a fall on the knee, or inflammation of the chest, develops white swellings or phthisis, so does exposure of the surface to cold, or insufficient diet, cause the development of one of the forms of secondary syphilis, which we shall presently describe. The length of time that this syphilitic temperament may exist without giving any evidence of its presence by the occurrence of the disease, we are unable to decide; but let it not be supposed that we belong to that school who think that secondary symptoms may break out twenty years after the cure of the primary affection ; all we can say on this point is, that care and non-exposure to the predisposing causes, or an insufficient mercurial treatment (we shall hereafter state what we mean by this term), may retard the development of seconda- ry syphilis. M. Ricord states that the exact period of this suspen- sion of the disease, or incubation, can not be limited; but he has not met with a case which ever led him to suppose that syphilis can break out after a lapse of years ; and as those who state that this l.as occurred do not furnish us with their observations, as the chances of self-deception are great, and as no such cases have been personally observed, without absolutely denying the possibility, he is little dis- posed to credit them. In our definition we stated that the term secondary symptoms was employed to designate the morbid phenomena which appear on the skin, mucous membrane, eye, testicle, &c. Let us now direct our readers' attention to each separately. The researches of modern anatomists have proved beyond a doubt, 246 SECONDARY SYMPTOMS ON THE SKIN. that there exists a great analogy between the skin and the mucous membrane. Physiologists have likewise established analogy of function between them, and modern surgeons, in a variety of their rhinoplastic operations, have proved on the human body, what was long known to the comparative anatomist, that skin may be, as it were, transformed into mucous membrane, and mucous membrane assume all the characters of skin. Pathology daily shows that the influence of disease on the skin reacts on the mucous membrane, as in cases of burns ; on the contrary, that irritation of the mucous membrane reacts on the skin, as in eruptions following the use of copaiba, &c. In fevers, particularly in typhus, the co-existence of the rosy eruption, or of petechiae, together with the lesions of the mucous membrane, have not escaped notice ; and in small-pox it is now well known that the pustules may appear on the mucous mem- brane, as well as on the skin. This analogy, then, between the diseases of the skin and mucous membrane is in no case more strong- ly marked than in secondary symptoms; they may be traced on the penis and on the prepuce, gradually passing one into the other; on the mouth we have often witnessed this transformation, and a good example is to be seen in Plate V., fig. 4. SECTION II. SECONDARY SYMPTOMS ON THE SKIN. The syphilitic affections of the skin are very varied and numerous, yet, by following the classification of our countrymen Willan and Bateman, we trust we shall give such a distinct and succinct de- scription of them, as will enable our readers readily to distinguish this large class of important diseases from those which depend upon other causes. Various as they are, they may all be reduced to one of the follow- ing forms :— Exanthematous affections. Papular affections. Vesicular affections. Pustular affections. Tubercular affections. SECONDARY SYMPTOMS ON THE SKIN. 247 By far the most common and earliest in appearance are— Exanthemata.—During the existence of the primary symptoms, or some few weeks after their disappearance, and generally in con- sequence of exposure to some of the predisposing causes mentioned above, the patient is surprised at observing a larger or smaller por- tion of the body covered with an exanthematous eruption, which sometimes assumes the form of measles ; so general is the affection of the skin, at other times, distinct patches appear, of a more or less circular form. At their commencement these eruptions are of a rosy color ; the surrounding skin is of an unhealthy appearance, of a dusky yellowish hue ; on pressure the spots disappear, but return im- mediately. The whole surface may be covered at once, or successively : this exanthematous eruption may pervade the abdomen, lower extremities, arms, face, and back. It may disappear from one part and shift to another, or reappear again on the same portions of the body in a few days. These spots, however, soon lose their rosy color, and daily become more and more dusky, until they assume a coppery hue, which is always best marked in the most dependent parts of the body ; it seems to arise from something more than simple congestion, as pres- sure does not remove it. These exanthematous eruptions may disappear without any treat- ment, or under the use of various agents, or may pass into the papu- lar form. Papulae, like the exanthemata, may appear on the skin without having given rise to any general disturbance of the system : often, however, the general health may be observed to suffer ; the face may have presented an unhealthy, pale, or earthy appearance ; the eye may have lost its vivacity, and the patient loses flesh : these premoni- tory symptoms are sooner or later followed by an eruption of papulae, more or less general; they, however, first usually appear on the ab- domen ; at their commencement rosy, they gradually assume the coppery hue. On passing the finger over the affected parts, they will be found to present a certain elevation above the surface of the skin, with a sensible hardness, and are grouped in clusters, or dis- seminated irregularly here and there; it is this condition of the papulae which has received the name of lichen. It may exist as a simple disease a long time, or it may disappear, as did the exanthemata, or the points of the papulae will become dry and whitish, the base will shrivel, and, instead of a papula, a surface covered with little thin scales is seen, very distinct from the adjacent 248 SECONDARY SYMPTOMS ON THE SKIN. sound skin ; these scaly surfaces may be quite distinct, or several may coalesce, forming a continuous surface, covered with silvery scales, which are reproduced as soon as they fall away, or are rubbed off. This appearance has given rise to the division squamae, but which we believe to be no other than the drying and exfoliation of the epidermis, and reproduction of little silvery scales on the papules (See eruptions in plates VI. and VII.) Those who have specially written on skin diseases, have, as it ap- pears to us, rendered more difficult an acknowledged difficult subject; they have attempted to create distinctions between lepra and psoria- sis, which, in our opinion, are both terminations of a papular erup- tion. The lichen above described may become dry at its summit, scales may form, fall off, and be reproduced, and this process may gain the base, and extend itself in an irregular manner, constituting what authors call psoriasis. On the other hand, the base of the papula may become scaly, the centre or apex remaining in a natural condition ; the result is, that a circle is formed of these little scales surrounding and surrounded by healthy skin, and as this circle is somewhat prominent, from a slight swelling of the dermis now secre- ting the scales, it has been considered sufficiently characterized to be termed lepra. On the same individual, lichen, psoriasis, and lepra, may be seen ; and we may here observe that the little white border, described by M. Biett as characteristic of the syphilitic affection, is often wanting. This scaly state of the diseased skin is very often exceedingly rebellious, remaining for a long time stationary; the progress of the circles deserves, however, particular attention. As they extend at their circumference, the centre heals; thus the circle enlarges, until it has reached the size often of a shilling ; the regularity of the circle is often interrupted by the fusion of a second one, and thus two become united, forming a figure of 8, or 3, or 5. When they are about to heal, the scales fall off, and instead of the white scaly sur- face, the circle is only to be distinguished by the difference in the color of the skin, which, after a lapse of time, assumes all its healthy characters. A good idea of this may be derived from plates V. and VII. There is a form of lepra occurring on the palms of the hands and soles of the feet, which deserves particular attention ; portions of the epidermis, of a circular shape, become white, hard, or horny, and fall off, but are soon replaced by others, which successively fall away, causing great inconvenience to patients. This condition of parts is SECONDARY SYMPTOMS ON THE SKIN. 249 often accompanied with crevices, or a chapped state of the interstices, which become irritated by any foreign substances that may be placed in contact with them, and they pour out a secretion which forms crusts upon the surface ; in fact, the palm of the hand becomes so horny, that the patient is in part prevented from making use of it. We have observed this variety particularly in bakers, grocers, masons, &c. We have every reason to consider it a form of lepra, which takes on this character from the condition of the epidermis in these situations. Vesicular Form.—This variety of syphilitic eruption has never presented itself to our observation. M. Ricord states it is of very rare occurrence; it resembles any other vesicular eruption, such as chicken-pox, but is more chronic in its progress, and surrounded with a coppery tint, and patches of discolored skin remain after the ab- sorption of the limpid fluid contained in the vesicle. Pustular Form.—Our readers will be much deceived, if they suppose that by the term pustular form we wish to speak of an acute affection of the skin, such as is found in small-pox, attended with full-formed pustules filled with a yellowish fluid. Such cases have rarely come under our notice ; most frequently pustules follow as a sequel of other eruptions, bad treatment, want of proper attention to cleanliness, or some other cause ; and at a later period, after the occurrence of the primary sores, a yellowish serum, which soon becomes thick and consistent, is seen raising up the epidermis on the centre of the various eruptions previously described ; the pustule does not put on the characters seen in the pustule of the drawing of artificial chancre ; it is often covered at the commence- ment with scales, and then seems to be the result of an inflammatory action beneath the spot of lepra. In other instances, it seems de- veloped in a papula, which becomes converted into an organ secret- ing pus ; scabs form upon it, which increase in diameter in con- sequence of the additional secretion of pus, becoming hard, brown, and surrounded by a livid or copper-colored areola; these scabs may assume a monstrous size, being at their base as large as a shilling, and projecting above the skin at least half an inch; on removing these masses of scabs superimposed one above the other, and often covering large portions of the body, a dirty, sanious, and ulcerating surface will be observed occupying their base ; the edges are often callous, and extend underneath the epidermis ; hence the ulceration is larger than it at first sight appears to be. This form of eruption is usually very chronic in its course, and shows little disposition to 250 SECONDARY SYMPTOMS .ON THE SKIN. heal; the ulcerations remain for a long time stationary, or when they show a disposition to heal, cicatrization takes place slowly ; a livid condition of the skin succeeds, a material loss of substance is evident, and white cicatrices are the result. It is especially under these forms that the general health suffers ; the skin is dusky, the countenance is shrunken, the capillary circula- tion is imperfectly performed, nutrition goes on badly, purpura often supervenes ; general prostration of strength, together with loss of appetite, and rheumatic pains, indicate that the constitution is severely suffering, and it is not until the health improves that the sores heal. It was probably under such severe forms as these that the epidemic of the fifteenth century showed itself, but it is happily only from time to time that we now see this disease in persons of bad constitution, or who have ruined their health by excesses. It is to this form of scab that the term rupia has been given, which, as we have seen, is merely the consequence of the formation of scabs ; however, there is another form which we have occasionally witnessed under the same circumstances ; large bulla, containing at first a thin, serous, and then a sanguineous fluid, of a most fetid na- ture, based on an ulcerating surface, are seen on various points of the body ; they form crusts, and follow the same course as the disease last described; they indicate a more impoverished condition of the system than even the pustular form, and are often attended with serous or sanguineous effusions into the various cavities of the body. Before quitting the pustular form, we must not omit mentioning a variety which occurs on the scalp, and which we call impetigo; it apparently commences at the bulb of the hair, showing itself by a small pustule ; a crust is formed around the root of the hair, which, as often as rubbed off, is reproduced by a thick viscid secretion mat- ting the surrounding hair together ; this condition of the scalp is usually confined to a few spots, but the whole hair becomes affected, loses its lustre, gets dry, falls off, and the patient may become bald. The glands in the neck may often be sympathetically enlarged, par- ticularly those behind the ears and at the base of the jaw ; it often accompanies the other forms of secondary symptoms. Tubercular Form.—In describing the previous forms, we have. followed what we believe to be the most natural course, that of suc- cessively describing those eruptions which succeed one another. Following the same plan, we ought to liave described the tubercular form after the papular ; but the following reasons have induced us to leave the tubercular form to the last. If the reader will carefully SECONDARY SYMPTOMS ON THE SKIN. 251 examine plates IV. and V., he will observe the transformation which insensibly takes place between the diseases of the skin and mucous membrances through the tubercular form, and consequently, we have reserved the description of it, that our account of the one should im- mediately follow the other, although at the expense of subverting the order we have previously traced out. The tubercular form, in the sense which it is used by writers on the diseases of the skin, viz., " consisting of little hard tumors more or less superficial, accompanied, most frequently, with a peculiar color of the skin ; capable of resolution, or remaining in an indurated state ; or, lastly, becoming the seat of ulceration—in the latter case crusts form on the surface," is rarely met with as a distinct form ; it is more frequently a papular eruption in the beginning, and after a greater or shorter lapse of time it degenerates into a tubercle, having the characters above described ; it appears on various parts of the surface, and may be often seen on the face, nose, or at the angles of the mouth, but more frequently shows itself soon after the primary sore on certain parts of the body, to which it appears to have a preference such as around the anus, the labia, the groin, the scrotum, the lining of the prepuce, the umbilicus, between the toes, and, lastly, though very rarely, in the arm-pits. (See plate VII.) This peculiar form of secondary syphilis has been more particularly described by the French writers ; as it is of frequent occurrence, is very characteristic, and has not yet been paid sufficient attention to in England, we shall dwell at some length on it. The French call it tubercule muqueux, papules muqueuses, or pustule plat; for reasons which will soon appear, we shall call it mucous tubercle, although in England it is called condyloma. The reader may form a very clear notion of it from plate VII. In appearance it will vary according to its situation ; usually of a more or less circular form, it presents a slightly firm tumor, rather elastic than hard, more or less elevated above the surface of the skin; at first it is pale, but, exposed from its situation to friction, it becomes shortly of a vermilion tint: the surface is somewhat similar to a mucous membrane ; it secretes an acrid matter, which causes and maintains great local irritation, and is of a very offensive odor; the epidermis which covers it becomes excoriated, and the tubercle may present the appearance of a blistered surface, as is well shown in plates IV. and V. The mucous tubercle may be isolated, as I wit- nessed lately in a female under Mr. Lawrence's care, who presented one in the axilla, and gave the only intimation of secondary symp- » 252 SECONDARY SYMPTOMS ON THE SKIN. toms ; frequently, however, they occur in groups, and then the secre- tion of one irritates the other. Our plate shows a severe case, but we have witnessed examples in which a large portion of the thighs, as well as the whole external organs of generation, vagina, and neck of the uterus, have been entirely covered with a crop of tubercles, attended with such local irritation and offensive smell that the female presented the most disgusting sight we have ever witnessed ; of course the rubbing of one part against the other caused pain, but the general health seemed little affected. By inattention to cleanliness this disease has a great tendency to extend, but when care is taken to wash the parts and prevent the accumulation of the secretion, the affection will remain stationary. Under proper treatment this disease gets rapidly well, but when left to itself it does not seem to have any tendency to cause ulcerations which, like those following the pustule, extend in depth; here there seems a tendency to superficial excoria- tion, rather than ulceration. The process of cure is somewhat singular: like lepra, to which it bears a close resemblance, the centre first shows marks of healing; as cicatrization takes place in the centre, the excoriating margin, which is elevated above the sur- rounding skin, extends until it has assumed the size of a half-crown, and it may then suddenly stop and the circle get rapidly well, but for> a long time after a livid purple or coppery-colored spot remains, and affords the only vestige of the disease ; such was the case in the in- stance of the woman above cited. The circles may intersect one another, giving rise to various varieties of cicatrization. Such are the course and termination of the mucous tubercle ; it, however, often presents varieties, as we shall now proceed to describe. Instead of beginning as we have just shown, it may arise on any point of the body which has been the seat of chancre, and which is irritated and moistened by the secretions of the parts; wTe have wit- nessed such an origin at the base of the penis or the scrotum ; M. Ricord calls this a change of chancre in situ into the mucous tubercle. It appears, likewise, that a chancre on one part of its surface may be converted into a mucous tubercle, while the other may continue to secrete the virus. Such cases as these have led to the notion that the mucous tubercle is contagious, but from the experiments of M. Ricord it is now satisfactorily proved that, unless under these circum- stances, mucous tubercles can never be transmitted from one adult to the other, notwithstanding all the attempts that have been made. The chancre, when it has lost its virulent character, and is covered with granulations, may, under any irritation, take on the character of the SECONDARY SYMPTOMS ON THE SKIN. 253 ulcus elevatum, as we mentioned at the commencement of this part ; it will then be very difficult to distinguish it from an isolated mucous tubercle ; but this is of no great importance.* Complications.—We have thus described the whole of the symp- toms of the skin called secondary; the reader would, however, be in error did he believe that they are always to be met with in the form we have described them ; instead of one form being present, it hap- pens occasionally that various part of the body may at the same time be the seat of the varieties described as papular, pustular, or tuber- cular ; as a consequence of various complications, the characters of the eruptions may be modified. We have frequently had occasion to observe the various affections called secondary masked by a gene- ral eruption of itch, for the idea that two diseases can not exist in the economy at one and the same time has long since become exploded, and we now say that itch is a complication of syphilis, and no longer believe in a syphilitic itch. From any local irritation eczema may break out on the surface, and the consequence will be, that this acute affection of the skin will for the time throw into the background that which depends upon syphilis. We have often witnessed a general eruption of Urticaria coming on during the progress of papular syphilitic eruptions. When lepra and psoriasis are habitual to some individuals, should secondary symptoms supervene, ot course thai depending upon syph- ilis may be much modified, and its distinctive characters lost; we have, moreover, witnessed the train of eruptions which attend the French typhus fever superadded to and aggravate the secondary syphilitic affection ; in fine, there is no disease which may not supervene, and alter materially the characters of secondary symptoms. As the reader, however, is now aware how much depends upon the syphilitic constitutional disease, he will be enabled to avoid falling into the error of calling everything syphilitic which comes en after a primary affection. There is, however, a complication which deserves particular atten- tion, and which, if not recognised, leads sometimes to the gravest errors ; we speak of the occurrence of primary symptoms. Should a primary sore or chancre exist, or should chancres be contracted while the system is laboring under the constitutional form of syphilis, it is * I believe this transformation in situ of the chancre into a mucous tubercle is a form or variety first described by Evans in his " Practical Remarks on Ulceration of the Genital Organs," under the term Venerola Vulgaris, ant Ulcus Elevatum, and more recently by Mr. Skey, in his lectures reported in the Medical Gazette. Our view of its nature, however, is very different from that taken by these gentlemen. 254 SECONDARY SYMPTOMS ON THE SKIN. hardly to be called a complication, provided the chancres be confined to the genital organs. But if the ulcerations or pustules, the con- sequence of secondary symptoms, become inoculated with the virus proceeding from chancres existing on the genital organs, or on any part of the body, such accidents may be justly called complications, for we may have secondary and primary symptoms existing on and covering the skin. We have been witness of these facts more than once, and we think them worthy of general attention. It is probably such instances as these which have induced the late Mr. Wallace of Dublin to believe secondary symptoms occasionally inoculable. If, however, the possibility of secondary symptoms becoming prima- ry once, through the direct contact of the virus coming from a prima- ry sore, be now put beyond a doubt, the reader must not imagine that this frequently occurs, or that every suspicious ulceration which follows secondary symptoms is, in fact, a primary sore or chancre : we have lately witnessed a case which proves how much the surgeon may be deceived. In M. Puche's wards at the Venereal hospital, a patient had a very severe form of pustular secondary symptoms, the consequence of chancres cured, as the patient stated, some months before. On examining the patient some days after, we found several serpiginous sores of the size of half-a-crown crowded together on the back of the shoulder, a point of the body where we had previously observed the large pustules before spoken of. Every one who saw these sores agreed that they had a most suspicious appearance ; they resembled perfectly a large chancre. The supposition that they were chancres was, moreover, borne out by the existence of primary sores on the penis, the consequence of connexion a few weeks pre- viously. Inoculation, however, proved that these sores on the back were not primary, but truly the result of secondary symptoms ; this case has, however, impressed more fully than ever upon us the little confidence that can be placed upon physical characters to distinguish primary from secondary ulcerations. Before quitting the subject of complications of secondary ulcers, we must not forget to state that scrofula, scurvy, as well as any inflam- matory affection, may completely alter their physiognomy, as well as materially modify their prognosis. Diagnosis.—We shall, in this section, attempt to give a resume of the general points in the diagnosis which have been mentioned in the preceding pages, believing that by this means the reader will gain a clearer notion of the subject ; it will, moreover, enable us to make SECONDARY SYMPTOMS ON THE SKIN. 255 a few observations which could not consistently find their place in the simple description. In forming a diagnosis on any supposed secondary symptom, the surgeon will, of course, never neglect to inquire into the previous history of the patient; this will aid him materially, but let it be re- membered that, unless care be taken, it may tend equally to deceive him. It is not only necessary that a chancre has preceded, but that it should have occurred within a certain length of time, otherwise the relation between the cause and effect is not apparent. There are persons, who, when they find that chancre has ever existed, consider every morbid symptom during the life of the individual as due to that cause ; we have above stated that this is not our opinion. When we learn that no chancre, but only gonorrhoea, in the male or female, has preceded, provided other reasons indicate it, we may often suspect that chancres have escaped the patient's notice, daily experience demonstrating that chancre may exist in the urethra in the male, or in the vagina or neck of the uterus in the female, and yet only give notice of their presence by leucorrhoea. Hence we must not rashly conclude, that, although a chancre has existed, the symptoms under which a patient is laboring are syphilitic or seconda- ry ; or when no primary symptom, but only a leucorrhoea, has been observed, deny the symptoms which bear the mark of syphilis to be really specific, because they are not corroborated by the patient's antecedent history. The next point upon which the surgeon will form his diagnosis is the occurrence of concomitant symptoms, or, in other words, upon the existence of other symptoms which are more characteristic. Let us take an instance : if he be doubtful of the nature of lepra, or psoriasis, or any pustule or ulceration, his opinion may be often confirmed or corroborated by the existence, on other parts of the body, of the papu- lar lenticular eruption, or by the presence around the anus, or else- where, of the mucous tubercle, as these eruptions are peculiar to syphilis ; hence their presence or absence must have great weight in aiding the diagnosis. In tracing the various forms of secondary symptoms, we had fre- quently occasion to notice that they often presented a peculiar dusky or coppery hue, and this is by some authors considered as characteris- tic ; when present, it may aid us very materially, but it should like- wise be borne in mind that it may accompany any other affection quite foreign to syphilis, and thus deceive the most experienced eye ; when this copper-colored appearance is absent, the eruption may still 256 SECONDARY SYMPTOMS ON THE SKIN. be syphilitic, as at their origin almost all secondary symptoms are not accompanied with this livid tint, which only exists when they have lasted some days or weeks. Little dependence can be placed on the mere circular shape, color, or thickness of the scabs, but, taken with other characters, they may assist the surgeon in arriving at a just opinion. Data on which to form an opinion have been taken from the treat- ment by mercury, which, both in primary and secondary affections, was considered as the touchstone. We shall return to this point in speaking of the treatment; but we may here add, that although mercury be of the greatest benefit, still secondary syphilis can be cured without it, and that, under certain circumstances, it will fail in curing some forms. To sum up, then, the surgeon, aware of the difficulties which beset the subject, must be guided by circumstances ; a knowledge of the disease will often cause the judicious practitioner to be in doubt, where a less practised one would at once condemn or acquit. Doubt is sometimes the result of knowledge ; here hesitation can do no harm, as time will usually clear up doubtful points, and a rational diagnosis will only wait for further proofs to convert it into a positive one. This must be always the case, until some one gives us a boon, like inoculation, to distinguish with certainty what depends upon primary sores, and what on secondary. Prognosis.—When we see an otherwise healthy individual, soon after the occurrence of secondary symptoms, which have broken out a few weeks succeeding the cure of chancre by simple local means, we may usually promise him a speedy cure, provided he will, for a few weeks, take those precautions which we shall hereafter recom- mend. We may truly say that there are few affections which get well so rapidly, and yet which, when left to themselves, produce such serious consequences. But too often our prognosis is not of this cheering nature ; the individual we have to treat is a debauched character, his constitution is impaired by poverty, or some disease foreign to syphilis ; he consults us at the latter stages, when already the complaint has existed many months, or when it has followed the injudicious use of mercury for primary sores, so that the system is impaired, the bowels disordered, and there is a distaste for the further employment of the mineral. Lastly, when the patient will not sub- mit to any fixed plans of treatment, but is determined to pursue his pleasures; when he exposes himself to cold, and commits all kinds of excesses—then must our prognosis be unfavorable ; and it would SECONDARY SYMPTOMS ON THE SKIN. 257 be well for the surgeon, could he avoid altogether patients of this description. As we spoke of the prognosis under the head of each form of secondary syphilis, as well as under that of complications, we think it unnecessary to revert to these points, but shall pass on at once to the consideration of the Treatment of Secondary Symptoms.—Had we not already described the means of prevention, we should have recurred to it here ; but enough has been said under the head of chancre. By taking precautions against the occurrence of chancre, we necessarily prevent secondary symptoms, which are one of its consequences. If we are, or should be, so solicitous to prevent chancres, we ought likewise to be equally anxious to curtail their progress; to strangle the disease, as the French call it, while it is still local, and by all the means in our power counteract those causes which we have stated to be the predisposing ones ; these are means which must occur to the most superficial observer, and the best plan of carrying them into effect we must leave to his judgment, thinking it would be futile to mention them. By the most simple precautions, then, the occurrence of secondary symptoms may be often prevented—an ob- ject heartily to be desired. Under the head of Prognosis of Chancre, particularly that of the indurated form, the reader will find this subject treated at length ; and that the employment of mercury is recommended, not only as a cure for the induration, but likewise as a preventive against secondary symptoms. The reasons why mercury is useless for the same end in other forms, is likewise there fully explained. Should, however, all our means of prevention fail, or if we are consulted when secondary symptoms have already appeared, it will be our duty to direct our attention to the Curative Treatment that medicine offers. In these cases the first care of the medical man is to remove, as far as lies in his power, all the predisposing causes, or all such as may keep up or be likely to aggravate the disease. Similar attention should be paid to the complications, which must be treated on general principles ; in fact, let secondary symptoms be reduced to their simplest expression, as the French say. Had this principle been always kept in view, we feel assured that humanity would have had cause to rejoice. Should any severe complications exist, let. the original disease be lost sight of for the moment; there is no hurry to treat it, more especially when other and more urgent symptoms exist; but, above all things, 17 258 SECONDARY SYMPTOMS ON THE SKIN. let us caution our readers against believing that at this stage a specific treatment is required ; unfortunately, syphilitic patients have been too often treated on exceptional principles, and the non-observance of the ordinary rules of medicine have led to the worst consequences. Although we are not pupils of the non-mercurial school, still we must render it the credit of having impressed on surgeons the neces- sity of treating syphilis by simple means ; it is true that its disciples have been led into exaggeration ; that they are unable to maintain what they advanced ; but science is much indebted to them, and this same exaggeration has been perhaps of great use ; and Mr. Rose, if he now lived, would perhaps allow that he purposely exaggerated the employment of simple means. Should our patient be plethoric, blood may be taken from the arm ; if he has been exposed to privations, let his diet be mild or generous ; if his digestive organs are impaired, let them be attended to, and then let his diet be regulated according to his constitution and previous habits. As long as any of the acute or severe complications exist, the surgeon need not turn his attention to the specific diseases, which will be found to have diminished very materially in intensity. Many persons believe that by the most simple treatment the specific disease will altogether disappear. That there is much truth in this statement we have every reason to believe, but the sword of Damocles is sus- pended over the patient's head, and he is exposed to a recurrence of all his symptoms, after a shorter or longer time, with redoubled vigor ; and granting that they disappear slowly, they reappear speedi- ly and severely. Such are the reasons which induce us to agree with the followers of Broussais in some, but to differ from them in other points. During the time that we are treating the secondary symptoms, it should be our intention to eradicate from the constitution any syphilitic tendency. To the description of the proper means of doing this, we shall devote the following pages. Baths.—When the extent of the skin is considered, and when we reflect on the influence that a due performance of its functions must have on the economy, we are not surprised at the effects that baths may produce, not only on skin diseases, but on the system at large. Those who have followed the practice at the Hopital St. Louis, must well remember the success which attended the treatment of M. Biett, but they must have been been equally struck with the quantity of baths which he ordered in that establishment, which furnishes many thousands annually. The advantages to be derived from them is SECONDARY SYMPTOMS ON THE SKIN. 259 daily being appreciated in England, but their exorbitant price will, we fear, prevent them from being generally employed. When there is no irritation of the skin, the tepid bath is alone re- quisite, and it may be repeated twice a week. When, however, there is a determination to the skin, or any acute affection of the general integument, we should strongly recommend that a pound or two of gelatine be added, and that the patient remain in the bath half or even three quarters of an hour every other day, and this space of time may be gradually increased to two or three hours; the temperature being kept up by the addition of warm water, or by covering the bath with a blanket. In the papular eruptions, and particularly in lichen, one or two pounds of subcarbonate of potash may be added to the bath with the greatest benefit. In the more chronic forms, when, instead of allaying inflammation, it is our object to excite the action of the skin, particularly in cases of lepra and psoriasis, the addition of half an ounce of corrosive sub- limate, gradually augmented to two or even three ounces, will be attended with good effects ; but this remedy must never be used when any ulcers are present, as its poisonous effects are of the worst de- scription. Equal benefit may be derived from the use of a bath in which is dissolved the sulphuret of potash ; should much irritation result, gela- tine or bran may be added. The state of the bowels likewise must be attended to. We have more than once alluded to the sympathy existing between the stomach and the skin ; constipation should be removed by gentle aperients, but the employment of brisk purgatives ought to be avoided as.highly prejudicial, particularly if the surgeon has the intention, at a later period, of giving mercury. The pharmacopoeia contains a variety of substances which are supposed to have an action on the skin, and to produce diaphoresis. Such are sarsaparilla and guuiacum ; the diet should be light, and, to* produce, the beneficial effects expected, the patient should keep his bed during their administration. We shall not here speak of the advantages that iron, quinine, or opium, may offer in persons of scrofulous, feeble habits, in curing nocturnal or rheumatic pains. Treatment of the Secondary Symptoms by Mineral Preparations.— Having never seen the various preparations of gold employed, we shall avail ourselves of the remarks of M. Ricord on this subject. 260 SECONDARY SYMPTOMS ON THE SKIN. In secondary symptoms, gold is the remedy on which the least dependence can be placed. The greater part of the symptoms reputed to have been cured by its preparations are far from bearing unequivo- cal marks of the constitutional disease of syphilis, and when they are given in well-characterized cases, or under circumstances when the other means, and particularly mercury, have failed, I am doubtful whether any benefit derived has not been rather due to the suspension of mercury, than to the administration of gold. Gold, then, and its preparations are, in my opinion, a means to be employed when nothing else can be done. As this is my personal opinion, it can in no way affect the interesting researches published on the subject. The preparations of silver, under all the forms I have employed them in, according to the indications given by Professor Serres of Montpelier, have appeared still more uncertain in their effects, as those who have followed my hospital practice can testify. When employed against primitive as well as constitutional syphilis, begin- ning by small doses, and increasing them gradually up to the enor- mous dose of sixteen grains daily, I have been unable to produce other effects than irritation of the digestive organs, a consequence which has induced me to abandon its use. Mercury.—The employment of mercury in its various forms, for the cure of syphilis, is not of modern date ; the advantages of its preparations were for so long a time recognised, that it was heresy to doubt their efficacy, and it was the remedy employed to the ex- clusion of all others ; but that its administration was always followed by success, admits of some doubt. However, the necessity for em- ploying this mineral was admitted on all hands, syphilis and mercury went hand in hand ; and even in works of the present day we find it stated, that when mercury does not produce its beneficial influence on the disease, the latter is of so rebellious a nature that no fault ought to be found with the preparation; that it should be persisted in, and the quantities employed should be in proportion to the severity of the disease. However, as observation became more accurate, a few hardy practitioners (many of which do honor to our own country) began to throw doubts on the advantage of its universal administra- tion. This opinion found at first little credit among practitioners generally: in vain were the lamentable accidents of loss of portions of the face cited as proofs of the inefficacy of mercury in controlling the disease ; a bad constitution was assigned as the cause, and converts to the new doctrine followed slowly. Truth, however, here as else- SECONDARY SYMPTOMS ON THE SKIN. 261 where, prevailed over prejudice ; it began to be admitted that mer- cury would not cure all cases of syphilis, and it was asserted that the remedy was not even necessary. In proof of these assertions, the practice adopted in various countries was cited, and history show- ed that the disease had been cured without mercury for many ages. Two doctrines now prevailed; the one absolutely declaring that mercury was the sine qua non in the treatment of syphilis ; that the cases said to have been cured were not those of true syphilis, but a bastard complaint, having some points of analogy with it; and that in the cases of true disease, where the remedy failed, it had not been employed in sufficient quantities. The other doctrine continued to gain ground, viz., that syphilis could be cured without having re- course to mercury ; that this supposed remedy was more prejudicial than useful; that it caused all the mischief which it was intended to cure, and should therefore be excluded from all judicious practice. In consulting those authors who have written on syphilis during the present century, this opinion is the most generally received, notwith- standing that many of those upholding the opposite doctrines are in high favor with the public. In face, however, of these opposite opinions, backed by names of great authority, the eclectic school arose ; on the one hand, they admitted that the administration of mercury was often attended with advantage ; history and daily practice proved this ; but, on the other, they held that syphilis was capable, in many instances, of being cured without mercury, and yet the patient never suffered from the ill consequences said to depend upon a non-mer- curial treatment. Not contented, however, with these generalities, the eclectic school began to observe the natural history of the disease, and carefully note what were the cases treated by simple means, which got well without having recourse to mercury. The same clinical investigation enabled them to watch those cases which re- sisted simpler means, and which improved immediately under mer- curial preparations; they too first pointed out the injurious conse- quences of mercury, under what circumstances it occurred, as well as the means of cure. It is to this school we belong, and it is clini- cal observation, founded on and supported by the opinions of others, which forms the basis of the treatment of syphilis by mercury, to which we now call the attention of our readers. When the means previously described are made use of in seconda- ry symptoms, the major part will disappear ; this, however, will take place very gradually, and many symptoms will persist, in spite of all we can do. When even they yield and disappear, they frequently 262 SECONDARY SYMPTOMS ON THE SKIN. return either in the same situation, or break out again after a short interval, and often in an aggravated form, on exposure to any of the predisposing causes ; thus we have every reason to expect, that al- though the local disease be cured for a time, the general infection is not removed;. in fact, the syphilitic diathesis remains ; and when the flame again bursts out, it is no longer so amenable to our means of repressing it. These are our reasons for considering the other means of treatment as valuable adjuncts, but do not induce us to place im- plicit confidence upon them, especially when we consider that we possess such a valuable medicine as mercury, which, given under proper restrictions, seldom produces any unfavorable symptoms or effects which we can not always remedy or prevent. There is no age or temperament which counter-indicates its use ; the sex does not prevent us employing it, although there are circum- stances which should render us more circumspect. In relation to the period at which mercury may be employed, experience shows that the sooner after the occurrence of the disease the more efficient it is, and the less likely is it to return ; for once it has gained a right of possession, the more difficult it will be to expel it from the consti- tution : neither climate, nor the state of the season, need deter us from its use. When mercury is used, it should be employed for a specific purpose, and we should only leave it off when that has been gained, or on the occurrence of any of the ill effects to be mentioned hereafter. When the symptoms which it is our intention to combat improve under its use, the plan and the dose we employ should not be augmented, but steadily persevered in. Should the disease re- main stationary, the dose may be augmented, or, should circumstances require it, the preparation may be modified; the surgeon, however, must be guided by individual cases, as there is no form or dose ap- plicable to all constitutions. On the action of Mercury in curing secondary symptoms, theories have not been wanting; but in the present day we believe it far more useful to watch carefully its effects on the system, than to bring forward hypotheses as to whether it decomposes the virus in the blood, &c. On one point observers are pretty generally agreed, viz., that the. exaggerated effects of mercury, such as fever, diuresis, diarrhoea, irritation of the skin, salivation, or certain nervous affec- tions, are never beneficial, but should be carefully watched for and avoided. Before proceeding further, let us call the reader's attention more particularly to some of these, and especially to SECONDARY SYMPTOMS ON THE SKIN. 263 SALIVATION. On this subject we can not do better than extract the following ad- mirable description from the work of M. Ricord :— " Salivation is a rare occurrence previous to teething, as mercury up to this period acts rather on the digestive organs, or on the skin. It occurs readily in females, in persons of lymphatic temperaments, in scrofulous habits, and especially in persons predisposed to scurvy ; in fact, we observe it in all those who appear to possess blood defi- cient in plasticity. Habitual constipation and decayed teeth especial- ly predispose to it. Changes of air, particularly when these occur suddenly, have a tendency to produce it. Soluble preparations of mercury excite salivation more easily than those which are in- soluble." The quantity of mercury necessary to produce it is relative to indi- viduals.—Salivation usually occurs during the first week of the ad- ministration of the mineral, and may follow twenty-four hours after the first dose, more commonly after the fifth day. It is liable to occur after every augmentation of the dose ; but when salivation does not occur at the commencement of the treatment, it has little tendency to set in at a later period. When salivation has not appeared eight or ten days after the sup- pression of mercury, its occurrence is not to be dreaded. Cases of this nature may justly be attributed to ulcerative stomatitis, which may be readily mistaken for that which is caused by mercury. Mercurial Salivation, Mercurial Stomatitis, or Ptyalism, does not commence in the salivary glands ; at first they are but sympathetical- ly affected, as has been proved by pathological anatomy. The augmentation in the quantity of saliva is the first symptom which strikes the observer ; but it is the mucous membrane which is primari- ly affected. The latter becomes partially or generally swollen, and is affected with inflammation, partaking of the oedematous and erysipelatous characters. The patient perceives a feeling of heat and redness, as well as a coppery taste in the mouth ; the teeth are raised in the gums, moveable, and seem to the patient to be separated by some foreign body; he believes that they are longer than usual; the tongue swells, and this sometimes occurs to so great an extent that it is incapable of being contained in the mouth, and may receive indentations from the teeth. The gums and lips likewise swell, and the mucous membrane may become tumefied in the interval between the lower and upper jaw. In proportion as these symptoms are 264 SECONDARY SYMPTOMS ON THE SKIN. aggravated, so is the saliva found to be viscous and abundant, and to have what is called a mercurial smell,* a sort of metallic odor, that may be perceived to some extent in other inflammations of the mouth, but which in these cases is very well marked, and which may be found previous to the occurrence of ptyalism. Wherever the swollen mucous membrane is pressed upon, ulcera- tions, which are very much disposed to bleed, succeed to the black pseudo-membranous exudation on the gums ; this appears to be the result of gangrenous or diptheritic inflammation. As the disease advances, the tongue may become gangrenous in particular portions, or in its totality ; the mucous membrane of the gums may be sphace- lated, so that, when cicatrization occurs, the mouth is closed ; the cheeks may be completely laid bare, the teeth fall out, and the bones become carious or necrosed. Nevertheless, except in cases of a systematic obstinacy, at present unpardonable, from rashness in the treatment, or under circumstances of idiosyncrasy, which are very rare, severe cases of salivation are so uncommon that I have seldom the opportunity of showing one at my clinique, at the Venereal hospital, during the course of the year. More commonly the salivation is partial, or becomes so as soon as it is noticed, and when we can check its progress. The lower gums first show indications of the affection, or it ap- pears on the mucous membrane around the dens sapientice, more par- ticularly when it pierces late. The gums of the upper jaw subse- quently become affected, particularly such as are placed behind the middle incisors; the borders of the tongue, the cheek, and internal part of the lips, become attacked at a later period. The palate and back portion of the mouth seem to establish a boundary to the affec- tion which is seldom passed, except in very rare instances. An observation that I have made repeatedly, and which I leave for future observers to verify, is, that partial salivation is most frequently ob- served on that side of the mouth on which the patient lies. Salivation is rarely preceded by fever ; the primary symptoms are those observed in the mouth ; but fever, though absent in the majority of cases, may, nevertheless, attend it, particularly in the severer cases, and may continue under a hectic form, when the patients have severely, and during* a long period, suffered. In addition, other symptoms, such as sleepiness, swelled face, erysipelas, enlargement * In the twelfth number of the Expirience for 1837, will be found some curious in vestigations of M. Gmelin, which prove that mercury is present in the saliva. I have repeated these experiments without success.—P. Ricord. SECONDARY SYMPTOMS ON THE SKIN. 265 of the glands of the neck, affections of the stomach or intestinal canal, oedema of the glottis, and all the direct or sympathetic consequences which flow from them, may occur. Salivation usually runs its course rapidly, and attains its height in a few days ; but provided the employment of mercury be persisted in, or even when the disease is left to itself, or when it is kept up by certain accessory causes, such as certain scorbutic affections which have pre-existed or determined it, it may assume a chronic form, and last an indefinite period. However, in the ordinary run of cases, when the cause which gave rise to it has been removed, and a proper treatment been employed, seldom do we observe it last many weeks, and most commonly we can check it in a few days. Salivation frequently terminates in a rapid resolution, more com- monly ulcerations follow, and gangrene sometimes succeeds. Death may result as a consequence of mortification or weakness brought on by vast suppuration ; by the excessive flow of saliva ; or from the absolute impossibility of the patient's taking nourishment: such, however, at the present day, very rarely occurs. The Diagnosis is usually very easy. When the symptoms above described immediately follow a course of mercury, it is to this mineral that we may reasonably attribute them. Mercury is, in fact, the best touchstone of salivation, as the disease increases if it be continued, and gets rapidly well when the preparation is altogether omitted. If some few syphilitic symptoms in the mouth happen to be aggrava- ted by its use, the greater part rapidly improve under the use of this powerful agent; while it always augments, and never cures, those affections which it has itself produced. If, on the other hand, we take into consideration the situation of the syphilitic lesions of the mouth and throat, their distinct character, their chronic course, the freedom from the oedematous or erysipelatous state of which we have spoken, accompanied, as they are, with an induration very different from that puffy state of the mucous membrane depending upon salivation ; the antecedents, the accompanying symptoms, and the particular circumstances under which these lesions arise, and when, above all, we add the effect of mercury itself, we shall be al- ways able to arrive at least at a rational diagnosis, if not an absolute one ; in either case sufficient to guide us in the employment of mer- curial preparations. The rigorous diagnosis in cases of aphthae or simple ulcerative stomatitis is not necessary, as any effects analogous to those produced by mercury counter-indicate, as long as they last, the employment of that mineral. 266 SECONDARY SYMPTOMS ON THE SKIN. The Treatment of Salivation ought, in the first place, to be prophy- lactic. Our primary object should be to remove the cause which has given rise to it, if that be in our power. Diminish the doses of mer- cury, or give them at longer intervals, or suspend the employment of the mineral altogether. As preventive means, we should mention keeping the mouth clean, the use of astringent gargles, and the em- ployment of aperient medicines. Such means, if they do not alto- gether prevent, will at least diminish, the effects of the disease. When, however, salivation has commenced, and at whatever period of the disease we may be consulted, we should employ that remedy which is the most powerful, and which never fails us: this is, touch- ing the affected parts with pure muriatic acid. Let the affected parts be touched daily with the acid, by means of a little piece of lint wrap- ped around a probe, care being taken that the acid does not come in contact with the teeth. When no ulceration is present, little pain will be felt, but when such exists, the pain will be severe but mo- mentary, and the ulcerated surfaces will bleed on each application ; the mouth should always be washed out after the use of this remedy, and the benefit which follows will become in a short time ap- parent ; the patients, instead of dreading, will claim a repetition of the treatment. When no ulcerations exist, an astringent gargle may be prescribed ; in other cases, one that is only slightly acid. Lemon- ade is the most agreeable drink. Circumstances may arise in which aperients, leeches to the base of the jaw, and bleeding from the arm, may be requisite, and the food should be in proportion to the patient's strength. It does not, however, suffice that the surgeon should be impressed with the belief that mercury may be advantageously used in secondary symptoms, that it should be persisted in as long as it tends to cure them, by improving the constitution, by exciting the appetite, by re- moving the leaden appearance of the countenance, by causing the gradual disappearance of the symptoms. We say, all this does not suffice to fulfil all the indications, and prevent ill consequences; the practitioner should be prepared to employ judiciously the divers prep- arations of the mineral, according to the urgency of the case, or the particular form present; the best means, then, of doing this, it will be our object to point out in the following pages. Mercury in its various forms may be made use of in two ways : first, either by causing it to be absorbed by the skin, according to the endermic method, or by its internal administration. There is a third plan, however, which we might allude to, that of absorption by SECONDARY SYMPTOMS ON THE SKIN. 267 the lungs. Although the Chinese still employ the latter at the present day, this treatment is not had recourse to in Europe. Mercury may be administered externally in a variety of forms and doses. We shall only allude to such as are in general use. Mercurial ointment employed in frictions is a very valuable prepara- tion, and has justly met with the approbation of surgeons. It is par- ticularly useful when we wish to bring the patient under the influence of mercury very rapidly; it is likewise strongly recommended in in- duration of secondary sores. It is advantageous when the intestinal canal is unable to bear mercurial preparations, as not unfrequently happens. The following simple rules may be borne in mind during its ad- ministration. The quantity used should not exceed a drachm, which may be rubbed in on the inner part of the calf of the leg or thigh be- fore the fire every other night; on the alternate days a bath should be taken: by this means there will be little disposition to irritation of the skin, as the ointment does not become rancid, and absorption will be promoted. The frictions should be made alternately on the lower extremities. They should be in the direction of the hair, as the disease called eczema pilaris is thus avoided. Instead of the bare hand, a pig's bladder may be soaked in warm water and turned inside out, and the hand thus enveloped in a sort of glove produces less irritation, and the patient's fingers are not soiled. M. Cullerier has proposed the plan of placing a drachm of the mercurial ointment in the arm-pit on going to bed, and desiring the patient to sleep without his shirt; absorption will be thus produced rapidly ; this is more especially useful when any eruption or ulcers exist on the legs, as the system becomes affected without any local irritation. Although mercurial ointment is a valuable preparation, still the dirtiness of it precludes its general employment, as conceal- ment may be often necessary; but when these objections do not exist, the surgeon may very beneficially employ this mode of treatment. Mercurial Plasters.—We have often had occasion to observe the good effects resulting from mercurial plasters, particularly one em- ployed by M. Ricord, called empldtre de vigo sparadrappe y in some instances its effects have been general, curing the disease, and pro- ducing an effect on the gums, after the other preparations have fail- ed ; usually, however, the beneficial results to be expected are purely local. When applied in strips, on chronic ulcers, on those papu- lar eruptions which assume a chronic form, such as the corona veneris and many others, it removes them, as by charm, a short time 268 SECONDARY SYMPTOMS ON THE SKIN. after its employment. We have not any remarks to make on the employment of ointments composed of calomel or corrosive sublimate, as in secondary taffections they are seldom to be used, and we have spoken already of the use of the latter in baths, and of the rules which should regulate its administration. Fumigations.—This plan of administering mercury is not of modern date, and is a very powerful means ; the following directions are laid down by M. Ricord. Fumigations should be made every other day, employing cinnabar at first in one-half-drachm doses, gradually aug- mented to two or three daily. The patient should have fasted five hours before employing the fumigation, and immediately after he should retire to bed, as by these means absorption is favored; but no plan can be more prejudicial when the skin is irritable. Various preparations of mercury may be employed internally; among others, we may mention the blue pill, one of the most effica- cious preparations in the Pharmacopoeia ; it has the advantage of crea- ting but little disturbance of the digestive organs. It may be given in doses of five, or ten, or fifteen grs. daily; however, on the first symptoms of diarrhoea coming on, it should be suspended. Calomel and opium, in the proportion of two grains of the former to a quarter or half a grain of the latter, is a preparation often pre- scribed with advantage, when we wish to act speedily on the system ; however, the tendency it has to produce salivation is an objection against its employment, and we have rarely seen it given. Corrosive sublimate, as an internal remedy, should, we think, be excluded from general use. It has a great tendency to produce colic and gastric intestinal irritation ; and, although we have seen it em- ployed on a large scale in France, we have observed few patients who have been able to submit to it long enough to produce a complete cure ; for this reason we prefer the Proto-ioduret of Mercury.—This preparation is one now very generally employed, particularly in the various forms of secondary symptoms; it rarely produces any gastro-intestinal irritation, and still less frequently salivation ; and when the first symptoms of the latter appear, a suspension of the remedy causes them to disappear immediately. It should be employed in doses of one grain at the commencement, in the form of pills ; the dose may be augmented according to the rules we have elsewhere given ; that is to say, if the symptoms gradually disappear under the employment of a certain dose, continue it; if they remain stationary, increase it every five or 6ix days, as experience shows this plan to be better than to gradually SECONDARY SYMPTOMS ON THE SKIN. 269 augment it. The dose thus daily taken may amount to six grains, and the quantity required may be often as much as two hundred grains. The exact quantity to be taken can never be accurately stated ; it must of course depend upon a variety of circumstances. When the secondary symptoms have yielded, it should not be laid aside at once. The dose should be gradually diminished, and then left off, when we have reason to believe the syphilitic diathesis has been removed, for it is from inattention to these circumstances that patients are subject to relapses. When any one of these prepara- tions has disagreed and been laid aside, provided the symptoms be not cured, some other form of mercury must be used, and it often happens that in a short time after the system will bear a preparation which previously disagreed with it; but this must be left in great measure to the discretion of the surgeon. Before quitting the subject of the treatment of secondary symptoms, we may pass in review the treatment of the various forms ; merely indicating, however, those which require any modifications from their form, situation, &c In affections of the skin, which are accompanied by much local irritation, or which assume an acute form, gelatine baths are very useful ; in cases of chronic skin diseases, those which contain sul- phu'ret of potash, or corrosive sublimate, should be employed. In cases of papular eruption, local frictions, with calomel, blue ointment, or applications of the plaster composed of mercury and vigo, may be employed with the greatest success, particularly when we wish to cure rapidly those on the forehead. We can not here pass over in silence the use of the tar ointment, composed of tar and lard; in lepra and psoriasis this is attended with the happiest results. The patient should rub the parts affected daily with the ointment, and his sheets and shirt should not be changed—he lives thus in a tar atmo- sphere, and the surface is constantly kept covered with grease ; it is, in truth, a most unpleasant position, but we have seen eruptions of simple as well as syphilitic psoriasis yield in a tew weeks, which had resisted all other means. It is stated by M. Biett that such treatment will not prevent a relapse ; this we believe, but we should nevertheless employ it. The mucous tubercles likewise require a peculiar treatment ; al- though cleanliness and the general administration of mercury alone suffice, still the followin^-4ocal treatment may be employed. Let the tubercles be washed twice a day with the solution of the chloride of soda, of such strength as to produce a pricking in the parts ; when 270 SYPHILITIC AFFECTIONS dry, let calomel be sprinkled upon them, and dry lint kept between the excoriated surfaces. In a few days the benefit will become visible, and a cure will take place. The disease of the patient repre- sented in plate V., fig. 1. was thus cured in fifteen days. SECTION III. SYPHILITIC AFFECTIONS OF THE MUCOUS MEMBRANE. Every portion of mucous membrane which the eye during life can observe is, like the skin, subject to become the seat of secondary symptoms ; thus the lips, inside of the cheeks, tongue, fauces, and throat, furnish the most unequivocal and characteristic features of a constitutional affection ; not only the margin of the anus, but the inside of the intestine itself, may be the seat of the disease ; the lining of the prepuce may likewise give undoubted evidence of the same fact, as seen in plate IV. The use of the speculum daily makes us acquainted with the fact, that the vulva, vagina, and neck of the uterus, are the seat of lesions which may with justice be attrib- uted to constitutional syphilis. To the description of these we shall now direct the reader's attention, and we hope to be able to furnish a more complete history of the secondary affections of these parts than has hitherto been given, for it is a subject on which we have bestowed particular attention. As it is in the mouth and throat, however, that we have been enabled to watch the course and progress of secondary symptoms most fre- quently, we shail more particularly allude to them in those situations, but our observations will apply to every syphilitic affection of these parts. SYPHILITIC AFFECTIONS OF THE MOUTH AND THROAT. The interest which must attach itself to the subject of syphilisi particularly when the mouth or throat is the seat of the affection, and the few pages that have been devoted to its description and treatment in works on venereal diseases, will, I trust, be a sufficient excuse for bringing forward here this regional sketch. OF THE MUCOUS MEMBRANE. 271 Some pathologists, and Cruveilhier among the number, have ex- pressed surprise at the tendency of syphilitic disease to break out in the throat.; but when the anatomical relations of the throat are con- sidered, when the great number of blood-vessels there met with is borne in mind, when it is remembered that the mouth is supplied with nerves from numerous and different sources, and when we recollect the sympathies existing between the throat and mouth and the various part of the economy—when we call to mind, likewise, the influence that puberty exercises on the genital organs and those parts contained in the throat, we can not be much surprised that in a disease like syphilis it should so often become affected as it is. The throat, from its functions, is frequently exposed to changes of temperature, and first feels the effects of all excesses ; these cir- cumstances, however, will be further alluded to in speaking of the various forms of the affection, which I shall at once proceed to describe. Clinical observation proves that syphilitic affections of the mouth and throat present various appearances, have separate terminations, give rise to different prognoses, and require each a peculiar line of treatment. I shall then follow what I believe to be a natural division of the subject, which I hope will possess the further advantage of rendering clear and concise a very difficult part of pathology. These affections may be divided into three classes — 1. Primary affections ; 2. Secondary affections ; 3. Tertiary affec- tions of the mouth and throat. The following cases will, I think, prove that primary affections of the mouth and throat do exists and as I am not aware of the details of any others in any work, I transcribe them in full from my case-book. PRIMARY AFFECTIONS. Case I.—On the 26th of February, 1839, a man forty years of age, of dark complexion, and small in stature, presented himself at M. Ricord's out-patient room at the Hopital du Midi, and requested that professor's opinion on the treatment of a chancre existing at the root of the penis ; accidentally, as it were, he called M. Ricord's attention to something unusual which he felt on the fraenum of the tongue. On examination, a sore of a size of a small split pea was observed in this situation, perfectly circular in shape ; the mucous membrane seemed as if it had been punched out; at the bottom of 272 SYPHILITIC AFFECTIONS the ulcer a yellowish matter was seen; the edges were somewhat raised, and surrounded with a scarlet-colored areola. The mucous membrane in every other part of the mouth was perfectly healthy. On account of the suspicious appearance of this sore, M. Ricord admitted the patient, and desired his house-surgeon to interrogate him as to the cause of the affection. The patient gave the following account of himself. A fortnight previously he went to a masked ball with a prostitute, drank freely during the evening, and acknowledged not only having had connexion with this female in the usual way, but admitted that in a moment of laisser aller he exposed his tongue to the chances of contagion. The appearance of the sore, and the confession of the patient, led M. Ricord to consider this as a primary syphilitic affection ; but still aware of the difficulties which such cases present, and wishing to come to a positive and not a rational diagnosis, he determined upon testing it by means of inoculation, and consequently inoculated the left thigh with the secretion of the sore on the fraenum linguae; on the following morning the characteristic pustule* began to appear, went though the regular phases of the artificial chancre, and conse- quently left no doubt in the mind of M. Ricord that the sore on the tongue was a chancre contracted in the disgusting manner above alluded to. The chancres on the penis and fraenum. as well as that which resulted from the inoculation of the virus, were allowed to remained without any local or general treatment, to enable the pupils to watch the natural course of the disease. I find in my case-book the following note :— March 9, 1839. The ulcer on the fraenum appears cured, the ap- pearances described as existing on his entrance have disappeared, and there remains only a pearly-white cicatrix. The artificial chancre is of the size of a split pea, the bottom covered with a yellowish sub- stance, and the edges of a bright redness. The caustic was applied to the cicatrix on the fraenum (to-day, 9th of March), to the artificial chancre, and that on the root of the penis ; aromatic wine and lint ordered to be kept constantly applied on the ulcers. March 21. This patient went out perfectly cured. Case II.—M. Ricord has kindly communicated to me the follow- ing particulars of a case on which he was lately consulted :— A patient presented an indurated sore on the mouth, accompanied with a lenticular eruption on the abdomen, leaving no doubt in M. * See page 176. OF THE MUCOUS MEMBRANE. 273 Ricord's mind that this man was suffering under secondary symp- toms ; he denied, however, ever having had chancres on the penis, but, on being pressed, admitted that he had exposed his mouth to contagion with a female who had come likewise to consult M. Ricord no traces of disease were present on the external organs of genera- tion, but by means of the speculum a sore was distinctly seen on the neck of the uterus. This female presented, likewise, traces of a lenticular eruption on the abdomen. Case III.—Some months previous to the occurrence of the last- mentioned case, a poet of some celebrity consulted M. Ricord for a sore throat ; on looking into the throat, a distinct ulcer at the back part, unaccompanied with any other disease of the mouth, was evi- dent ; around this sore there was some redness, but otherwise the mucous membrane appeared quite healthy ; no enlargement of the glands of the neck was present. On questioning this patient, he avowed that in a moment of exaltation he ran the risk of direct con- tagion. The thigh was inoculated with the secretion of the sore on the pharynx, and an artificial chancre followed on the inoculated point. A mild nutritious diet was ordered, the ulcer was cauterized, and the patient got rapidly well without the use of mercury. Since my return to London I have met with two cases of what I believe to be primary syphilitic affections of the mouth. The first example presented itself on the under lip of a dressmaker ; in size it was about as large as a shilling, and had all the characters of sores of that size on the organs of generation. The existence of all syphilitic affections, past or present, was denied, and, as far as my examination went, there were no traces of syphilis. This patient attributed the sore to the habit of putting pins in her mouth. It be- gan, like a pimple, three weeks previous to her admission into the hospital. Inoculation was not attempted, but the gentleman who treated her, believing this to be a syphilitic sore, prescribed blue-pill twice a day, and the patient left quite well. The second case occurred in a young man who acknowledged tha it was probably a chancre; it became indurated, and after cicatri- zation the under lip was twice its natural size in the centre. Mer cury was given, and the swelling and induration rapidly yielded. Mr. Lawrence has permitted me to mention that a case of this nature fell under his case some time ago. A young man consulted him for a sore on the lip, which, observed Mr. Lawrence, presented 18 274 SYPHILITIC AFFECTIONS so much the characters of chancre, that I did not scruple to tell my patient, that if the sore had been on the penis, I should have declared it to be lues. The patient, then avowed that my suspicions might be well founded, as he had exposed his mouth to the chances of conta- gion with a prostitute. M. B. de Leury, the surgeon to those prostitutes under the care of the police in Paris, told me that from time to time he meets with primary sores on the mouths of these unhappy creatures ; and this is not surprising, when we learn from Parent Duchatelet" Sur la Pros- titution," that " II est peu de vieilles prostituees qu'on ne puisse ranger parmi les tribades."—tome i., p. 165. The preceding cases show that the anatomical characters of prima- ry sores on the mouth and throat are similar to chancres occurring on any other part of the body; they likewise prove that in good con- stitutions the disease may limit itself, and get well under very simple means ; but should phagedena or gangrene attack this specific sore, the course of the affection may be altered, and it may take on all the severity that chancre, complicated with gangrene or phagedena, else- where assumes ; the soft palate may be moreover destroyed, and necrosis of the surrounding bones take place, with all the consequen- ces which these accidents may entail. The cause of the affection I have traced, in the above and in some other cases, to direct contact of the mouth with a chancre, and inocu- lation has shown that the sores were identical ; but I believe that mere contact of the secretion of a chancre and a sound surface, be it mucous membrane or skin, is not alone sufficient, in order that the virus produce its specific effects. I believe, judging from what I have observed elsewhere in investigating inoculation, that it must remain a sufficient length of time on the mucous surface to destroy the epithelium ; should it have introduced itself into a mucous follicle, the lining probably is destroyed before the pustule becomes developed ; should, however, the virus have come in contact with an excoriated surface, or one deprived of epithelium, mere contact seems to be sufficient, as a chancre will be immediately developed. The above opinion is confirmed by the impunity with which many persons have swallowed pills containing syphilitic virus mixed with bread crumbs ; and this leads me to mention, that if the virus be mixed with much foreign matter, the probability is that it will produce no effect, unless there is a lesion of continuity. These remarks are not without prac- tical importance, as they tend to explain the reason why primary sores are uncommon in proportion to the number of cases of exposure to OF THE MUCOUS MEMBRANE. 275 contagion, and from the accessory conditions which are necessary for the occurrence of the disease. The immediate cause, or syphilitic virus, may (as probably hap- pened in the above-named cases) come directly in contact with an excoriated or abraded surface, or at least with one deprived of epithe- lium ; I believe that this is the usual means of contagion. Previous writers, who have admitted the existence of primary sores on the mouth, think that the virus may be transmitted through the medium of various agents. Thus, Cullerier believes that tobacco-pipes, drink- ing-glasses, &c, may transmit the disease from one individual to another. Of course it is not my intention to question the truth of the facts advanced ; but in my long study of the disease in hospitals, I have never seen a case which might reasonably be attributed to such a source ; it is true that patients will often attempt to explain the presence of these sores by tobacco-pipes, &c, to conceal the true means by which the disease has been contracted ; but I have, after gaining the confidence of the patient, too often learnt that this was only a fiction to conceal the source of the affection, as well as the depravity of the patient. I believe that this means of transmission is possible, but that it is very rarely met with, from the following circumstances : 1. Chancres, or rather primary sores on the mouth, are very rare, for reasons stated above; hence the possibility of transmitting the virus from them by means of glasses and tobacco-pipes must be very rarely met with ; for we are no longer under the impression that chancre on the penis can infect or render contagious the other secretions of the body, or that the breath of an individual can infect another by whispering, or that a kiss may be the means of conveying the virus, unless a chancre exist on the lip. Should, however, a chancre exist on the mouth, and the secretion soil a pipe or glass, that pipe or glass may communicate the affec- tion ; but even this must be rare, for the virus will become mixed and diluted with saliva, which, although it does not destroy the effect, will nevertheless diminish the probability of its action ; and if no excoriation of the mouth or abrasion of the mucous membrane exist, probably (from what we see elsewhere) no chancre will follow even the introduction into the mouth of the contagious principle.* These reasons induce me to ask if certain writers have really seen primary affections of the mouth and throat? I am well aware of the high authorities whom I criticise; but although they describe the * Vide Ricord, Traite des Mai. Vener., passim. 276 SYPHILITIC AFFECTIONS affections of the mouth as primary, they still seem in doubt on the point in the observations they make, and allow that the diagnosis is very difficult, in some cases almost impossible. Mr. Colles states, in his valuable treatise on the venereal disease, that these primary syphilitic sores on the mouth are not of uncommon occurrence in Ireland, and that he knows of no disease which is more contagious—not even the itch. I have carefully read over the cases which he has given, but I am obliged to acknowledge myself unable to decide upon their nature. I have seen in the Foundling hospital at Paris a disease so similar to what he has described as syphilis, and which the French, in its ulcera- tive stage, call muguet, that I am almost inclined to think he has been mistaken in his diagnosis. This disease, which Monsieur Guersant has so well described in the French dictionary of Medicine, reigns epidemically, may attack the mouths of persons of all ages, though usually seen in children, and may be communicated to the nipples of nurses ; and M. Guersant thinks that the sores which arise on the nipples are the effect of a direct and mechanical action, which determines a local inflammation of the same nature—a result which may be compared to pseudo- membranous irritation arising on a finger which is constantly sucked ; although (continues the same author) it is epidemical, still it is not contagious, for notwithstanding the children drink out of the same cups in the hospital, 1 have not remarked that it is communicated from one to the other. I would ask, therefore, Mr. Colles, if the cases he has described may not have been ulcerative muguet, occur- ring epidemically in families, submitted to the same influences of damp, clothing, and food.* Symptoms.—These, I think, have been described at sufficient length in the above cases, and as they resemble those of simple ulceration, I have nothing to add; they are usually slight, unless in- flammation or gangrene attack the sore. Under these circumstances they may become very severe. Diagnosis.—When a sore exists on the lip or tongue, I need not state that its character may be easily studied ; but when the surgeon (and I of course address myself now to the young surgeon) is con- sulted for some affection of the throat, as is often the case in hypo- * The same observations may be made relative to the cases of John Hunter, which he believed were not syphilitic, but which he classed under the title, " Diseases resem- bling Syphilis," which his learned commentator, Mr. Babington, like Mr. Colles, says he has no doubt were syphilitic. OF THE MUCOUS MEMBRANE. 277 chondriacal patients, it is not always easy for an inexperienced eye to decide if an ulceration exist, more especially if the patient be suffer- ing, or has had syphilis, and complains of the throat.* I had an op- portunity of seeing a case which impressed this on my memory, in the month of February, 1839. A young man complained of great inconvenience in his throat, and consulted M. Ricord, fearing that he should lose his palate. He stated that, several months previously, chancres had appeared on the penis a few days after connexion with a female who was diseased ; notwithstanding the employment of mercury and sarsaparilla, a hard point remained in the situation which the chancre had occupied, and was excised by a country surgeon. The wound healed in a few days, and he has suffered no further inconvenience from the complaint until lately, when he has felt inconvenience in his throat. On looking into the mouth, the mucous membrane is perfectly healthy, but at the posterior part, and on the amygdalae, the following appearances are seen : the surface, instead of possessing its natural color, viz., a rosy tint, like that of the lips, presents a mottled charac- ter ; some parts are white, and others red, and pus is irregularly spread over the whole. Some persons who witnessed this appear- ance of the throat for the first time, considered that an ulceration was present, and the history of the case seemed to render it probably syphilitic ; but on wiping the parts with lint on a probe, and viewing the throat in a good light, vessels were seen traversing these supposed ulcers. Not unfrequently these same appearances have presented * To gain a good view of the throat, the surgeon will do well to employ Dr. Holt Yates' Speculum Oris. This useful little instrument was introduced to the profession by Dr. Holt Yates of London in the year 1826, since which time he and others have been in the habit of employing it, both in private and public practice, with great ad- vantage, in all cases in which an accurate and extensive view of the fauces was re- quired. To the surgeon it is of essential service in the removal of tumors, or when called upon to perform any similar operation about the tonsils. By its aid, not only may the jaws be distended without inconvenience to the patient, and the adjacent parts pro- tected from injury, but the operator is enabled to see what he is about, take his own time, and to have both his hands at liberty. The facility of observation and precision which it affords to the medical attendant in important cases is incalculable ; and being made of silver, the most fastidious person can not object to it.-- use. The instrument is perfectly simple, and tells its own story. It consists of a graduated hoop, with a sliding button, so placed that it may be regu- lated according to the age of the patient and other circumstances. Being gently pressed upon above and below by the teeth, the spatula, which is concave, and slightly inclined downward toward the extremity, depresses and protects the tongue, and thus an extensive and uninterrupted view of the fauces is obtained. Any gentleman wishing to see the speculum may do so by applying to Mr. Ferguson, surgical-instrument-maker to St. Bartholomew's hospital, London. 278 SYPHILITIC AFFECTIONS themselves to my notice, and it has been only by looking for the vessels that I have been able to decide if an ulcer really existed or not; it was, I believe, Boyer who first pointed out the error the sur- geon may fall into, and the means of avoiding it. The young surgeon should be aware that the glands on and around the tonsil are sometimes very large, and when their secretion is adherent, this natural state of the parts may be mistaken for ulcera- tion ; in such a case, the use of a probe covered with lint will re- move all doubt as to the nature of the appearance.* I may likewise state that stimulating gargle, aperient medicine, and a nutritious diet, will in a few days cure these simple cases of irritation, or the mottled state of the throat. Primary syphilitic affections of the mouth and throat may be mis- taken for various simple affections of these parts. I have already alluded to the Thrush in a state of ulceration, which, although in ordinary cases it may be easily distinguished, still in a great number can only be known by a consideration of the cause, form at the com- mencement, general symptoms, knowledge of the epidemic, or spo- radic cases, &c. Still, however, if the surgeon bear in mind that a chancre is unattended with any affection of the gums or mouth, that it is usually isolated, that it occurs in persons otherwise in a perfect state of health, and is unattended with any general symptoms ; on the contrary, that the aphthous disease termed Thrush attacks sev- eral parts of the mouth, and particularly the gums and throat, is pre- ceded and accompanied by fever, disorder of the digestive functions, and of the other mucous membranes, and frequently with affections of the skin, which assumes a purple appearance, and may terminate fatally by wasting of the patient's strength in a short space of time; that it occurs in moist, damp, or ill-ventilated situations, either spo- radically or epidemically, and consequently must not be confounded with the contagious nature of other diseases—I say, considering this, he will pause before attributing the affection to syphilis, the primary form of which is very rarely met with in this situation. This affection might be sometimes confounded with ulcerated aphthae of the mouth, the consequence of indigestion, or ulcerations of the gums brought on by decayed teeth, or caused by tartar accu- * It may seem puerile in me to lay so much stress on points which may appear so easy of decision; but I frequently see cases in which ulcers are overlooked; few patients know how to open their mouths; others place their tongue in such a position that it is next to impossible to see anything. I find that the manner of opening the mouth, and keeping quiet the tongue, should be learned previous to the use of the spatula, which often produces a convulsive action of the lingual muscles. OF THE MUCOUS MEMBRANE. 279 mulated around them ; but it is only necessary to allude to these causes, to prevent any one mistaking the effects for those of syphilis. Primary affections should be distinguished from the secondary ones ; but I shall defer the consideration of this subject for the present, until I have treated of the latter. Prognosis.—It is of no little importance to form a correct opinion of the nature of an ulcer on the mouth or throat, as the prognosis will materially be altered by it. A chancre on the mouth of a healthy individual will, by proper treatment, speedily get well, and in this respect differs greatly from all other affections. Should it occur in a person of bad or broken-down constitution, either from bad living or dissipated habits ; should it become complicated with gan- grene or phagedena, the situation of the parts must lead the surgeon to dread the loss of the palate, exposure and necrosis of the bones, and their consequences. On the probability of the occurrence of secondary symptoms, the same rule holds good, here, as in other parts of the economy; they are to be expected, not in proportion to the number, size, or length of time of the existence of the chancres, but in proportion to the number of cases attended with induration. What the relation is be- tween induration and secondary symptoms I can not stop here to in- quire ; but it is a fact well supported by statistics and daily observa- tion, that secondary symptoms will follow simple chancre in a feeble proportion, whereas scarcely one person will escape constitutional syphilis, who suffers from indurated chancre : it was for these reasons, probably, that our great master, Hunter, refused to designate as syphilis any sore which was not indurated. Treatment.—The first indication to be followed is the removal of any cause which can increase or keep up the affection. In the first instance we need not pay any attention to the specific disease ; if inflammation be present, the usual antiphlogistic remedies must be had recourse to ; if there be decayed teeth in the gums, they must be extracted ; if any disease of the digestive tube exist, it should be combated with the usual remedies : having, then, reduced the affec- tion to its simplest state, the surgeon may turn his attention to the specific disease, which in the previous pages I have induced him to believe is local, is a surface secreting a specific virus, and conse- quently to be destroyed as soon as possible. The best agent for doing this is a finely-pointed stick of nitrate of silver, with which the ulcer should be lightly cauterized, and the operation may be repeated as often as the little eschar falls off, until cicatrization be complete. 280 SYPHILITIC AFFECTIONS In the majority of cases no other treatment is requisite ; should induration exist, this treatment must be varied ; cauterization is then of little avail; cicatrization will not occur, or if it does, the sore is Uable to break out on the slightest irritation. Mercury, which in the former case I objected to, is now of the greatest benefit. Under its use all induration ceases, the sore cicatrizes kindly, and secondary symptoms will most probably not follow. However, the best plan of employing mercury; the reasons for employing it in frictions or in- ternally ; the preparations which are preferable ; the dose ; the quantity necessary for the cure of the affection; the abuses in its administration ; and the ill consequences to which it gives rise—are points which I have treated of very fully, when speaking on that subject, at page 260, to which I must refer my readers for further information. SECONDARY SYPHILITIC AFFECTIONS OF THE MOUTH AND THROAT. If the primary form of syphilitic affections of the mouth and throat be rarely met with, and have been, by those authors who consider it a common affection, confounded with other diseases, it is no less cer- tain that the secondary form which I am about to describe is of every- day occurrence, and has been very well depicted by authors who have written upon syphilitic affections of the throat. The diagnosis and treatment have not, however, been noticed in the manner that the subject deserves ; and trusting that I may be able to throw some light upon this affection, I shall treat of it as if nothing had been written upon the subject; taking my descriptions from nature, and illustrating my views by cases which have fallen under my own notice. I extract the following case from my note-book :— February 1st, 1839.—The patient who occupies the bed marked twenty-eight in the second ward at the Hopital du Midi, presents the following symptoms:— No eruption on the abdomen or extremities; on the scalp two or three impetiginous sores are observed. On the penis an indurated sore completely surrounds the base of the glans. The throat is red, particularly at the back part, on the pharynx and uvula. We ob- serve on the tonsil of each side a whitish semicircular character of the size of a silver penny, giving the tonsil the appearance of an ex- coriated surface. Lint wrapt round a probe, and rubbed over the OF THE MUCOUS MEMBRANE. 281 surface, does not remove this tenacious pearly-white substance. The amygdalae are somewhat swollen ; the speech is little altered, degluti- tion good, and no pain in the throat, but the patient complains of a constant source of irritation there. (See plate VI., fig. 1.) . The patient gives the fallowing account of himself. Has enjoyed excellent health. A year ago he contracted a gonorrhoea, followed by chancre and bubo. Was treated for these complaints in the Vene- real hospital during the month of August, and left cured in the com- mencement of September. Since that period has repeatedly con- tracted fresh chancres, and has treated them with the aromatic wine. The indurated sore on the penis he states to have existed about two months ; has employed no treatment, except the local application of the aromatic wine, which he finds diminishes and has benefited vastly the sores. Has been liable to the uneasiness in his throat for some time ; can not exactly say how long, and attributes it to exposure to cold. He is a wagoner. M. Ricord ordered this patient a simple gargle, and to continue the aromatic wine as a local application to the chancre ; wishing to show his pupils the effect of a warm atmosphere and good diet. February 15. The condition of the patient has not altered. March 11. This patient now takes four pills, containing each one grain of the proto-ioduret of mercury daily ; he commenced with one on the 15th of February. March 18. Went out perfectly well to-day. The preceding observation may give the reader a good idea of what I believe to be a secondary sore-throat; an affection which may be met with very frequently in private and public practice, and into the history of which I shall at once enter. The Anatomical Characters of secondary syphilitic affections of the mucous membrane are, generally speaking, very characteristic. A redness appears on the surface ; the centre of the red circle be- comes pale, extending in size until it attains that of a sixpence. Very often several points take on this character, and coalesce ; thus neither the circular nor semicircular appearance persists, but the affected points present an irregular patch of whitened epithelium, which resemble the skin on a washerwoman's hands, or the appear- ance of the finger which has been covered with a poultice. If any attempt be made to remove this whitened patch, it will be found very adherent to the tissues beneath ; and I have never been able to satis- fy myself as to its nature, viz., if it be simply the epithelium altered, 282 SYPHILITIC AFFECTIONS or if it be a secretion superadded to it. I am induced to lean to the latter opinion, as the centre of this bleached surface may be raised above the level of the surrounding healthy mucous membrane. In many persons only one of these patches of a circular shape, as thus, © is met with. One circle may intersect another, so that a patch of mucous membrane may contain several imperfect circles, as \?^, . It is only the mucous membrane here represented between the lines that is affected, giving the throat the appearance of containing so many semicircular bands of swollen mucous tissue, and this appearance we have in vain sought for in other diseases. These patches are spread in great quantities over the mouth, gums, tongue, pharynx, or uvula. Usually there is no redness of the mucous tissue around, but compli- cations may supervene. Thus I have frequently witnessed an ery- thematous blush surrounding each patch ; ulcerations may take place on the whitened surface, in the form of points, which unite, and the entire bleached appearance is destroyed, or only remains at the cir- cumference, in the shape of a grayish fringe. I have often witnessed these white patches remain in a stationary state during entire months, particularly when the patient is not exposed to cold or damp, and even under simple care they may disappear, but such a circumstance is very rare. They usually become, sooner or later, the seat of ulceration, which destroys the surrounding part, and the sore, which at first extends only in circumference, at a later period, particularly in bad constitutions, gains in depth, and assumes a dirty unhealthy character; inflammation or gangrene may seize upon it, or if neg- lected, it may become what I shall hereafter describe as the tertiary form of sore-throat, causing destruction of the deep-seated tissues, and a loss of the palate, nose, &c. These are the anatomical characters of the affection ; such is the course of the disease ; and it will be at once seen that, commencing at the surface, it gradually gains the deeper tissues; but it is a peculiarly chronic affection, unless some complications interfere with it. Situation of the Patches of Ulceration.—This subject is not without its interest in several points of view; most, frequently the patches are observed on the amygdalae, or on the sides of the tongue, or close to the fraenum on its under surface ; they are met with, though less frequently, at the corners of the mouth, and they here soon as- sume the appearance of scabs, which are very characteristic, and liable to bleed when the mouth is examined. Sometimes they are met with on the dorsum of the tongue, here assuming an elevated charac- OF THE MUCOUS MEMBRANE. 283 ter, like the condyloma around the anus. There is at present (Octo- ber, 1840) a case of this description under the treatment of Mr. Law- rence, at St. Bartholomew's hospital. More rarely this form of disease is seen on the back part of the pharynx; on the uvula it is so rare that I can recollect but a very few cases, although it may oc- casionally occur, as I witnessed a case lately in Lazarus' ward. The importance of these observations will appear hereafter, in treat- ing of the other form of syphilitic sore-throat. Causes.—In tracing back the history of patients affected with this disease, it will be found that, in the adult, chancre has preceded or co-exists; in the infant, on the contrary, a chancre will be rarely discovered as the antecedent, but the mother will be found to bear traces of primary sores, or it will be ascertained that she is suffering under secondary symptoms, which she has transmitted to the infant during utero-gestation. Although we thus trace the disease to chancre, or to constitutional infection, it is no less true that, all chancres do not necessarily give rise to this affection. Fortunately for humanity, the greater number of primary sores are not followed by these appearances, but observa- tion proves that, in a great majority of indurated primary sores, these appearances will be observed ; and on interrogating the patient it will be discovered that an indurated chancre has preceded them. Usually, however, the indurated chancre seems only to give a pre- disposition to the affection, or rather to give rise to a state of the constitution which has been called a syphilitic diathesis. In fact, the appearance of this identical symptom seems to depend upon chancre as the cause ; but to give rise to its development, various exciting agents are necessary: these seem to consist in exposure to cold, damp, or moisture ; fatigue ; improper or insufficient food ; excesses of all kinds, &c. Every surgeon must be fully aware that a patient who has been«the subject of an indurated sore, although he has taken no mercury, or employed any so-called specific remedies, may with proper care escape sore-throat for some months ; but no sooner does he expose himself to any of the exciting causes above spoken of, than he observes these appearances in the mouth and throat. Such are the reasons which induce me to admit a syphilitic diathesis, which gives rise, under certain circumstances, to secondary symptoms, on the exposure to exciting causes, in the same way that, in a scrofulous constitution, health may be preserved during a long period, provided various precautions be taken; but should cold, un- wholesome food, or an accidental fall or blow occur, a train of local 284 SYPHILITIC AFFECTIONS and general symptoms follow, which betoken phthisis or a white swelling. The consideration of the influence of exciting causes is very im- portant, as explaining some exceptional cases of this affection that appear a long period after the chancre. We can usually detect a distinct and natural relation between the primary and secondary symptoms : thus, during the existence of an indurated chancre, this affection often appears ; in other cases it is some few weeks after its cure : when the chancre has been imperfectly treated with mercury, the time which elapses may be longer. However, the affection of the throat may be usually said to appear six weeks or two months after the appearance of an indurated chancre. Age, professions, and sex, will only act as predisposing causes, inasmuch as they cause excitement of the mucous membrane ; thus the child, from the fact of sucking, is greatly predisposed; persons who use tobacco-pipes are very liable to it: for here, as in those who play upon wind-instruments, there is a great call upon the secreting apparatus of the mouth ; and in the treatment of such diseases these points should not be lost sight of. The Symptoms of the affections are, in the commencement very trifling, only a slight irritation or swelling ; should, however, inflam- mation follow, the usual symptoms of inflamed sore-throat will occur, and the general symptoms may run high. Concomitant Diseases.—The affection I am describing rarely occurs alone. I have already mentioned that an indurated primary sore often exists on the penis, while, at the same time, an affection of the scrotum, anus, or genital organs in the female, which is called in France mucous tubercle, and in England condyloma, often precedes or co-exists with it. A lenticular eruption is often visible on the abdomen ; on the scalp an impetiginous affection occurs, as in the case mentioned above ; the hair falls off, having previously become dry; the glands in the neck are often enlarged ; in fact, all the symptoms described as secondary may be present. The importance of these affections I shall now show in speaking of the diagnosis of the disease. Diagnosis.—When one or more of the white patches, circular in form, or assuming the semicircular character, are seen on an hyper- trophied portion of the mucous membrane, unaccompanied with sali- vation ; when the patient admits having lately had, or still bears traces of, an indurated chancre ; when various well-marked seconda- ry symptoms are evident on the patient; when these have been but OF THE MUCOUS MEMBRANE. 285 little benefited by care and local applications—few persons will be found who deny that the symptoms are produced by syphilis, and perhaps, with me, they will call the disease a mucous tubercle of the mouth, the consequence of general and constitutional infection. Were it in all cases as easy a matter to diagnosticate the affection, the study of the subject and the treatment of the patient would be very easy ; but those who have seen much of these diseases are fully aware that cases present many difficulties, and it is to the study of these that I propose now calling the reader's attention. It is frequently found in practice, that in consequence of some disorder of the stomach, or from the use of mercury, aphthae or sali- vation has occurred ; the mouth may thus present an appearance which masks the disease, and the anatomical characters above de- scribed furnish no guide, as it is impossible, from the appearance of the mouth alone, to give an opinion ; it is well in such a case to wait a few days, to treat the salivation by a gargle composed of muriatic acid and infusion of roses, and touch the gums with a camel-hair brush dipped in the concentrated hydrochloric acid. This local treat- ment, combined with a gentle aperient every other morning, and a light and nutritious diet, will cure aphthae and salivation; but the characteristic mucous tubercle will now become evident, for this local treatment will not remove it, and thus the diagnosis will be- come clear. With relation to the history of the case, considerable difficulties often prevent us from forming a diagnosis ; patients, intentionally or through ignorance, or inattention to the previous complaints, state that they have never had chancres, much less indurated primary sores. The absence of chancres should not prevent us from judging from the other symptoms. Let it ever be borne in mind that chancres may heal in a few days, that they may be contracted in unnatural intercourse, and consequently may exist on other parts of the body- as well as on the penis, that they may be contracted from wounds on different parts of the body, by scratches, &c. ;* thus the denial of the patient is not a sufficient reason to make us conclude that chancres have never existed.! * See page 197. t A short time ago a patient was admitted under the care of Mr. Lawrence in Faith Ward, with one of the best-marked cases of syphilitic affection of the tongue 1 ever saw. Believing, I presume, that she could deceive the practised eye of that eminent surgeon, this female wished to appear indignant at certain questions being asked as to her pre- vious complaints, and stoutly denied the possibility or pre-existence of chancres; find- ing this, Mr. Lawrence passed on quietly, telling her that she should improve, for her 28G SYPHILITIC AFFECTIONS Other forms of secondary symptoms are not always present, and in such cases we are deprived of one of the most valuable guides the surgeon can possess. On the other hand, the practitioner should be well convinced that to come to a correct diagnosis on the nature of syphilitic affections of the mouth, the symptoms by which he judges should themselves be correctly diagnosed as syphilitic ; thus, should aphthae on the mouth be mistaken for the mucous tubercle, should a sore on the penis, without sufficient reason, be considered syphilitic, or should the chancre have existed years previous to the appearance of the affection—lastly, if the supposed secondary symptoms are not well marked, viz., if no lenticular eruption or mucous tubercles about the anus or scrotum be present, a very cautious opinion should be given, for there are two very great faults which surgeons fall into ; the one sees syphilis everywhere, the other seems to shut his eyes to symptoms which can be rationally and truly connected with the disease ; but I trust I have said enough to show the necessity of weighing each symptom, and giving it only its proper value ; each individual sign must be compared with and corrected by the other, and practice will assist us in forming a correct decision. Prognosis.—It may be inferred from the description above given of the course of the disease, that the prognosis is favorable ; provi- ded no excesses are committed, or the patients do not expose them- selves to cold or damp, the disease will not assume a worse aspect for many months, but will, on the contrary, by care and the simplest treatment, gradually subside. I have frequently witnessed such cases ; the relief, however, is but delusive, and the disease returns again and again, each time committing greater ravages, and in this way years will pass over, if, however, the case be seen at the commencement, there is no form of secondary symptoms which can be more speedily cured ; but the patient should be given to under- stand that in the more advanced stages, when the relapses have been frequent from want of any treatment, or from an injudicious one, the case will be always more difficult to cure, and the chances of further relapses greater ; in fact, there are cases which it becomes very difficult to treat in consequence of constitutional peculiarities, viz., an intolerance of mercury, and other circumstances I shall not stop here to speak of. In fine, it may be stated that the disease is more readily cured in proportion to the early period at which we "are called tongue was a sad telltale; the patient, feeling the truth of this witty and sensible re- mark, on the subsequent visit acknowledged the existence of a very little sore some months previously, and she left the hospital well in a few weeks. OF THE MUCOUS MEMBRANE. 287 upon to treat it, and to the mildness of the other secondary symptoms which accompany it; at later periods, I have witnessed one or two of these patches on the mouth which persist, but these are observed when the patients have neglected themselves at the commencement. Their existence, however, annoys the patient, and vexes the surgeon. Lastly, the general health of the patient most not be lost sight of in forming a prognosis. Treatment.—The first indications which result from a considera- tion of the causes, symptoms, and complications, are to withdraw your patient from everything which can be considered an exciting cause ; to put him upon a mild but nutritious diet, to combat any in- flammatory symptoms by ordering antiphlogistic means. Having thus paved the way, the surgeon may feel called upon to employ mercury. Notwithstanding all that has" been written against this mineral, it is the only remedy that can be depended upon in all cases ; and so much am I assured of this, that I have seen the very men who declaim most bitterly against it, obliged to have recourse to it after all other remedies have failed. I admit most readily, however, that this affection will often get apparently well without mercury; but as the patient is liable to relapses on slight causes, it is far better to commence immediately a mercurial treatment, which, as I stated elsewhere, is attended with no bad results, when properly adminis- tered. For this purpose, blue pill may be given once or twice a day, or the proto-ioduret of mercury in one-grain doses ; however, from causes which I am at present unable to explain, this latter prep- aration produces a great degree of colic, and although I found it so useful in France, I have been obliged to leave it off latterly and ad- minister blue pill. The mouth or throat may be gargled with the following:— Acidi Hydrochlorici diluti %i. Decoct. Cinchonae corticis Jiv. M. The length of time that the mercury must be continued, and the manner of giving it in increased doses, are so fully treated of at pages 260-268, that I shall not here again allude to them. Were the syphilitic affections of the mouth and throat confined to the two forms we have described in the preceding pages, much hu- man suffering would be saved, and the duties of the medical practi- tioner considerably simplified ; but such is not the case ; the severest form still remains to be described, and will form the substance oi the next section, under the title— 288 SYPHILITIC AFFECTIONS TERTIARY SYPHILITIC AFFECTIONS OF THE MOUTH AND THROAT. This third variety in the form of syphilitic affections may com- mence in any of the following ways :— 1. Most frequently (in shattered constitutions, or in persons redu- ced by the combined effects of dissipation and bad treatment) some pain is felt in the throat or tongue ; there is a thickness of the speech, which at first excites but little attention; on examining the affected parts, the medical man will not fail to observe more or less redness and swelling confined to a particular portion of the mucous membrane, and the parts present all the characters of the formation of an abscess ; this point will soon take on an erysipelatous redness, break, and expose a tawny-colored slough. See plate VI., fig. 1. A probe will detect the extent of the ulceration, which, if situated on the back of the pharynx, may expose the bone, having previously destroyed the periosteum ; when seated on the roof of the palate, a portion of the palate-bone will be found carious, and a communica- tion to exist between the nose and mouth; the peculiar fetid smell will, moreover, convince the surgeon of the destruction of the bone, of which large portions often come away. The disease, however, does not seem confined to the mouth ; in a great number of cases an erysipelatous redness and thickening is perceived at the root of the nose, not, however, larger than a shilling in circumference ; these pursue the same course as on the palate, break, and expose the diseased bones. Not unfrequently, pustular eruptions, forming the scabs of rupia, appear on the extremities, and the general emaciation continues ; the countenance has now a cadaverous appearance, and the pulse bespeaks the general feebleness of the patient, who, if not relieved by proper treatment, sinks under the combined effects of colliquative sweats, diarrhoea, great suppuration, and want of sleep from severe pain in the bones and joints, and loss of appetite. Such, I believe, is a concise sketch of the most frequent form of tertiary syphilitic sore-throat, with its accompanying symptoms, not to be mis- taken when once witnessed. It may, however, commence in another way; the secondary form of syphilitic affection of the mouth or throat described in the prece- ding section may become aggravated, and the superficial ulcerations be converted into those excavated tawny sloughs which are described in the last page, and they may produce such a destruction of parts as to lay bare the bones, which, however, do not necessarily ex- foliate. These forms are frequently met with on the dorsum of the PL 17. ^S'i-. OF THE MUCOUS MEMBRANE. 289 tongue, see plate VI.,fig. 1. They form also on the tonsils or the hard palate, and are covered with detritus of the ulcerated parts, and viscid saliva, forming a picture of disease which seems more exten- sive than it really is. The progress of the affection and concomitant disease are similar to that of the first form just described. In cases which are far less numerous, the patient perceives little lumps gradually form in the substance of the tongue, which becomes irregular on its surface. To the feel, these little tumors are very hard, varying in size from that of a pea to a hazel-nut; at first chronic in their progress, these masses become soft, suppurate, and open by fissures ; the edges are often everted and indurated ; livid chasms run in a perpendicular or transverse direction on the tongue, which is covered with a viscid secretion ; the organ is very much fettered in its movements from its increase in size, and deglutition and articulation are interfered with. Now, although one or other of these forms may be found alone as described, cases are met with in which they occur together; more frequently, however, one form predominates, thus showing that they are varieties of one and the same stage of syphilis, a fact which I shall not further attempt to prove. History.—If patients laboring under these forms are interroga- ted, the surgeon will not fail to discover that chancres have preceded them ; in the few exceptional cases, the patient may not have obser- ved them, or may be desirous of concealing the fact, but in ninety- nine out of every hundred cases the previous existence of chancres can be ascertained. It is not, however, sufficient merely to ascertain that primary sores have preceded ; the surgeon should not fail to in- terrogate the patients on the period which has elapsed and the symp- toms which have followed. The apparent striking contradictions be- tween their answers will not fail to astonish the young surgeon. Thus one class of patients will tell you that several years ago (say four or five) they contracted chancres ; a period of four years elapsed when the present symptoms broke out; during that interval not a symptom of disease was apparent, and they enjoyed excellent health. Another class will state that some time ago (two years) a chancre existed ; at the end of three or four months, secondary symptoms of a marked character appeared, which were relieved from time to time, and then broke out again ; thus months passed on, occupied with alternate attacks and cures, until the present affection showed itself. On questioning further these two classes of patients, the former will generally tell you they took mercury; the latter did not, or only in 290 SYPHILITIC AFFECTIONS small quantities ; and it would appear that we must attribute this immunity from disease for some years to the mineral preparation. In one and the other class a point of resemblance is almost univer- sally found, viz., that many months or years have elapsed since the occurrence of chancres ; in the exceptional cases (as I met with one lately) there had been a primary sore which had healed some months only, but two years previously there had existed likewise a chancre. The surgeon, bearing this in mind, will, I think, find my position true. Hence there is a difference, not only between the characters of the secondary and tertiary affections, but likewise as to the period of their appearance after the primary sore. Under the head of History I may say a few words on the frequency of these affections ; they are to be met with very often in practice ; perhaps, however, not so frequently as formerly; but, in relation to the number of persons who contract chancres, the disease in ques- tion is fortunately rare. What, then, are the predisposing causes 1 will become the next question. If the appearances on the penis or the statements of patients can be relied on, the chancre which leaves an indurated mass after its cicatrization is the one followed most frequently by secondary symp- toms, and subsequently by the tertiary. It has often struck me that the chancres must have been phagedenic, for we perceive consider- able cicatrices on the prepuce of patients laboring under tertiary symptoms : and it is, moreover, to be noted that, secondary symptoms have not here preceded. Can it, therefore, be stated that phagedenic chancres do not cause secondary symptoms, but predispose to ter- tiary ? I am uncertain, but I incline to the idea that the same con- dition of the system which predisposes to phagedenic primary sores does so equally to tertiary symptoms, and not to the secondary. Years of experience can alone clear up this point. Constitutional disposition, excesses of all kinds, poverty, insufficient clothing, scrofula, intestinal affections, any depressing passions, seem to act as predisposing causes ; but again I repeat, happily these affections are relatively rare ; although they are to be met with from time to time. Diagnosis.—I shall first consider the diagnosis of this the tertiary form of syphilitic affections from the two preceding ones, and shall then indicate the points of difference of the tertiary form from those diseases with which it may be and is confounded. Few of my readers will be at a loss to distinguish between a pri- mary sore on the mouth or throat, and the affection I am now de- OF THE MUCOUS MEMBRANE. 291 scribing; inoculation and the history of the two affections will at once enable them to distinguish it. If, however, phagedena or in- flammation attack the throat, the distinction will for the moment be difficult. The appearances, the period after the primary affections, the concomi- tant affections, are such striking points of difference between the secondary and tertiary affections, that I think there are few of those who have read the preceding pages but will admit the distinction I have here attempted to depict. However, as these are novel points in surgery, I shall here recapitulate them. When the mouth or throat presents that superficial bleached ap- pearance, that excoriated condition of the mucous membrane, which ultimately becomes extensively but not deeply ulcerated ; when this character has been preceded by a chancre for some two or three months, and is attended with the scaly or tubercular papular eruption, together with condyloma on the scrotum or vulva, and little impair- ment of the general health, the surgeon will not, I should think, have much difficulty in distinguishing this as a syphilitic affection, and will justly style it the secondary form of sore-throat. See plate VI., fig. 2. If, on the other hand, the disease, commencing in the submucous cellular tissue, periosteum, or bony structure, ultimately destroys the mucous membrane of the mouth or throat, giving rise to a deep ex- cavated tawny ulceration, or if tubercles form in the substance of the tongue, which cause rents and ugly transverse fissures in that organ ; if, moreover, some two years have elapsed since the occur- rence of the primary sores ; and if, together with the above symp- toms, rupia and ill-conditioned sores occur on the extremities, to- gether with an impaired condition of the general health, the practitioner will be in no doubt as to the nature of such an affection, and I think he will with me call it syphilitic, but distinguish it from what I have above called secondary, and recommend that treatment which I shall presently advise. See plate VI., fig. 1. The diagnosis from other affections, not syphilitic, is not always so easy ; it is a very generally-received opinion, that all ulcerations about the throat are syphilitic ; and I have been often astonished at hearing this opinion from men holding high positions both in France and in England. In the present instance it will, I think, be neces- sary to make a few observations on the subject. In what respect, I would ask, do the tissues which form the walls of the mouth or pharvnx differ from those of other parts of the economy? I am acquaint- ed with none : hence, if (as is generally admitted) every other part of 292 SYPHILITIC AFFECTIONS the body be liable to various forms of ulceration, which are uncon- nected with syphilis, so may be the throat. I am personally unac- quainted with any cause which can give an immunity to the throat from the lesions which are common to other parts of the body, and I therefore think this opinion unsupported (though pretty generally received), that all ulcerations of the throat must necessarily be syphilitic. I have heard, however, an objection whispered, if such ulcerations exist, surely we must have seen them ! I might reply, as has been done on similar occasions, you are not omniscient; there are many things which you may not have seen, and yet which exist. I, however, waive such a reply, and would say, if you have not seen such cases, it is not from want of opportunities, but from paying insufficient attention to the history of patients, and to having preconceived notions on the subject. I have often heard a patient examined who denied altogether the existence of syphilis, nor could the surgeon either meet with traces of a cicatrized sore, or any concomitant disease whatever; yet he regarded syphilis as the cause, the reader will judge with what justice ; and then this same surgeon will assert that no other disease ever does or can occasion ulcerated throat. Let the reader or the skeptic peruse the following cases, and say if he has not met with many similar ones which prove the truth of what I have advanced, namely, that other diseases may produce severe forms of ulcerated throat. Case I.—A. B. No. 11. Salle 7. Hopital des Veneriennes. February 8th, 1839. Complains of sore-throat; on examination, some redness of the amygdalae is apparent, but unaccompanied with ulceration ; on firmly depressing the tongue on the right side, at the back of the pharynx, a dirty secretion is seen, which, on being removed with a probe, dis- played an irregular sloughing surface, extending as far down the throat as was visible. The patient gives the following history of himself: A wagoner by trade, he has enjoyed good health to the moment the present com- plaint began. His family not subject to scrofula. In the month of February last (twelve months ago), while driving his team to Paris, he was seized with a severe sore-throat, which he paid little atten- tion to; but about Easter it became so much worse,that he was con- fined to his bed for fifteen days. Gargles and leeches were applied. OF THE MUCOUS MEMBRANE. 293 Since that period his throat has never been completely well, but he has pursued his avocations as usual. The patient states that his master was seized with a sore-throat about the same period as himself. A short time since, this patient was recommended to come to Paris, and entered the wards of La Pitie under M. Piorry ; but that gentleman, finding little benefit follow his treatment, sent the patient to M. Ricord. The patient denies ever having had any venereal complaint, and at first did not know what it meant until this was explained : there is no apparent reason for his telling an untruth. I omit the observations I made at the time on this case, or on the success of the treatment. Feb. 26. This patient went out to-day. The ulceration has com- pletely cicatrized ; there is, however, some thickness in his speech. Case II.— V . . . Eighteen Years of Age. Salle 7, No. 27. Hopital des Veneriennes. February 6th, 1839. This patient is a boy—very young-looking for his age ; of a pale, languid habit of body ; complaining of his throat. After well rinsing out the mouth and throat, and before a good light, I examined care- fully the affected parts. The uvula is completely destroyed; the amygdalae are likewise in great part wanting; the back of the pharynx is covered with a thick ropy mucus, which, on being re- moved by means of a probe and lint, shows a partly ulcerating, partly cicatrizing surface, covered with large flat fungous granulations, irregularly scattered over the throat, and looking very irritable. The pulse is feeble, and the appetite bad. The patient states that previous to his twelfth year he enjoyed excellent health, when he was affected with fistula lacrymalis of the left side. Has never had either clap or chancre, and the genital organs are very small; no traces of chancre to be observed. He has lived in Paris five years with his parents ; is well fed and lodged. A twelvemonth after the occurrence of the fistula, for which he was treated by M. Recamier, his throat first became bad ; for this he took sarsaparilla and pills, two daily, for a long time (he says from Octo- ber to March). He left the hospital in March cured, and remained so for eighteen months. He again entered the Hotel Dieu, and was treated from October to January ; not being successful this time, the case was considered a fit one for the Venereal hospital, and he was sent to M. Ricord. 294 SYPHILITIC AFFECTIONS I find in my note-book, on the 22d of February, this patient was dismissed for refractory conduct, very nearly well of his complaint. Should my readers now admit the existence of chronic ulcerations of the throat following acute inflammatory affections, or if they con- sider that I have adduced proof of a scrofulous affection (a thing not unfrequently to be seen in institutions dedicated to strumous diseases), they may expect to learn what are the means by which they can be distinguished from the tertiary form above spoken of. To these dis- tinctions I shall now particularly allude. When the patient denies the pre-existence of primary sores, and his assertions are borne out by other appearances which corroborate them, such as the absence of cicatrices, of marks of secondary or tertiary symptoms, past or present, we have negative evidence of great importance in arriving at a correct diagnosis. I may here observe, however, that the pre-existence of chancre does not enable the surgeon to arrive at the conclusion, that the affection which the patient is at present laboring under is syphilitic. In the present day, to arrive at a correct opinion, more is required than the pre-existence of syphilis, for we do not say post hoc, propter hoc; and I have seen several cases of patients who have acknowl- edged that they had primary sores, yet I have believed the affections to be scrofulous, for reasons to be stated below ; hence neither the non-avowal of patients of having had chancres, nor their acknowledg- ment, will of itself influence our diagnosis. Caution in either case must be used. The positive evidence of an ulceration being scrofulous may often be derived from the general condition of the patient, his age, and the position of the ulceration on the back part of the pharynx, although at a later period it may extend to other parts of the throat. The history of the case, and the little probability of its being scrofulous, from the conditions noted above, will induce the belief that an ulcerated throat may often depend, like others, upon chronic inflammation, and on an atonic state of the system. I have lately seen a case, under Mr. Lawrence, at St. Bartholo- mew's hospital, which induces me to ask if scurvy will not produce a similar affection of the throat to syphilis, although I am not aware that authors who have treated specially of scurvy allude to it. The case is the following :— A boy, eighteen years of age, entered Henry the Eighth ward, complaining of his throat; on examining it, a large ulcer was apparent on the back part of the pharynx, of some months' standing. He was OF THE MUCOUS MEMBRANE. 295 in a weak state of health, had lived badly, and dwelt in a low, con- fined alley. The peculiar feature of the case was the spongy, fun- gous state of the gums, and the existence of petechiae on various parts of the body, particularly on the abdomen. Now this patient, some years before, had a chancre, probably a phagedenic one, for on his entrance we observed on the prepuce a cicatrix, as large as a shilling, which was much lighter colored than the surrounding skin. The sore, the patient stated, was healed in about a month after its appear- ance, and from that time to the present date, October, 1840, no symp- tom of any kind followed ; and, with the exception of the throat, the gums, and the petechiae, no traces of secondary or tertiary syphilis existed. Was, then, this a scorbutic affection ? I leave others to decide ; for my own part, my opinion will be decided by future experience. I might mention that the patient improved under occasional fumiga- tion, and went out nearly well, after the use of the hydriodate of potash and a nutritious diet. It still remains for me to speak of the diagnosis between the ter- tiary syphilitic affections, aud cancer of the tongue and throat. The indurated state or tubercles on the tongue have often been mistaken for cancer, and the distinction is not a little difficult even to those who have had frequent opportunities of seeing both com plaints. The principal points of difference are, however, the fol- lowing :— The History.—On this sore little information can usually be de- rived, inasmuch as cancer may come on in persons who have suffer- ed from chancres ; instead, then, of clearing up the diagnosis, the history of the case would only mislead the practitioner. I have stated that tertiary symptoms may appear, although the patient be- lieves and states that he has never had primary symptoms. Hence too much stress must not be placed on the history alone. Previous to ulceration of the tubercles, I have noticed that the number and position of the indurated points are different in the two affections. Thus in cancer there is usually but one, in syphilis there are several. In cancer the disease is seated at the side of the tongue, close to the teeth, about opposite the first molar. In syphilis it is the dorsum of the tongue which is affected. The same rule has been observed when the affection takes on an ulcerative character; then the characteristic features of the two complaints become more marked. In syphilitic affections, the ulce- ration is covered with a dirty, foul secretion, and the glands in the 296 SYPHILITIC AFFECTIONS neck are but slightly swollen. In cancerous affections the ulcers are clean, florid, looking as if they were about to throw out healthy granulations ; yet weeks and months go on, and no restorative pro- cess is set up, and the glands in the neighborhood become of that stony hardness so peculiar to cancer. I have been able to place but little confidence in the general ap- pearance "of the patient, for in both affections a yellow cadaverous look is met with. The cautious surgeon will, however, not readily give an opinion until he has commenced the treatment; it is the best means of diag- nosis, for I need not say that the one can be only palliated. Hap- pily surgery can triumph over the other. Prognosis.—This must be gathered from the preceding pages: it follows that it must be much modified by form, stage, complications, condition of the patient, number of relapses, and the treatment that has been pursued. The surgeon should always inform his patient that the disease can be checked, but he must be given to learn, at the same time, that no means exist of regenerating bones or mucous membrane ; otherwise the surgeon will often be blamed for causing that which the disease has done previous to the time he was con- sulted. Treatment.—The indications of treatment are few, and must present themselves at once to the mind of the reader from what has preceded. In the first place, every exciting cause must be removed which can in any way aggravate the complaint. In public practice, no sooner does the patient enter an hospital than the effects of a warm bed, nutritious diet, and abstinence from spirituous liquors, at once suffice to relieve many of the symptoms. The surgeon's next object is to reduce the local irritation ; for this purpose a sedative mucilagin- ous gargle is very useful, together with a few leeches applied to the angles of the jaws, if the condition of the patient allow it; small doses of morphia will tend greatly to quiet that general irritability of system so frequently found combined with ulcerations of the throat; at the same time tonics, particularly the vegetable ones, with good, nutritious, unstimulating food, will be most efficacious. As the con- tact of the teeth with the ulcerating surfaces is very prejudicial, a layer of lead, such as is used by grocers, may be employed as a protective means ; and it will be often necessary to attend to the state of the gums and teeth, for the tartar accumulated around them causes great local irritation. When all these preparatory steps have been taken, the surgeon OF THE MUCOUS MEMBRANE. 297 may then commence the employment of that heroic remedy, the hydiodate of potash; given in doses of three grains at the com- mencement, this substance should be increased in quantity every five days, and patients have, without danger, taken one hundred and twenty grains in the twenty-four hours. Its first effect is to increase all the secretions, and the appetite is not the last to receive an im- pulse from this salt. Its principal action, however, is on the ulcera- tions ; the secretion is first checked, then altogether stopped ; healthy granulations spring up in the centre of what was lately a slough, and often require to be repressed by the nitrate of silver. In some of the more chronic cases a local stimulant is necessary, a gargle is often all that is required, composed of iodine and water, in the pro- portions of 3j to f viij., of water, or the edges of the ulcer may be touched with the tincture of iodine. The appearance of the throat after cicatrization is very curious; bridles of a thick mucous mem- brane, of a peculiar mother-of-pearl white, are seen running in differ- ent directions, which differ much from the surrounding mucous membrane ; to the uninitiated these white bridles look like so many patches of lymph, and I have often wished to remove them with a probe, so convinced was I that a mere layer of lymph was seated there. This is the usual rapid progress of the cure. Examples, however, occur which cause the surgeon to despair; the local irritation does not diminish, and no attempt at cicatrization is observed. In such cases the presence of a portion of dead bone may be anticipated, and can usually be detected by a probe : as long as this remains, it must cause mischief; it should be removed with caution as soon as it can be detached, for however efficacious the hydriodate of potash may be, it can not produce absorption of a dead portion of bone ; it is the forceps of the surgeon which most quickly gets rid of it, and the case will go on prosperously afterward. When complete cicatrization has occurred, the deformity that re- mains is often considerable, though not to such an extent as may have been expected; the speech of the patient is not distinct, in consequence of those bridles of mucous membrane above spoken of, and if a communication exist between the palate and nose, that peculiar nasal twang betrays the nature of the accident. These are permanent defects that medicine can not cure, but various mechanical contrivances, called obturators, may be employed with considerable success. As regards any operation for the purpose of bringing the sides of 298 SYPHILITIC AFFECTIONS OF THE EYE. these fissures together, it should never be sanctioned ; the tissues around are not highly organized, and union by the first intention will not. take place ; the knife detects a lardaceous substance, which readily sloughs; so that all rhinoplastic operations are now given up, more especially as great relief may be obtained from the obtura- tors. It must not be forgotten, however, that as foreign substances they will produce great irritation, and may require to be left off. SECTION IV. SYPHILITIC AFFECTIONS OF THE EYE. The eye, like the skin and throat, may become affected by syphilis in both its secondary and tertiary forms ; the importance of the organ, and the rapidity with which the disease can destroy the tissues com- posing it, deserve the particular attention of the reader. SECONDARY AFFECTIONS. Among the patients admitted into the London hospitals, covered as they often are with scaly and tubercular eruptions, the surgeon may frequently corroborate the statement of Mr. Lawrence, " that syphilitic eruptions frequently appear on the external surface, and on the ciliary margins of the lids." We may often be able to trace the gradual changes between the affections of the skin and mucous membranes, corroborating the statements we have made elsewhere, that they are but one and the same disease, appearing on tissues which closely resemble one another. In some instances the corners of the eyelid have that cracked, scaly appearance, well delineated, as occurring at the angles of the mouth, in plate V., fig. 4. In other cases a distinct papule, one half like psoriasis, the other similar to mucous tubercle, may be witnessed on the ciliary margin ; more rarely, we observe a softened condition' of the mucous mem- brane, which is reduced to a sort of pulp, and at the same time the conjunctiva is very red and flocculent; one or more small pustules of the size of pins' heads may appear on this softened membrane. I have not yet seen the bleached excoriated surface on the palpebra so frequently seen on the mouth and tongue, though analogy would expect us to meet with it. Usually, the symptoms above described SYPHILITIC AFFECTIONS OF THE EYE. 299 do not occur alone. There is more or less redness of the tunics of the eye; there may be oedema or inflammation of the lids, and usually the body bears marks of other syphilitic eruptions, particularly the scaly or tubercular form, and the secondary symptoms as they occur on the throat, head, anus, &c. On the subject of Prognosis, Diagnosis, and Treatment, I have nothing to add ; it must be guided by the same indications that have been already so fully alluded to elsewhere. The conjunctiva is not the only component part of the eye which may become affected. The iris may simultaneously or consecutively show signs of disease, and this leads me to speak at length of this affection. SYPHILITIC IRITIS. History.—If the reader believes that any particular symptom of syphilis began to exist only about the period that we first meet with descriptions of it, he must conclude that syphilitic iritis first appeared about the year 1801, when Schmidt of Vienna* wrote an essay on the subject.| Since this period few authors on affections of the eye, or venereal diseases, have neglected to notice the complaint, con- sidering it more or less confidently as a syphilitic symptom. I should not dwell upon this fact, did it not serve to explain differences of opinion on the history of venereal diseases, and show how easily so important a symptom as iritis was overlooked by them, and by * Since writing the above, I have obtained possession of a very rare book, written in 1773, entitled, " Exposition Anatomique des Maux Veneriens sur les Parties de l'Homme et de la Femme," par M. Gautier Dagoty Pere. Paris, fol., plates. He says, page 9: " It happens that persons become blind, not by an obstruction of the optic nerves, as in cases of the Goutte sereine, but by a thickening of the vitreous and crystalline humors, which lose their transparency, preventing the rays of light from falling upon the retina. The salt and acid nature of the virus is very fit to pro- duce this effect upon the humor which it coagulates. We observe an infinity of con- cretions of the aqueous humors, which seem to form cataracts, which moving about in this humor cause objects to appear as if pierced, like a spider's web, or as little flies ; this is occasioned by a relaxation of the glands, which allows these lymptiatic concre- tions, thickened by the virus, to pass into the body of the humor, thus confirming my hypothesis. It seldom happens that a person recovers from these affections by means of the sovereign remedies (les grands remedes).* However, patients are met with who do recover sufficiently well to find their way about, read and write, which they can not, however, previous to submitting to these sovereign remedies. t Nachstaar und Iritis Nachstaar Operationen, 4to. * Grands remedes meant, in 1773, to employ frictions until a patient spat one or two pints of saliva in twenty-four hours, and the salivation was to be kept up eighteen or twenty days. I quote the words of the author at page 15. 300 SYPHILITIC AFFECTIONS OF THE EYE. authors of the present day. If, then, modern, authors, previous to 1801, have failed to describe iritis, or connect it. with syphilis, can we be surprised that those who wrote previous to 1496 should not have accurately described primary symptoms, or connected them, as we do now, with general infection and various affections of the skin which we call secondary symptoms ? On looking into the most modern treatises, I find that Mr. Law- rence describes a distinct syphilitic affection of the eye. Mr. Tyrrell speaks simply of iritis, although he admits " that a specific taint, by its influence upon the system, no doubt, in many cases, modifies the local disease." Mr. Bacot seems to have no doubt that syphilitic iritis is a con- sequence of general contamination of the system. Sir Astley Cooper states, however, at page 299 of his lectures, " I have, I must say, considerable doubt on the subject, for I have never met with a person laboring at the same time under any other secondary symp- toms of syphilis, with eruptions or nodes on the bones." M. Ricord speaks of syphilitic iritis, and gives a brief description of it in his Notes on Hunter. Mr. Carmichael likewise admits a venereal iritis, although he says it is difficult to distinguish it from the other forms, except by the presence of some other venereal symptoms. My own opinion has been greatly modified within this last twelve- month. During the period I carried on my investigations on venereal diseases in Paris, although my opportunities of seeing disease were immense, I witnessed so few cases of iritis, compared to the great number of syphilitic complaints, that I was induced to deny any re- lation between them. At one period of my studies I would have corroborated the statement of Sir A. Cooper, and I believed that the few cases which I witnessed were mere coincidences, so slight were the secondary symptoms which attended the complaints; and it was my intention to exclude syphilitic iritis from this treatise, so unsatis- factory were its diagnostic signs. I even could not go so far as Mr. Tyrrell, and believe that " a specific taint, by its influence on the system, no doubt,in many cases, modifies the local disease." When, however, on my return to London, I wished to corroborate my views, my confidence became shaken, and I had not long witnessed the severe cases to be met with weekly in St.. Bartholomew's and other London hospitals, before I began to see the correctness of Mr. Lawrence's description, as given in his valuable work on " Venereal Diseases of the Eye," without, however, being able to diagnose the SYPHILITIC AFFECTIONS OF THE EYE. 301 affection always from that which is the consequence of rheumatism or gout, by the symptoms which, as I shall presently show, are not always to be met with. Symptoms of Syphilitic Iritis.—Were this treatise one which professed to treat on affections of the eye, I might be induced to dwell at great length on the various symptoms of iritis, but I must here refer such of my readers as would require a knowledge of them to Mr. Lawrence's admirable description. For my object, a very cursory enumeration will be sufficient. The syphilitic affection of the iris is usually ushered in by con- siderable constitutional disturbance, headache, inability to sleep from constant pain over the brow, which is aggravated toward evening; but, as Mr. Lawrence observes, even in acute cases such symptoms exist only in a slight degree, or are entirely wanting. Mr. Tyrrell lays great stress, and I think deservedly, on the state of the general health and constitution ; in nearly all the case that have come under my notice, the powers of the system were depressed by bad treatment, insufficient food, exposure to all the inclemencies of the weather, frequent attacks of syphilis, excesses of all kinds, and, lastly, severe depletory measures ; even in cases where these circumstances have not been so very apparent, the result has shown that the power of the pulse was usually deceptive, and the disease rarely accompanied with evident inflammation ; when blood is drawn from the arm, it does not present a firm coagulum, but is sizy, dark- colored, and contains more than its average quantity of serum. The skin is dusky or cadaverous, and often covered with eruptions, as I shall have again occasion to allude to. When the eye is viewed under a strong light, intolerance of that agent is very marked, or it may be little affected ; usually, there is more or less external redness of the eye, in the form of a red band round the cornea. " The iris," says Mr. Lawrence, " becomes changed in color ; a light-colored iris assumes a yellowish or greenish tint; occasionally it is distinctly yellow ; and if the eye be blue, a bright green is some- times seen. Generally, however, the tint, whether yellow or green, is of a dull, muddy cast, and darker than in the sound state." When the iris is naturally dark-colored, it presents, when inflamed, a red- dish tinge. Its natural brilliancy disappears, and its beautiful fibrous arrangement is lost, absorbing the rays of light instead of reflecting them, as Mr. Tyrrell observes. The color of the iris is not only thus altered in consequence of the effusion of lymph into its inter- 302 SYPHILITIC AFFECTIONS OF THE EYE. stices, but it becomes thickened and fringed. Coagnlable lymph is likewise effused in distinct globules or masses, usually presenting a reddish color on the surface or margin of the iris, which appearance has been compared by Beer to condylomata. There is, at the same time, partial closure of the pupil, or adhesions of the iris may occur, and the pupil be drawn in a variety of directions ; but none of these changes are peculiar to syphilitic iritis. Vision is of course impaired in various degrees. . Syphilitic iritis may occur at any period of life ; Mr. Lawrence mentions two cases in children: in one the child was eighteen months old. But the disease is most frequently seen during the middle period of life, as persons are most liable to syphilis at this age. In analyzing the cases which Mr. Lawrence has reported, I find that one man out of the seventeen had arrived at the age of fifty-three years. Among the thirteen cases of females, two are stated to have been thirty-five years of age, and one to have arrived at forty-five. Now, if any deduction can be drawn from statistics of thirty cases of syphilitic affections of the eye, I might state that in this number seventeen occurred among men, and thirteen in women ; this propor- tion of females is large, if compared with the number of males and females, who are laboring under secondary symptoms, for ten men apply at hospitals -for one female. This greater frequency in the female I must attribute to her greater exposure to the exciting causes —a subject I shall presently allude to. It is remarkable, likewise, in these cases, that we find so great a proportion of syphilitic iritis among persons of advanced life. Syphi- litic affections are rare at this period compared with the earlier ones, and yet no less than four cases exist in thirty. This corroborates an observation I have myself made, that, ceteris paribus, iritis is more frequent at the later periods of life, and advanced stages of secondary symptoms. Mr. Lawrence's thirty cases further prove that syphilitic iritis occurred twelve times in persons of good or moderate constitu- tion, and five times in cases of an opposite nature. In the thirteen other instances, no notice is taken of the condition of the patient, but it may be inferred from statements made in the course of treatment, that the constitution was greatly impaired. This, again, agrees with an opinion I have above advanced, which I find coincides with the statements of Mr. Tyrrell. Causes.—In the preceding paragraphs I have traced the cause to constitutional infection, in common with syphilitic secondary symp- SYPHILITIC AFFECTIONS OF THE EYE. 303 toms, therefore it is not my object here to allude again to this cause ; but as every case of secondary symptoms is not accompanied with iritis, it is necessary for us to study the exciting causes, as they may lead to the prevention of the complaint. On consulting authors, however, I have been able to gain but little information on this point; I must, therefore, depend upon my own obser- vations. I have already mentioned that the disease is rarely met with in Paris, compared to London ; of this fact. I have no doubt ; but of its explanation I am not so certain. I believe it to depend upon the following circumstances : the French prostitute, from the strict vigilance of the police, rarely suffers under any severe form of secondary symptoms ; because the primary ones are instantly attend- ed to, and should secondary affections supervene, measures are at once taken to check their progress ; hence this, then, sufficiently ac- counts for the fewer number of cases among this class of women. Why iritis is rarely met with among the male population, I was some time in discovering, but my investigations have led me to the following conclusion : those patients, or at least the majority I have seen in London, belong to one or other of the following classes : some appertain to the poor, half-starved, emaciated Spitalfields weavers, who have no creature comforts, are ill fed, badly clothed, and worse lodged ; disease has a greater hold upon them than the well-fed mechanic. Other patients in London, who suffer under iritis, belong to the class addicted to drinking large quantities of porter or gin ; they are bloated and unhealthy, and furnish a large number of those afflicted with severe syphilitic affections. In Paris these two classes barely exist. Where will a surgeon see a being that he can compare to the sickly mechanic of London, who has but work three days in the week, and spends his earnings in gin? Neither gin nor porter is indulged in at Paris by the lower classes, and hence, in that capital, we do not witness those deplor- able pictures of penury, gin-drinking, and dissipated habits, to be met with at each step in our London hospitals. I am inclined, then, to attribute the exciting causes of iritis to ex- posure, when the system is depressed or over-excited by want, cold, damp, dram-drinking—for it is in such cases that we witness the most formidable instances of iritis. J have clearly traced more than one case of iritis to cold caught from the patient's bed being exposed to a draught of air. In most cases there exists an assignable cause for the affection of the iris, independent of the syphilitic infection. 304 SYPHILITIC AFFECTIONS OF THE EYE. The Prognosis may, generally speaking, be favorable, but must always depend upon a variety of circumstances. When seen in the early stages, and the constitution is good, a favorable result may be always anticipated ; but when the disease has been left unchecked by treatment, or has become chronic in consequence of ill-directed treatment, or the lymph effused has become organized, or the con- stitution very much reduced, the surgeon should not too favorably judge of the case. Even here much may be done, although too often the patient escapes with an impaired organ and feeble vision. I should here state that relapses are not unfrequent. Diagnosis.—It is not my intention in this section to enumerate all the diseases with which iritis may be confounded, or to speak of the various means which we must employ to distinguish the syphilitic from the other forms ; I shall only allude to those which will most materi- ally assist the student, as the greater number of those that have been vaunted are now found to be useless. The History of the case is a circumstance which may either assist or mislead the surgeon, when taken alone; yet it is the diag- nostic sign that I mostly rely upon. When a patient has had syphilis, it does not follow, as some would believe, that iritis depends upon it, for, I have had previously occa- sion to observe, a certain period must have elapsed, and this will often be modified by the treatment which has been had recourse to. Usually, when mercury has not been employed, the patient who labors under syphilitic iritis will tell you that three months after a primary indurated sore, eruptions appeared on various parts of the body, which continued, and some weeks later iritis followed. When mercury has been used, the secondary symptoms occur later, and so does the iritis; but even here a twelvemonth seldom passes between the chancre which has preceded, and the iritis which is a consequence of it. Under the head of history I may mention the other coexistent symptoms. Thinking that statistics may, in a case like this, be use- ful, I have analyzed Mr. Lawrence's thirty cases. I find that in nineteen male patients iritis was accompanied—four times by a papular eruption ; once by sore-throat; seven times by a scaly tubercular eruption ; by no symptoms in three cases ; no notice is taken of an eruption in one case ; in three cases, eruptions not specified are said to have occurred. In the eleven females the iritis was complicated—twice with the papular eruption ; twice with sore-throat ; three times with a scaly SYPHILITIC AFFECTIONS OF THE EYE. 305 eruption ; with the pustular once ; condylomata were present in three cases ; one case presented no other secondary symptom ; the perios- teum was affected in one case; the remaining one had a primary sore. In forming a diagnosis, then, these thirty cases lead to the con- clusion that great stress should be placed upon the coexistent second- ary symptoms, and my own experience leads me to infer, that on them alone our diagnosis can be founded, for all other supposed syphilitic characters may be wanting. Ophthalmologists are now convinced that the color of the lymph, the direction of the adhesion of the pupil, &c, are signs common to all forms of iritis. When then iritis de- pends upon syphilis, it rarely occurs as a sole symptom ; in fact, so rarely, that it becomes a question if it be truly syphilitic iritis. The above statistics prove, most conclusively, that iritis occurs with a peculiar train of secondary symptoms, usually with the scaly, tubercular, or papular eruptions. Mr. Lawrence mentions having met with one case accompanied by a pustular disease, resembling scabies purulenta; but at page 231 he mentions that there exist like- wise copper-colored scaly blotches. It is curious that ulceration of the throat was so rarely met with by him. In almost every case of syphilitic iritis I have witnessed, it has been attended with a super- ficial excoriation. There is but one solitary case in which the periosteum was affected. This agrees with my view of the subject; hence I have with reason placed it among the secondary symptoms of syphilis. The preceding cases likewise prove that primary symptoms may not have disappeared when the iritis commences, as happened in five instances. Treatment.—The consideration of the causes will often enable a surgeon to prevent the occurrence or recurrence of the affection, and I shall not again refer to them, or state how these exciting causes should be avoided. When the disease is at its commencement, and the general symp- toms run high, it may be necessary to deplete generally and locally ; but this treatment should not be too long continued. Mr. Tyrrell has related several interesting cases to show the inefficacy of an- tiphlogistic measures when carried to excess. The preceding pages, moreover, show that the affection is not one of those complaints which would probably be benefited by bloodlet- ting ; and experience confirms this view of the subject. The indica- tions are, to relieve pain, which is said to depend upon inflammation of the unyielding sclerotic coat; to check that inflammation, prevent 20 306 SYPHILITIC AFFECTIONS OF THE EYE. theeffusion of more lymph, and cause the absorption of that which is already poured out ; destroy any adhesions the iris may have con- tracted, and. by dilating it, allow more light to enter the pupil. These indications are best fulfilled by mercury ; not, however, given in the manner that has been previously recommended. The importance of the organ, and the rapidity with which mischief may occur, demand a more liberal use of the mineral. The opponents of mercury are.here unanimous in favor of its utility; it is the neutral ground upon which we all meet. The preparation that modern surgeons prefer, is calomel and opium, in the proportion of two grains of the former to a quarter of a grain of the latter, given every six 01 eight hours : and as the disease yields, the frequency of the dosea may be diminished. There are some observations on the administration of mercury in Mr. Tyrrell's work, which will amply repay the attention of my readers. As that gentleman so justly observes, mercury is of in- valuable service even in the worst cases and most depressed states of constitution, provided we at the same time support the system by generous diet and a small quantity of stimulus. From a non-observance of this plan, mercury has fallen into discredit in some people's hands. In very weak and feeble constitutions, it may even be necessary to renovate, by tonics and stimulants, the powers of the system previous to commencing with mercury, which may be then employed as above described. When mercury gives rise to unfavorable symptoms, it should, however, not be persevered in ; its disagreeing with the patient will, however, usually depend upon inattention on the part of the oatient to diet, or to some other cause. The other indications are fulfilled by drawing blood from the temples, rubbing the brow with belladonna, and by attending to the state of the digestive organs ; these, and the indications we have given, will usually bring the case to a favorable termination. TERTIARY SYMPTOMS Generally appear on the eyelids in the form of ulcerations, for the first description of which we are chiefly indebted to Mr. Law- rence. I have lately witnessed several cases which that gentleman has had under his care, and they correspond in every respect to the account given in his treatise. Syphilitic ulcerations may commence on the papular secondary eruption which occurs on the eyelid, and which has been neglected or irritated; more frequently, however, as SYPHILITIC AFFECTIONS OF THE EYE. 307 Mr. Lawrence observes, " the ulcer commencing on the ciliary margin, where it is generally described as beginning with a small hardness supposed to be a sty, may occupy the whole thickness of the lid, involving all its tissues." The surface is usually grayish, with bloody points, the surrounding edges sloughy, and considerable inflammation may supervene. This form of ulceration I have not yet seen occurring without other tertiary symptoms. Mr. Lawrence, however, cites two or three such instances, but admits that they occur most frequently with other affec- tions. There are foul sores on various parts of the body, rupia, exostosis, periostitis, nodes, &c. The cases we have met with have not been in young people, but those advanced in life, and who have been reduced by excesses, or who are naturally of bad constitutions ; and, in all the cases we have witnessed, these ulcerations have occur- red at a very advanced period of syphilitic affections, generally eight or ten months after primary symptoms. Treatment.—Nearly all the cases I have witnessed of these affections have been treated by mercury, and, as Mr. Lawrence states, " I have found the free use of mercury to be the quickest and most effectual mode of arresting and curing the disease. As soon as its influence on the system was produced, the sores lost their syphilitic character, and then quickly healed." Notwithstanding this opinion, coming from such high authority, I would pause before prescribing the mineral. Modern surgeons find so much benefit following other means employed in tertiary symptoms, that I may perhaps be excused for recommending a milder treatment, and I believe that the cases I have seen treated and arrested by mer- cury would have yielded nearly as rapidly under other means. From what I have witnessed then, I should recommend the sur- geon to lose sight of the specific disease, and treat the case on gene- ral principles. A warm bed, good and generous diet, will alone often tend to put a stop to this species of ulceration ; local and general pain may be relieved by the internal use of morphia, the saturated solution of opium and warm poultices should be prescribed to the ulcers, and the hydriodate of potash, in doses above alluded to, may be combined with tonics. I have not yet seen this treatment fail in arresting ulceration; but I must likewise state that my experience has been limited. Did I, in spite of these means, observe the ulcera- tion increasing, I would without scruple immediately resort to mer- cury, to prevent the loss of substance which would occur in the lid, if the disease were allowed to go on uncontrolled. 308 SYPHILITIC AFFECTIONS OF THE TESTICLE. SECTION VI. SYPHILITIC AFFECTIONS OF THE TESTICLE. Occasionally we meet with an affection of the testicle coming on at a late stage of secondary symptoms, which has been variously termed by different writers. Sir A. Cooper has a chapter on the " Venereal Inflammation of the Testicle." M. Ricord entitles the affection Sarcocele Syphilitique. Symptoms.—Some months after the occurrence of primary symp- toms, the patient will complain of vague pains in one or both testi- cles, particularly felt toward night, and which shoot upward toward the loins. In other instances no pain is felt, and the patient is sur- prised at finding one or both testicles gradually enlarging, and he consults the surgeon merely on account of their additional weight. On examination by the finger, the organ will be found enlarged, heavier than usual, but without discoloration of the skin. The sur- face of the testicle will be more or less regular; its elastic feel will, however, be lost; the epididymis often participates in the enlarge- ment as well as the spermatic chord, and some fluid may be present in the tunica vaginalis. The functions of the organ will be generally impaired, but secretion of sperm still takes place, and in nocturnal emissions no blood will be observed mixed with the seminal fluid. Pathology.—Sir Astley Cooper, at page 104 of his work on the testes, says : " When the venereal poison affects the testicle, it prob- ably attacks the tendinous structure—for example, the tunica albuginea, and thence extends into its interior fibres, and not its tubular part; but this I allow to be hypothetical, and am led to that opinion from the structure of that part most resembling the periosteum in its tendinous composition, and from the very ready and complete recovery of the organ ; but I wish the reader to understand that I have had no opportunity of dissecting this disease." Causes.—The predisposing causes are similar to those we men- tioned when speaking of epididymitis ; we, therefore, shall not again allude to them. The exciting cause is constitutional infection, which seems in particular constitutions to give rise to the affection. The Diagnosis must generally be founded on the history and co- existing secondary symptoms, as well as on the absence of the symp- toms peculiar to other affections of the testicle, which it is not our intention here to allude to. TERTIARY SYMPTOMS. 309 The Prognosis is usually favorable : under judicious treatment we may expect to see the affection rapidly disappear, and the func- tion of the organ will be recovered when the disease is not of very old standing; under opposite circumstances, atrophy of the testicle, or a scrofulous or scirrhous degeneration may supervene. Treatment.—We have had occasion to speak several times, in the course of this work, of the wonderful action of mercury ; it is no less beneficial and rapid in its effects when given in syphilitic affec- tions of the testis ; in fact, little else but mercury need be prescribed ; the chronic course of the complaint calls generally for no other treat- ment, unless it be to support the organ ; we have occasionally seen resolution of the complaint expedited by compression, with strips of mercurial plaster, as recommended at page 88. CHAPTER III. TERTIARY SYMPTOMS. Definition.—By the term tertiary symptoms, we mean those con- stitutional syphilitic affections usually included under the name of nodes, inflammation of the periosteum, exostosis, caries, and tubercles of the subcutaneous and submucous cellular tissue; like secondary symptoms, they are not inoculable, but are incapable of transmitting, hereditarily, constitutional syphilis. History.__Previous to Hunter, these symptoms were confounded under the term secondary effects of syphilis, or constitutional syphilis. That original observer, without placing them in a division quite apart from the rest, thought it, however, necessary to distinguish them in some measure from secondary symptoms, properly so called ; hence we find them placed together, and classed under Paragraph III., in his work, which is thus headed : " Symptoms of the Second Period of Constitutional Syphilis." M. Ricord, in his classification, preferred separating them from secondary symptoms, and making a distinct division, which he has called tertiary symptoms. In the following description it will be seen that they differ from secondary symptoms in various points, and to a sufficient extent to authorize us in placing them in another division. 310 TERTIARY SYMPTOMS. Though they depend upon chancre, they follow it after a much longer interval; they are seated in other and deeper tissues, can not be transmitted from mother to child, but are capable directly of produ- cing in the offspring a scrofulous diathesis. Causes.—Those who have seen syphilis of late years treated by simple means, without the aid of any mercury, must, like ourselves have been able to observe the natural history of the disease uncom- plicated with those effects which we admit mercury may produce. In such cases we have been able to trace tertiary symptoms to the effects of the syphilitic virus, at first committing local ravages, next infecting the constitution, and, lastly, giving rise to such lesions as we are about to speak of. In consequence, then, of these symptoms appearing when no mercury or any other treatment has been had recourse to, from their occurrence usually after a certain period, from the primary introduction into the economy of the syphilitic virus, surgeons are agreed to attribute them to constitutional syphilis. It would be wrong to suppose, however, that syphilis, when left to itself, universally produced these effects. Experience has shown that in the majority of cases, fortunately for humanity, such does not happen ; this, then, brings us to the consideration of the Predisposing Causes.—It is not so easy to discover the predispo- sing causes of tertiary, as it was of secondary symptoms ; however, it is to the constitution that we may generally ascribe them, and to the treatment which has been null or injudicious ; still, tertiary symp- toms will occasionally occur, in spite of all our endeavors. Such cases are, however, of very rare occurrence. The constitution, as a predisposing cause, has a considerable effect. Observation shows that it is in persons of lymphatic tem- perament that syphilis commits the greatest ravages ; this we have seen throughout the whole history of the disease, and is more espe- cially true of this stage ; for, as we shall presently see, scrofula and tertiary symptoms have many points in common. Let it not be sup- posed, however, that it is only in the pale and the emaciated that we see such effects, for syphilis often appears in very severe forms in stout and plethoric individuals. The previous habits of the patient will act as a powerful predisposing cause : thus, a constitution naturally good, but depressed by dissipation, poverty, insufficient clothing, exposure to damp or unwholesome air—in fact, all those causes which induce secondary symptoms, have a great tendency to produce likewise the tertiary form. Previous disease will naturally have a great influence ; in the first TERTIARY SYMPTOMS. 311 place, we may mention the existence of secondary symptoms. It is a fact which can not be denied, that where syphilis has produced secondary symptoms, with or without treatment of the primary sore, the probability, is, that the tertiary form will sooner or later make its appearance, showing a tendency in the constitution, which, if not controlled, will produce the worst effects. The severity of the form of secondary symptoms, the late period at which they have been treated, the obstinacy with which they have resisted, and the length of time the syphilitic- temperament has existed, are so many predis- posing causes, and v/ill furnish the surgeon with so many indications which may induce him to judge of the probability of their occurrence. The Treatment of the Primary and Secondary forms may act as a very powerful predisposing cause. We shall not here repeat what we said, when speaking of primary sores, under the head Predis- posing Cause of Secondary Symptoms ; the same observations apply equally to tertiary symptoms. With respect to the treatment of secondary symptoms, daily observations prove that if they be treated without mercury, tertiary symptoms will frequently occur ; that even when mercury be employed at an early period of their (secondary symptoms) occurrence, the appearance of tertiary symptoms can not be prevented ; that in such cases, provided the mineral has been used judiciously, they will, however, be slight; lastly, that if mer- cury have been indiscriminately used, or if the precautions spoken of under the chapter on the employment of mercury, be not attended to, tertiary symptoms will not only occur in spite of, but become complicated with, those effects which depend upon the mineral; thus, the constitution will be depressed, and the two diseases carried to an extent that now fortunately is rarely witnessed. Course.—This stage of syphilis has a peculiarly chronic charac- ter. In the majority of cases, and under the circumstances above described, the secondary form passes insensibly into the tertiary, for we should be guilty of a great fault, did we lead our readers to sup- pose that the limit between the two stages is always distinct ; in the natural course of syphilis, this transition is insensible, without any accession of general symptoms, the tertiary form appearing fre- quently during the existence of the secondary, in the same way that the latter may come on during that of the primary. Under other circumstances, from treatment, care, &c, the secondary symptoms have successively disappeared and returned ; and, lastly, assume the tertiary form. Finally—and these are by far the rarest cases after the treatment 312 TERTIARY SYMPTOMS. of a primary indurated sore by mercury—a considerable lapse of time may pass away, and secondary symptoms do not follow ; when, after exposure to cold, from disease or some exciting cause, tertiary symptoms all at once declare themselves, at first under a slight form, but successively increasing in severity. Such cases, though rare, we have met with ; and they further prove the protective power of mercury, though they militate against the idea of its specific powers. The Complications are various ; inflammation, gangrene, scor- butic diseases, scrofula, may occur, masking altogether the disease, which gradually loses its specific appearance, and degenerates into a general disease of the economy. Of course, as one or other of these complications occur, so will the course of the tertiary symptoms be altered, and the termination be different. The Prognosis is always grave ; it shows that syphilis has made deep inroads on the constitution, and that its cure will require time, and a treatment which demands patience on the part of the surgeon and the patient; the latter, however, should be made aware of the precautions necessary to be taken, and the consequences of their non-observance; although we may often triumph over the disease, we are liable to see it return ; and there are cases in which our treatment can be only palliative, or the patient, having consulted us too late, is obliged to bear the deformities which nature is unable to remove, although art may frequently alleviate them. Diagnosis.—The reader will doubtless have remarked, that as we receded from the point of primary infection, the diagnosis became less certain ; that during the ulcerative period of chancre, a positive diagnosis could be arrived at though inoculation, but when cicatriza- tion had once taken place, we were obliged to confine ourselves to a rational diagnosis. This became more evident as we spoke of secondary symptoms ; however, we showed that there were certain features which are peculiar to secondary symptoms, as, for instance, mucous tubercles, seen in the frontispiece. In the form we are describing, however, our diagnosis must be founded on rational principles alone, for we have no certain test. The history, the antecedents, the course, concomitant circumstances, the treatment, the character of the affections, will, if taken together, indicate the nature of the complaint, and enable us to form a diag- nosis, but this should be always done with caution. The treatment must still be such, that if our diagnosis be incorrect, the remedies made use of can not be injurious. This is a rule that, our readers will shortly be enabled to appreciate. pi. vm. •v .v-jr"'.' ■ - •'• TERTIARY SYMPTOMS. 313 Particular description of Tertiary Symptoms.—This stage of syphilis, as stated in our definition, seems to attack the submucous and cellular tissue, and the osseous system, in preference to any others ; to the description of each of these we shall now direct the attention of our readers. Lesions of the Subcutaneous Cellular Tissue.—At a late period after the first occurrence of secondary symptoms, and in persons whose constitutions are deeply affected by constitutional syphilis, small tumors may be observed, either isolated or occurring on various parts of the body. At first the patients pay little attention to them, as they are not accompanied by much pain, and produce no uneasi- ness ; the first notice taken of them is often some months after their first appearance ; they may be hard, and unattached to the adjacent structures. When after several months they have attained the size of a hazel-nut, a distinct fluctuation may be perceived through the hard shell which surrounds them, and which is firmly impacted in the cellular tissue. The skin over them may become discolored, thin, and ultimately ulceration of the surface follow ; thus the small tumor may make its way to the surface, and by one or more openings a serous or ichorous discharge take place. Fistulous openings result, and may extend by ulceration, or in consequence of inflam- mation corning on in the surrounding tissues, and it is kept up by the irritation of the cyst, which does not usually become wholly separa- ted. When, however, this happens, cicatrization slowly follows, leaving a considerable depression at the point affected. No sooner, however, is one tumor removed, than another appears on some other part of the surface, or several may run through this course at once, during a period of several months. These tumors may be observed on every part of the body, we have frequently noticed them on the tongue, where, from shackling the movements of that organ, they give rise to great inconvenience, and it is from their rupture that those rents or deep crevices are occasionally seen in the substance of the tongue. Among others, we have lately witnessed a very severe case in the person of a medical man at Bordeaux, which, however, ter- minated in a favorable manner. These tumors may be the only symptoms present, as in the case just mentioned ; but more frequently they co-exist with affections of the bones or mucous membranes. The tumors may exist in the submucous cellular tissue; at least we have observed in the throat, on the palate and pharynx, the chronic swellings which eventually are converted into the most in- 314 TERTIARY SYMPTOMS. tractable ulcers ; and as the bones at first do not seem diseased, though they subsequently become so, we are justified in concluding that these tumors have their origin in the submucous cellular tissue. Tertiary Symptoms, as they occur in the Osseous System.—The earliest notice of constitutional syphilis attacking the bones consists in pain at first of a vague or intermittent kind, like that of rheumatism ; sooner or later, however, it becomes fixed to particular bones or por- tions of bone, and is more severe at night; these nocturnal pains are, however, not peculiar to syphilis ; they occur in other diseases, and depend upon the resistance made by the periosteum to any swelling of the bone itself; thus, then, the pain is often the first symptom of inflammation of the bone ; it is, however, at the com- mencement, very difficult to distinguish from rheumatism, though the latter, as M. Ricord observes, usually appears at a different period, is not generally fixed, is more superficial, and attacks by preference the joints, or those portions of bone around them. Periostitis, says M. Ricord, is a disease less frequently met with than is generally imagined ; and the effects attributed to it depend more frequently upon a superficial ostitis; he, however, describes three varieties. They have the following characters in common : they consist of small tumors, more or less circumscribed, situated most frequently on the superficial bones, as the clavicle, tibia, ulna, radius ; on the bones of the cranium, sternum, metacarpus, and particularly on those points of these bones nearest the surface. They are sometimes indolent; more frequently, however, painful on being touched, and the finger may detect a sort of doughy feel, or fluctuation may be more or less apparent. The skin which covers them may remain moveable and unchanged. Periostitis, though susceptible of resolu- tion, may terminate in suppuration or abscess. The first variety, which is often indolent in its course, is capable of resolution. When the diseased structure is divided, we find a tumor containing a serous liquid, such as may be witnessed in scrofulous patients ; in other cases the fluid resembles synovia. In the second variety, the affection may be an acute or subacute inflammatory one, and free suppuration may follow ; but in such cases we rarely fine the surrounding bone sound ; whether this has taken place previously or subsequently, it is difficult to decide. The third variety is more slow in its progress, at the same time that it is more painful {sua sponte), as M. Ricord terms it; that is to say, when no pressure is made upon it. On examining such tumors, TERTIARY SYMPTOMS. 315 they will be found to consist of organizable lymph, which raises up the periosteum, and is capable of producing one form of exostosis. Ostitis shows the same preference as periostitis for particular regions. Circumscribed in some cases, in others diffused, it may attack the superficial parts, or the parenchymatous structure of the bones. Although chronic in its course, it may assume a subacute form ; and after having existed a considerable time without giving other indications of its presence than pain, the swelling it ultimately gives rise to betrays itself externally. This tumor, which ultimately succeeds inflammation of the bone, sometimes depends on a deposi- tion of osseous secretion similar to the callus around fractured bones, or resembles that we have described as seen in the third variety of periostitis, and constitutes an epigenic exostosis, differing in form and volume, having a large or pedunculated base, and a smooth or irregu- lar surface. In other cases the swelling may depend upon general hypertrophy of the whole thickness of the bone, giving rise to the parenchymatous exostosis, or hyperostose. Ostitis may terminate in resolution, in suppuration or caries, in necrosis, or in induration like ivory; this constitutes the eburnee of French writers. The termination by resolution easily takes place when the swelling depends on a cellular layer of bone, or on a deposition of plastic lymph. When the disease is seated in a spongy bone, those of the face for example, and particularly in the maxillary bones, suppuration readily and frequently occurs. Necrosis, although frequently caused by the violence of the inflammation, in proportion to the vitality of the osseous system, still more frequently occurs in consequence of depositions taking place suddenly in the tissue, or from the bone being laid bare, or the destruction of the soft parts which surround the bones, thus depriving them of their sources of nutrition. Necrosis may occur previous to the appearance of caries, or simultaneously with or subsequently to it; most frequently, however, as may be often observed in diseases of the bones of the face, what has been considered as a necrosis is nothing less than the result of caries, by which the whole organic tissue has been destroyed by means of ulceration and suppuration peculiar to bones, leaving noth- ing more than the calcareous portions, which thus form a sequestrum very different from necrosis properly so called, and in which we may find the anatomical elements of the bone. Lastly, the termination by induration, or the conversion of bone into ivory, takes place in consequence of a deposition of the saline in- 316 TERTIARY SYMPTOMS. organic matter which enters into the composition of bones, together with a more or less complete disappearance of the cellular tissue. Treatment.—The preventive and prophylactic treatment of ter- tiary symptoms will consist, in a great measure, in the employment of the same means spoken of in the preceding chapter, and in atten- tion to the rules there laid down. We think it, therefore, unnecessa- ry to return to that subject here. The same remark applies to causes both predisposing and exciting. The knowledge of any predisposing cause being attained, the surgeon will necessarily remove it if it already exist, or prevent ils development by all the means in his power; this can not always be obtained, however much it may be desired, or the patient demands our advice too late ; it then behooves the surgeon to remove, in as short a time as possible, the effects produced ; and this brings us then to a consideration of the Curative Means.—In M. Ricord's work on the treatment of ter- tiary symptoms, which, before proceeding further, we beg permission to quote, we find the following paragraph :— " Although we recognise the syphilitic virus as the regular cause of tertiary symptoms, we must allow that it undergoes a modification in secondary symptoms, in consequence of which it is no longer inoculable. In tertiary symptoms this modification is still more striking. If it were not hazardous to form an hypothesis in order to explain facts, the proximate cause of which it is difficult to fix upon» it might be said, that in the secondary symptom, which is kept up by its presence, the virulent cause still exists ; that in the tertiary symp- tom it is completely transformed." The important consideration of this last phrase we can not too strongly impress on our readers; it forms one of the best indications for the treatment which, whatever may be said on the subject of secondary symptoms, ought not and can not be specific here. Ter- tiary symptoms must be treated on general principles; the same means should be employed as if the diseases we are called upon to treat depended upon any other than a specific cause now completely transformed. Our first care should be to remove all inflammation or irritation which can aggravate the local disorder; this point gained, we may next turn our attention to the constitution. The employment of tonics, nutritious diet, proper clothing, &c, will often have the best effects. Among other preparations, we have observed those con- taining the principles of opium to be followed by the best effects in allaying local and constitutional irritation. Mercury, in its various TERTIARY SYMPTOMS. 317 forms, is, generally speaking, as prejudicial at this stage as it was beneficial in secondary symptoms ; and although in those symptoms of transition between the secondary and tertiary, as in deep tubercles of the skin, attended with callous ulcerations, it may still be advan- tageously employed, it is nevertheless true that the further we retire from the early stage of secondary symptoms, the less efficacious it becomes, until it ends in being highly prejudicial ; and when used even in the former cases, it should be combined with iodine in the form of proto-ioduret; of the dose, quantity, &c, we shall not here speak. If mercury then be, generally speaking, prejudicial, surgeons have the satisfaction of knowing that modern practitioners have the credit of discovering this, and rating the effect of the mineral at its just value, while their observations have enabled them to replace it by a preparation which daily experience in various parts of the world promises to establish as one of the most efficacious in the Pharma- copoeia—we mean iodide of potassium. Iodide of Potassium.—Those who have, like ourselves, witnessed the effects of this preparation given in all the stages of syphilis, will allow that its good effects seem pretty nearly confined to the cure of tertiary symptoms ; it has been much vaunted, but as we think in- judiciously, in the other forms, although the cases in which it has produced relief are not sufficiently detailed, and in the successful cases the disease had arrived at what we term the tertiary form. We shall, however, in the following pages, state the results that may be expected from it, and the best means of producing them, the more especially as, when employed in the cases now under consideration, it is a treatment new to English practitioners. We prefer giving M. Ricord's description : in speaking of the treatment of tertiary symptoms, he thus expresses himself:— " We may commence by a dose of ten grains taken daily in a mixture, for which I give the following formula :— Distilled water, liij. Iodide of Potassium, gr. x. Syrup of Poppies, f j. This mixture should be taken in the course of the day, in three glasses of decoction of sarsaparilla, or some bitter infusion. The doses may then be augmented by ten grains every five days, until the dose of a hundred grains may be taken daily : this dose I have rarely exceeded. In addition to the curative effects, the iodide of potassium may 318 TERTIARY SYMPTOMS. have an action on different parts of the economy, which it may be well to mention. The digestive organs usually bear it well ; but in some cases the patients complain of pain or an uncomfortable feel at the stomach; this pain has some analogy with that met with in pleurodynia, but differs from it in being deeper seated. In certain cases the thirst is augmented, although usually the appetite alone becomes increased, and nutrition so much exaggerated that patients grow quite fat. I have seldom had occasion to observe diarrhoea or vomiting. The skin may become the seat of certain eruptions analogous to acne, or ech- thyma, with small pustules. The urinary system may be consider- ably affected, and the quantity of water voided may be considerable. The circulation has not appeared to me particularly affected, at least in the majority of cases. In respect to the nervous system, some patients have experienced what is called iodic intoxication, characterized by a slight uncertainty in the voluntary movements, some subsultus tendinuin, heaviness in the head, a species of intellec- tual idleness, and sometimes slight delirium. In all cases, even at the extreme dose to which I carried this remedy, all the symptoms have been very trivial. Their appearance, however, and especially any tendency to become aggravated, has always been an indication for me to stop the dose, whatever that may have been ; in the same way that each time a symptom got better, I have continued at that dose which produced the amelioration, not wishing to increase it until a stationary condition supervened. It seldom happens that the affection we are called upon to combat does not show marks of amelioration during the second week of the administration of the iodide, or sometimes later. The tubercles become absorbed, the ulcerations grow cleaner, suppuration diminishes, the pains in the bones cease ; and the osseous tumors, provided they have not reach- ed the indurative state, which resembles ivory, speedily become dis- sipated. Treatment of particular or individual forms of Tertiary Symptoms. —If the above treatment be beneficial in relieving and curin^ the diathesis, or state of constitution in which we have found the patient, we must nevertheless not neglect the local treatment; for here, as elsewhere, although the local depends upon and is kept up by the gene- ral diathesis, it in its turn reacts on the general health, and maintains it in an unfavorable state for recovery. Local Treatment of Tumors seated in the Subcutaneous Tissue.— It is unnecessary here again to remind the reader that any 'aiflam- TERTIARY SYMPTOMS. 319 matory symptoms should be combated by antiphlogistic measures adapted to the condition of the patient ; when all such have ceased, the tumor, if at its commencement, or even when fluctuation is per- ceptible (provided the skin has not become discolored), should be covered with a blister, and the denuded skin may then be dressed with a solution of iodine ; this acts as a local irritant, and is far pref- erable to the solution of corrosive sublimate, as it may produce beneficial effects both locally and generally. Usually, after the first blister, the tumor will be sensibly diminished ; in such cases let a second or third be made use of, until complete resolution is effected. We have seen no cases resist this method when they have been treated sufficiently early, and when the constitution has been sup- ported by the general means spoken of above, for we repeat this form of the affection principally occurs at a late stage, and in very unfavor- able subjects. When, together with distinct fluctuation, there is dis- coloration of the skin over the tumor, it is useless to attempt this plan of resolution : the pus may be allowed to escape by puncture, and should the hard shell mentioned as surrounding the cyst be present, the cure will be often expedited by its excision. When called upon to treat those cases which assume, at a later period, a fistulous char- acter, and are surrounded with an indurated margin, their local ap- pearance may be benefited by covering the surface with the following application :— Honey . . . .12 parts. Proto-ioduret of mercury . 1 part. The same effects will be obtained if the margin of the ulcer be touched with the solution of iodine, which is thus composed :— Tincture of iodine, 3ii. Distilled water, ^viii. The latter preparation is particularly useful in cases where no indura- tion exists; these chronic ulcerations will slowly cicatrize, and their edges rise to the level of the surrounding skin. This may be often hastened by applications of strips of plaster composed of vigo cum mercurio. An alternate treatment with sedatives and stimulants may, likewise, often be employed with advantage. These observations equally apply to those cases of submucous cellular tumors, which admit of this treatment from their position, when placed beneath the mucous membrane of the mouth and pharynx. On the first symptoms of the appearance of suppuration, the cysts should be at once opened, and treated by emollient, gargles ; the parts may then be touched with the watery solution of iodine, or a gargle 320 TERTIARY SYMPTOMS. may be employed, which, containing 3i. of iodine to eight ounces of water, and gradually augmented in strength, will speedily bring a healthy action of the affected parts ; but this local treatment alone will not suffice. The general one of the iodide of potassium com- bined with mercury, in proper proportions, when any induration exists around the edges of the ulcerations, must likewise be put in practice, and its success will surpass the most sanguine expectations. Local Treatment of Affections of the Osseous System.—Pains in the Bones should be treated, at first, by repeated applications of a few leeches, followed by poultices; or the parts may be covered with lint dipped in a warm decoction of poppies, or water and laudanum; this treatment, together with a general one compatible with the state of the patient's constitution, will usually suffice, when the pain does not depend upon deep inflammation of the bones. How- ever, there are forms of this affection which resist, and, although we are unable to detect either periostitis or ostitis, yet only cease on employing the treatment adapted to them. The Treatment of Periostitis should consist, at first, in attempting to allay all irritation by leeches and poultices ; when the first and third varieties exist, such a practice will often suffice ; in other cases we must have recourse to a treatment which acts like a charm on the disease. Let a blister be applied on the painful portion of the bone ; when it has risen, the serum may be allowed to escape, but the epidermis need not be removed, as the pain will be less ; lint spread with the ceratum opii may be laid over it, and the whole covered with warm poultices, which should be constantly renewed. The severity of the disease, or its return, may require a repetition of the blisters, which should be treated on the same plan. When the tissues have not undergone much organic change, the relief felt is immediate and lasting ; we have frequently seen patients fall into a calm sleep even during the drawing of the blister, and this in the case of persons who have been kept awake by violent pain for weeks; if swelling- be present, it may be often removed by the employment of blue oint- ment, applications of tincture of iodine and water, as by the formula given above, or the suppuration may be kept up by means of the solution of corrosive sublimate. The pain attending this last sub- stance will, however, generally preclude its employment. In the second variety of periostitis, this treatment is less efficacious ; it may be necessary in such cases to make incisions and let out the pus, as by such means we may prevent a further separation of the periosteum from the bone, an object always to be desired. SYPHILIS IN CHILDREN. 321 Local Treatment of Ostitis.—The treatment recommended in the two former affections, viz., pain in the bones and periostitis, is equally applicable and judicious in the early stages of ostitis, accompanied with a deposition of callus forming the epigenic exostosis; but it may be necessary to employ the treatment more actively, and for a longer time, particularly in the parenchymatous exostosis. When called upon to treat a patient for diseased bone which has been converted into a species of ivory, all treatment will be unavailing, and it will become a question whether or no we might be justified in removing, by a surgical operation, this form of exostose. In cases of caries or necrosis, particularly of the bones of the face, no time should be lost; they must be removed as soon as that is possible. M. Ricord observes, that the surgeon should be fully aware that caries produces caries ; that a bone, the organic matter of which has been destroyed by suppuration, or which is dead, can never be regenerated by any treatment, general or local; and that it should never be left to be eliminated by Nature's efforts, except in those cases where the surgeon is unable to reach it. Bone of this descrip- tion is truly a foreign body, keeping up and maintaining the disease, which, by means of the suppuration it gives rise to, may gain still deeper parts, and thus occasion death. The means adopted to re- move these portions of necrosed bones need not be mentioned here. CHAPTER IV. SYPHILIS IN CHILDREN. This subject has been already treated of in various parts of this work, but it has been suggested to me that, in a " Complete Practi- cal Treatise on Venereal Diseases," a chapter ought to be devoted to syphilis as it occurs in infancy. I therefore shall, in the following pages, speak of such peculiarities as may be met with in early life. Primary Symptoms.—On the subject of contagion in children, I may mention that the same laws exist as in the adult, with this dif- ference alone, that the tissues being very delicate, inoculation would be more liable to occur, provided children were as frequently exposed to the effects of the virus. This, however, is not the case ; and I have met with no instances of primary symptoms, nor can I find in 21 322 SYPHILIS IN CHILDREN. authors any cases where distinct chancres have existed. In early life, however, ulcerations of the genitals are not unfrequently met with. I have lately seen in St. Bartholomew's Hospital two instances of children (both females) with some ten or twelve ulcers on the thighs and labia, attended with discharges from the vagina, and a considerable excoriation of the surrounding parts. Such appearances I could attribute alone to dirt and want of cleanliness on the part of the parents, together with pustular itch which had ulcerated; but as inoculation was not employed, it was impossible to speak more pre- cisely of their nature. Cleanliness alone speedily produced a per- fect cure. In the children's hospital at Paris, I have not unfrequently met with ulcerations about the anus, mouth, and throat, depending upon a disease called Muguet or Thrush. A very able article on the subject has been lately written by my friend M. Roget, which may be seen in the French Medical Dictionary, in twenty-five volumes. Such appearances have been often attributed to syphilis, but, I believe, on insufficient grounds. Without, then, in any manner denying the occurrence of primary symptoms in children, I think they must, be very rare. Should they occur, the treatment would be necessarily simple, and guided by the same indications spoken of in the chapter on Chancres in the Adult. Secondary Symptoms in children are, as far as my own experi- ence goes, much less common than is generally supposed; such, however, is not the opinion of those who have written upon the sub- ject ; but when the difficulty which surrounds the whole question is considered, when the little attention that has been paid to the diseases of infants (until within the last few years) is considered, this sup- posed frequency of syphilis is not so surprising. The opportunities I have possessed of studying infantile disease in special hospitals, and of seeing the children of prostitutes, lead me to urge the correct- ness of my opinion. The result of my own observations I shall, therefore, now describe. Infection of the foetus in utero is stated to occur, and is now sup- ported by so many facts, that it would be superfluous for me to insist upon it. Authors, however, are not agreed upon the manner in which this takes place. The physiological school would attribute it to sympathy ; my own opinion is, that as the foetus partakes of the existence, and lives on the mother, so does it participate in many of her diseases, although, as we are in ignorance of the exact connexion between the foetal and maternal placenta, how this is affected must SYPHILIS IN CHILDREN. 323 still be unknown, and I could but amuse my readers with a more or less probable conjecture. We must, therefore, be content with the knowledge of the possibility of infection, in the present state of physiology. Some modern authors believe that syphilis is communicated to the child by means of the milk of the nurse, the parents being perfectly free from disease, as well as the child previous to suckling a nurse who labors under secondary symptoms. This opinion, as far as I can collect from the cases which I have read, seems to require further corroboration ; without denying the possibility, I should believe it very improbable. I have never met with a case, and those recorded in books are liable to so many objections, that on this score I would give no opinion of my own. It is a very prevalent opinion that the father who labors under secondary symptoms will beget offspring who show visible marks of constitutional syphilis, and such cases are scattered up and down medical writings and books on midwifery. This opinion, like the last, however, seems very problematical; the chances of error are so great that I can hardly credit them ; and the fact, if true, is so contrary to direct experiments, that I am inclined to be skeptical. My incredulity is based on the following reasons : The father may have chancre in the urethra, and the semen, acting as the vehicle to the virus, will thus infect the mother, and secondarily the child. (See case in note to page 202.) The father or mother may have gone astray and contracted chancres, of the existence of which they are ignorant, or wish to conceal. The mother may have contracted chancres in other parts of the body, by the virus coming in contact with a sore or abraded surface. There are, in fact, a thousand chances of contagion, as modern investigations have proved, and which have been alluded to in various parts of this work. Mr. Colles and Mr. Carmichael, if I mistake not, believe that secondary syphilis may be communicated to the child by the dry- nurse ; how this could occur I am unable to understand ; and I must believe that parties have conspired to deceive these eminent surgeons, who have such claims to public confidence, as correct observers and faithful delineators of symptoms. In the commencement of my studies I was taught to believe that the death of the foetus, and abortion about the seventh month, was due to constitutional syphilis in the female, and to its effects on the foetus as characterized by a discoloration and peeling of the skin of the expelled embryo. Modern treatises on midwifery and diseases 324 SYPHILIS IN CHILDREN. of children still repeat these opinions, and support them with what is supposed to be corroborative evidence, namely, that if mercury be given, these abortions cease, and living children are born at the full period When I was attached to the Venereal hospital in Paris, a great many pregnant prostitutes passed under my notice, who were labor- ing under secondary symptoms, but I did not remark that abortions were more frequent at the seventh month than at any other period. If the reader will refer to the valuable work of Parent Duchatelet, he wiU find that abortions frequently take place, but syphilis is not the cause : unnatural means, excesses of all kinds, abuse of the sexual organs, are there stated as the exciting causes, and the period at which it occurs varies from the fifth week to the ninth month, and no mention is made of the peeling off of the skin, or other marks of secondary symptoms. I am inclined, then, to believe that these statements, once started by eminent accoucheurs, have been admitted and believed on too slight grounds, and that they have not yet passed through the crucible of modern analysts of facts. The children that I have seen laboring under secondary syphilis, have usually at birth presented no morbid appearance, although the mothers were severely affected with well-marked constitutional symptoms. Such children may have a healthy appearance, or be puny and weak ; a few weeks pass over, and spots are seen about the anus or scrotum. A child was lately brought to Mr. Wormald, the assistant-surgeon at St. Bartholomew's hospital, with very dis- tinct condylomata encircling the anus, which, the mother stated, ap- peared three weeks after birth. Frequently these spots resemble those seen in plate VIII., are raised, of a livid color, and have a very unpleasant odor. They may disappear, and a papular eruption cover the little patient, the stains having that coppery-colored hue which is so very characteristic, and lasting long after the papules have disappeared. The general healthy color of the skin is lost, the eye is dull, and the corners of the mouth and tongue present those white pearly patches so characteristic, and which have been alluded to elsewhere. Mr. Carmichael, in No. lxxvi., of the Dublin Medical Press, says, that the eruption in children is always found to be scaly ; such an opinion does not accord with my investigations. Prognosis.—As far as my own observations go, the prognosis is favorable, provided the mothers can and will take proper care of the children; in a few weeks the disease can be cured, and the child will rapidly gain its strength. I can not help here calling attention SYPHILIS IN CHILDREN. 325 to a statement of Mr. Tait, in his book lately published, entitled Magdalenism. According to his account, the mortality among chil- dren born of mothers laboring under secondary symptoms is dreadful. In the Lock hospital of Edinburgh, he states, out of twelve children seen during a period of three years, only one lived to the age of twelve months. Now I would appeal to any surgeon if this has ever been equalled in any other city in Europe. I answer no ; and I am al- most afraid that professional readers must admit, either that the treat- ment in the Lock hospital does not keep pace with the progress of knowledge elsewhere, or that Mr. Tait has been led away in draw- ing a too unfavorable picture of the severity of syphilis, not only in this case, but in others where he has deigned to enlighten us with the few medical passages which can interest the surgeon. Treatment.—Had I not dwelt, elsewhere, at considerable length on the treatment of secondary syphilis, I might devote several pages to it; but, as far as my experience goes, I should say that the same indications must be followed in the treatment of infants as in adults, the doses being diminished, and the mildest preparations being em- ployed. For this purpose we refer the hydrargyrus cum cretd, in doses of two or three grains twice a day, and continued until the entire disappearance of the eruption. Other means have been recom- mended, but we have not found them so successful. It may here be mentioned that salivation is not liable to occur in the child, and that under the use of a mild preparation the recovery of the infant may be expected: it then rapidly gains flesh and recovers, but is liable to relapses, although, as Drs. Evanson and Murphy state, each will be slighter than the last. The mother at the same time should undergo a course of mercury for the cure of her complaints; and the child should not be allowed to take her breast, but may be fed on spoon food. Provided, however, it has no affection of the mouth, we can see no reason why it may not be suckled by a healthy nurse ; we have not seen any disease produced on the nipple of its wet-nurse, or the occurrence of secondary symp- toms follow, although instances are stated to have occurred in pre- viously healthy young women who have nursed syphilitic children. We have, however, met with a few instances where a child with aphthae on its mouth has produced sores on the nipples of its nurse, who affirmed that she had never had syphilis. We believe that such ■cases may be classed under two categories. In the one, the sores have no specific character ; they are the result of irritation and the contact of the diseased secretion of the child's mouth on an irritable 326 SYPHILIS IN CHILDREN. nipple. Such instances are not followed by secondary symptoms. The second category includes those cases where the nurse has suf- fered under syphilis, although she may have reasons for denying it, or motives for concealing it, wishing to attribute it to a sickly child she has taken in to nurse ; such cases are very frequently followed by secondary symptoms, and may give rise to the supposition that the child was the cause. An interesting example will be found at page 508 of M. Ricord's valuable treatise : notwithstanding all his endeavors, the sores on the nipples (stated by the female to have resulted from suckling a diseased child), tested by inoculation, failed to produce the characteristic pustule ; only slight irritation of the inoculated point followed, and passed away in a few days. EXPLANATION OF THE PLATES. PLATE I. FIG. 1.—EXCORIATION. The subject of this drawing had suffered many months from a greenish purulent discharge. She was a married woman, and attrib- uted it to a disease which her husband had contracted about the same period. The introduction of the instrument was not attended with much pain. The characters of the excoriated condition of the epithelium, and the color of the secretion, show the analogy which it bears to balanitis in the male. FIG. 2.—GRANULAR CONDITION. This granular appearance of the os uteri and vagina is a very marked instance of what is often to be met with in the hospitals of Paris and London ; though generally in a less degree. The subject of it was a short stout female servant; she stated that a discharge from the vagina had appeared eight months previously, and had con- tinued to increase. The introduction of the instrument was very painful. The secretion was purulent, of a green color, of the con- sistence of cream, and so abundant that it ran out of the speculum. The analogy between this disease, and the granular condition of the conjunctiva in chronic affections of that membrane, can not escape the notice of the surgeon. 328 EXPLANATION OF THE PLATES. PLATE II. FIG. 1.—ULCERATIONS. This view was taken from a female, the wife of a shoe- maker at Tours ; she came to Paris in consequence of a discharge which had existed twenty months. This patient attributed it to abortion which occurred about that period ; her husband, she stated, had suffered from several successive venereal complaints. Inocula- tion was tried on several and separate occasions, by M. Vidal de Cassis and myself, but the inoculated point healed in twenty-four hours, and as we always failed in producing the characteristic pustule, we concluded that these ulcers were not specific. FIG. 2.—CATARRH. This affection occurred in a young girl, a Belgian by birth, seven- teen years of age, who presented a lymphatic temperament. She had been placed as servant to wait upon an old lady in Paris, and entered the hospital for a discharge. She stated, that previous to her arrival in Paris she had used much exercise in the open air, but during the last few months had hardly ever left the house, and lived in a very crowded and damp situation. The condition of the os tincae in young females is well shown, but the mucous membrane is paler than usual. The artist has very correctly represented the glairy white of egg like discharge proceeding out of the os uteri, in which we occasionally meet with globules of pus, a secretion very different from those witnessed in the other forms of blennorrhagia. EXPLANATION OF THE PLATES. 329 PLATE III FIG. 1.—BALANITIS. The character of balanitis may, with advantage, be studied in this plate. It was impossible to say if sexual intercourse or a want of cleanliness was the cause. The general erysipelatous redness of the glans is well seen, and the excoriated appearance so often to be met with in this affection. FIG. 2.—VEGETATIONS. The subject of this complaint was a young man twenty-four years of age. States he never has had either gonorrhoea or chancres. The characters of the complaint are well seen ; the clusters of the granules are very florid, each granule presenting a conical appear- ance, though collected into masses. FIG. 3.—ECZEMA. The appearances as seen in this plate are very characteristic of the affection ; namely, the exudation of a serous fluid forming little scales, and the crevices are distinctly seen running between these little lamellae, resulting from the drying of the exuded fluid. The history of the case was obscure ; the patient advanced in life. FIG, 4.—HERPES PRAEPUTIALIS. Herpes in its various stages is delineated in this plate; commencing as a vesicular disease, its vesicles may ulcerate, and assume all the physical characters of chancre. The five or six vesicles will be seen on distinct patches of inflamed skin, differing in this respect from all other vesicular eruptions. PLATE IV. FIG. 1.—INOCULATION—SIMPLE UNCOMPLICATED CHANCRE. The original drawing was taken at the Venereal hospital, Paris. from a patient forty years of age. Connexion had taken place six weeks previously. The patient had continued his usual occupation of a blacksmith until two days prior to entering the hospital. The characters of simple chancre are well seen, more or less circular in shape, with loss of substance ; the edges of the sore neither elevated nor indurated, only slightly oedematous, with a red areola. The bottom as well as the sides of the sore are covered with tenacious yellow, lymph. The letters a, b, c, d, e,f g, point to the progress of the artificial chancre produced by inoculation on the thigh with the secretion of fig. 1 ; a represents the inoculated point six hours after the operation, the other letters at intervals of twenty-four hours. Letter h is the chancre on the thigh about the tenth day. FIG. 2.—FOLLICULAR CHANCRES. Represents a case similar to that of Mr. H., detailed at page 188. The drawing was taken two days after the appearance of the af- fection, and ten days after connexion. We observe the co-existence of gonorrhoea; the pus is seen issuing from the urethra. The principal object, however, is the development of the virus in the follicles on the glans, resembling the appearance seen in figure, marked a, b. EXPLANATION OF THE PLATES. 331 PLATE V. FIG. 1.—DIPHTHERITIC PHAGEDENIC CHANCRE. This drawing was taken from a patient under the care of M. Ricord. A mason by trade ; twenty-nine years of age. On entering the hos- pital this patient's constitution appeared broken down by the combined effect of dissolute habits and poverty. A thin ichorous discharge flows from under the prepuce, from which a piece of lint, soaked in opium, is seen projecting. A distinct chord was felt, extending up- ward, in the direction of the ganglionic bubo, which commenced as a pimple. It was impossible to collect dates from this person. On un- covering the glans it presented the appearance figured in fig. 1, the phagedena is seen extending rather in breadth than in depth; no in- duration accompanies it; but we observe some oedema around the ulceration. I should wish to call attention to the analogy of ulcera- tions in the same individual. FIG. 2.—INDURATED PHAGEDENIC CHANCRE. This patient, a tailor by trade, twenty-three years of age, of a beautiful transparent complexion, stated that six weeks previously he had contracted chancres ; they healed under simple treatment, and the cicatrix became indurated, and then red; and lastly a sore began in the centre, which has since been extending; a similar sore exist- ed on the other side of the glands. The molecular gangrene is very marked, and the transparent indurated circle around it, elevated and distinct from the surrounding skin, is well seen. FIG. 3.—GANGRENOUS CHANCRE. This affection occurred in a young man twenty years of age, a bargeman on the Seine ; who drank freely. He stated that eighteen days previous to his admission, he had had connexion with a prosti- tute at Rouen ; fourteen days after a black spot showed itself on the upper part of the prepuce, which had become swollen and red, and had increased to the extent seen in the drawing. The whole of the prepuce was destroyed in the succeeding thirty-six hours. Fie 4 shows the mouth of a person affected with mucous tubercles in different parts of the body and the white bleached mucous mem- brane is well shown. 332 EXPLANATION OF THE PLATES. PLATE VI. SYPHILITIC AFFECTIONS OF THE MOUTH AND THROAT. FIG. 1.—SECONDARY This patient entered St. Bartholomew's hospital, in February last, under the care of Mr. Stanley. He stated that in the previous Sep- tember he contracted chancres, which he cured with some aperient medicine. About Christmas he first perceived eruptions on the scalp, and his throat soon after became sore. I would direct atten- tion to the analogy between the affections on the skin and the mucous membrane ; they are seen to pass insensibly one into the other. In fact, the white and bleached superficial excoriation of the throat answers to the syphilitic lepra seen on the body. The speculum oris allowed us to gain a good view of the back part of the throat. FIG. 2.—TERTIARY. The subject of this complaint was a young girl who had led a very dissipated life. About fifteen months previous to the time the draw- ing was made, she had had primary symptoms, and had been in various hospitals, but I could not learn that she had ever taken mer- cury. The principal features of the disease are well seen. The absence of papilla on the tongue, where ulceration had previously existed, excavated ulcers covered with a pulpy secretion, and sur- rounded with a red areola, bespeak at once the tertiary symptoms ; this is made more evident by the occurrence of rupia, which was present on various parts of her body. EXPLANATION OF THE PLATES. 333 PLATE VII. (see frontispiece.) This plate (the frontispiece) represents different phases in the ev- olution of tubercles. In the middle of the cheek are maculae; on the upper lip and the external and lower palpebral region, are several small and separate tubercles ; on the left side of the nose are con- fluent tubercles, which are thicker at the back part of the ala, and there form a large tubercle. On the cheek also are two pustules of ecthyma with tubercular base and surrounded by a dark red areola. On the lower pustule the crust appears. 334 EXPLANATION OF THE PLATES. PLATE VIII. This plate represents those abnormal vegetations which some- times occur in syphilitic patients and are seen around the anus, and sometimes even on the penis. BOOKS PUBLISHED BY J. S. REDFIELD. -g-c>-©-------------------—---------------------------— oo-s- MEDICAL BOOKS. RUDOLPH WAGNER, M.D., PROFESSOR OF COMPARATIVE ANATOMY AND PHYSIOLOGY IN THE UNIVERSITY OF GOTTINGKN, ETC., ETC. ELEMENTS OF THE COMPARATIVE ANATOMY OF THE VERTEBRATE ANIMALS. EDITED BY ALBERT TULK. In one vol. 8vo. Price $1 50. 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I regard the result of his labors of more importance than anything which has appeared since the days of Hunter, and it gives me great pleasure to know that so valuable a work as his " Practical Treatise on Venereal Diseases" is to be presented to the Profession in the English language. " WILLARD PARKER, M.I)., " Professor of Surgery and Surgical Anatomy." " M. Ricord's •' Practical Treatise on Venereal Diseases" is a substantial addition to our stock of sound professional knowledge. The reprint of his book in this country will do vast good, and none need doubt that the task will be ably performed by his American editor. "JOHN W. FRANCIS, M.D., " Late Professor nf Obr.tctrirsin the College of Physicians and Surgeons " " M. Ricord's Treatise on Venereal Diseases is generally acknowledged, to be one of the most valuable on the subject which has ever appeared. I doubt not that every subscriber will be fully repaid for tiie small expense he will incur, by the large amount of original and useful information which he will receive. "ALFRED C. POST, M.D., " Professor of Surgery." o~ cijcp 6) r lior i \^M^V 5 SXJ^S W- N 1NOIQ1W JO AHVK9I1 IVNOIIVN 3NI3IQ1W JO A«V»«I1 IVNOIIVN JNI3IQ3W JO ARVaBIl IE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF N 3NI3IC-3W JO A ■ V I a I 1 IVNOIIVN 3NI3I03W JO A ■ V ■ a I 1 IVNOIIVN 1NI3IQ1W JO A*Vi«ll jNOiasw jo Aavaan ivnoiivn inoiqiw jo Aavaan ivnoiivn inijioiw jo Aavaan v NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF M NATIONAL LIBRARY OF MEDICINE NLn Q3n2L77 b affflRsfiflaB^H Baa " »i^BB^iljiBj-y^ .-■..-..■..■■• acrjfi NLM031926776