r *~ .'i ~„ •X v^ Y if I 1ST Entered, according to Act of Congress, in the year 1854, by SAMUEL S. & WILLIAM WOOD, In the Clerk's Office of the District Court for the Southern District of New York. STEREOTYPED BY PRINTED BY THOMAS B. SMITH, E. If. GROSSMAN, 2 i 84 Beekman Street. 82 4 84 Beekman M TREATISE VENEREAL DISEASES. BY A. YIDAL, (de Cassis,) SURGEON OF THE VENEREAL HOSPITAL OF PARIS', AUTHOR OF A "TRAITE DE PATHOLOGIE EXTERNE ET DE MEDECINE OPERATOIRE," IN 5 VOLS., ETC., ETC. WITH COLORED PLATES. TRANSLATED, WITH ANNOTATIONS, BY GEOEGE C. BLACKMAN, M.D., FELLOW OF THE BOYAL MEDICAL AND OHIRUKGICAL SOCIETY OP LONDON; FOBMEELY ONE OP THB PHYSICIANS TO THB EASTERN AND NOBTHEBN DISPEN8AEIES, NEW YOBK. SECOND EDITION, NEW YORK: SAMUEL S. & WILLIAM WOOD, 261 PEARL STREET. 1855. iy EDITOR'S PREFACE. October, 1840. The value of these can be hotter appreciated in another part of this work. Through the politeness of Dr. Van Buron, the editor has recently had an opportunity of seeing (though too late to incorporate the details in his Notes) an instance of that exceedingly rare affection, tertiary syphilis in the infant. In this patient, there were nodes on the ulna and forehead, and enlargement of both testicles ! The article on Stric- tures of the Urethra, omitted in the Treatise of M. Vidal has been sup- plied by a somewhat free translation of that in the author's well-known work on External Pathology. For the remarks under the head of Urinary Infiltration, and Urinary Abscesses, the editor is alone responsible. In illustration of these subjects he has also added a few woodcuts, bor- rowed from various sources, and although some may consider these topics as foreign to a special Treatise on Venereal Diseases, he is disposed to believe that the junior practitioner will not regret the liberality of his publishers which has enabled him to make these additions. GEORGE C. BLACKMAN. New York, Jan. 1st, 1854. PREFACE OF THE EDITOR. In preparing the Treatise on Venereal Diseases of M. Vidal for the press, the American editor has aimed to furnish the reader not only with a faithful translation, but also with the views of some of the leading British and American practitioners. Messrs. Vidal and Ricord are both attached to the Hopital du Midi, the great venereal hospital of Paris, but in many respects the doctrines of our author are directly opposed to those of his distinguished rival. The annotations of the editor will be found to correspond, generally, with the views of the author, and he has been personally assured by many of the most prominent surgeons in Great Britain and this country of their cordial assent to the doctrines here inculcated. To Mr. Samuel A. Lane, of the Lock Hospital, London, and to Mr. Langston Parker the distinguished syphilographer of Birming- ham, he would return his warmest acknowledgments, as well as to Dr. Byrne of the Westmoreland Lock Hospital, Dublin, and to Messrs. Cusack, Porter, Adams, Egan, Fleming and Wilmot of that city, for their very polite attentions and for the communication of many valuable facts by which the object of his visit was greatly promoted. Although American syphilographers are few in number, yet we may with pride refer to the contributions of Dr. John Watson, of the New York Hospital, " On some of the Remote Effects of Syphilis," published in the first and fifth volumes of the New York Journal of Medicine and Collat- eral Sciences, and to the elaborate paper of Dr. H. D. Bulkley, "On Syph- ilis in Infants," in the New York Journal of Medicine and Surgery for VI TABLE OF CONTENTS. CHAPTER III. PAOI Blennorrhagia in the Female............................................ 172 CHAPTER IV. Blennorrhagia in both Sexes............................................ 188 Anal Blennorrhagia............................................ 189 , Buccal Blennorrhagia........................................... 190 CHAPTER V. Chancre.............................................................. 190 Diseases which may be regarded as accidents of Chancre, Phimosis, and Para- phimosis..................................................... 227 Phimosis...................................................... 227 Paraphimosis.................................................. 229 CHAPTER VI. Bubo.................................................................. 234 CHAPTER VII. Vegetations........................................................... 25C CHAPTER VIII. Mucous Tubercles..................................................... is < » PART II. CONSECUTIVE VENEREAL DISEASE (VEROLE). CHAPTER I. General Remarks..................................................... 277 Section I.—Symptoms.................................................. 277 Section II.—Period and Order of Appearance............................. 278 Primary Accidents................................................... 281 Secondary Accidents................................................. 281 Tertiary Accidents................................................... 281 Section III.—Exciting Causes..............................,............283 Section IV.—Syphilitic Fever........................................... 285 Section V.—Blood of Syphilitic Patients................................. 286 TABLE OF CONTENTS. yii PASI Section VI.—Can a person have syphilis more than once ?................ 290 Section VII.—Therapeutics............................................. 292 I. Mercury......................................................... 293 External employment.......................................... 293 Internal use of Mercury......................................... 300 Mercurial Compounds........................................... 301 II. Other Mercurial Preparations...................................... 305 III. Accidents produced by Mercury................................... 305 Salivation and Stomatitis........................................ 305 Cholic and Diarrhoea, Mercurial Tremors......................... 315 IV. Iodine.......................................................... 316 V. Iodide of Potassium............................................... 817 Accidents attributed to Iodide of Potassium...................... 322 VL Iodide of Iron.................................................... 324 VII. Gold, Silver, Platina............................................. 325 . VIII. Double Salts.................................................. 328 IX. Sudorific Woods................................................329 X. Compounds, partly mineral, partly vegetable........................ 330 CHAPTER II. On Special Consecutive Venereal Affections............................ 331 Section I.—Syphilitic Eruptions—Syphilides..............................331 I. General Characters................................................ 332 II. Varieties....................................................... 336 Exanthematous Syphilitic Eruptions............................. 337 Syphilitic Papular Eruption.................................... 338 Syphilitic Squamous Eruption.................................. 340 Syphilitic Vesicular Eruption................................... 341 Syphilitic Bullae................................................ 344 Syphilitic Pustular Eruption..................................... 347 Syphilitic Tubercular eruption................................... 365 III. Causes.......................................................... 370 IV. Diagnosis....................................................... 372 V. Prognosis........................................................ 374 VI. Treatment....................................................... 375 Internal Treatment.............................................375 External Treatment............................................ 376 Section II.—Diseases of the Appendages of the Skin....................... 378 I. Loss of the Epidermis............................................. 378 II. Alopecia......................................................... 378 III. Onyxis........................................................... 380 Section III.—Affections of the Mucous Membranes........................ 383 I. Mucous Membrane of the Mouth..................................... 384 II. Mucous Membrane of the Nose...................................... 392 III. Mucous Membrane of the Genital Organs........................... 394 IV. Mucous Membrane of the Epiglottis and Larynx.................... 396 V. Mucous Membrane of the Ear..................................... 397 VI. Mucous Membrane of the Anus and Rectum........................ 397 Section IV.—Affections of the Eyes..................................... 399 Syphilitic Iritis................................................ 399 viii TABLE OF CONTEXTS. PAOI Section V.—Diseases of the Testicles.................................... 407 Syphilitic Sarcocele............................................ 407 Section VI—Diseases of the Cellular Tissue.............................. 418 Section VII.—Affections of the Muscles, Tendons, and Aponeuroses.........420 Section VIII.—Affections of the Bones and Periosteum.................... 427 I. Osteocopes........................................................428 II. Periostitis and Ostitis.............................................431 Periostitis..................................................... 431 Ostitis......................................................... 433 III. Exostosis........................................................ 435 IV. Caries and Necrosis..............................................443 Section IX.—Affections of the Viscera...................................447 I. Cerebral Affections................................................448 IL Hepatic Affections.................................................450 III. Cardiac Affections...................................;........... 451 IV. Pulmonary Affections.............................................452 PART III. INFANTILE SYPHILIS............■........ 458 PART IV. PROPHYLAXIS OF VENEREAL DISEASES. CHAPTER I. Private Prophylaxis.............................................. ^ 488 CHAPTER II. General Prophylaxis—Medical Police............................... 493 PREFACE. Innumerable are the works on venereal diseases, but the majority have been written for the purpose, more or less candidly admitted, of establish- ing or overthrowing some particular doctrine. Many volumes have been devoted to the vindication or subversion of the dogmas that emanated from idealism, and the school of Galen, as well as from his successors, the chem- ists and the vitalists. The same is true of the school of Broussais, which so recently denied the existence of a venereal virus, and of those who be- lieved, on the other hand, in the entity of this virus. These productions have sometimes exhibited marks of genius, and have been distinguished by their elevated and splendid diction, but they were designed only for those acquainted with the subject. I write for a different class, and for those who have but little time to devote to the study of these affections. I pro- pose to collect such facts and opinions as are of practical application, and which have survived the wreck of systems, the founders of some of which Bhowed themselves profound observers. With this view, I have selected a plan sufficiently extensive to embrace the most important practical details, and yet which, without having too wide a scope, will, I trust, enable all to comprehend the substance of our knowledge on the speciality now termed syphilography. From the time that venereal diseases were first somewhat carefully studied, it has been admitted, that, shortly after the application of the virus, certain lesions are generally produced on the parts contaminated; these are the primitive venereal accidents. Again, there are certain other morbid conditions, \fhich are ordinarily observed subsequently to the above; these are the consecutive venereal accidents. Under this by no means modern division, these affections may be advantageously studied. I have adopted it, believing it to be the most rational and best adapted to the purposes of instruction, and not as serving as the basis of any particu- lar system. Hunter recognized two varieties of the consecutive or constitutional dis- ease and M. Ricord having availed himself of this subdivision, includes all the accidents under the heads of primary, secondary, and tertiary vene- X PREFACE. real disease. In this species of triad, of ancient date,* this writer fancied that he had discovered the basis of a true classification, on which he has engrafted not only a system, ljut a system the exact symmetry of which was well calculated to captivate an age inclined to absolute certainty, whilst its apparent simplicity has been greatly admired by certain minds, which it is unnecessary here to characterize. A distinguished writer has remarked, that system and hypothesis are synonymous terms; now we know the result of subjecting the latter to a somewhat rigid criticism. Still this system seemed to withstand not only the force of reason, but of arguments based on clinical observation. It rested its claims upon exper- iment, the influence of which may be imagined during the period to which we have alluded. Its opponents were therefore compelled to descend to the same ground, and it was attacked with the same instrument, as it were, that had been employed in its establishment. Various were the experi- ments performed, and the proceedings adopted. Some of these proved, that chancre was not the only accident that admitted of inoculation, but that those termed consecutive might also be thus transmitted. Now as the system was based essentially upon the exclusive inoculability of chan- cre, these results struck at its very foundations. They likewise seriously compromised the classification dependent on it, as the only admitted dis- tinction between chancre and the other accidents was thus destroyed. Other experiments showed that chancre itself, or the most virulent syphi- litic poison, from some natural or accidental cause, was perfectly harmless when applied to certain individuals; therefore, as the system boasted as its test for syphilis, the infallibility of chancrous inoculation, it found itself wanting in view of its practical application. Thus, the immutable laws of experiment, proclaimed by M. Ricord, were annulled by experiment itself, and the promised certainty resulted in un- certainty.! It required but a slight knowledge of medical philosophy, and a little reflection upon the results of experiments, according as they are performed in the exclusively physical, or in the exclusively pathological order, to have anticipated what here occurred. Then came the cases prov- ing that the secondary might appear after the tertiary accidents, and vice versa. The order of the system being thus compromised, what remained ? In the body of this work may be found the proofs of what has been here asserted. However, I shall be brief upon these pofhts, for the main ob- ject of this work is to collect the practical truths which are the results of observation, and those which have survived the downfall of systems. Still * Vid. "La methods curatoire de la maladic vinerienne" of Thiery de Herry, and p. 259 of this work, where I have exposed this triad in its author's own words. f In the Introduction, under the heads of Inoculation and Syphilization, behold the glimmer thrown by the eloquence of M. Malgaigne, over the enormous breaches in the system of which this Professor was at one time a defender, and which had foi its leader a friend of twenty years' standing 1 PREFACE. XI I have thought it my duty to warn the young practitioner against disap- pointments and regrets, there being nothing, in my opinion, more danger- ous, either in study or in practice, than to invest mere forms with cer- tainty, and to pronounce that to be infallible which can be but pjobability or uncertainty. After the two principal divisions,—primitive %ud con- secutive venereal diseases,—will follow the section on infantile syphilis. In this, we shall discuss the questions of the hereditary descent of the dis- ease ; its transmissibility from the child to the nurse, and from the nurse to the child. The importance o£ this chapter is evident, for, in the opin- ions there examined, the interests of the family, of justice, and of society in general, are involved, and yet the majority of French works on these topics are very incomplete ? In the fourth part, we shall consider the prophylaxis of venereal diseases, including general and private prophy- laxis, and regulations of medical police. In the Introduction, after a few observations upon the synonyms, may be found an historical sketch of the venereal disease. I shall express an opinion on the nature of the syphilitic virus, and its principal effects. The causes of error in observation will be shown; experiment justly appre- ciated ; the process of inoculation explained, whilst syphilization will be judged. This introductory chapter will conclude with some general ob- servations on the transmissibility of secondary accidents. Since I have stated, in the commencement, that I propose to make a resume of the facts, opinions, and therapeutics, constituting syphilography, my great indebtedness to my predecessors will be obvious. All shall be quoted with acknowledgment. I will submit to the reader what expe- rience has taught me at the Lour cine, in the female wards; and what I have learned at the Hbpital du Midi, during a service of more than ten years, since I became the successor of Cullerier,—the honest man', the sage practitioner. Placed in a theatre so vast, I could not remain indifferent to questions by which science was agitated. I have ventured to discuss one of the most important, the transmissibility of the secondary disease. I think that, by experiment, I have decided it in favor of the contagionists. My experiments have been repeated in France and in Germany; all have pro- duced a brilliant discussion in the Academy of Medicine. MM. Vel- peau, Lagneau, Gibert, Gerdy, and Roux,* maintained, with their well- known abilities, the transmissibility of the secondary accidents, and what is without a parallel in the annals of the Academy, the opposite side of the question had but one defender ! If from France we pass to foreign lands we shall find that the opinions of learned academicians are generally * It will be observed that among these orators are two distinguished syphilogra- phers, and three professors of the Faculty of Paris. Read their discourses in the Bulletin de VAcademie de Medicine, where they are correctly reported. (Nos. for Oct. et suiv. 1852. xii PREFACE. divided. We may see, particularly in the German press, how ably this doctrine has been sustained by Waller, Simon, and Droste. To facilitate the study of the venereal accidents, the most important to be known, I have illustrated them by colored engravings, from designs which it is unnecessary for me to praise since they were executed by M. Bion. The necessity of these will be admitted when we come to the chap- ter on the cutaneous affections, for we know the importance of the syphi- litic tint in forming our diagnosis, and the difficulties which the student encounters who wishes a tableau of the principal varieties. He will find it here, true to nature. Lately, some syphilographers whose tenets have been shaken, have allowed themselves to descant bitterly, or in a jesting tone. They have even written in the same style. Having no motive for sharing in the sen- timents which have inspired a literature of this kind, having, besides, re- marked that it has neither thrown light upon, nor advanced the questions in dispute, I have abstained from it, and have endeavored to speak as clearly as possible, the language of science, since it is the latter only which I have in view, and the interests of those who would become her earnest votaries. INTRODUCTION. The object of this is to assist the comprehension of matters which constitute the body of the work; it contains also a critical exposition of the method of investigation, and generalities on the great questions of syphilography. Thus, after a few remarks upon the synonyms, and a brief history of the venereal disease, I will describe the method, observation, and experiment applicable to this specialty. I will speak of syphilization, and conclude with an article on the transmissibility of secondary accidents. SYNONYMS. The diseases which I am about to investigate have received an infinity of names, sometimes originating from their mode of propa- gation, sometimes from a prominent symptom, sometimes from the country accused of giving birth to the malady, or from the peo- ple who communicated it to strangers; sometimes, indeed, from fable. Thus they were called venereal, from the fact that they were generally contracted during the venereal act; verole signifies pus- tules on the skin, which are observed in certain stages of the disease, and which have been considered analogous to those of variola; and they were called Mai francaise, Mai napolitain, be- cause the French and the Neapolitans were supposed to have com* municated them to other nations. Other people, too, have, in their turn, been accused, and have contributed in giving a name to these diseases; the Turks as well as the Germans, the Poles as well as the Moscovites, &c, &c. But it must be admitted that the French, in this respect, have gained the greatest notoriety. Syphilis is the creation of Fracastor; in his poem he imagines that the shepherd Syphilus, was the first who was smitten with the disease, which the gods, in their wrath, invented. I will not exhaust this subject, which might be made to fill many pages; with- out interest, however, either in a scientific or practical point of view. The names still employed are these: Venereal Disease^ Syphilis, Verole. Some physicians use them indifferently. Never- theless, the first is generally adopted, as it indicates the most common source of the disease, viz., coitus, or other libidinous connections. Syphilis denotes that a virus, a morbid poison, has intervened, and that it plays a principal part, whilst verole or con- stitutional syphilis signifies that this virus has produced a profound 14 INTRODUCTION. change in the organism, constituting, indeed, a diathesis, a disposi- tion, a temperament. This virus is sometimes inoculated by acci- dent, by a wound, and the affections to which it gives rise may be entirely independent of any libidinous act. At present, there is a patient under my care, &\ the venereal hospital, who, in a strife, was bitten on the thumb by his comrade, and who was thus, at the same time, inoculated with a chancre. HISTORY. I shall be brief in my sketch of the history of syphilis, shrouded as it is in darkness, and from no point shedding light upon doctrine or practice. The point most obscure in its history is that of its origin. Is it as old as humanity ? Is it modern, and did it origin- ate towards the end of the fifteenth century ? The vast learning of Astruc, the dates by him collected, and the commentaries which he has written in his efforts to solve these questions, have not in the least advanced our progress. We know, it is true, that Astruc is a believer in the modern origin of the disease, but we do not become acquainted with this fact until we have carefully perused his work unto the end. The majority of writers are opposed to Astruc, and maintain the doctrine of its ancient origin. To sim- plify the question, I should, in the first place, remark, that there are venereal affections which are not virulent or specific, as well as those that are. Now, no one can deny that the first have always existed; for in every age, inflammations, discharges, and ulcera- tions of the genital organs have been observed, caused by the too frequent indulgence in the venereal act, or by its performance during the menstrual period, or pregnancy, &c, &c. Thus, certain venereal affections had their origin in the earliest antiquity. The question remains to be settled, whether the specific disease, syphilis, in fine, is equally old, or whether it originated towards the end of the fifteenth century. In passing over the three principal phases in the history of these diseases, I shall endeavor to throw some light upon both of these questions. Antiquity.—It is true that in antiquity the venereal disease had neither name, therapeutics, nor a special treatise. But Moses pre- scribed the observance of certain precautions to prevent the con- tagion of gonorrhoea (profluvium seminis,) the blennorrhagia of modern times. Hippocrates alludes not only to ulcers on the penis, but to pustules and the loss of the hair. Celsus is more remarkable still, for if rightly interpreted, we find that he was acquainted with almost every kind of ulceration on the penis, and with our present notions, it is possible to recognize in his descrip- tions, not only chancre but several of its varieties; as the common, and even the indurated chancre. Still further, Celsus points out the complication of phimosis, and of paraphimosis. But scientific distinctions could not have been established by Celsus, and it would be unjust to exact from him a diagnosis, to which many physicians, even in our own day, are incompetent. INTRODUCTION. 15 In ancient times, everything was regarded as a result, .and variety, of inflammation; a specific cause was unknown, and the connection of the different symptoms was not recognized. How- ever, one fact, that of contagion, known to the most eminent, should have aroused the attention of the ancients; thus, Galen, with his genius, traced blennorrhagia to contagion, and his fol- lowers, in this as in other matters, adopted the opinions of their leader. As we depart from antiquity the elements of the disease become more distinct, and so connected as to constitute the vene- real disease with its special forms. Thus the Arabs and the Arabists are very instructive in a historical point of view; Avicenna and Areteus describe a peculiar disease of the throat, which the latter calls the Egyptian disease, and supposed it to be confined to young people. The fact of its being contagious is distinctly noticed, and "William of Salicet, Lanfranc, and B. Gordon had some idea of a specific cause: they note the deplorable consequences of carnal connection with unclean* females, affected with discharges which even then they designated as virulent, (virulentes;) they refer to inguinal abscesses, genuine buboes having their starting point, the penis, and marked the cutaneous eruptions as constitu- tional affections, classing them with lepra. These abscesses were noticed not only as cold or hot, and distinct from their cause, but as having their starting point on the penis. Thus, we find this remarkable passage in William of Salicet; " And the bubo occurs when a man has a disease of the penis from connection with an unclean woman, or from every other cause, which gives rise to an accumulation of corruption in this organ, which corruption being unable to find an exit, returns to the groins, according to that law of affinity which these parts have with the infected organ." Lan- franc, who was a pupil of William, speaks of abscesses in the groin that follow ulcers on the penis: Scepe provenit aposthema in inguine propter ulcer a virgai, propter a quod est decensus humorum ad ilia loca* Further, Lanfranc advises a method of prevention, which I will mention when I discuss the subject of prophylaxis. I will add, that even before the fifteenth century there existed, as for example in London, regulations of medical police for certain houses of prostitution. There can then be no doubt of the existence, in antiquity, of local non-virulent venereal diseases, and there is strong presump- tive evidence also, that there were those of a specific nature, which produced both local and constitutional symptoms. Thus, it is very probable, that more than one syphiloid affection might have been found in that confused mass of cutaneous diseases, and among those lepers so often noticed among the ancients, and which have not yet disappeared, as is maintained by the hygienists. What led to the use of mercury after the epidemic of the fifteenth century ? It was the success obtained in the earlier ages, when it was em- ployed for the cure of those diseases which were confounded with lepra, and among which were the syphilides. Is this not another * Pract. III., doctr. II., cap. IL 16 INTRODUCTION. proof showing the connection existing between the affections observed before the fifteenth century and those which occurred subsequently to this period? Further, as I have already stated, the diseases called leprous, have not yet disappeared; but, having been more carefully studied, and better specialized, the part that lepra plays in the production of these affections, has been reduced to so narrow a compass that it would seem no longer to exist. That belonging to syphilis could not be shown without under- standing the dependence existing between the primitive and the consecutive accidents, the cutaneous eruptions; now this depend- ence was unknown to the ancients; ignorant of the interval between the phenomenon of inoculation (primitive accident), and that of infection (consecutive accident), these two elements of the same malady have passed for two distinct diseases, proceeding from a different cause. Perhaps this kind of incubation of the consecutive affection, was in ancient times of longer duration, from circumstances which we cannot appreciate, and thus a new obstacle has been added to our progress. Fifteenth Century.—During this epoch many persons were smit- ten with a scourge which has been represented as cruel and dis- gusting. The skin of the afflicted was covered with numerous pustules, agonizing pains racked their limbs and head, resembling those row called osteocopes rhumatoides; these were accompanied with sleeplessness, scalding of the urine, and fever. It was partic- ularly during the latter part of this century (1495), and at Naples, whilst it was occupied by the French army commanded by Charles VIIL, that this scourge was most violent, and counted its greatest numbers of victims. The rapidity with which the disease spread, the extent of country over which it travelled, gave to it the char- acter of an epidemic; on which account, this period in the history of syphilis has always been known under the name of the epidemic of the fifteenth century. But if, as was thought by some authors, this was a new malady, others again regarded it as a degeneration or aggravation of an- other disease. It was a kind of maranique pest, or indeed, an affection analagous to the epidemic lichen of Hippocrates, or a mentagra, having also an epidemic character. It is not surprising that, at this epoch, a certain conjunction of the stars should have been regarded as its cause; and still less that the atmosphere, the breath of speech, should have been considered the vehicle of the morbific principle. What first struck the observer, was the state of the skin covered with pustules, and the pains in the limbs with which the patient was tormented. The lesions of the genital or- gans were unknown, or appeared of but little consequence, com- pared with those which shortly followed. It is even probable that these lesions, which at this day are called primitive accidents, were sometimes completely absent. For my own part, I am in- clined to think that such was the case, especially since I have proved in so positive a manner, the transmissibility of the pus- tular form of the syphilitic eruptions; indeed, at a certain pe- INTRODUCTION. 17 riod, the pustules on the skin may be transmitted from a diseased to a sound person. Whatever may be the explanation, the disease was considered not only as epidemic, but contagious, and different nations ac- cused each other of having spread the plague. When the American origin of the disease was invented, these mutual accu- sations of European nations were somewhat checked. It was supposed that the Spaniards, on their return from the conquest of the new world, had brought with them a new malady, which they scattered in Italy, where, at that time, was stationed a French army. This opinion of the American importation, has found and still counts, many advocates. Numerous serious objections have been urged against it. M. Eicord, for example, who believes in the exclusive inoculability of the primitive affection, thinks it very astonishing that this should have retained its virulence during the long voyage of the Spanish sailors, and the long time which must have passed before their arrival in Italy. To this we may reply, that the consecutive affections may also be inoculated, and that the disease of the army in Italy having been specially characterized by the existence of pustules, these might have occurred among the Spaniards during the voyage. But there is a still more em- barrassing objection against the doctrine of importation, based upon the immunity of the Spanish ports, when these voyagers first landed, and where they resided, and this too, after the long* continence which had been forced upon them. Thus, it is well known that the greater part of the crews of Columbus remained at Seville, and yet this city did not suffer from the disease sup- posed to have been imported by these navigators. They could, therefore, have been dangerous only to the Neapolitans, and this too after having failed to contaminate the Spaniards! Besides, when the Spaniards arrived in Italy, this, like other European countries, was already infected. Swediaur goes so far, indeed, as to assert, that Europeans, the Spaniards—carried the disease to the new world. But I know not why the believers in the American im- portation of syphilis, would find no trace of it in antiquity; for, ad- mitting their opinions to be true, we are compelled to ask, how did it originate in the new world. The question then of the first origin of syphilis, according to this view of it, is only shifted, not solved. However this epidemic of the fifteenth century may have orig- inated, to us it appears to have been accompanied with symptoms, in many respects different from those of the syphilis of antiquity, or of our own day. The illustrations given by those who ob- served the epidemic under consideration, show us, indeed, many traits in common with the modern disease, but certain tints and colors prove that the lesions really belonging to syphilis, were blended with certain other lesions and general symptoms, which render probable the existence of serious complications, arising from unfortunate hygienic conditions, or from very corrupt man- ners. Finally, it is quite probable that other diseases of a serious character prevailed at the same time with syphilis, and that they were mutually complicated with each other; thus lepra, typhus, 18 INTRODUCTION. farcy, blended with syphilis, have been supposed to have given to the scourge of the fifteenth century the fearful character which it assumed. A strong argument in favor of this hypothesis, is, that the worst cases of syphilis observed at the present day, are found among the unfortunate beings who are compelled to suffer great privations, or who are laboring under a strumous or scorbu tic diathesis. Under these circumstances, we sometimes find re- produced more than one feature in the horrible picture furnished by the fifteenth century: for example, I have at present undei my care an excessively feeble young man, of a scrofulous habit, whose body is covered with pustules, whilst his lower extremities are affected with rupia, deeply excavated ecthyma, with cracked black crusts. Under these scabs, ulcerations have burrowed, some of which have taken the serpiginous form, and are the seat of atrocious pains. Has this case not more than one feature in com- mon with the scourge of the fifteenth century, which has been de- nominated morbus pustularum ? The pathognomonic signs of sy- philis become more distinct and easy of recognition, in proportion as we isolate them from the diseases with which they were com- plicated, and from the epidemic influences by which they were modified. Then indeed, we may collect the elements of syphilis, and establish a form of disease entitled to a scientific nomencla- ture. In alluding to the earliest period in the history of the vene- real disease, I have stated, that it could then boast neither of name, therapeutics, nor of books; but from the commencement of the sixteenth century, it has received many names, has had a special therapeutics, and has given rise to innumerable volumes. Sixteenth Century.—A great genius now appears; his name forms an epoch; it is Fernel. Now a specific cause is discovered, the local and general symptoms are recognized. True, in 1552 James Bethemont had furnished Fernel with a hint of the fact; and Para- celsus, during the prevalence of the epidemic had seized upon the symptoms peculiar to syphilis, with the design of forming a new species in pathology. But Fernel will always maintain his place at the head of the truly scientific epoch of syphilis, and this too, with the greater justice as subsequent ages have made but few additions to his teachings. Not only did Fernel scientifically es- tablish the necessity, and the existence of a specific cause, but he traced it from a diseased to a sound person ; he demonstrated its transmissibility by different modes of contact, especially by the venereal act, whence the name of Lues Veneris. The disease had its name, and its cause; symptoms were recognized and de- scribed ; they were the primitive, and the consecutive or constitu- tional symptoms; in fine, the application of the poison, its local effects and general results, were traced with a masterly hand by Fernel. But, when he attempted to classify the effects of the virus according to the depth which it had invaded, when he had the presumption to establish four varieties of the malady, according as it progressively attacked the four layers of tissue between the skin and the bone ; then, and then only, was he misled, as are all those who would imitate him, and number the varieties of the disease. INTRODUCTION. 19 The fundamental part of his doctrine, however, still reigns in the schools to which it has descended, especially through the labors of Astruc. SYPHILITIC VIRUS. This, according to Hunter, is a morbid poison, resulting from disease, which poison, unlike other toxic agents, may reproduce a similar disease. The syphilitic virus, in substance, cannot be detected; in its simple unmixed state, it eludes all our efforts at observation; here, micrography and chemistry have shown their impotence. This poison is manifested only by its effects, of which the most remark- able is its great facility of reproduction. Brought into certain re- lations with the living tissues, and in certain conditions, the virus develops a morbid action, the result of which is its reproduction, its multiplication. It is there a kind of germination, for the cause. produces an effect which becomes of itself again the cause. Obser- vation has demonstrated the existence of a syphilitic virus, for the number is infinite who have contracted chancres by connection with those affected with chancres. But to remove the doubts of certain minds, a resort must be made to experiment. In fact, pus from a chancre, inserted on the point of a lancet beneath the epi- dermis, has given rise to the same .form of ulceration, possessing the same property of reproduction. The syphilitic virus has ordinarily fop its vehicle a thin, sero- sanious, mal-assimilated pus, in which organic detritus is more or less apparent. But pus the most laudable, muco-pus, may also be the means of conveying the virus, and it would seem to possess no influence in modifying its nature. The virus may exist not only in the morbid secretions, but it has not been proved that it may not change the normal secretions. It unites with the blood, and there undergoes certain modifications by which it becomes inti- mately blended with it. A particular kind of pus, that produced by gangrene, seems to neutralize the virus. Virulent pus may, like vaccine matter, for a long time be pre- served in tubes, or between two glass plates, without losing its properties; of this* Percy has furnished the proof. But to develop these properties" of pus, it must be applied in a liquid state, or be so placed that it will be rendered such by the moisture of the part in which it is inserted. Even when greatly diluted, a solution of this pus may be inoculated, and M. Puche has shown that one drop in a glass of water suffices to render this liquid virulent. This is worthy of note, as it sanctions what I denominate physio- logical absorption of the virus, and will place us on our guard against the use of water which has been used for bathing or for washing by those affected with the venereal disease. The gastric juice, or a solution of the sulphate of iron, does not change the properties of the virus (Hernandez). Certain acids destroy it. This however will be more fully noticed when we come to the subject of prophylaxis. 20 INTRODUCTION. Is there more than one virus ? The existence of a virus is no longer doubted, but the question constantly arises, Is there more than one virus possessing different strength and different qualities? This question has been proposed by every syphilographer who has sometimes met with such different effects from the virulent matter. Thus, they have asked, Is there not one virus which inflames, and another which gives rise to ulceration ? Or, to speak more cor- rectly, Is not blenorrhagia produced by one kind of virus, and chancre by another? To these, Hunter replied in the negative, and explained the different effects by the difference in the surfaces to which it is applied. If specific pus is brought into contact with secreting surfaces, blenorrhagia is the result (these surfaces are the lining membranes of the vagina and urethra) ; if the same pus is applied to the skin and the mucous membranes bordering upon it (as, for example, those of the glans, the prepuce, the vulva, and the lips), a chancre will follow. But as chancres have been observed in all the mucous membranes to which it has been applied, the fbeory of Hunter was necessarily abandoned. A double virus was then adopted as a substitute, and this doctrine was defended by Benjamin Bell and Hernandez. I shall notice this theory when I treat of blennorrhagia, but I feel bound here to show how it has been defended by Hernandez, in the face of arguments deemed most weighty, since they were derived from the results of experiments. An experimenter by the name of Andre inoculated himself with gonorrheal matter, which produced a chancre. To this fact Hernan- dez replies that it is of but little importance as it is an isolated one, and because it has been reported by an unknown surgeon. But Hunter likewise produced chancres in the same manner. The ob- jection now raised by Hernandez, is, that these ulcers healed spontaneously, and consequently they could not have been chancres! But he had a bubo which was followed by consecutive symptoms. The bubo, replies Hernandez, might have arisen "from the irri- tation of the ulcer of the glans." The consecutive accidents, such as ulcers in the throat and pustules, might have proceeded from other causes. We have just seen, that Hernandez would not be- lieve Andre*, because he was unknown; should we not suppose that the name of Hunter, so widely known, would therefore in- spire him with the greatest confidence? Far from it, however, and he concludes by saying; " can we moreover place much de- pendence on the syphilitic nature of all the affections pronounced venereal by distinguished physicians?" Still farther, Hernandez believes not even his own experiments. Thus, he inoculated convicts who preferred the operation to the labor of the arsenal. In seventeen, ulcers occurred which had no appearance of syphilis, and which were promptly cured without internal treatment. "In the others," says Hernandez, "it pro- duced obstinate ulcers, some of which had every appearance of syphilis, with the general symptoms which would seem to establish it. Two were cured only after using mercury. Should we not suppose that our experimenter having inoculated twelve out of seventeen of these convicts with chancre, and that too with the INTRODUCTION. 21 muco-purulent discharge of gonorrhea, would have believed in the possibility of producing chancres with this same pus ? But no, these ulcers could not have been venereal, as they occurred in scorbutic and scrofulous subjects! Now Hernandez himself se- lected his own subjects for these experiments. Of course, he must have known previously that they were the victims of scurvy and the king's-evil! I have quoted the above remarkable passage from Hernandez to prove not only the identity of the pus of blennor- rhagia and chancre, but also to show for once that experiments, no more than observation, can destroy systematic prejudices, or guard against subtilities, since we here see Hernandez, possessed with this idea of a double virus, resisting the most substantial proof drawn not from the experiments of two physicians only, but even from his own. For him, theory was stronger than proof.* It is generally supposed that it is peculiarly in our own day that imagination plays so active a part in positivity (positivisme), but this is a great mistake. Hernandez having besides at his disposal the chancre larve—since he invented the term—availed himself of it, but without abusing it. M. Eicord has again brought this forward, but he has abused it. According to his views, there is but one virus, that of chancre. Blennorrhagia is but a catarrhal inflammation, like any other arising from a simply irritating cause, but it has no connection with syphilis. When by accident, we succeed in inoculating a chancre from the urethral discharge, and when this discharge has been followed by constitutional symptoms, then the patient could not have had blennorrhagia proper; the discharge comes from a chancre hidden from our observation, deep in the urethra—a chancre larve—since we must call it by its name.* Now, although some of these hidden chancres may be discovered, others cannot be found. I have stated that Hernandez invoked their aid, and we know that before Hernandez and M. Eicord, when evidence was to be destroyed, in the absence of other arguments recourse was had to occult causes. The human mind has never been more fertile than in this respect; generally it retards, when it would advance our progress. Thus we cannot be accused of sustaining our views by superannuated Tlieses-. Let us see, moreover, if the admission of a single primary ac- cident, that of chancre, removes the difficulty. Granted, for the sake of argument, that the specific virus, which gives rise to con- secutive symptoms—to syphilis—is secreted by chancre alone. But there will always remain a disease of the mucous membranes, with- out ulceration, occurring under the same circumstances as chancre, *«Under the head of Blennorrhagia, we shall attempt to show that our author's observation applies with equal force to M. Ricord, and we think that we shall be able to prove, even by the experiments of this distinguished surgeon, that blennor- rhagia is occasionally inoculable, and that too, under circumstances in which he does not intimate his suspicion of the existence of a concealed chancre.—G. C. B. f I am satisfied, as must be those who have carefully examined the two patho- logical specimens on which M. Ricord relies to establish his theory, that they wore tubercular ulcerations * f the urethra, similar to those observed in the prostate glands of the same patient. 22 INTRODUCTION. and which in the same individual produces metastatic affections, such as opthalmic and arthritic inflammations; there will always re- main a disease, caused by contagion, which is not a simple phleg- masia, and which gives rise to primitive effects, such as I shall in another place describe. If in this we do not see a specific disease, if we refuse .to admit that the two lesions are produced by the same virus, we must find some other cause, some other virus, and with Benjamin Bell, we must adopt the doctrine of a double virus, one for gonorrhea, one for chancre. Still, even here, we originate nothing, we only revive the doctrine. To explain the difference between blennorrhagia and chancre— their primitive and consecutive accidents—a virus of different strength has been admitted, a whole virus, and a demi-virus. MM. Lagneau and Baumes seem inclined to this hypothesis, to which I shall again advert. Instead of a double virus, Carmichael contends for four kinds, which produce four different accidents. I repeat, the lesions which sometimes follow a suspicious connection, are sometimes of such different forms, and so varied in their re- sults, that we cannot be surprised that they should have been attributed to a different cause. But, thus far, we have arrived only at hypothesis, as we have studied under the influence of theory only. The experiments lately made to prove the inocula- bility of secondary accidents, or to show that the system may ar- rive at such a point of saturation as to resist all kinds of syphilitic action, or that chancre may be communicated to animals, have re- newed the questions, whether the virus is of different strength, whether it is modified by the blood, or in passing through the various organs, or from one individual to another, or from one kind of animal to another kind, and indeed if the virus is not changed by the different conditions of the organism with which it is brought into contact. Finally, it has been asked, are the differ- ent products due to the seed or to the soil. It has been justly maintained that differences, and these too very great, may arise from certain peculiarities of the organism created by a particular hygeine, by affections which preceded the invasion of the syphili- tic poison, by an immethodical treatment, administered without re- gard to time or quantity; thus long privations, excesses, scrofula, scurvy, a badly-managed mercurial treatment, may exert an in- fluence on the progress and the form of a chancre. But, even among the numerous chancres produced by inoculation on the same indi- vidual, on the same' organism, at short intervals, for the purpose of syphilising or saturating the individual, some have been ob- served to be very rapid in their march, others to remain a long time stationary, others, in fine, to become phagedenic, whilst others assumed the form of the real indurated, classic chancre; and what is worthy of note, these varieties have not always put on the charac- ter of the ulcers which furnished the matter for their inoculation. Thus just as the day would seem to dawn, darkness reappears, as has almost always been the case in syphilography, especially since it has made pretensions to positiveness. But, in this place, we can only glance at the questions. In studying the different forms of INTRODUCTION. 23 syphilis, they will again come under our consideration. Then, whilst studying them in connection with cases, we may perhaps be permitted to have a glimpse at their solution. In investigating the nature of chancre, I shall particularly notice the connection of induration with constitutional infection, as this form of ulcer has been regarded as that which alone furnishes a contagious matter, or a specific virus.* Modes of Propagation.—Each virus, has, so to speak, its peculiar method of propagation. In the great majority of cases it depends upon sexual connection, and the genital organs are those most commonly affected. But debauchery has devised other forms of connection, other methods of contagion, involving other parts, as for example, the arms, the mouth, the lips. Lactation may like- wise favor contagion. The touche, operations with the fingers denuded of their cuticle, and wounds, have been the means of com- municating the virus. The more intimate and prolonged the con- nection the greater the risk of contagion; it is from this cause that it is most frequently communicated by coitus and lactation. The chances will be still greater if there be a solution of continuity, a wound or laceration; thus coitus with organs of disproportionate size is attended with more, hazard than is the act under opposite circumstances, for the first-mentioned condition may be the cause of lacerations, which singularly facilitate the introduction of the virus; this is the reason that, all things being equal, there is less risk in having connection with a woman who has born children, than with those who have not, particularly young females. So much for immediate contagion. The possibility mentioned, of * An impression generally prevails that the question of the plurality of poisons has been definitely settled in favor of the doctrine of a single virus. It is admitted, however, by M. Ricord (Lett, xviii. p. 143), that it is far from being yet solved, and in his xixth Letter (p. 145), he acknowledges that his experiments have failed to establish the doctrine. Mr. Acton recognizes the coj^nection between the indu- rated chancre and the scaly eruption. (Treatise, 2d Amer. Ed. p. 285.) Mr. Egan is disposed to adopt with but slight modifications the views of Mr. Carmichael, and with the latter regards the experiments made by M. Ricord as lending a support to the doctrine of a plurality of poisons (op. cit. pp. 49, 52; and Carmichael's Clin. Lect. p. 52). M. Ricord, indeed, states that in his experiments—"always per- formed on the patients themselves1—the ulceration produced by inoculation has invariably assumed the form and character of that with the inoculable matter." (Lett, xviii. p. 142.) Mr. Herbert Mayo, on the other hand, has reported a case in his work on Syphilis, p. 38, in which a clearly-markedunderated chancre was produced upon the forearm of a patient, from the matter of a bubo following unindurated chan- cre. Again, whilst the experiments instituted in Dublin, furnish proof in favor of the doctrine of plurality of poisons (Egan, p. 54), those made at Turin (Sperino, on Syphilization, p. 300), tend decidedly to support the theory of a single virus! We may attribute the varieties, the characters of mildness or severity of primary sores, to constitutional influences, but of the nature of these influences we are, and probably must long remain ignorant. Still, as observed by Mr. Porter, in his ad- mirable lectures on syphilis, published in the Dublin Medical Press for 1846-1 (vid. Lect. viii.), "we are in this respect no worse off with syphilis than with many other affections; out of fifty patients, the subjects of operation, we know not the few that may be seized with erysipelas; out of a hundred wounded on the field of battle, we cannot point out the one or two that may subsequently die of tetanus ; neither can we explain the occurrence when it has happened, otherwise than by saying it depended on the constitution."—G. C B. 1 (Case viii. p. 198, in his Treatise, is reported as an Inoculation on a healthy person.—G. C. B.) 24 INTRODUCTION. preserving the virus for a long time, would lead us to suspect that of its transmissibility by mediate contagion, by means of objects on which it has been deposited, as, for example, the tubes or edges of glass in which it has been preserved. The story is familiar, of the young girl, who, to disguise herself, put on the breeches of a man, and thus contracted syphilis. A mask, the clothes of a per- son infected, the seats of a privy, it is said, have each been the means of conveying the disease. The authenticity of these cases, however, is not beyond reproach, and even if it were, it would furnish an argument in favor of the communicability of the second- ary disease. The sexual organs of the female may serve, so to speak, as a depot, from which the virus may be extracted. A man having connection with this female may contract the disease, and yet the woman herself escape infection1. This has long been known. Thus, we read in Astruc (torn. II., p. 16): "A woman having connection with a man diseased, if repeating the act shortly afterwards with a sound man, may infect the latter, and yet her- self escape." Hernandez, with those who, in turn, have copied from him, makes use of this fact, and of this hypothesis, to support the doctrine that chancre alone can produce constitutional syphilis. For example, when a man contracts a chancre from a woman affected only with blennorrhagia, this woman must, according to them, have had a chancre larve ; if this cannot be found they invoke the aid of this doctrine of recently-deposited virus in the organs of the female, a virus which the man carries off to his own great detriment, but to the decided advantage of the woman, who thus escapes infection. Ever thus do conjectures come in to the support of hypothesis. Action of the Virus.—What is the modus operandi of the virus? To this question Fernel gave an answer, which, even at this day, is not without its value. He asserted that it acts like other poison- ous agents, producing a venomous effect, similar to that resulting from the sting of an asp, the bite of a mad dog, or from the small- pox virus. Chemistry and vitalism have furnished their explana- tions, of which the exposition here would be of no real value. The solution which has met with most favor is that by Hunter; accord- ing to him, the virus produces upon the living tissues a peculiar irritation, and determines a particular kind of inflammation, the special product of which is virulent pus. (I use here the words of the French translation). In another place Hunter adds: " The presence of inflammation is not necessary to the continuance of this peculiar action, for the poison is still formed long after the signs of inflammation have disappeared." Besides the specific action, he adds, "it acts as an irritant, then it excites new inflam- mations, the products of which are not contagious." This first supposition, which has been reproduced in our day for the purpose of concealing the mistakes of experimenters, has singularly ob- scured the questions concerning the nature of* buboes and blen- norrhagia. Hunter admits the absorption of virus without any lesion of the surface to which it is applied, that is, without ulceration, without INTRODUCTION. 25 previous inflammation; this I call physiological absorption. After its absorption the virus passes into the blood, reaches every part of the organism, and may produce a double poisoning; one, which is acute, with local reaction in the point contaminated, character- ized by what we call the primitive accident; the other, chronic, more profound, and maintained by the persistence of the first, and according to M. Cazenave, capable of being constantly aggravated by new infections until the state of cachexy is reached; this is characterized by the consecutive accidents. I have mentioned that some would restrict the terms primitive accidents to chancre; thus implying that only through its surface can the syphilitic virus be absorbed. But chancre is not indispensable to infection. Indeed, as I have already advanced and as Hunter himself taught, the virus applied to certain points of the mucous membranes may readily reach the circulation, without any solution of continuity in the tegumentary surface; the mucous membranes may easily be impregnated, and the absorption which it irresistibly exercises over most toxic agents which are presented to it in a liquid form, and over semi-fluid substances, is not confined to the syphilitic virus alone, since we see the virus of glanders, and that of variola, enter the blood from their simple application to sound surfaces. Physiological absorption does therefore occur. Once absorbed, the syphilitic virus may rest dormant, and remain a cause without effect. This is the period of incubation. When it becomes developed, independent of the primitive symp- toms, it is called primary or non-consecutive syphilis, (verole d'em- blee.) In this case the general infection has preceded the appear- ance of the symptoms which have erroneously been called local. Thus, as M. Bousquet has proved, the vaccine pustle does not appear until the organism has been modified by the vaccine virus. MM. Lagneau, Baumes, de Castelnau, and Cazenave, are those, who, by their observations, have lately most contributed to estab- lish the fact of the incubation and the reality of the non-consecu- tive syphilis, (verole d'emblee). When I treat of chancre I shall reproduce the facts which are peculiarly my own, and which harmonize with those of my confreres. Furthermore, analogy was already in favor of the incubation, for every virus possessing con- tagious properties lies dormant for awhile, and then reproduces itself; for a certain time the cause produces no effect, at least no perceptible effect. M. Eicord denies both the incubation and the non-consecutive syphilis, (verole d'emblee). According to him, it is fundamentally and radically a local effect, that is produced by the virus in the part to which it is applied. And here this author rests upon experiment. Immediately after the lancet has placed the virus in contact with the living tissue, this virus acts, and. then commences at once the evolution of the primary symptom, which is attended with redness, like that of a flea-bite, a pimple scarcely raised above the level of the skin, which uninterruptedly passes into the pustule and chancre. But the operation by which the skin has been divided and more or less irritated, a proceeding which places the pus in direct contact with the divided tissues, is 26 INTRODUCTION. not the physiological act that applies the virus to the surface, and subjects this surface to a kind of friction, thus promoting absorp- tion, which remains physiological in proportion as the tissues are intact. Inoculation cannot justly be compared with coitus^except when a laceration occurs during the latter act. Then, indeed, there is immediately a pathological condition; a local action is at once begun without incubation; or, in other words, the general does not precede the local action, but they are simultaneous. OBSERVATION. The surest foundation of all theory and practice, is derived from the observation of natural phenomena; but observation, always in pathology difficult, presents still greater difficulties when it re- lates to the accidents produced by the syphilitic virus. It must be acknowledged that it is rare to find patients whose statements can be believed, and certain facts escape the attention of the observer, either from his inability or want of capacity in observing them accurately. Let us first examine the causes of error dependent on the patient, after which we will notice those which may be attrib- uted to the observer. Patients attempt to deceive, or are themselves deceived. It is particularly the case in syphilis that we encounter deception on the part of the patient; the reason of which is obvious. But this source of error has been singularly exaggerated, and when it is found that by the statements of the patient certain theories are compromised, the patients veracity is too readily doubted. Gene- rally, this disposition to deceive springs from interested motives, and not from any pleasure in the act. Now, the circumstances in which a patient can find it for his interest to conceal the truth, are not numerous ; it is generally, when they would repel the charge of having transmitted the disease, or when the manner in which they have become infected is regarded disgraceful or wounds their pride; thus, the story of the nurse who accuses the nursling as the cause of her infection, that of the libertine, who denies having had connection or having been guilty of other libidinous acts, should be received with allowance. But patients of this class may still furnish us with useful information; indeed, if we question them with care, to their affirmations they will add an exposition of a series of phenomena which have had their influence, and in this manner sometimes conduct us to the truth. M. Castelnau, who has written a work on the observation and interpreta- tion of facts in syphilography,* cites in support of this opinion, the following: A grandmother took her grandson to wean ; the child was in a wretched condition and had an eruption of pimples over the whole body, with excoriations in the mouth; after some weeks it died, and two months after its death, the grandmother as well as her * Vid. Annates des maladies de la peau et de la syphilis, No. 1. I have profited by this work. INTRODUCTION. 27 daughter (the aunt of the child) became affected with a squamous syphilitic eruption* Here, the only testimony we have in reference to the antece- dents of the case, was that of the two patients themselves; how- ever, it was hardly possible to doubt their accuracy, as, besides their own assertions, we find a series of morbid phenomena which often occur in a natural order; and the patients, as M. de Castel- nau remarks, could not have known how to arrange them so as to give an appearance of truth, consequently we must admit the veri- similitude of their own statements. Sometimes there exists another reason for believing the patient's own history of the case, as in the instance already quoted ; it is, that it will be very difficult to understand the nature of the affec- tion, if for their supposed falsehoods, we can substitute only ex- planations which are more or less improbable. In the case just noticed, the only other explanation left us, would be the existence of primitive symptoms in the aunt (the grandmother was about 70 years of age, and it is not very probable that she was thus affect- ed) ; to establish the truth of this supposition, the aunt must have infected the child; and the latter must have communicated prim- itive symptoms to its grandmother, without her knowledge of the fact (which is still more difficult to believe, as these symptoms must have shown themselves as evidence in certain parts, such as in the mouth, or in some other part of the face or hands) ; that this child had been so promptly affected by the virus as to die in two months, and this too while the grandmother and aunt were in excellent health ; that, in fine, these two women, of such opposite ages, had been attacked at the same time with constitutional symp- toms, although according to this hypothesis, the period of primi- tive infection must have been very different in the two cases. We see how similar explanations would be improbable, and how it would be more natural to believe the statements of the patients, especially when we know that they correspond with what many physicians have observed in cases where they have been able to fol- low, step by step, the development of all the phenomena. (Loc. cit.) At the same time, in approving the distrust with which those facts should be received, the authenticity of which rests solely on the patients honesty, I am far from justifying the conduct of those who reject them altogether, no matter what their source, provided they tend to conflict with their preconceived theories. Do we not, in the most serious affairs of life find that certainty is established by testimony which has no other warrant than the honesty of the witness ; why should we not in the same manner arrive at a scientific certainty ? Are there not men whose moral- ity is above suspicion, and whose testimony is equivalent to the most scientific demonstration? When Hourmann, observes M. de Castelnau, declared that he could not have contracted syphilis, except in the discharge of his duties as a physician, no one thought of doubting his veracity, and had any one dared so to do, * This case was communicated to the author by M. Alph. Robert, surgeon to the hospital Beaujon. 28 INTRODUCTION. he would have provoked but a just and universal feeling of in- dignation, among all who were acquainted with that virtuous man. I was the colleague of Hourmann at the Lourcine, and I can but repeat the language of his pupil. Besides, we shall remark, that the syphilographers who are least disposed to admit moral proof, and who subject every female to suspicion, do not hesitate to in- voke the chastity of a husband when it is necessary to support their theory. We will now consider the statements given by those patients who, without having any interest in so doing, yet deceive them- selves. Here, as in the study of other diseases, some of which present still greater obstacles to their investigation than syphilis, we are obliged to have recourse to the recollection of the patient for the causes, the first phenomena which appeared, and for the termination. It is evident, from the concordant results of differ- ent observers, that these may often lead us to the truth. Here, indirect means, artificial methods of arousing the patient's memory, every precaution, in fine, which is recommended in the best trea- tises on general pathology, must be made subservient to our pur- pose. Besides, there is a class of patients so intelligent, so careful of their persons, who are, indeed, such good observers, that their statements merit the greatest confidence, at least in the establish- ment of certain facts. Thus we shall see in examining the subject of incubation, that we do meet with patients capable of furnishing us with the most precise information on this point. Moreover, what is here required to be established? Two capital circum- stances : 1st. The precise date of the coitus; 2d. The time of the appearance of the first symptoms. A number of patients may very satisfactorily establish these circumstances. It is true that others require to be noted ; it is well also to take into account the habitual frequency of the coitus, for what is due to one of these acts may be attributed to another; we must know if there was any preceding infection, and if any excesses have thrown the system into such a commotion as to disturb the natural order of the phe- nomena. But all this is not only possible, but sometimes unat- tended with difficulty, and we shall discover, in treating of incu- bation, that certain patients have been able, by their own state- ments, to furnish the elements essential to the solution of this important question. Still further, on this point, it is curious to observe these same systematists. who deny a patient the necessary intelligence to establish a compromising fact, afterwards find this same patient quite competent to furnish details most difficult to be known, but which are favorable to their views. We shall have occasion to admire this inconsistency when we come to the chap- ter on the Syphilida. Some of these are not easily diagnosed; we know that the syphilitic eruption appears after chancre and before exostosis, that it is, in fine, a secondary symptom. Now, if in interrogating a patient, who has had these three symptoms, there is the least shadow of an eruption at the epoch required by their theory, his story is at once accepted, for the patient merits all con- fidence ; he is then intelligent, and his memory has not deceived INTRODUCTION. 29 him. But if, on the other hand, he places the most strongly- marked eruption after the exostosis, for example, then no matter what the precision or the number of his facts, the patient is no longer intelligent, his memory fails him, he is incompetent to de- scribe the eruption on his skin, he is mistaken in its form, color, &c, &c. We see, then, that confidence is given or refused to a patient, not according to the degree of his intelligence, but accord- ing as his story is favorable or unfavorable to a particular theory. Would it not be better then to disregard in toto the testimony of the patient? Away with all exaggeration, and let us try to distinguish the patient who can, from the one that cannot instruct us. We should not always judge of a patient's intelligence by the reply given to our first question, nor to our direct questions, but only after we have become better acquainted with them, and have subjected them to a cross-examination. In this manner certain patients may furnish us with valuable assistance in eliciting the truth. This, however, may be much more surely attained when we can see the patient at the outset of the disease, and can follow it through all its evolutions and note all the phenomena which it may present. Unfortunately, every observer does not feel the ne- cessity of collecting the minutest details; indeed, some are content with the most prominent facts, which, in their estimation, are quite sufficient to establish the character of the disease. The young practitioner should let nothing escape his attention, not even the most trifling circumstances, for the absence of one of them, though it may not be essential, may prove a prize to those whose theory may be impaired by the facts of the case, and may afterwards unexpectedly compromise its authenticity forever. The ignorance and unskillfulness of the observer may be ad- mitted; but sometimes he is unjustly accused: thus, in the ques- tions to which blennorrhagia gives rise, it is all important that the facts in favor of, or against its specific character, should be col- lected with the greatest care; no means of aiding our diagnosis should be neglected. In the case of a female, for example, not only the external parts of generation should be explored, not only should we press with the finger the urethra from behind forwards, expose the vagina with the speculum, explore it both when the instrument is introduced and when it is withdrawn, but we should bring into view the neck of the uterus, cleanse its mouth with a brush, and all this to see if we can discover no chancre to explain the specific nature of the symptoms which may occur, or to prove that they may arise, in the absence of chancre, from the inflamma- tion of a mucous membrane. It cannot be denied that formerly this physical examination was too much neglected, and even in our own day it is not always thoroughly made. But since Hun- ter duly warned us of the sources of error in his remarks on blen- norrhagia in the female, since the speculum has been so frequently employed, and especially since it was known that chancre might be hidden from our sight, our investigations have been more accu- 30 INTRODUCTION. rate, and there is daily less cause for the reproaches which have been made against observers. To complete the subject, I will borrow the conclusions of M. de Castelnau, as contained in the first part of the work already quoted: 1. Patients, with but few exceptions, do not attempt to deceive, except when they are impelled by interest, shame or fear. 2. Such cases are exceedingly rare in porportion to the number of persons affected with venereal disease. 3. Patients placed in such circumstances may still furnish us with reliable information, either because their testimony is corroborated by the fact of its conform- ing to the natural order of a series of pathological phenomena, or because we have no right to suspect their honesty. 4. There are patients who, by their intelligence and regard for their persons, may impart precise and sufficient details, respecting the diseases with which they are, or have been affected. 5. The physician may sometimes have the opportunity of witnessing all the morbid actions which constitute the disease in question, and then collect his facts without any doubt of their exactness, provided he has devoted to their study sufficient time and care.* Observation is therefore difficult, and when not beyond reproach, may be productive of error ; but there is still greater difficulty, in that operation of the mind by which we form our induction from the facts observed. There are facts, the connections of which are so simple, so evident, that their expression alone forms the axiom. But there are others which are not self-evident; these must be subjected to our reason, before they can attain a scientific value. This process is attended with serious difficulties; if the mind have not a proper bent, if it be biassed or imbued with some particular theory, error is sure to be the result. In this operation, we must, first of all, never lose sight of the facts themselves, and must guard against substituting suppositions in their place. Thus, in the ques- tion of the dependence of syphilitic blennorrhagia upon chancre, we should seek on all sides for the ulcer, and when found, note it particularly in interpreting our facts, but we should guard against supposing its existence, because a certain system positively re- quires that it shall figure in every case of the kind.f We must * Annates des maladies de la peau et de la syphilis. No. 1, p. 10. f The following remarkable instance of substituting supposition for facts is worthy of record. Dr. Riehet, the family physician of a Parisian merchant, met M. Ricord in consultation. The case was that of a child, affected with syphilitic ulcerations in the ano-genital regions. Both parents and nurse being apparently perfectly sound, much perplexity was felt in deciding upon the origin of these ulcerations. The fact was mentioned, that ten clerks lodged in the same house, and perhaps one of these might be affected! Seizing upon this happy suggestion M. Ricord at once attributes the infection to the dandling of the child upon the naked hands of one of these clerks. M. Velpeau, in his communication to the Academy of Medicine, Sept. 21st, 1852, states that by accident he had learned from Dr. Riehet, that this story of the poxed clerk was a mere invention, having no other foundation than the circumsta-nces above mentioned. In a letter subse- quently addressed to M. Velpeau, Dr. Riehet observes: "No, positively, no, neither M. Ricord nor myself saw any such clerk!" M. Ricord's apology, as furnished in his communication to the Academy, Oct. 12th, 1852, is, that his report of the case was given from memory, which report in his Letters (xiii., p. 104), is followed by INTRODUCTION. 31 not reject certain facts, or deny the importance which they really possess, because they do not accord with those which have gener- ally been observed. Admit that they are exceptional, but if well established, nothing can destroy them, for a thousand negative facts cannot destroy one positive fact: this is an axiom that has been admitted since men have known the art of reasoning. Is more than one fact required to prove that wounds of the heart admit of recovery ? It is not inappropriate to notice in this place a part of the dis- course of M. Gilbert, in support of the doctrine of the transmissi- bility of the secondary accidents. The orator, wishing to show what errors may result from interpreting facts whilst swayed by the narrojving influence of theory, exclaims: "Thus, to limit primary syphilis to chancres, an urethral chancre in certain cases of blen- norrhagia must be supposed, and chancres with flat primary tubercles, or mucous pustules, the occurrence of primary buboes (d'emblee), be denied as well as the contagious character of certain vegetations, and we must metamorphose into chancres certain consecutive ulcer- ations of the tonsils, mouth or skin ; thus, must we torture and in- terpret the instances of the tardy appearance of the secondary ac- cidents of syphilis, and the cases in which some of these accidents have been transmitted, a transmission which has occurred more than once from the habitual and intimate relations which exist between the husband and the wife, the nurse and her nursling, and between the latter and other children under the same roof. The testimony of most credible witnesses must be rejected, and those who do not wish to explain clinical facts in the most difficult and irratiotial manner, must be accused of error or credulity. In a word, we must cull, prune, strike off, polish, and reduce to a certain measure marked in advance, all the elements of science that they may fit the famou% square* without distorting its regular lines, or chang- ing its solidity. The difficulties in the way of observation, the qualities of mind, the time and patience required to render it complete, the sound- ness of judgment and intelligence necessary to a correct interpre- tation of facts, the doubts which cannot be removed, even by the union of all these qualities on the part of the observer, have some- some observations upon th|e tact and skill required to discover the trire origin of the disease in these perplexing cases! For all the details connected with this case the reader may consult the collection of Reports and Discussions, entitled " Be la Syphilization," i emplastrum, "de vigo" plasters, folding them one over another, as in the method of dressing par occlusion, and in less than a month this patient was cured. This fortunate result may fairly be attrib- uted to the absorption, by a large surface, of the mercury con- tained in the plaster.* But perhaps it may be said that in this instance the reparative stage of the ulcer had arrived, that the system was in a condition to react effectively, and that nature alone had effected a cure. Had I syphilized this patient he would * Something similar to the Emp. ammon. cum hydrarg.—G. C. B. INTRODUCTION. 49 have been cured; it may be a little less rapidly, but still he would have been cured; and then!—From what I have stated the reader may surmise my views on the so-called lamentable cases of syphilization, which cases may have been unfortunate, independent of syphilization. Thus M. Laval, whose name is so frequently mentioned in this work, this German physician, who has been pronounced the victim of syphilization, became infected from the matter of a consecutive accident in one of his confreres. After the inoculation a papular eruption appeared, which he desired to be treated by the successive inoculations of several varieties of chancrous pus. In this manner he produced on himself an infinite number of chancres. The progress of his disease, however, was not arrested, as would probably have been the case had he not been inoculated, and especially if he had followed no plan of treat- ment. The facts yet produced by this prophylactic or curative syphilization are far from entitling it to a place in medical science, but may be of real value in assisting to destroy a system resting on a false basis.* TRANSMISSIBILITY OF SECONDARY ACCIDENTS. This question, viewed in connection with public or private hygiene, is one of vast importance; it presents itself daily in ordinary practice, and not unfrequently in courts of justice. Ee- garded purely in its scientific bearings, it is one of the most interest- ing in etiology. The earlier writers on syphilis believed that the disease might be communicated by everything which surrounds, and by all that is within man; thus, they supposed that the atmosphere, every emanation from the body, the breath, perspiration, the natural or morbid secretions, the blood, in fine that anything might serve as a vehicle for the poison. Syphilis was regarded as an epidemic, and capable of being propagated in every possible manner. With such views, they must have admitted for facts fictions, sometimes absurd, as for example, that it might be communicated through the grates of a confessional, by the perfume of a bouquet, and a minister was actually put to death, because, knowing that he had the disease, he had dared, nevertheless, to breathe into the ear of the king. The absurdity of such notions was early discovered, and it was exposed even by Fernel; at a later period they were attacked, and * The Treatise of M. Sperino, to which we have already alluded,, contains the results of some 94 cases of syphilization, performed for curative purposes, which results this surgeon regards as highly favorable to the practice. Permission having been granted by the Government to institute a series of experiments on this subject, M. Sperino, who is at the head of the venereal hospital at Turin, immediately availed himself of the means at his disposal, and in his elaborate work, the reader interested in this matter will find copious details. Fifty-three of these 94 cases were primary syphilis, the remainder being constitutional syphilis. Fifty of the former, and twenty-five of the latter cases are reported as cured! But we must refer the reader to the work itself, and will only add that syphilization, as yet, has found but few if any advocates either in Great Britain or this country.—G. C. B. 50 INTRODUCTION. in our own day tne truth has been revealed. Not only has the idea of an epidemic and fantastic contagion been abandoned, but some have gone so far as to admit but one mode of propagation, but one vehicle of the poison, viz. the pus of chancre. Thus, the atmosphere, the human breath, and perspiration are very properly no longer regarded as the mediums of propagating the poison, but with these some would include the blood, the normal secretions, as well as those that are morbid, except pus, a question which is by no means settled, as Hunter and his disciples would seem to believe. According to M. Eicord, who has given an absolute character to the doctrines of his master, infection can occur only from the matter secreted by a chancre, which matter alone is the medium of the virus; the latter can enter the system only by a chancre, and its infecting properties do not reach beyond the first lymphatic ganglion in direct relation with the chancrous surface. Beyond this ganglion, the virus may still injuriously affect the individual inoculated, producing secondary symptoms, such as pustules and syphilitic ulcers over his body, but can do no harm to others, as it no longer exists as a contagious agent. Of course, if but one individual could be found, whose chancres had cicatrized, but who was still covered with ulcers and pustules, who, in fine, was completely saturated with syphilis, the disease would die with him, he could not communicate it to those thrown into contact the most frequent, intimate and prolonged, and the syphilization of the world would then be complete! This is the latest doctrine advanced by the disciples of Hunter. But a grave and incontest- able fact here presents itself, it is that of the infection of the child in its mother's womb, a fact admitted by all syphilographers. It is unquestionable, that a woman, having neither chancre nor bubo, but that form of syphilis only, which it is asserted, can no longer be infectious, may give birth to syphilitic children, which may infect their nurses, whilst the latter, in turn, may communicate the disease to their families. This is the same syphilis that should have disappeared with the cicatrization of the last chancre, but which here reappears and recommences its ravages. The principle of contagion may therefore exist elsewhere than in the pus of chancre, and other than the primary ulceration. Analogy could not fail to seize upon a fact so widely known, and should have led to its admission, since, even after the cicatrization of a chancre, the system may still contain an infectious principle capable of being transmitted to another being; by multiplying the relations, diversifying the experiments, and employing different humors, we may expect to prove the transmissibility of syphilitic accidents independent of chancre or its products. Observation here confirming analogy should have anticipated the results of experiment, and, doubtless, in any other epoch than the present, would have rendered it unnecessary, for the instances of the infec- tion of the nurse by the child, which is seldom affected with other than secondary accidents, are exceedingly numerous, and MM. Bouchacourt and Bardinet de Limoges, have recently reported cases with details so precise as to leave no room for doubt. Again, the INTRODUCTION. 51 .transmissibility of the mucous tubercle by means of intimate rela- tions and contact is generally admitted. On this subject the works of MM. Lagneau, Baumes, Cazenave, Gibert, and of other unpreju- diced observers, may be consulted. Among the patients which come under the practitioner's care, opportunities will occur, if the two be treated together, of seeing the mucous tubercle in both, in its different stages of origin, seat, and isolation from other acci- dents, thus removing all doubts of its contagious character. In another place I shall appeal to M. Eicord himself. Me shall find that he admits the infection of the nurse by the clud,* and the contagiousness of the mucous tubercle in the adult, but, as he expresses himself in his Treatise, it is by some incomprehensible vital process, f He admits contagion only, that is, physiological inoculation, and still denies the fact of experimental inoculation. As it is chiefly with contagion itself that we are now concerned, and not with this or that method of it, in my opinion the question is settled by M. Eicord's own admission, and for this reason, I am the more astonished that he still persists in opposing my views. Thus, the clinical fact is known even to my opponent, that sec- ondary accidents are contagious, since M. Eicord acknowledges the contagion of the mucous tubercle, an accident which he classes among those regarded by him as secondary. It remained, how- ever, to establish the fact by experiment, a matter of importance in an age so given to experiment. I cannot too often repeat, that for those whose minds have been trained to observation and legit- imate induction, the question needed no experimental proof. But for the school, especially as it was not long ago, we were compelled to descend to experiment. I have experimented, and for the first time in France, have succeeded in inoculating the pustule of sec- ondary ecthyma. At the simple announcement of this result, whilst the case was still in my cartons, the attacks commenced, and they were directed chiefly against the experimenter. I saw the position in which they would place me, and for a long time I submitted in silence, knowing that sooner or later the end would come, and I continued to observe, to experiment. During this period, men of indepen- dent minds, whose attention had been awakened to the subject, also observed and experimented ; they were attacked in the same manner. In the body of this work may be found, indeed, an ac- count of observations made in Paris, and in Germany, observa- tions which accord entirely with my own. These formed the basis of an essay which I read to the surgical society, and which drew forth a discussion. At a later period, a German physician was presented to the Academy of Medicine, who had inoculated him- self with a consecutive affection ; this gave rise to another discuss- ion, the results of which, in the estimation of every unprejudiced person, must have been a condemnation of the doctrines I op- pose. * Vid. section of this work on Infantile Syphilis, p. • f Vid. p. 182, of M. Ricord'f Treatise. 52 INTRODUCTION. Objections have been made to the small number of facts which experimentally prove the transmissibility of the secondary acci- dents. It has been stated, especially by M. Eicord, that if these accidents can be inoculated once, tney can always be inoculated. Now, it is not correct to say that the facts of -inoculation are rare. A different impression will follow the perusal of the writings of Wallace, reprinted in the Annales des Maladies de la peau et de la syphilis, as well as of the contents of this book. These facts, as my opponents, have lately been forced to admit, are rare and ex- ceptional, onry when they chance to possess great weight in this question. It is well known, indeed, that all the negative facts in the world cannot destroy one positive fact. M. Diday, whom M. Eicord persists in citing as a partisan of his doctrine, referring to the experiments by which Wallace proved the transmissibility of the secondary accidents, remarks : " These cases are not very numerous, but more are not required to shake the security which reposes on negative facts."* f M. Eicord, who had asserted before the Surgical Society, that if the secondary accidents could once be inoculated, they could al- ways be inoculated, no longer repeats this argument before the Academy of Medicine, because, during the interval which passed between the two discussions, the question was settled experiment- ally, since which he has been silent on this point. It has been proved, to my certain knowledge, that chancre, even when inoculated according to the most approved method, and by the most skilful experimenter, is not always reproduced. Chan- cre, then, can be transmitted only under certain conditions. Now, the same observations should apply to the secondary accidents. However, as the principal conditions which are favorable to the success of the inoculation of a chancre are known,—witness the great number of experiments already made for this purpose—those which affect that of the secondary accidents have been less studied, and are almost completely unknown. Further, the secondary af- fection, which should be especially inoculable, is that which is of a purulent character; now, this is represented by ecthyma, which is rare. This form of cutaneous disease consists of several varieties; there is one which appears shortly after the chancre is healed; it resembles varicella ; the pustules have a thin scab, which, in fall- ing, leave no ulceration, or that but trifling. I am almost certain that this variety is more easily inoculable than that which appears at a later period, when there exists an affection of the bones ; the number of pustules is then very limited; they are to be found principally on the extremities, the legs; they are very large, and * Gazette Medicale, Oct. 6,1849. "We are also indebted to M. Diday for the pub- lication of the most conclusive fact concerning the inoculation of chancre in the brute, a fact denied by M. Ricord. t Dr. Skae successfully inoculated four out of thirty-six cases of mucous tuber- cles.—Northern Journal of Medicine, April 1844, or Cormack's Lond.andEd. Month- ly Journal, July 1844, p. 620. M. Sperino (op. cit. p. 502), refers to other suc- cessful inoculations of secondary accidents not alluded to by our author; they wfre made by MM. Sigmund, of Vienna, and Gamberino and Galligo, of Italy.__ INTRODUCTION. 53 their thick scab, in falling, leaves a deep ulcer. Thus, the condi- tions required for the inoculation of the secondary affections being almost completely unknown, and these affections which are inocu- lable, being themselves rare, the experiments on the subject, un- like those on chancre, being also of recent date, the success obtain- ed in the one case forms no criterion by which we may judge of that in the other. I am satisfied that certain non-syphilitic affections, which are re- garded as not admitting of inoculation, would become so, could we but seize on the right moment when they contain inoculable matter. Thus, at present, when attempts have been made to inoc- ulate chancre, the ichorous discharge from the ulcer has been used, or the detritus of the cancerous mass. But are these really the parts inoculable ? Is it not rather the cancer-cell at a certain period, whilst yet recent, that should be employed ? The success obtained by Langenbeck, leads me to believe that that is the ele- ment required: This experimenter took fresh cells from a cancer yet warm, removed from the humerus, and introducnd these cells into the blood vessels of a dog. Cancerous tumors in the lungs were the result. * To return to the consecutive syphilitic affection, I would re- mark, that in France, inoculation has succeeded only, after the method adopted for that of chancre, that is, with the lancet as used in vaccination. We know that the manner of applying the agent may exercise a great influence upon its effects. I have already shown, that for the inoculation of the brute with chancre, the ordinary proceeding is insufficient, since M. Auzias was obliged to resort to another already described. Aside even from the inoculation of syphilis, substances are found which remain inert after the ordinary method of inoculation, and yet which produce very marked re- sults when applied in another manner. Tartar emetic ointment is one of these; I have tried to inoculate it without success ; while by frictions I have succeeded in producing pustules. The mucous tubercle which is so readily communicated by prolonged and repeat- ed coition and by suckling, is not inoculable by a simple puncture of the lancet; but rf a blister be previously applied, and if we dress the denuded dermis with charpie steeped in the pus of the pustule, in fine, if we adopt the method of Wallace, as M. Boulay has done, as I have done, then the inoculation will succeed. It is also prob- able, that a simple puncture of the lancet dipped in syphilitic blood, would not produce positive results. But if, as has been done by Waller (de Prague), we scarify the skin, if with a par- ticular instrument we introduce infected blood into each trifling incision, and if the whole is covered with the same blood, we shall have strong reasons to expect the same success which Waller ob- tained. Besides the arguments which I have mentioned and op- posed, others have been raised less and less scientific, in propor- tion as my adversaries haVe lost ground. At first, the cases left * Smidt, Jahrbuechcr; t. xxv., quoted in the Encyclopedic Anatomiq te, t. ix. p. 279. 54 INTRODUCTION. something still to be desired on the score of authenticity;_ the diag- noses of the inoculated affection had not been made ; instead of taking matter from a secondary disease, it had been taken from a chancre; then followed insinuations against the credulity, the dis- honesty of the observers, &c. In all desperate causes the same course is adopted With regard to the experimenters, I will cite the names of Wallace and Waller, who were at the head of an ex- tensive venereal service; MM. Bouley and Eichet, who experi- mented at the Lourcine, and M. Cazenave, the author of a Treatise on the syphilida, whose experiments were made at the hospital St. Louis. The names of the pupils in Paris who reported these cases, are MM. Pellagot, Schneph, Lafargue, Piberet, Eossen, Co- det, Dubreuil, and Dumenil, all of whom are distinguished internes. Now I entreat those who are investigating this subject, and who are desirous of coming to some conclusion, to peruse these reports, together with those of the internes mentioned, and of my confreres, all of which show the transmissibility of syphilis otherwise than by the pus of chancre, (these cases are particularly noticed in the chapters on mucous tubercles, the syphilida, and exostosis;) then let them examine those presented by the opponents of this doctrine, which may be found in the Treatise of M. Eicord. Having duly con- sidered the arguments offered by both parties, they may then ob- tain a satisfactory decision. They will be surprised at two circum- stances in the work just quoted, first, the small number of the ex- periments, their want of connection, and the absence of all details; second, the limited time after the experiments that the patients re- mained under observation. Constant allusion is made to the very numerous negative experiments, as was the case with those relating to the inoculation of animals. Now go to their sources, and see what number they can offer! Of course we refer to authentic sources, to books and writings, not to private conversations. M. Yelpeau has exposed the value of the facts brought forward in op- position, in a discourse which must long be regarded as a remarkable specimen of annihilating criticism ; they have been reduced to the character of simple assertions, in some instances of no importance whatever. Waller has likewise noticed the brief period, during which the subjects inoculated with secondary accidents were watched ; and the incubation being occasionally quite prolonged, as in, the instances reported by Wallace and the physician of Prague, M. Eicord may have regarded as failures some really successful inoculations. In this case, he would not be the first who has un- consciously succeeded. I am certain that this has happened to another experimenter with whom I am acquainted. It may have been observed, that when I alluded to the fact of incubation after the inoculation of secondary accidents, I did nOt speak in decided terms, for it may be absent, or rather a small pustule may at first be developed, which miscarries, and yet some time afterwards the genuine pustule may appear. In this case, the first pustule seems to be but traumatic, whilst the other is a specific effect. Further, since I started this question of the transmissibility of the second- ary accidents, M. Eicord has not seriously examined the subject, INTRODUCTION. 55 and he has even rejected the facts brought forward without an ex- amination. At this, however, I should not feel wounded, since he has been guilty of the same conduct towards his own pupils and friends. In the discussion on tubercular affections of the testis, M. Malgaigne proclaimed in full tribune, that M. Eicord com- menced by rejecting the observations of his brethren, and that he treated in the same manner those of his pupils made under his own eyes. Even those made by himself have shared the same fate, when opposed to his theories.* If M. Eicord thus treats obser- vations relating to tubercular affections of the testis, what would he not do with those which endanger the safety of his system! Examine the discourses and writings of M. Eicord in reply to the arguments and facts adduced not only by myself, but by every orator in the Academy, his answer is always the same; it is always what we call petitio principii; for supposing that to be demonstrated which is precisely the point in question, and his opinion upon this point being unchangeable, he responds by the question, that is, by his opinion. The whole, in fine, may thus be briefly expressed; chancre alone is inoculable. Now this is the point in dispute, and the contrary we aim by facts to prove. This has long been a fa- vorite method of reasoning with M. Eicord, but with no bad inten- tions. It is thus noticed in the Thesis of M. Helot, formerly an interne of the hopital du Midi: " My dear master, like others who are wedded to some favorite doctrine you have established the value of inoculation on the petitio principii. For such I write not, but for those who seek the truth, and I believe that I have here furnished them with the elements of conviction, drawn from analogy, observation, and experi- ence." Our author has clearly demonstrated that secondary accidents are trans- missible, yet as important medico-legal questions not unfrequently arise in con- nection with this subject, it may be satisfactory to the young practitioner to know that this doctrine is defended by the following eminent British and American authorities, viz., Sir Astley Cooper, Lectures on Surgery, by Tyrrel, Am. ed., p. 497 ; Mr. Liston, Elements of Surgery, by Dr. Gross, p. 205 ; Mr. Colles, On Venereal, p. 263; Mr. Wallace On Venereal, p. 335; Mr. Hey, Med. Chir. Transactions, vol. 7th, 1830, p. 541; Jesse Foot, On Venereal, p. 402; Herbert Mayo, On Syphilis, pp. 122, 123; Sir Benjamin Brodie, Lecture in Lond, Lancet, Feb. 1844, p. 677; Mr. Babington, Notes to Hunter, Am. ed., p. 321; Mr. Lawrence, Lectures on Surgery, Lond. Med. Gazette, March, 1830, pp. 806, 807 ; Mr. Porter, Lectures on Syphilis, Dub. Med. Press, Feb. 17th, 1847, pp. 99 ; Mr. Whitehead, Illustrations of Trans- mitted Syphilis; Samuel A. Lane, Lectures on Syphilis, Lond. Lancet, May 28th, 1842, p. 294; Mr. Bacot, On Syphilis, p. 252; Mr. Carmichael, Clin. Lectures on Ven. Diseases, p. 51 ; Langston Parker, Modern Treatment of Syphilitic Diseases, 2d ed., p. 169; Mr. Egan, On Syphilitic Diseases, pp. 293, 294; Erasmus Wilson. On Syphilis, p. 36; Geo. McLellan, Principles and Practice of Surgery, pp. 250,^fel; Dr. Neligan, Dub. Quart. Journal of Medicine, Feb. 1853, p. 119; Dr. CampDelL' North. Journal of Medicine, 1844, or Cormack's Journal, Sept. 1844, p. 773; Dr. John Rose Cormack, Lond. and Ed. Monthly Journal of Medical Science, Sept. 1844, p. 773 ; Evanson and Maunsell, On Diseases of Children, Am. ed., p. 350 ; Dr. James Stewart, On Diseases of Children, 4th ed., p. 468 ; Dr. John Watson, United States Med. and Surg. Journal, vol. 2d, p. 103; Dr. H. D. Bulkley, On Syphilis in Infants, New-York Journal of Medicine and Surgery, Oct. 1840. We might add to the list, but surely it is unnecessary. During our recent visit to Dublin, we were person- ally assured by Messrs. Cusack, Adams, Fleming and Wilmot, that they entertain no doubts of the correctness of the doctrine here advocated, and we know that * Take the orator's own words. It should be recollected that M. Malgaigne is the friend of M. Ricord, and that it is from the journal of a friend that they are copied. " M. Ricord, possessed of a theatre of observation vast as could be wished began by rejecting the observations of others ; then adopting a certain theory, he disregards those of his pupils made under his own eyes, in his own service, and finally, 1 must say it, he takes no heed of his own, when they conflict with his own preconceived views." Vid. F Union Medicale, Aug. 30, 1851. 56 VIDAL ON VENEREAL DISEASES. among our own countrymen, this view of the subject is inculcated in the lectures of Profs. Mott, Mussey, and Parker. Indeed, it is not difficult to find, even in the works of the most prominent opponents of this doctrine, viz. Messrs. Ricord and Acton, positive proof in its support. As such, we regard Case XV. (God. Eulalie) in M. Ricord's Treatise, 4th Am. ed., p. 204, and that of the child infected by the cavalry officer, mentioned in his Letters, xiii. p. 105. Again, in his Notes to Hun- ter, 2d ed., p. 776, he fully admits the transmissibility of the secondary accidents in the following language : "There exists a great number of incontestable cases of syphilis transmitted from the nursling to the nurse, and vice versa." Further proof may be found in the work of Mr. Acton, 2d Am. ed., p. 420. "We refer to the re- port of the case of the infected foetus, which contaminated its mother. Can a husband, who has suffered from syphilis, but who is apparently sound, communicate consecutive accidents to his wife, which accidents, in the latter, shall not be preceded by any form of primary sore ? It was the opinion of Mr. Colles (op. cit. p. 263), that " a newly-married man, who is himself free from every appear- ance of syphilis and every other disease, shall yet infect his wife in such a man- ner, that secondary symptoms shall appear in her a few months after marriage, and these not be preceded by any primary symptoms, or by any discharge what- ever from the genitals." Mr. Carmichael (Clin. Lect, p. 50, 51) states that he has met with instances of young married women above suspicion, who were affected with constitutional symptoms, yet who, on the minutest inquiry, he could not learn ever had any primary venereal affection. But their husbands, though equally free from primary, at the time of their marriage, had on them secondary symptoms in the form of eruptions or ulceration of the throat. A case of the latter kind came under our own care a few years since. The individual married in spite of our remonstrances, and about two or three months afterwards, his wife had a similar eruption on her lower extremities. "We here insert the details of two very interest- ing cases, for which we are indebted to Mr. Langston Parker: "Case I.—A gentleman contracted a superficial primary sore, which healed without leaving a mark or induration behind it. Being apparently in good health, he married. Three or four months after his marriage, he perceived on his body numerous red, smooth, elevated, scaly blotches ; very shortly his wife broke out with an eruption of a similar character, and the hair came off rapidly in both patients. In this state, they were sent to me. Neither had any primary disease, and the lady had never had the slightest irritation in the genito-urinary organs. I examined them both frequently and carefully, and I am positive the wife had never suffered from sore, excoriation or discharge. " Case II.—A gentleman, who had suffered both from primary and secondary Byphilis, married, after having been free from all symptoms for twelve months; soon after this he had another eruption and sore throat; his wife became affected with the same eruption, excavated ulcers of the tonsils, and was prematurely de- livered of a dead child, in the sixth month of her pregnancy. Both patients lost their hair and eyebrows. On account of the obstinacy of some of the symptoms, in both cases, they were sent to me from a distance to be treated by the moist vapour of mercury, under the use of which they both perfectly recovered. In this case the lady was more than once carefully examined; she was free from all evi- dence of primary disease, and never had suffered from the least irritation in the parts." Mr. Porter remarks (Lect. cit, p. 100), that the cases which have come under his observation, have led him to the conclusion, " that the semen of a diseased mar dejKited in the vagina of a healthy woman will, by being absorbed, contaminate thW^woman, without the necessary occurrence of a chancre, or any other sore secreting matter on either the man or the woman." Prof. Willard Parker has fur- nished us with the particulars of three cases in support of this doctrine, and others of a similar nature may be found in the paper of Dr. John Watson, to which we have referred. Now, if the doctrine here broached be true, and if it also be true, as is main- tained by Messrs. Ricord, Cazenave, and Erasmus Wilson, that the syphilitic tem- perament or diathesis, when once formed, may last ten, fifteen, and twenty years, or, indeed, never be eradicated, when can a man with safety marry, who has had constitutional syphilis, but who is free from every external manifestation of the disease? Will it do to give him "a clean bill of health," after a "six months' quarantine," as proposed by Mr. Acton (op. cit, p. 416), or after that which has lasted from "two to five years," as advised by Mr. Wilson (op. cit, p. 49)?— A TREATISE ON YMEREAL DISEASES. PART I. PRIMITIVE VENEREAL DISEASE. In the announcement of the classification which I have adopted, I have already explained what I understand by the terms primitive venereal disease. It may arise simply from irritation, or, from a specific cause, hence may follow affections non-specific; or specific, virulent. Thus, the lesions discussed in our first division may be regarded as simple local inflammations; certain instances of blen- norrhagia are of this class. But, as the syphilitic virus is the most common cause, these affections are, generally, neither simple nor local; if, for example, chancre should possess this character, it would no longer be a chancre, that is, a specific ulceration, but simply a suppurating wound. After the accidents, which, by all, are regarded as primitive, will be found discussed in this division those which by otters are called consecutive, hence the despair of the nosologists, who pre- tend to be strictly logical, and of the syphilographers, who profess to be governed by absolute laws; among these diseases are the mucous tubercles. I have assigned them a place between the primitive and consecutive accidents, to show that when caused by a specific virus the disease is the same, and that the facts which relate to it belong to both. A more arbitrary course might sepa- rate them; but it should be understood that the arrangement here adopted is but provisory and artificial, to assist the compre- hension of junior minds. . Most of the diseases of this first division are of an acute nature, and assume a more or less inflammatory form. Besides'the symp- toms which may be attributed to the virus, others more direct, more immediate, of an inflammatory character, manifest themselves. Indeed, if the testicles, the prostate gland, the articulations, the eyes, the lymphatic gangha, become involved through sympathy or metastasis, it is under the form of a phlegmasia. The practi- tioner is therefore most frequently required to treat an inflamma- tion ; and to subdue that which threatens he should promptly direct all of his attention, all his means, without reference to its specific cause. First of all, the effects must be combated. Antiphlogistics must then occupy a prominent place in this division. They seem, 58 VIDAL ON VENEREAL DISEASES. indeed, ultimately to decide everything. The advocates of the doctrine of the non-existence of a specific virus have seized upon this circumstance, and taking the exception for the rule, the tem- porary for the permanent, have proclaimed the constant success of simple treatment, such as antiphlogistics, emollients, hygiene, and that, consequently, venereal affections do not depend upon a specific virus. It is true that simple treatment is sometimes sufficient, since nature alone is occasionally adequate to the purpose, especially in those cases which are not virulent; the error lies in the generaliza- tions from these results, and particularly in the conclusions drawn of the nature of the disease from the means by which it has been cured; they cannot be specific, because they have been cured by a non-specific treatment! The whole science of medicine properly- interpreted, protests against this error, which would deny the vix medicatrix naturce, the greatest and most brilhant fact in pathologi- cal physiology. CHAPTEE I. BLENNORRHAGIA. From the time of Swediaur, the term blennorrhagia has been applied to the inflammation of certain mucous membranes, which generally follows impure connection, and the characteristic of which consists in a more or less abundant secretion of mucus mixed with pus, (muco-pus.) This disease has also been called gonorrhoea, which denotes a discharge of semen, and it has been known like- wise under the name of chaudepisse, derived from the burning sensation which the patient suffers in urinating. These terms, like others which I purposely omit, express only a symptom of the disease that may be wanting, in which case they would mean nothing; thus the seminal flux is an hypothesis; the burning sensation may be entirely absent. The word blennorrhagia itself is far from being without reproach, for the discharge is not always of the same nature; for example, in the commencement it may be mucus, then it may be mucus mixed with pus; finally, it may consist of pus alone. Still worse would it be if there were actually a dry blennorrhagia. Seat.—The ordinary seat of blennorrhagia in the male is the urethra, sometimes it affects the mucous lining of the prepuce and the glans penis; in the female, it occupies the vulva, vagina, ure- thra, and the uterus; in both sexes, the oculo-palpebral mucous lining, that of the anus, and lower part of the rectum. The buccal blennorrhagia is excessively rare, and it is probable that that of the nose is but an imaginary disease. In certain regions, when the skin suffers a kind of mucous transformation, blennorrhagic discharges may be observed, as, for example, in the genito-crural fold, at the internal face of the thighs, and the umbilical region. Several of the parts mentioned may be simultaneously affected with blennorrhagia: in the male, blennorrhagia of the glans, of the prepuce, and of the urethra, may simultaneously exist; in the BLENNORRHAGIA 59 female, the entire vulva, the vagina, urethra, the neck and body of the uterus, may at the same time be affected. Causes.—Blennorrhagia is most frequently observed at that period of life during which the functions of the genital organs are most exercised, viz. adult age. It has, however, been noticed at a very early age, particularly in little girls of a lymphatic tempera- ment, which temperament is also favorable to its development in the adult. Women are more frequently affected than men, and communi- cate the disease with greater facility. All climates have been observed to be favorable to its develop- ment. Among the causes of the disease have been ranked certain aliments and exciting drinks; for example, salted food, spices, asparagus, truffles, strong liquors, coffee, beer, may really promote the action of the direct cause. The excessive use of beer alone has been accused of producing a blennorrhagia. Is there any foundation for this belief? I am well convinced that this beverage will exasperate, and even rekindle an urethritis of long standing which has scarcely disappeared, but more than this I have not observed. Further, beer exerts but little influence on other than urethral blennorrhagias. Gout, rheumatism, dartrous, and scrofulous vices have been noted among the causes of blennorrhagia. It is certain ^ that the existence of a rheumatic, or of a dartrous affection in a patient, may modify the progress of the disease: thus, we see rheumatic patients affected with blennorrhagia, in whom, during a rheumatic paroxysm, the discharge ceases, and yet upon the subsidence of the former, the latter reappears; on the other hand, there are patients who notice the appearance of a discharge at each access of their rheu- matic attack. Patients afflicted with dartrous affections have been observed, whose discharges, like the cutaneous disease, assume a chronic character; in such cases it becomes of a serous nature, and small in quantity; the secreting surface is affected with a trouble- some itching, and the urethral affection is cured by remedies addressed only to the cutaneous disease. Scrofula renders a blen- norrhagia chronic, and the discharge in these cases readily assumes a gleety character. This is all that can be said of the part which the above morbid conditions play in producing or modifying the characters of a blennorrhagia; beyond this all is hypothesis.* * Mr. Henry James Johnson, On the Genito-Urinary Organs, part i. p. 37, after alludim* to the influence of gout or scrofula in predisposing to blennorrhagia, observes: "but, I am mistaken if those peculiar states of system do not, occasion- ally, produce the complaint without the interposition of any obvious exciting cause." He then gives the details of two cases which support the above view of the subject. As to the influence of gout in producing a blennorrhagic discharge, we have no doubts whatever. About four years since we treated a patient some seventy years of age, who was the victim of gout, and during one of his attacks he was seized with a most copious urethral discharge. We know, positively, that this dis- charge depended upon no other cause than the gout. Dr. John Watson, of this city, informs me that two cases of the kind have come under his observation. Numerous and serious medico-legal questions may arise in connection with the subject of urethral and vaginal discharges, both in children and the adult. The reader may find, both in the works of Beck and Taylor, on Medical Jurisprudence, 60 VIDAL ON VENEREAL DISEASES. The direct causes are either physical, chemical, or pathological: thus, a calculus passing through the urethra, the introduction of a sound, an ammoniacal injection (Swediaur), all of these agents may give rise to a muco-purulent secretion. Coitus too often re- peated, or performed with organs of disproportionate size, mastur- bation, menstrual blood, the ichorous discharge from a cancer, the lochia, and especially the fluor albus, are so many causes which have been accused of producing blennorrhagia, and which, of course, are particularly furnished by the female. Virulent pus, that which is the medium of the syphilitic virus, is, in my opinion, the most frequent and powerful cause of blen- norrhagia. Those who deny that specific pus can give rise to a virulent blennorrhagia, have nevertheless supposed that it may act upon the mucous membranes like any simple irritant; those who are unwilling to admit the power of the virus to produce a primi- tive syphihtic blennorrhagia, have acknowledged that it may give rise to the same disease, but of the consecutive form. Syphihtic virus is therefore entitled to a prominent place in the etiology of blennorrhagia, a fact which should be borne in mind when we come to the treatment of the disease. A general view of the causes mentioned shows that they act di- rectly upon the mucous surfaces, or indirectly after they have passed through the system. Thus, the syphilitic virus should have this double action, and the rheumatic diathesis can act but indi- rectly. It is evident that blennorrhagia, from an indirect cause, cannot be of a simple nature, and that among the cases which pro- ceed from a direct cause, there are few whose action is limited to the production of an inflammation. Such is the fact only where the disease has been caused by foreign bodies, excessive indulgence in coitus, masturbation, menstrual secretion, and the fluor albus which has accidentally become a little acrid. Whatever may be the nature of the blennorrhagia, certain pecu- liarities of the discharge, of its organic vital conditions, affect its con- tagious properties. Thus, the predominance of pus in the secretion is favorable to contagion; in proportion as mucus predominates, that is, as the disease is less acute, the less are the chances of contagion. But there can be no doubt that very trifling discharges, drops, several interesting and instructive cases recorded, from* which he may learn the great difficulty which occasionally attends the diagnosis between the virulent and non-virulent discharges. We can only refer to some of the principal sources of information upon these questions. Rayer, On Diseases of the Skin, Translated by Dr. Willis, London, 1835, p. 765. Also Memoir by the same author, " sur les infam. non-virul, memb. muq. des org. de la generat. des Enfans," Paris, 1821. Capuron, Med. Leg. des Accouchemens, p. 41. Mr. Kesteven, Lond. Med. Gaz., vol. xlvii. p. 372. British Amer. Journal, May 1848, p. 19. Dr. John Rose Cormack; Observations on Gonorrhoea and Syphilis, with reference to Forensic Medicine, &c, in Lond. and Edin- burgh Monthly Journal, Sept. 1844, p. 753. Sir Astley Cooper, Lectures on Surgery. Benjamin Bell, On Venereal, vol. i. p. 416. Dr. Underwood, Dise<* of Children. Mr. Moses, Lond. Lancet, Dec. 1835, p. 443. Frederick C. Skey, Lectures on Vene- real Disease, Lond. Med. Gazette, vol. xxiv. pp. 439, 440. Wm. Lawrence, On a Pecu- liar Affection of the Genitals in Female Children, Lond. Med. Gazette, Aug. 21, 1830 p. 828. Mr. Egan, On Syphilitic Diseases, p. 130. G. C. B. BLENNORRHAGIA. 61 which are regarded as of no consequence, may communicate very severe and sometimes very virulent attacks. There are individuals so constituted that they may with impu- nity expose themselves to the risk of contagion. There exists be- tween the parts brought into contact during coitus a certain sym- pathy of action, an adaptation of form and volume which singu- larly favors or prevents the development of blennorrhagia: thus, a man shall live for many years with a woman who has a discharge from the vagina, and yet shall himself escape; habit has created a kind of harmony in the vitality, the form, and the volume of the organs which produces this immunity; but let the habits of the woman become changed, let her have a new lover, and the latter shall perhaps contract a blennorrhagia at every menstrual period. Facts of this nature have been observed by every practitioner who is consulted by patients affected with venereal disease. Fallopius, a writer of the XYIth century, remarked that certain infected women communicated nothing to their husbands with whom they had no sexual pleasure, but gave disease to their lovers who grati- fied their desires. Certain conditions of vitality may then promote contagion, and it is an established fact that blennorrhagia is almost always com- municated by coitus. But blennorrhagic pus, which is simply de- posited upon a mucous surface, may produce the same effect; the experiments of the students mentioned by Benjamin Bell prove this fact. It has been asserted that pus which has been swallowed and absorbed in the stomach, so directs itself to the genital organs as to determine a blennorrhagia. The proof of this is still wanting. Nature.—In discussing the question of the nature of the syphi- litic virus, I have anticipated the difficulties which would arise when we come to study the etiology of blennorrhagic discharges. I have stated that Hunter believed that these discharges recognized the same cause as chancre, and that this cause was the syphilitic virus, the effects of which differ according to the surfaces to which it is applied. But, as the vagina, according to Hunter, is a secret- ing surface, and as upon the mucous lining of this canal true chan- cres have been observed, the theory of the English surgeon is thus strongly compromised. I have noticed the opinion of Benjamin Bell, who admits two morbid elements, the one blennorrhagic, the other chancrous. Finally, I have mentioned the opinion which views blennorhagia as dependent upon an inflammation caused simply by an irritation, the effects of which are local; and never resemble those produced by a morbid poison. When the latter effects have been observed, then it was owing to the carelessness of the observer, or indeed he was ignorant of the proper method of investigation, or he knew not how to manage; he could not have discovered a chancre hidden under a narrow prepuce, in a fold of the vagina, or upon the neck of the uterus, or in the canal of the urethra. The observer could not or knew not how to detect anything but the discharge, and takino- this symptom for the disease itself, he has placed on his list under the head of diagnosis, blennorrhagia, when it should have 62 VIDAL ON VENEREAL DISEASES. been chancre. It must at once be admitted that errors of this kind have been largely committed, especially at a time when the hint had not been given, and before they possessed the means of investigation which we now enjoy. But Hernandez had already inaugurated the chancre larve; Hunter dwelt at length upon those cases in which a chancre may escape detection, and our contempo- raries, at the head of whom must be placed M. Eicord, for twenty years have spoken of these errors and their causes, and have taught the method of avoiding them. The speculum, in fine, has rendered the argument drawn from the imperfection in observation, much less forcible than it was before. With regard to ignorance and want of skill, these are daily disappearing, and there are practi- tioners who from their position and reputation as honest and saga- cious observers, put to naught this argument as well as another too often employed in desperate cases. These practitioners believe that there really exist syphilitic discharges which have no connec- tion with chancre, which has always been absent at every period of the blennorrhagia; further still, the syphilitic nature of these discharges has been shown by the appearance of secondary acci- dents, by the general manifestations of poisoning. No objection can be seriously urged against similar facts observed in the female where the urethra remains sound, without any discharge ; for the Vulva, vagina, the neck of the uterus, the anus may here be direct- ly explored, but when it concerns a urethral blennorrhagia in the male, the chancre larve renews all its claims. This has been sup- posed, even when the pus from the urethra could not be inoculated. Thus then, in order to combat a pretended supposition, that is to say, the non-existence of chancre in virulent blennorrhagia, a sup- position has been employed, an established principle has been vio- lated, a chancre in the urethra has been supposed when syphilitic accidents have supervened, and all this because it is pretended, that chancre alone can produce these accidents. Now this is the point in question. I myself, do not admit the existence of chancre be- yond the navicular fossa. I am aware of what has been written concerning the deep-seated urethral chancre; some pathological specimens even of which have appeared satisfactory to those who exhibited them. But I must confess, after a very careful exami- nation of that regarded the most important in proving the exist- ence of a profound urethral chancre, I am convinced that it was a case not of syphilitic, but of tubercular ulceration, which existed at the same tune in the form of cavities in the prostate gland, in the testicle and in other organs of the same patient. I observe that some excellent surgeons partake of this same doubt* M. * In his Communication to the Academy of Medicine, Oct. 12, 1852, (De la Sy- philization, &c, p. 367,) M. Velpeau thus remarks: " The specimens presented by M. Ricord as examples of chancre, are far from being incontestable. In one of them, I recognize that of a tubercular young man, having large cavities in the prostatic portion of the urethra, and I see no indication that chancre had existed there ; the other is that of an old man, almost equally obscure. I saw these spe- cimens when first exhibited to the Academy, but they were far from satisfying me of the existence of chancre.'^ The report of these cases in the Treatise of M. Ricord (4th Am. ed. pp. 126, 127), is exceedingly meagre and unsatisfactory; compared BLENNORRHAGIA 63 Baumes cannot understand how the pus of a chancre can traverse the great extent of the urethra without leaving any trace on its passage; in fine, without producing ulceration but at one point of this canal. M. Chomel remarks, with his accustomed modera- tion : " It is only an exceptional case where the presence of a chancre in the urethra has been demonstrated or rather presumed."* But admit, for a moment, the existence of chancre deep in the urethra, provided that it is rare, and exceptional, and that we have the candor to acknowledge. Now compare the frequency of ure- thral chancres with the number of consecutive syphihtic accidents which have been seen to follow urethral discharges, and the enor- mous number of the latter compared with the former cases, will at once be apparent. Physicians who devote special attention to the diseases of the skin, as, for example, MM. Cazenave, Martins, Legendre, will tell you that blennorrhagia produces as many cu- taneous affections as chancre. Now, deduct some cases of blen- norrhagia which you may carry to the column of urethral chancres (if you admit their existence), there will remain a considerable number of eruptions which ca» be attributed only to blennor- rhagia. This truth has been proclaimed before the whole Academy of Medicine, particularly by men who have long been observers, and who have been committed to no particular theory in syphil- ography, such as MM. Moreau, J. Cloquet, Velpeau, P. Dubois, &c. Now, admit still further, that every specific syphihtic discharge is but a symptom of chancre. There will still, however, always Remain a form of inflammation of the mucous membranes, a sero- purulent discharge,—in fine, a blennorrhagia, which by its progress, its duration, its accidents, its complications, can never be referred to an inflammation like that produced by simple irritants, by for- eign substances, by ammoniacal injections, or that which Swediaur produced upon himself. These simple inflammations are not communicated with the same characters, from one individual to another; they are not followed by the accidents of metastasis, such as blennorrhagic ophthalmia, or blennorrhagic arthritis; they do not continue a year as did the blennorrhagia which that student gave himself, by applying between the prepuce and the glans, pledgets dipped in gonorrheal matter.f All these effects, with that in his Notes to Hunter (pp. 799, 803), it will be found to differ in several particulars, and in our humble opinion, the chapter (p. 147) on ulceration of the bladder in the excellent Treatise on the Urinary Organs by our countryman, Prof. Gross, or that on Scrofulous Prostate in the work of Mr. John Adams on the Anat- omy and Diseases of the Prostate gland, pp. 117, 125, afford a far more correct solu- tion of the true nature of these cases. The ulceration in these cases was of very great extent, involving the urethra, bladder and prostate; yet when we find M. Ricord, in 1851, (Letters, viii. pp. 59, 60,) inculcating the doctrine, that the urethral chancre is never very extensive, and that when we find an abundant discharge (as existed in these cases), we may conclude that it is something more than the pro- ducts of a chancre, we are astonished that he does not even allude to these very remarkable exceptions. At any rate, the fact that his diagnosis in these cases is questioned by such men as MM. Velpeau, Vidal, and Prof. Gross, (as we learn from a recent letter from the latter gentleman,) is sufficient to render them far from be- ing, as is asserted by M. Ricord, "incontestable."—G. C. B. * Abeille Medicale, Jan. 1851. Lecon clinique de M. Chomel. f B. Bell, on Venereal, t. ii. p. 492. 64 VIDAL ON VENEREAL DISEASES. which are not denied by my opponents, proceed from a single cause, which does not simply irritate the mucous membrane, but which penetrates the system. Now this cause we may call a vice, or virus; we may say, that it is not syphilitic, that it is gonorrheal. We come then to the conclusion of Benjamin Bell, and admit a double virus, or more properly speaking, we apply two names to the same virus, which really requires much less expense of the imagination, much less research, much less time, since it is already made.* M. Baumes also admits a double virus, that of chancre, and that of blennorrhagia ; the action of the latter, in his opinion, is not confined to that of irritation, it is absorbed, and then it does terminate in the production of primitive accidents, such as bubo, ophthalmia, arthritis, but it gives rise to such symptoms as are de- scribed in the following remarkable passage: " I can affirm," said Mr. Baumes, " that during the past three years alone, I have seen at the hospice de VAntiquaille, exclusive of my practice in the city, five cases of simple blennorrhagia, where I am certain that there was no chancre in the urethra, which cases were followed after some time, by constitutional sjHnptoms, such as well-marked rounded ulcers on the tonsils; mucous tubercles at the commissures of the lips, about the anus, and on the scrotum ; syphilitic ecthyma ; fur- furaceous, squamous, and papular eruptions, &c, &c. In two of these cases, on the seventh or eighth day from the commencement of the blennorrhagia, I inoculated with muco-pus, by three punctures on each thigh, without any result."f M. Baumes then admits, that * For further proof of the existence of a blennorrhagic virus, which virus pro- duces ulceration, buboes, arthritis, ophthalmia, sore throat and papular eruptions —the reader may consult Mr. Carmichael (Clin. Lectures, pp. 2041); Mr. South (Ed. of Chelius,\6l. i. Am. ed. p. 188); Erasmus Wilson (on Syphilis, p. 53); Mr. Bacot (Treatise, p. 126;) Langston Parker (Mod. Treat, of Syph. Diseases, pp. 32, 43); Mr. Egan (on Syph. Diseases, pp. 17, 18, 21, 59, 60); Mr. Wallace (on Venereal, p. 264); Henry I. Johnson (on Gonorrhoea, &c, p. 23); M. Ricord (Notes to Hunter, pp. 59, 60; also Treatise, Am. ed. pp. 70, 284), in both of which he insists upon the fre- quent connection between blennorfhagia and ulceration. Even Mr. Acton, (2d Am. ed. of Treatise, p. 222,) states that " we are compelled to admit that in gonor- rhea the system is so modified as to become affected by rheumatism;" again, at page 36, he says, that we should not be deterred from attempting to cure gonor- rhea rapidly by the fear of driving the disease into the system, for, "it will rush in fast enough." And yet, in view of the above fact, Messrs. Ricord, Acton and Bransby Cooper persist in proclaiming that blennorrhagia is a non-virulent, non- specific disease! But, asks the former, (Lett v. p. 37), is it not true that in the immense majority of cases, blennorrhagia is not followed by syphilitic infection ? Very true, and in this respect, it resembles the superficial primary chancre. " There are chancres," says the same high authority, " and perhaps these constitute the greater number, which do not infect the system." (Lett, xxviii. p. 207). The testimony of Mr. Acton is to the same effect; at p. 264 of his Treatise, (Am. ed.) he observes, " that in simple, uncomplicated chancres, secondary symptoms occur in such feeble proportions that they should not enter into our calculations." Again, blennorrhagic matter, applied to the lining membrane of the eye-lid, contrary to the assertion of M. Ricord (Treatise, Am. ed. p. 67), does sometimes produce chan- cres (ulceration) of the palpebral lining, which is followed by periauricular bu- boes. For proof, as furnished by Dr. Mairion of the Military Hospital at Louvain, Mr. Wilde and Dr. Egan of Dublin, see the Treatise of the latter gentleman, pp. 114, 115. These facts viewed in connection with those which we shall presently adduce in favor of its inoc*ulability, and its mode of propagation, we believe suffi- cient to entitle blennorrhagia to be regarded as a specific disease, independent of the existence of chancre larve.—G. C. B. T T. i. p. 233. BLENNORRHAGIA. 65 urethral discharges may be produced: 1. By a chancre ; 2. By a virus, which is not chancrous, but which gives rise to the accidents already mentioned; 3. By an irritation or inflammation which produces but sympathetic effects. M. Eicord is of the opinion that M. Baumes has arrived at these conclusions from conciliatory mo- tives. For my own part, I believe that M. Baumes has, by a long and directly opposite method to M. Eicord, formed the opinion, that there are urethral discharges without any chancre, which are virulent, and capable of giving rise to consecutive syphilitic acci- dents ; only, these accidents may be less frequent, less profound. But there are chancres which frequenly do not produce consecu- tive accidents, and the latter are not always profound. Experi- ment, besides, here steps in with unanswerable arguments; for Hunter proved that the pus of chancre and that of blennorrhagia might produce both chancre and blennorrhagia.* When I reach * Mr. Carmichael claims Cases xiv. p. 108; ix. p. 104; xx. p. 113, and xv. p. 109; in the Treatise on Inoculation (4th Am. ed.) by M. Ricord, as proof that the matter of blennorrhagia like chancre is inoculable. To the above, we would add Case lxi. p. 185. In this case the matter was taken from a bubo following blennorrhagia, and the pustules produced are called false pustules. If with the report of this case, the reader will peruse M. Ricord's account of the characteristic pustule, (Lett, xviii. p. 14'2), and that of the false pustule at page 146 of the same Letter, we think that he will hesitate before he accepts the pointed pustules with slight induration, pro- duced by this inoculation, for pseudo-pustules. The latter, we are distinctly told, (Lett, cit.) never lasts longer than from five to six days, yet the pustules in this case lasted thirteen days. That they healed without treatment is surely no evidence that they were nbt syphilitic, for this is a test on which, we believe, neither M. Record nor any modern authority relies. 'In his Treatise, (p. 255,) he states that " the primary specific ulcer may often heal without treatment," and Mr. Acton (op. cit. p. 255) assures us " that some syphilitic sores heal in twenty hours." In- deed, this spontaneous healing of chancre was known even to Abernethy, (pp. 48, 9.) In the report of the above case, it is mentioned that the pustules did not assume the appearance of specific ulcers. Now, what is the appearance of a specific ulcer. In another part of this work, we have already shown that an absolute diagnosis cannot be formed from the physical characters of an ulcer, a fact admitted even by M. Ricord himself. Though in his Letters, (xviii. p 138,) he informs us, that in true inoculation, the dermis is completely bored, as if with a punch, in the same Letter, (p. 141,) he states, that the primary ulcer does not always destroy the entire thick- ness of the skin or mucous membrane. Indeed, this distinguished syphilographer has at length been compelled to admit that, after all, there is no characteristic pus- tule. In his inoculations on M. Laval—that martyr to syphilization—M. Ricord in- sisted that the little ecthymatous pustules which he produced, and which speedily disappeared without ulceration or suppuration, were genuine chancres, only, of a particular form (sculement avec une forme particuliere). For proof of this assertion, see the Communication of M. Depaul to the Academy of Medicine, July 27, 1852, (De la Syphilization, &c. p. 54,) and that of M. Ricord himself, (op. cit. p. 67.) But, is it reasonable to suppose that a virus, which, when applied as in the ordinary modes of propagation, produces effects so diversified, should on artificial inocula- tion produce the same invariable results ? The numerous experiments of Mr. Egan, of Dublin, and M. Sperino, of Turin, if further proof be wanting, conclusive- ly settle this question. Mr. Egan (op. cit. p. 27) observes: " in some of the cases to which I allude, the only effect produced (on inoculation), was slight inflamma- tion, which in the course of a few days subsided; in others, the inflammation ran to a higher pitch, and terminated in an unhealthy phlegmonous abscess; while, iD a third, no visible effect was at all discernible. These remarks apply more parti- cularly to the first class of primary ulcer" (the superficial). It will be remem- bered that the matter used in these experiments, was taken from ulcers which were followed by constitutional infection. On this subject, the reader may also consult the Treatise by M. Sperino, " on Syphilization," p. 94, At p. 501, he informs us that the pus of the so-called false pustules has been proved by his experiments to be improbable. There is at present (August 9, 1853), in the New York Hospital, a 66 VIDAL ON VENEREAL DISEASES. the subject of balanitis, I Avill prove that the pus secreted by the glans and the prepuce, which is not ulcerated no*r even excoriated, may produce chancres. Now, in this case, even the pretext of the chancre larve cannot be invoked, for it is one of external blennor- rhagia ; the whole surface furnishing the humor may be directly explored. Thus the existence of virulent blennorrhagia is proved by the writings of those opposed to the doctrine, and this from the simple circumstance, that it is a fact. Incubation.—Incubation, like that of chancre, has here been admitted and denied. The period of incubation is generally exaggerated by patients : thus, it is not uncommon to hear them speak of eight, and fifteen days elapsing between the suspected coitus and the first appearance of their blennorrhagia; they have even gone as high as fifty days. The majority of patients, having suffered nothing at first, and the discharge being but trifling and colorless, they mistake the starting point of their disease. We should, therefore, in general, mistrust the computation' of most patients. But there are those who begin immediately after their suspected coitus, to watch the most trifling phenomena which ap- pears on the genital organs; and among these observers are found not only men of the world capable of noting these phenomena, but even experienced physicians. Now, these persons have noticed a real incubation; that is, twenty-four hours and three days have passed without anything being discovered, absolutely nothing; after this interval, a sensation of pricking, of itching, followed by a more copious secretion of mucous, which afterwards becomes troublesome, indicates that they have contracted the disease. This has been observed not only in urethral blennorrhagias, but also in those of the prepuce and glans, which are directly open to our observation. It must be admitted, however, that certain cases of blennorrhagia, especially those which follow sexual intemperance, are said to create, even on the first day, a modification in the sen- sibility of the parts ; and that on the second, the discharge appears. Most generally the truly inflammatory phenomena are not estab- patient, named Hugo Kiel. He is 18 years of age. On the 6th of June, eight days after exposure, he first felt a burning sensation at the meatus. This was followed in a day or two by a discharge, which soon became profuse. He is positive that he has never suffered pain except when urinating. A bubo appeared on the right side two days after the commencement of the discharge. In the course of a week, this was opened, and the matter successfully inoculated three weeks from the first attack. At present, we can detect no roughness within the urethra, though we have examined most carefully with a bougie, nor can we detect any induration along the track of the canal. The patient assures us that he has never been able to detect the slightest hardness, or any unnatural feeling. Is this a chancre larve ? As such it is regarded by the talented surgeon (Dr. Van Buren) who performed the inoculation, and who has charge of the patient. The only proof however of the existence of a concealed chancre in this case, *s the fact, that inoculation pro- duced positive results. Believing with M. Ricord, that chancre alone is inoculable, the successful inoculation is to him proof positive of the existence of a chancre larve. The fact being now mcontestably established, that secondary accidents, and blennorrhagia, may produce positive results on inoculation, (for further proof of the latter, see Thesis of M. Barthole, 1845,) witti all due respect to the opinion of the above-named surgeon, in the instance of Hugh Kiel, we can, after the most diligent search, discover nothing more than an ordinary case of blennorrhagia — BLENNORRHAGIA. 67 liihed until the fifth day, at which period pus predominates over the mucus. Symptoms.—I have already stated that in the commencement there is a modification of sensibility, which is most frequently in- creased as are the functions of the organ, especially its normal se- cretion. In the second stage, there is real pain and dryness of the mucous membrane, which is out of short duration, and soon gives place to a morbid secretion. This secretion is a mixture of pus and mucus, muco-pus. At first of a white color, it assumes a yel- low shade, and after awhile a deeper color. As the discharge be- comes more abundant, the muco-pus is turned to a greenish color. This is owing to the presence of some blood-globules which by their increased numbers give to the discharge a reddish aspect. These shades are particularly observed in cases where the discharge is of a sanious sero-sanguineous character. But in general the color depends upon the mixture of pus with the mucus. In the acute stage of the disease the matter discharged has an odor which gene- rally resembles that of decayed codfish; sometimes, even in the urethral discharges of the male, it has a faint sickish smell like that of leucorrhcea. It is very true that the odor may be rendered remarkably strong by a neglect of cleanliness. But this alone does not give rise to it, nor decide its character. Thus, when we find a subject with a large number of mucous pustules on the geni- tal organs, we perceive an infectious odor, which, however, is not the same as that exhaled by a patient affected with blennorrhagia, even when both subjects are guilty of the same want of cleanli- ness. I do not agree with those who so much despise the odor in trying to distinguish the different kinds of blennorrhagia. I have observed urethral discharges in the male of a sour and nauseous smell like that of the fluor albus of the woman with whom he had had connection. - Progress.—Sometimes at the commencement of an attack of blennorrhagia, we find general disturbance of the system, such as chills and febrile reaction. It often begins without any premoni- tory symptoms, and proceeds to a chronic state, or what is less fre- quent, to a rapid and perfect cure. This termination is often ob- served in those forms of the disease which are, so to speak, exter- nal, like that of the prepuce and the vulva. But, when the disease is more deeply seated, when irritating humors are brought into contact with the inflamed surfaces, as happens to the urethra so often traversed by the urine, then there is less hope for a speedy termination. Sometimes, especially in those who have been often affected, it puts on a chronic form from the beginning, and then the tenacity of the discharge is in direct proportion to the number of attacks which the patient has suffered. The decline of a blennorrhagia is particularly marked by the predominance of mucus over the pus, by the separation of these two elements of the blennorrhagic discharge. Some globules of pus, so to speak, are found wandering in the mucus, or the stain upon the linen is of a grayish color with a point at the centre of a deeper tinge: finally the linen is no longer marked. The duration 68 VIDAL ON VENEREAL DISEASES. of blennorrhagia, where it is somewhat severe, varies from four to six weeks, from six months to a year. There are few exceptional cases where the discharge is permanent, but in such cases there is reason to suspect the existence of a stricture, an absence of hygiene, an imprudence in the diet, which incessantly renews or rekindles the discharge. M. Cazenave believes that when these relapses occur, it is owing to the existence in the first place of a virulent blennorrhagia, which has left the urethra susceptible to the least irritation, and there it is that non-specific causes produce discharges with the greatest facility. Diagnosis.—The diagnosis of blennorrhagia brings us to the con- sideration of the chancre larve. In the female, by the proper ap- plication of the speculum, we may discover ulcerations on the neck of the uterus, the walls of the vagina, or learn whether the disease be simply one of blennorrhagic inflammation. In the male, the difficulties are great in the way of diagnosing a chancre deep in the urethra.* Some syphilographers who admit the existence of this chancre, are satisfied when with a catheter they detect a roughness at the seat of ulceration; but a thickening, or a fold of the mucous membrane may give rise to the same sensation. Then comes inoculation: now nothing can be more unfaithful than this latter means, since those who admit the urethral chancre maintain that it is inoculable only at a certain stage of the disease, and be- cause the matter withdrawn by the lancet may be furnished by the portion of the canal which is in front of the chancre, where the inflammation is supposed to be of a simple character. In this manner may be explained the fact, that M. Bigot, in the service of M. Puche, inoculated with urethral pus sixty-eight times with- out success. These difficulties besides have been admitted by those with whom urethral chancre plays so important a part in the pro- duction of virulent discharges. As I do not believe in the deep- seated chancre, and admit only that of the meatus and the fossa navicularis, my mind is less prepossessed with the difficulties of diagnosis. It is difficult to distinguish simple blennorrhagia, that wtiich is but a catarrhal inflammation from virulent blennorrhagia. How- ever, if we can establish a true incubation, if the discharge has a tendency to become chronic, we have reason to suspect a specific discharge; if, on the contrary, it has followed excessive sexual in- dulgence, if its progress be rapid and the interval brief between the coitus and the attack, if the termination be sudden and rapid, * The best speculum for the male urethra with which we are acquainted, is that devised by Mr. Avery of the Charing Cross Hospital, London. It consists of a coni- cal metallic tube, into the outer funnel-shaped extremity of which the light is thrown from a reflector fastened to the forehead of the surgeon, through which is an orifice sufficiently large to admit the light to reach the eye of the examiner. Through the politeness of this skilful surgeon, we have had opportunities of ex- ploring the seat of strictures, and could not but admire the distinctness with which the interior of the urethral canal was brought into view. Still, as we have already shown on the authority of M. Ricord, the physical characters, even of the external primary ulcer are so diversified, that from them alone we cannot pronounce upon its nature, and though we may succeed in exposing an urethral ulceration our di- agnosis is not yet fully established.—G. C. B. BLENNORRHAGIA. 69 we have strong grounds for deciding in favor of a simple blennor- rhagia. At a later period, if accidents supervene, the diagnosis is then completely established. Prognosis.—The prognosis depends upon the seat of the blen- norrhagia, the age of the patient, the temperament, the intensity, and the duration of the disease. In urethral blennorrhagias we have to dread the occurrence of strictures, affections of the bladder, of the kidneys, and in the male, the prostate gland. In advanced age the latter accidents are most frequent: at an earlier period of life orchitis is oftener observed. The more protracted the disease, the more have we to fear the production of strictures. Previous attacks are favorable to new contagions, and renders the treatment less successful; but the patient suffers less in proportion to the fre- quency with which he has been affected. The nature of blennor- rhagia modifies the prognosis: there is a vast difference between the gravity of that which is simply inflammatory, and that which is virulent. Pathological Anatomy.—The lesions of tissue observed in cases of blennorrhagia must vary according to the seat of the disease; these will be particularly examined when we treat of urethral blennorrhagia in the male. I may observe, in a general manner, that the mucous membranes have been found of a deep red color, and thickened by plastic infiltrations of the subjacent cellular tissue, and by abscesses. Ulcerations have been observed, even simple ulcerations, the reparation of which by inodular tissue may give rise to stricture, if a canal be the seat of the disease. The same re- sult may be produced by the reparation of the loss of substance caused by the passage of the pus through the urethra which was formed around this canal. Accidents.—These depend upon the seat of the disease; they will be made known when we come to treat of particular forms of blen- norrhagia, especially that of the male urethra, described in the next chapter. Treatment.—This, in the first place, should be prophylactic. I do not believe that we are ever under the necessity of practising coitus under circumstances where we have reason to apprehend contagion, and still less wheh we have reason to suspect that we are sufficiently diseased to communicate a blennorhagia. Mediate coitus has been recommended where there is reason to fear conta- gion ; it certainly is a means of prevention, but not an infallible one.* The coitus attended with the least risk is that which is quickly performed, is not often repeated, and which is complete, as the ejaculation may carry away the contagious matter which might have entered the urethra. For the same reason it is of ad- vantage to urinate immediately after the act; the latter, however, should not lead one to dispense with thorough ablutions with some mild astringent lotion. Those who have suffered, if their * The intermediate consists of a small sac made from csecum of a sheep. This discovery, which by its utility deserves the gratitude of the public, gave to the unfortunate Englishman who left to it his name, such an unenviable notoriety, that he was obliged to assume another. 70 VIDAL ON VENEREAL DISEASES. memory serve them, will admit that a surprise, carelessness, too much confidence in the person with whom they had intercourse, prolonged coitus, a false shame in asking for the means of ablution, were among the circumstances which led to their misfortune. As in the case of chancre, some advise in this disease, the abor- tive method of treatment. This can be proper only at the com- mencement of the disease, before inflammation appears; in fine, at the very outset of the malady. Now, the interval between the suspected coitus and the first appearance of the inflammation is not always the same, for sometimes it occurs in twenty-four hours from the application of the cause, whilst in other instances seven days have passed before it becomes well marked: then, the means could no longer be abortive, but on the contrary would tend to aggravate the inflammation, to prolong its duration, and to pro- duce serious consequences. I shall never forget the case of a man whose absent wife was expected in a very short time after he dis- covered that he had contracted a blennorrhagia. He applied to me for a sure method of at once arresting the disease. As I could not promise this, he consulted another practictioner who advised a caustic injection into the urethra, which produced a most severe and painful inflammation of the canal and of the bladder. I was requested to treat this patient, who was confined in his bed for a month, during which time the most energetic antiphlogistic treat- ment was required.* Could we be consulted at the very moment of contagion, when the virus is producing its first effects, and were there a characteris- tic symptom of this period in blennorrhagia, we should act at least rationally in trying to destroy the cause at the part affected, as well as its effect, which must then bedocal and very limited. But this is very seldom possible. Besides, it is necessary that the point * Mr. Langston Parker, in a letter to the writer, dated May 31st, 1853, thus ex- presses his opinion of the abortive treatment in blennorrhagia: " When a patient seeks advice before the inflammatory symptoms are set in, an attempt may be made to extinguish the disease by what has been called abortive treatment, but if there be decided marks of inflammation and any pain in micturi- tion, and if the disease have existed more than twenty-four hours, this treatment will be attended, to say the least, with risk, if »ot with injury, and under the most favorable circumstances it will not always succeed." In addition to the above extract from the manuscript copy of the third edition of his valuable work on the " Modern Treatment of Syphilitic Diseases," now in preparation, which he has had the kindness to furnish me, he observes, " but under- stand, I never employ the nitrate of silver in stronger solutions than from 2 to 5 grains in 8 ounces of water. I have seen death result in one case from a stronger solu- ion. For the details of another fatal case, from the nitrate of silver, see the work al- ready quoted of Mr. H. J. Johnson, p. 59. We think that it may be safely asserted that the majority of the London and Dublin surgeons are opposed to the abortive treat- ment, except under the circumstances mentioned by our author, with whom, as will be observed, M. Parker so strongly coincides, During our recent visit to Dublin, Mr. Adams, of the Richmond Hospital, assured us that it was not a favorite method in that city, and that in Dublin it is called the "abominable" treatment I We have tried the chloride of zinc, as proposed by Mr. Lloyd, of St. Bartholomew's Hospital, London (London Lancet, Dec. 1850), and though at first much pleased with its effect, have been taught by further experience, that in some of our sup- posed cures, we had produced only a temporary suppression of the discharge. We still prefer this substance to the nitrate of silver, as we are satisfied that it causes less pain.—G. C. B. BLENNORRHAGIA 71 of the mucous membrane affected should be discovered, before one application can be really topical, direct and limited to the lesion; this may be done, in affections of the glans, the prepuce, and, un- der certain circumstances, of the vulva; but the most common form of blennorrhagia, the urethral, does not admit of an appli- cation so methodical, so direct; we should have reason, therefore, to apprehend an extension of the inflammation from the applica- tion of an irritant to the sound portion of the mucous membrane. At one time the sulphate of zinc was much employed; at pres- ent, however, preference is given to the nitrate of silver. Car- michael was the first in England, as was M. Debeney in France, to highly extol this method to which I shall again refer. Besides, it should be well known that the pretension to cut short a blennorrhagia is an old one, and that the abortive treatment was long since tried, judged, and condemned. Indeed, Charles Musi- tan professed to cure a gonorrhea in three days by injections. If we employ them when the purulent discharge first appears, it is at once arrested. If they be used before the discharge has appeared, whilst the parts suffer from an extraordinary itching, the disease is prevented. Astruc, who quotes Musitan, has already remarked that unfortunately for the debauchee, both reason and experience demonstrated the falsity of this method, and that it is possible in place of preventing a gonorrhea sometimes to operate when no disease exists.* Finally, Astruc very justly remarks, that physicians are seldom consulted whilst gonorrheas are forming, and still less before they have appeared.f This passage from As- truc is very remarkable. For my own part, when there is but a suspicion of congestion, or when the inflammation has commenced, I recommend, distinctly, rest of the organs, bodily repose, abstinence from food and drink which can render the urine irritating, or excite or inflame the genito-urinary mucous membrane; then follow emollients, baths, diluent drinks, a diet not too severe, and most powerful antiphlo- gistics when the inflammation is,really established. If the patient is young, vigorous, and the inflammation very active, very painful, I at once abstract blood and thus greatly promote resolution, and a decided resolution. I have never found that antiphlogistics, even when used for a length of time, produce the chronic state to which blennorrhagic discharges too often tend. The contrary I have very often observed; I have seen, indeed, that the cases which most readily become permanent, are those in which the abortive treatment has been tried, and in which violent means have been employed. When the symptoms of a decline are apparent, and the violence of the inflammation is less marked, I have recourse to anti-blennorrhagics, to a combination of cubebs and copaiba. In the last place, and. when the inflammation is extinguished, if the discharge persists, I resort to injections. With regard to t^e order in which injec- tions should be used, I am entirely of Swediaur's opinion. I pre- fer astringent to caustic injections, and when I wish to produce * T. iii. p. 86. f T. iii. p. 87 * 72 VIDAL ON VENEREAL DISEASES. the effects of the latter, I prefer the solid nitrate of silver, which is more easily managed than the solution of the same salt. I believe that it is of great advantage in the treatment of blennorrhagia, to isolate, as much as possible, the inflamed surfaces; thus, in bala- nitis, in vulvitis, and in a certain stage of vagnitis, we may with lint, or charpie, or wadding, produce this isolation. But such is not the case with urethritis; the tents and foreign bodies which we suffer to remain in the urethra, can only exasperate the inflam- mation. The same effect would be produced by plugging the vagina, in females in whom it is narrow, and whilst the inflamma- tion is at its height. The details of the treatment will be particu- larly exposed in the following chapter. CHAPTER II. BLENNORRHAGIA IN THE MALE. SECTION I. BLENNORRHAGIA OF THE URETHRA. Causes.—There are certain predispositions to urethral blennor- rhagia in the male which may be called organic; thus, its development may be promoted by the unusual size of the penis, a large meatus urinarius, and hypospadias. These conditions favor the introduction of muco-pus in the urethra. This is par- ticularly the case with hypospadias, which prolongs, so to speak, the meatus towards the scrotum, enlarges the opening of the urethra, and brings the mucous membrane in contact with that part of the vagina in which the humors are collected. These etiological notions should prevent us from taking any steps by which the meatus shall be increased in size. In discussing the etiology of blennorrrhagia in general, I endeavored to appreciate the influence of age, temperament, ali- ments and certain antecedent pathological conditions. I have stated that the direct causes were physical, chemical, or patholo- gical. Thus, the passage of a calculus through the urethra, the introduction of a catheter, an irritating injection, may all produce ■ a muco-purulent secretion. Too frequent connection, or that per- formed with organs of disproportionate size, masturbation, men- strual blood, cancerous ichor, the lochia, the product of a uterine or vaginal catarrh, are among the causes which have been accused of giving rise to blennorrhagia. I designedly repeat, that specific pus, the pus containing syphi- litic virus, is, in my opinion, the most frequent and powerful BLENNORRHAGIA OF THE URETHRA 73 cause of blennorrhagia. Those authors who have denied that this virulent matter may produce a syphilitic blennorrhagia, have ad- mitted that it may act as an irritant to the mucous membrane, and at the same time that they have denied to it the power of produc- ing a primitive syphilitic blennorrhagia, they have acknowledged that it may give rise to this disease, but under a secondary form. This virus therefore deserves a prominent place among the causes of the disease, and this fact should not be forgotten when we come to its treatment. Indeed, to render it complete, after anti-blennor- rhagics, we should adopt the treatment of chancre, distinctly under- standing that blennorrhagia should be regarded as a specific disease. Seat.—Attempts have been made to mark the point of the urethra affected in the form of blennorrhagia under consideration. According to my observation, it is found most frequently at the commencement of the canal. Thus, Stoll fixed upon that point of the canal which corresponds to the frsenum. Desault speaks of the fossa navicularis. In the two criminals dissected by Hun- ter, the urethra was somewhat more than ordinarily injected, especially towards the glans. Feu Cullerier also mentions the fossa navicularis, and lastly, M. Ph. Boyer, having made the autopsy of a subject connected with blennorrhagia, noticed a red- ness at the anterior part of the canal. Swediaur maintained that in all cases, the disease is seated in the fossa navicularis ; accord- ing to him, when the inflammation extends to a greater depth, it is owing to improper treatment, the sudden suppression of the discharge, or to some internal cause. The appendages of the urethra have also been designated as being the seat of the disease in question. Thus Astruc speaks of the vesiculae seminales, the prostate, Cowper's glands, and the lacunae of the urethra. William Eondelet believed that in cases of virulent gonorrhea, the disease was particuly seated in the prostate gland. M. A. Severin points out the kind of lesion of this gland; it is an abscess. It is known that before the time of Morgagni, the majority of writers admitted the existence of ulcer- ations which secrete the purulent matter, which, in their opinion^ could not be produced except by a mucous membrane in a solu- tion of continuity. The idea of locating the disease in one of the glands annexed to the urethra, was suggested by the abundance of the discharge. Whatever may be its seat, the anterior part of the urethra is really that which is first and most frequently affected. At this point, as Benjamin Bell remarked, blennor- rhagia in its first stage is seated, from which, by extension, it may invade other points of the urethra, and extend not only to Cow- per's glands, the prostate, the vesiculae seminales, the bladder, and even reach the kidneys. Blennorrhagia has, therefore, really in- volved all the different parts mentioned by authors. But these are exceptional cases, complications and accidents. Thus, certain inflammations of the prostate gland and bladder, are only com- plications of urethral blennorrhagia; such is also the case when the tissues surrounding the urethra become inflamed and suppurate, producing abscesses which are called peri-urethral. 74 VIDAL ON VENEREAL DISEASES. Symptoms and Progress.—Blennorrhagia appears in from one to three days after the suspected coitus. "I have observed," says Cullerier, the uncle, "what is extraordinary, the discharge com- mence the next day, and I have seen it, in two instances, first show itself not until a month afterwards." Cullerier, the nephew, and M. Eatier, refer to an instance in which the disease did not appear until five months afterwards coitus. The following is the report of it, given by these authors : " There is, at present, in the Hopital des Veneriens, a man aged fifty-eight years, of a good con- stitution, accustomed to the enjoyment of excellent health, and who never had the venereal disease. One day, together with four other individuals who did not suffer, he had connection with a woman. Five months afterwards, a blennorrhagia appeared. It lasted fifteen days, when the discharge ceased, and he became affected with mucous tubercules about the anus, for which he required my services. Whence these morbid phenomena ? For eight years previously, this patient had had no connection with a female, nor had he after that above mentioned."* For myself, I can only say, that this case is unique. Generally the discharge is not the first symptom which appears: some patients experience at first a peculiar kind of itching in the anterior part of the urethra, and a feeling of weight in the peri- neum ; others have an uneasy feeling in the groins; some complain of general indisposition, and of chills; cases have been observed which have all the symptoms of blennorrhagia, minus the dis- charge, constituting, as it were, a dry blennorrhagia^ which ordi- narily is but a stage of true blennorrhagia. Sometimes, on the contrary, the discharge precedes all the other symptoms; the patient perceives stains upon his linen, and yet he has suffered nothing. But, in the majority of cases, the following is the order of events: the patient feels an itching sensation at the commence- ment of the urethra, which increases, and soon becomes changed to pain, particularly at the moment of urinating; there follows a discharge of a thready, slightly-troubled humor, which dries upon the linen. Astruc observes: " The first oozing from the ure- thra is attended with a pleasant sensation, and glues together the lips of the meatus."* This humor looks like nasal mucus. When it becomes dry, the first jet of urine breaking the mucous scab (which is soon formed again), produces acute pain. But the lips of the meatus become swollen, and of a redder color; the pain in urinating increases, and as the urine traverses the urethra, it gives rise to a burning sensation ; hence the popular name of chaudepisse, that of arsure, and internal burning of the penis, long ago employed. In proportion as the disease becomes more severe, the pain seems to extend more and more towards the neck of the bladder; it may be produced by pressing along the course of the canal; the sensibility and tumefaction of the walls of the urethra * Dictionnaire de Medecine et de Chirurgie Pratiques. f Astruc, t. iii. p. 2. BLENNORRHAGIA OF THE URETHRA. 75 are found gradually to extend towards the posterior part, and the matter discharged comes daily from a more distant point. These symptoms showing that urethritis is fairly established, are gener- ally observed about the fifth day. Whilst passing urine, the pain is most violent; it is felt strongly in the perineum, and is increased when the patient crosses his legs, and during defecation, particu- larly if he be affected with hemorrhoids. The emission of semen is also painful; when the inflammation extends beyond the mem- braneous portion of the urethra at the moment of ejaculation, a lacerating pain is felt. The semen issues, foaming as if overflow- ing, and this occurs shortly after the contraction of the muscles of the perineum. The erections are painful and frequent in pro- portion to the abstinence of the patient. The pain is accounted for, by the passage of the urine over an inflamed mucous surface, by the inflammation itself, and the obstruction arising from the tumefaction of the urethra and the ejaculatory ducts, a tumefaction- which impedes the emission both of semen and of urine. The stream of the urine is modified; sometimes it is bifurcated, and it is always diminished in volume. If the inflammation has reached the prostate, a complete retention may follow. The ingredients and the color of the discharge vary ; it consists of a mixture of pus and mucus, or, as it is now called, muco-pus. At first, it is of a whitish tinge, and of the consistence of cream ; then it becomes yellow, and afterwards green; it has a bloody tinge in very acute cases. Astruc remarks that the discharge is of a greenish yellow color, such as we observe in the last stages of pneumonia. The blood may even flow in the form of a ure- thral hemorrhage. • During the progress of the disease, the prepuce and the glands become more or less swollen; the summit of the latter resembles a cherry nearly ripe. The tissues subjacent to the mucous mem- brane of the urethra, become likewise swollen. The little glan- dular bodies in which terminate the ducts of Morgagni, Cowper's glands, and the prostate itself, are all sometimes inflamed; they rarely suppurate, particularly the latter gland. The canal feels knotty. The abscesses which form here and there open within the urethra, or externally, this last termination becoming more frequent as we approach the glans. On the sides of the frenum, two small collections sometimes form, which always open exter- nally. Cases do occur in which the inflammation extends over the whole urinary apparatus. Erections occur during the progress of a blennorrhagia. But when the latter is severe, and the patient is very nervous, these erections may become very frequent, painful, and obstinate. Then occurs that symptom to which has been applied the name of chordee. It is often very troublesome when the patient is in bed. During an attack of chordee, the penis is hard, very sensitive, sometimes even painful. It preserves its natural shape, or it be- comes curved; in the majority of cases it is bent downwards, sometimes to one side, and rarely upwards. Astruc has noticed this last curvature; Benjamin Bell twice observed it; I have my- 76 VIDAL ON VENEREAL DISEASES. self seen it. Chordee may occur at any period of blennorrhagia; but it is found most frequently when the inflammation is com- pletely established, in the second stage of Benjamin Bell. It has been seen to remain even after the subsidence of all inflammatory symptoms. Hunter recognized two varieties of chordee, one inflammatory, the other spasmodic. In the first, the inflammation is not limited to the mucous membrane and the little glands, but it affects the reticular tissue of the urethra, into which coagulable lymph is effused; these cells become adherent, the walls lose their pliancy, and the canal, no longer able to follow the cavernous bodies in their development, assumes the office of a cord, by which the curve is maintained ; and hence the curvature of the penis. The spasmodic chordee is but a nervous phenomena; it appears and disappears, but at no regular intervals. Is there a dry blennorrhagia? According to Swediaur, the inflammation of the urethra sometimes becomes so intense, that its internal surface and the orifices of the glands which border upon it, yield no secretion, as occasionally occurs in inflammation of the mucous membranes of the nose and lungs. In a severe catarrh, all discharge is arrested. This Fabre denies. He maintains, on the contrary, that the inflammation in these cases is not severe. A very small number of carefully-observed cases have been re- corded, establishing the absence of the discharge with all the other symptoms of blennorrhagia. I have really observed cases of urethritis without any morbid secretion. Cullerier and M. Eatier report a case which is perhaps the most authentic on record. But, in my opinion, this form of urethritis is never dry through- out the disease; the discharge is wanting either at the commence- ment or towards the end. It was at the latter period that it became dry in the instance mentioned by Cullerier.* The duration of the principal symptoms of blennorrhagia varies from ten, fifteen, and even to twenty days ; when it begins to sub- side ; then the patient suffers pain only during the passage of the urine, the erections are less frequent, and the matter discharged is less in quantity. Besides it turns yellow, then of a dirty white color; it puts on, in fine, the characters of mucus, which denotes the most fortunate termination of the disease. But, when after the cessation of the principal symptoms, the matter discharged does not assume this consistence, this particular elasticity which characterizes mucus; when, on the contrary, the drops easily separate, like those of milk, somewhat thickened, we have reason to apprehend a chronic state. Then the discharge sometimes assumes an intermittent character; it ceases, still to reappear; it is, as is commonly said, a relapse. It consists sometimes of a single * Dr. Beadle reported to the New York Medical and Surgical Society, March 7th, 1840, the case of a young man, who was under his care twice within the year, for an affection of the urethra resembling gonorrhoea in all its symptoms, except "there was not the slightest discharge." This patient had impure connection forty- eight hours before his attack, and he was cured, in both instances, by an injection of Nit. Arg. and mucilaginous drinks. Vide N. Y. Journ. of Medicine and Suraerv Oct. 1840, p. 435.—G. C. B. J ff' BLENNORRHAGIA OF THE URETHRA. 77 drop, which is seen in the morning, if the glans be pressed before urinating. The least imprudence in diet, coitus, &c, produces a return of the discharge. Occasionally, however, connection with a healthy woman causes it for a long time to disappear. In these different states, pain properly speaking does not exist, the dis- charge seems entirely passive, nothing indicates the least irritation of the urethra; the canal may be said to have contracted a habit of an abnormal secretion, which requires no inflammatory conges- tion to produce it. This is the blennorrhagia of Swediaur, which I have partly described. Generally, then, the urine does affect the canal, and the proper relations between the properties of this fluid and the sensibility of the urethra, would seem no longer to exist. Diagnosis—Here the question of the chancre larve again presents itself; I have already discussed it in speaking of blennorrhagia in general. [In the text, the author here repeats the observations made at p. 62, which we have taken the liberty to omit.—G. C. B.] Chancre at the commencement of the urethra is distinguished from blennorrhagia by the induration, tumefaction, and pain under the glans. In separating the lips of the meatus, the ulcerated surface may sometimes be detected. The discharge from the urethra is small in quantity; it is badly assimilated pus, rather serous than mucous, and generally there is a bubo more or less marked.* Like all other forms of blennorrhagia, it is difficult to distinguish the simple urethral blennorrhagia, that which is but a catarrhal inflammation, from that which is virulent. But still, when in this case we can establish a real incubation, when the discharge has a tendency to become chronic, we have reason to suspect a specific disease; on the contrary, where it follows excessive coitus, when its progress is rapid, the attack almost immediate after exposure, if the termination is sudden, rapid, there are strong presumptions in favor of a simple blennorrhagia. If, at a later period, syphilitic accidents supervene, our diagnosis is rendered certain. Prognosis.—Urethral blennorrhagia is more liable to be followed by stricture, affections of the bladder, kidneys, and in the male, of the prostate gland. At an advanced age the latter accidents are most frequent. Orchitis is the most common of all the accidents. Pathological Anatomy.—As the opportunity seldom occurs of making the autopsy of a subject affected with blennorrhagia, anatomy, on this point, has but little to offer.f Accidents.—I have already spoken of chordee and peri-urethral abscesses; the other accidents in part mentioned under the head of prognosis, will be examined separately when we come to con- sider the consequences of blennorrhagia. Treatment.—In speaking of blennorrhagia in general, I have * Mr. Henry James Johnson observes (op, cit. pp. 19, 20), that the pain in mak- ing water is not so decidedly referred to the navicular fossa, or the orifice, as in blennorrhagia. The induration in question, he adds, is found from an inch to an inch and a half from the orifice, is circular, yet flattish, about the size of a three penny piece, or less—tender to the touch—and gives to the finger just the same lq pression as is conveyed on pinching up an indurated syphilitic sore upon the surface.—G. C. B. f Vid. p. 69, for remarks here repeated in the text.—G. C. B. 78 VIDAL ON VENEREAL DISEASES. indicated the basis of our treatment; I now proceed to enter into the details and the methods particularly adapted to the urethral blennorrhagia. 1. Abortive Method and Injections.—The abortive method here offers the greatest pretensions; 1. It proposes rapidly to extinguish the inflammation, and thus to prevent the accidents of the disease. 2. To neutralize the virus and to destroy it in situ. I have expressed my opinion of this method in my general remarks on blennorrhagia. I have stated that it would be rational at the very onset of the disease, before inflammation is really established, and at the moment of inoculation. Now, the surgeon very seldom is consulted at this stage of the disease. It is only at this period that M. Eicord proposes this method; it is therefore applicable only in very exceptional cases. M. Debeney generalizes it and resorts to it in all stages of the disease, even in blennorrhea, and according to him, none, even of the most chronic cases, resist it when well managed. M. Debeney prefers caustic injections. A very old, very general, and almost popular reproach against injections, is their liability to produce strictures. To this it has been replied, that stricture, in reality, is but an inflammation of the urethra, which has become too protracted; and that the best method of avoiding this is to cut short the inflammation, in fine to effect its absorption. This reply, first made by Benjamin Bell, would be unanswerable if we did truly subdue the inflammation, or if we only abridged its duration. Now, of this there is but very little proof. During an entire year I made use of caustic injections in blennorrhagia, and once only did I obtain a cure which did not require a week's treatment. In almost all the other cases the cure was retarded, and in three a urethritis very rapidly produced a stricture, which compelled me to discontinue the injections and to substitute in their place antiphlogistics of a decided and energetic character. One of these patients was finally cured after a moderate dilatation with the yellow wax bougies; the other two, weary of the tedious treatment, demanded their discharge; six left with blennorrheas, which I could not cure. Among the latter, several have probably suffered from strictures. I have been told that I employed the injections in every stage of the disease, which is true; otherwise I should never have had before me a large number of observations. I am convinced that those who would employ the abortive method only when the inflammation is about to com- mence, will employ it but very rarely, for the reason already given, that we are almost always consulted, too late. What I have said in reference to the prevention of inflammation, I would repeat for that of syphilitic infection. Still, even for this purpose we are almost always too late. I am convinced that many practitioners, instead of treating the first stage of the disease, as they suppose, in reality treat different stages, and for this reason, their practice differs less than they imagine from that of M. Debeney. Therefore I consider the abortive method liable to reproach, for instead of cutting short the disease, it produces the opposite effect. As to the cases of orchitis, of abscesses, of arthritic and opthalmic • BLENNORRHAGIA OF THE URETHRA. 79 inflammations, which have been attributed to the use of caustic injections, I beheve the picture has been greatly overdrawn. Soon I will notice the accidents which even M. Eicord admits. I have already mentioned a case where a caustic injection did violently inflame the urethra an'd the bladder, so as to compromise, if not the life of the patient, at least the peace of his friends. Further, this was the most severe accident which I have observed. But the most common accidents, and those most to be apprehended, are not of a primary but a consecutive nature; these are, I repeat it, strictures. It is evident that a cauterized, burnt mucous mem- brane will undergo a solution of continuity, a kind of ulceration, the reparation of which must always be accompanied with a dim- inution in the diameter and elasticity of the canal. What has deceived practitioners who believe in the efficacy of caustic injec- tions, is, that there really follows, after the pain and immediate effects of this method, a suppression of the discharge, a subsidence of one of the symptoms of the disease. But with this suppression we have not subdued the urethritis; it has been rendered dry only, and this is but a transient, a temporary effect. Now caustic injec- tions are not the only means which can thus suppress a blen- norrhagia; the same result may be obtained by the powerful agents belonging to a rational or empirical therapeutics of the disease. For example, cubebs often produce this effect, and I have suppressed the discharge in more than one instance by the application of leeches to the perineum. But in the majority of cases the discharge returns, and these relapses should be noted and acknowledged if we would advance science. In my general remarks on blennorrhagia, I have already shown that the pretensions of this abortive treatment are very old. I have quoted the critical remarks of Astruc. Behold the formula of Musitan, which according to the pretensions of the above named author, was to cure instantaneously: "Take of plantain water eight ounces, in which dissolve some sweet mercury reduced to a very fine powder; agitate them together, and with an ivory syringe inject an ounce of this fluid lukewarm, into the urethra three times in a day." M. Debeney, in a case which he has denominated, Blennorrhagia with irritation of the neck of the bladder, employed the following formula: I>. Nit. Argent. 3i. Aq. distill. §i. According to M. Debeney the surgeon must himself administer the injection ; having first washed out the canal so that the muco- purulent matter may not impede its direct action upon the mucous membrane; this wash should consist of a solution of nitrate of silver about one-thirtieth of the ordinary strength; and should be allowed soon to escape. Immediately after this another injection is made which should be retained in the canal for a minute, if we would produce a decided impression. The fluid enters the canal 80 VIDAL ON VENEREAL DISEASES. more deeply by pressing with the fingers towards the root of the penis. The following is M. Eicord's formula, and his manner of pro- ceeding :* fy. Nit. Argent, grs. xv. Aq. distill. §i. The patient sits upon the edge of a chair; the penis is put slight- ly upon the stretch, and the extremity of the syringe is introduced within the canal. The lips of the meatus should be so pressed as closely to embrace the canula. The injection must be sudden; in this manner we take the mucous membrane by surprise, otherwise the urethra would close upon itself and oppose the further pro- gress of the fluid; one half of that contained in the syringe _ is sufficient to moisten the whole canal. The patient should be in- formed of the sensations which he will be likely to experience, lest he attribute to the progress of the disease what is but the tran- sient effects of the treatment. This injection produces severe pain, the discharge is augmented, a serous, sero-sanguinolent or bloody exhalation, appears, and this is soon followed by phlegmonous pus forming a swelling in the urethra. The first emission of urine is extremely painful, the pains being most intense in that portion of the urethra corresponding to the glans ; the stream of urine may assume every variety of form observed in cases of stricture. These pains may be mitigated, if the patient will urin- ate with the penis immersed in cold water, and if he will refrain from making any efforts. These accidents subside in the course of twenty-four hours ; if the bloody exhalation and suppuration continue, the injections should not be repeated until they disap- pear. In certain patients blennorrhagia ceases suddenly after the dis- charge of some globules, the cure is preceded by the discharge of a kind of thready mucus which is of short duration. Sometimes a greenish muco-purulent matter appears; in this case we may ex- pect that the blennorrhagia will continue. If the abortive treatment fail, we find on the third day that the characteristics of the disease are reproduced; sometimes, however, it is not till after a longer interval, some five or six days for ex- ample, that the discharge re-appears. These are the cases in which a complete cure has been supposed to have been obtained, but in which there really has been but a suppression of one element of the disease, viz. the muco-purulent discharge. The careful ob- server who will follow these patients, and closely question them, will learn that there remain in the urethra modifications in its sensibihty, unusual heat, especially at the moment of the emission of urine; sometimes there is a real pain, or an itching sensation, with a disposition to urinate frequently. The circumstances show clearly, in fine, that a urethritis remains, that there is a dry blen- * M. Debeney claims this formula. BLENNORRHAGIA OF THE URETHRA 81 norrhagia which will soon exhibit all the characters of a true blennorrhagia. When the'discharge reappears the injection should be repeated, if it has not forfeited the confidence both of the practitioner and patient. M. Eicord admits that the injection of nitrate of silver according to the', formula wnich he has so long employed, may produce fainting, hemorrhage and retention of urine. Add to these, the pain experienced at the moment of injection, and the inconveniences of the method are already manifest. It should not be forgotten that the abortive method of M. Ei- cord does not consist exclusively of injections of greater or less violence, but that in addition to them, he recommends the use of balsams, of which we shall soon speak. Now, as the&e balsams are given in ljeavy doses, as they are very powerful, and may of themselves speedily cure blennorrhagia, we can comprehend how those who have confounded in the same statistics the results of M. Eicord's practice with the facts of M. Debeney, have furnished a very decided proof of their ignorance of the most common rules of true medical statistics. What I have stated in relation to M. Eicord's practice, has been based upon his lectures reported in the Gazette des Hopitaux. Now, I find in his Notes to the second edition of Hunter,* that he ad- mits the inconveniences to which we have alluded, and that he has almost entirely renounced the use of injections. At present, M. Eicord prefers, the following formula : • JJ. Aq. Ros. §vi. Sulph. Zinc. Acet. Plumb, aa grs. xv. M. Yenot has tried injections' of chloroform; he has published in stances of cure resembling those which we have* cited as being fa- vorable to the employment of very strong injections of nitrate of silver. It is in the commencement, a period in which the practi- tioner seldom sees a patient, that chloroform is recommended. 2. Balsams.—We now come to the consideration of the balsams, at the head of which must stand copaiba. This is an oleo-resinous substance which is obtained from an American tree, growing in the Antilles, which tree has also been elsewhere cultivated. M. Guibourt prefers, for internal use, the copaiba of Cayenne. It may be administered in doses from ten drops to two ounces in a day. Pure and in the liquid form, the copaiba has a prompt and power- ful action. But the disgust, the retching and vomitings which it produces, have compelled practitioners to employ some correct- ives, or adjuvants, in order that it may be tolerated by the stom- ach. Combined with magnesia, it has been rendered solid so as to be made into pills. It has also been inclosed in capsules. The pills when very hard are difficult of digestion, and are sometimes passed entire by stool. The same objection applies to the capsules. * P. 157. 6 82 VIDAL ON VENEREAL DISEASES. Besides in this form, it is difficult to give very large doses of co- paiba, at least to increase considerably the number of pills and capsules without disturbing the stomach. In the form of potion it is more sure, but even thfen it still requires correctives ; these I will specify4>y formulas. The most celebrated is that of Cho- part: : • .ft. .Copaib. . ? • • Spt. Vin. rec't. Syr. Hals. Tqlu. Aq. Menth. pip. Aq. Fleur. orang. aa 3 ii.. Alcohol, Acet. 3 ii. With all of§ these* corrections, however, there are s/>me patients who cannot* tolerate the use of copaiba, even when thus adminis- tered. Yet I have seen those who could take it without repug- nance ; one of these was almost a gourmand. The above potion is given in doses of a fablespoonful, from two to six tijnes in a day. At the hopital du Gros Caillou the following formula of M. Gimelle is much esteemed: . ft. Copaib. 3 iii. Cubeb. 3 ii. • Yin. A^romat. § iv. This is to be taken in a single dose, having previously shaken the bottle strongly. . The aromatic wine is intended to prevent vomit- ing. ' _ .-• Copaiba has also been given by enemas, according to the follow- ing formula-: ft. Copaib, *3v. . .Ov. Yitel. 3 i. Ext. Op. (gummy), gr. i. Aq. | viss. Before using the injection of copaiba, a simple lavement should be administered, so as to empty the rectum. I have been accustomed to combine copaiba with cubebs in the following manner: ft. Copaib, 1 part. Cubeb, 2 parts Ess. Menth. q. s. ft. Electuary. This forms an electuary, of which about half an ounce is to be taken in the course of a day. A bolus is made of this by the patient himself, and covered with unleavened bread. He is generally cured after having used about four ounces of the above electuary, it being distinctly understood that he has been suitably prepared by the means which I shall presently indicate. Some practitioners begin with small doses of copaiba, which they gradually increase, without, however, ever reaching a very BLENNORRHAGIA OF THE URETHRA 83 strong dose. This mode of administration is less efficacious and more likely to disturb the digestive organs. Patients who have taken copaiba are attacked first by an intense thirst, the throat becomes dry, and they drink abundantly. Ac- cording to M. Eicord, they must not indulge in drink, that they may pass urine less frequently, and this, as it were, will be ren- dered more balsamic, more impregnated with the principles which it derives from the blood. Copaiba also produces other effects. Sometimes it acts upon the stomach in such a manner as to pro- voke vomiting by the disgust which it occasions. These vomitings now and then occur at a later period, and proceed from another modification of the stomach, being then rather the effect of an irritation of the ventricle. More frequently the intestinal canal suffers, active purgation being produced. Both vomiting and purging are sometimes present, in fine symptoms of cholera mor- bus. Sometimes, on the contrary, there is constipation. It may happen, and this is most fortunate, that the bowels are not unusu- ally free. In all these cases the blennorrhagia may be suppressed even rapidly, but this result, it must be admitted, is more frequent and most complete when the digestive organs have well tolerated the copaiba. Attempts have been made to explain the modus operandi of this substance. The majority of the French school attribute the cure to a displacement of an irritation from the urethra to the intestinal canal. The Italian school recognizes in copaiba neither an irritant nor a specific, but an antiphlogistic hyposthenisant; instead of accelerating and strengthening the pulse, as is generally supposed, copaiba, on the contrary, diminishes both its force and frequency. According to M. Eicord, there is an element of the copaiba which enters the blood, reaches the kidneys, which then secrete urine having medicinal properties which produce a beneficial effect upon the lining membrane of the urethra. This question is of but little consequence, but it is of importance to remember that copaiba is the most powerful of anti-blen- norrhagics. If it is not often employed it is because it is antipathic to most patients, in whom it produces an unconquerable disgust. There is an accident which I have not yet mentioned, and which may deceive the young practitioner; it is the affection of the skin. This is sometimes an erythema, a variety of roseola, or an urticaria. These effects of copaiba are more frequently observed in the spring and autumn. In the majority of cases, this eruption, which varies in different individuals, is of a simple character and soon disap- pears ; however, as it is proved that it does not promote the cure of the disease, but that it rather tends to aggravate it, the copaiba must then be discontinued and the patient allowed repose, during which he may take some acidulated drinks preparatory to sub- mitting to the use of some other anti-blennorrhagics. Copaiba, combined with cubebs, according to the formula which I shall presently mention, very rarely produces this eruption on the skin. Let us examine this substance, cubebs, for a moment. It is a variety of pepper reduced into powder, having somewhat the odor 84 VIDAL ON VENEREAL DISEASES. of copaiba. It has a hot, pungent, and slightly bitter taste. _ As I have already stated, I often combine this powder with copaiba so as to form an electuary. It has also been used both in the form of an extract and infusion. The powder, however, is that which is most generally employed. A dose of from 2\ to 5 drachms is given twice a day. M. Puche sometimes gives as much as 2£ ounces in a day. Cubebs does not disturb the stomach nor inspire disgust like copaiba, it produces vomiting less frequently, and especially, it does not purge. Indeed it often gives rise to constipation. Some- times the stomach is swollen; the appetite becomes keen, and nu- trition most active; rarely does it produce cutaneous disease like that from the use of copaiba. The powder is placed in half a glass of an infusion of lime-tree and orange peel, or it is enveloped in bread, or capsules, or coated with sugar in the form of saccharated capsules. M. Puche's treatment.—The following is his practice in cases of acute blennorrhagia. His prescriptions which I here insert, are copied from his own writings. M. Puche never administers co- paiba before the twentieth or twenty-eighth day from the commence- ment of the discharge. GUMMY SYRUP OF COPAIBA. ft. Copaib pur. 3" ii. Gum. Arab. § ss. Aq. 3 iss. Ess. Menth. pip. utxxxii. Syr. Sacch. | xiiss. Dose from 1 to l£ and 2 ounces of this emulsion in a day. BALSAMIC GELATINOUS BOLUS. ft. Copaib. Terebinth. Inspiss. aa 3* iss. Cubebs, | iii. Dissolve the turpentine over a hot-water bath, and then incorporate with it the copaiba and cubebs ; divide this mass into 100 boluses, which cover with gelatine. Dose from IZtoZA in a day. Two to be taken at once, at regular intervals. M. Puche administers cubebs according to the following method • POWDERED CUBEBS. Take 1st day, 2i drachms for a dose. " 2d " 5 « in 2 doses. " 3d " 1 ounce in 3 " " 4th " li ounces in 4 " / » 5th " 1| « in 5 «i " 6th " 2 « in 6 " " 7th « 2i « in 7 « BLENNORRHAGIA OF THE URETHRA. 85 If the medicine arrest the discharge, says M. Puche, I diminish the dose in the following proportion: Take 8th day, 21 3 ounces in 7 doses u 9th " 2 a in 6 " (( 10th " n u in 5 " « 11th " H u in 4 " « 12th " i a in 3 " a 13th " 5 drachms in 2 " u 14th " 21 a in 1 dose. These doses are to be taken in a well-sugared lemonade at regular in- tervals, between meals. When the disease is of more than two months standing, and has become chronic, M. Puche employs the following injections: , ft. Nit. Argent, grs.li Aq. dist. § iii. An injection every morning and evening for five days.* ft. Nit. Argent, grs. iii. Aq. dist. | xii. An injection morning and evening for five other days. M. Puche adds: after these injections have been used for six days, the patient is to take no medicine for the next five days. Yery frequently the discharge is entirely suspended; but whether it does or does not continue, it is prudent to give the cubebs in 2-| drachm doses for eight days. Author's Treatment.—The following is my method of treating blennorrhagia. I always commence with antiphlogistics, the ac- tivity of which is proportioned to the duration and severity of the disease. Thus, in the majority of cases, I recommend in the first place the use of baths, a soothing tisane, and quietude. If the patient is strong and plethoric, and the disease severe and painful, accompanied with frequent erections, to the above I add the ab- straction of blood; this is generally effected by the apphcation of twenty leeches to the perineum. It sometimes happens that these means, aided by a mild regimen, are sufficient, that is to say, in about eight days after their use, the blennorrhagia subsides. If the discharge continues, I have recourse to indirect anti-blennor- rhagics, to copaiba or cubebs, but more frequently to a combi- nation of the two in the form of the electuary of which I have al- ready given the formula. In conjunction with repose, the baths alone, or leeches, this anti-blennorrhagic produces a very speedy and powerful effect; very rarely does it effect the neck of the * It will be noticed that this corresponds to the injection which I employ after the use of balsams. 86 VIDAL ON VENEREAL DISEASES. bladder in the manner which is observed when antiphlogistics have not been previously employed, and when it gives rise to frequent dispositions to urinate, to high colored and sometimes bloody urine, or by a more or less decided dysury. I never resort at once to injections. I employ them only when the antiphlogistics, the indirect anti-blennorrhagics, have failed to arrest entirely the discharge. Then, only, do I make use of in- jections, and these not of a caustic but an astringent nature. The following is my favorite formula ; it is old, not very scientific, but excellent in a practical point of view: ft. Aq. Ros. 1 v. Acet. Plumb. Sulph. Zinc, aa grs. viii. Shake the vial. At least two, sometimes four injections in tlie day. When I employ the nitrate of silver, it is generally as an as- tringent, and then I prefer the following formula : ft. Aq. Ros. 3 viss. Nit. Argent, gr. i When we wish to produce a caustic effect, it is better to use the nitrate in a solid state. This may be done with a straight porte causlique for the anterior portion of the urethra, and with the curved forte caustique of M. Lallemand for the membranous and prostatic portions. We should resort to this means only in the chronic state, when we have reason to suspect that the disease has become seated on a limited extent of the urethra. A long and extensive experience, both in hospital and private practice, with the method of treatment which I have recommended, authorizes me to declare that its results are more certain and even more rapid than those obtained by methods which make preten- sions to much more speedy cures. It is easy to perceive, that in any case it has neither the inconveniences nor the dangers of that which is called the abortive treatment. There is one phenomenon quite intolerable to the patient, and to which I have alluded in the symptomatology of the disease, viz. chordee, an inflexible condition of the urethra which does not permit it to follow the cavernous body during an erection. Even here, in the majority of cases, the first and best means, is the ap- plication of leeches to the perineum. Next come the sedatives, properly so-called, such as opium, camphor and hyoscyamus. The first named are often thus combined: ft. Camph. Ext. Opii. aa gr. viii. Ov. Vitel. 3 i. Aq. 1 v. For an enema. blennorrhagia of the urethra 87 The following pills are generally preferred: ft. Camph. gr. ii. to grs. 6. Ext. Opii. gr. \ to gr. i. Mucilag. q. s. One, two or three pills a day, commencing in the afternoon. Thirty or forty drops of laudanum may also be administered when the patient retires, or when the first erections occur. Cold applications to the genital organs, to the feet, a walk upon the cold marble slabs have sometimes succeeded. The patient jumps out of bed, and by walking with naked feet upon the floor, is sometimes relieved. But it occasionally happens, that, when the patient returns to bed, and becomes warm again, the erections are stronger than before. The hyoscyamus niger was sometimes successfully administered by Benjamin Bell, even when opium had failed. This English surgeon gave from one to eight grains of the extract, three times in a day; eight grains being administered after the patient had become accustomed to this medicine for some weeks.* But if the patient suffered from chordee during all this time, I think it would have been better to have resorted to some other means. A number of topical applications have also been employed. I once succeeded in relieving a chordee with very painful erections, by means of mercurial ointment applied along the track of the urethra in front of the scrotum. After the employment of fric- tions, a thick layer of the ointment was left upon the penis. Com- presses dipped in equal parts of cold water and laudanum may be applied so as to cover the penis, scrotum and perineum. Brandy, camphorated oil, bran and water, have been used in the same man- ner. AYhen there is nothing more than an erection, or a spasm by which a superficial urethritis is complicated, these means may succeed. But when the chordee depends upon an inflammation which involves the tissues covered with mucous membrane, when plastic lymph is already effused in the cellular tissue, the antispas- modics and sedatives above mentioned will fail, we must then re- sort to antiphlogistics, to local and sometimes to general bloodlet- ting, particularly if the patient be young, vigorous, and plethoric. Benjamin Bell has proposed, as have other writers, to depress the penis, and to bind it to one of the thighs. It has been recently recommended to pull upon the prepuce, to press on its extremity, so as to compress the glans and penis by its sheath. These means, which may have succeeded where the erections have not been very painful, would not only prove ineffectual but might ag- gravate a case of really inflammatory and painful chordee. Hygeine must be recommended. Thus, the quantity of drinks taken should be diminished, and those used should not be of an exciting character. The patient should be advised to cover him- self lightly on retiring, and to apply cold lotions to the penis. * Vol. i. p. 246. 88 VIDAL ON VENEREAL DISEASES. Consequences of Blennorrhagia.—The consequences of blennor- rhagia are numerous, as an urethritis may in its course involve the whole genito-urinary apparatus. I must, however, here confine my remarks to those which are closely allied to the primary dis- ease, the others being discussed in every treatise on surgery; thus, strictures of the urethra, chronic affections of the prostate gland, affections of the seminal ducts, could not be embraced in this work, without disproportionately increasing its bulk. But I will treat of blennorrhoea, hemorrhage, and of pains and perverted sensa- tions in the urethra; I will afterwards consider the subject of or- chitis, prostatites, cystitis, nephritis, arthritis, and blennorrhagic ophthalmia, accidents sometimes of a very serious nature, and which we should endeavor to prevent, which we must often com- bat, and the study of which cannot be separated from the affection of the urethra. Blennorrhoea.—According to Swediaur, blennorrhoea is a passive discharge, (fluxus passivius,) whilst blennorrhagia is an active, in- flammatory discharge (fluxus activus). In accepting Swediaur's definition, because it is generally admitted, I cannot receive it, at least in the majority of cases, in the sense in which it is used in English syphilography. Because, in my opinion, blennorrhoea, that is to say, the discharge which is generally the result of blen- norrhagia, more mucous in its character and less abundant in quan- tity, which ceases but to re-appear; in fine, that discharge which is called a gleet, military drop is but a chronic inflammation of the urethra with or without a complication of an analogous inflamma- tion of its appendages. I have already remarked that this opinion should not be received in the most absolute sense, for there may be gleety discharges without a previous blennorhagia, that is with- out an active discharge. I would not therefore deny the existence of a passive discharge, or at least of one which is entirely indepen- dent of an actual urethritis or one already extinct. It is difficult to name the precise period at which blennorrhagia ceases, and a blennorrhoea begins. Some authors maintain that the discharge is no longer blennorrhagic but a gleet, when it ceases to be contagious, others regard it as a gleet when it is no longer troublesome, when the discharge is transparent, and viscous like mucus. , But it is well-known how difficult it is to establish con- tagion from an urethral discharge, and as regards its transparency and mucous character, this may change from day to day ; indeed, a gleet which to day may be transparent, and mucous to-morrow, may be opaque and more or less purulent, and all this may come from the least imprudence in regimen. But an examination of the causes of blennorrhoea will lead to a better idea of its nature. Causes.—The principal and most frequent cause of a gleet is the persistence in a chronic form of the urethritis which caused the blennorrhagia. For, according to my views, blennorrhoea is chiefly a chronic blennorrhagia. Indeed, when after forty or fifty days the blennorrhagia does not cease, we have reason to appre- hend that it will become chronic. Then, if the patient be care- fully examined, as well as the circumstances by which he is sur- BLENNORRHAGIA of the urethra 89 rounded, it will be found that he is of the lymphatic or bilious temperament; or that he has a strumous, rheumatic, dartrous, or a syphilitic diathesis. According to M. Cazenave, syphilis plays an important part in the etiology of blennorrhoea. In his opinion, every slight discharge which becomes permanent, is due to a morbid disposition left by the virus which first affected the urethra; blennorrhoea, in fine, is but the remnant of a virulent blennorrhagia imperfectly cured. If no particular diathesis or vice exist, it will be found that the patient has not submitted to hygienic rules; during the treatment, and the decline of the blennorrhagia, he has not observed the necessary repose, and has indulged in improper aliments and drinks, and sexual intercourse, or masturbation. Among my city patients, the discharge is maintained by the presence of a com- panion, near which the patient cannot remain without excitement; and in hospital practice, I have had opportunities of knowing that the very youngest of those affected with an obstinate discharge were inclined to masturbation. In the etiology of this disease, we must not omit the influence of the absence of all treatment, or of improper treatment. In speaking of the therapeutics of blennorrhagia, I have designated as a cause of chronic urethritis the so-called abortive treatment, because it is that which most frequently fails, and which has the strongest tendency to render the disease protracted. If we take a general view of the causes, we find that they are of two kinds, the one pertaining to diathesis, the other irritant, excitant. The first gives a chronic and specific character to the disease, rendering it exceedingly rebellious to treatment; these are, therefore, complicated cases, for to the inflammatory element there has been added the rheumatic, the dartrous, the strumous, qt syphilitic. The obstacles in the way of treatment may already be anticipated, obstacles which will render it especially difficult when they depend upon a complication with a peculiar diathesis. Thus, there are patients with dispositions to catarrh, to discharges with- out provocation, from the ears, nose, and eyes, which, once affected with blennorrhagia, never get rid of the disease. These are the patients who may have a primary or non-consecutive gleet (d'em- blee), that is to say, a blennorrhoea which has not been preceded by a blennorrhagia. A neglect of hygiene is chiefly the exciting cause. The patient devotes himself too much to his occupations, is guilty of luxurious indulgences, and makes not a proper selec- tion of his aliments. Seat and Anatomical Characters.—I have already shown that the part first involved in blennorrhagia was the commencement of the urethra, in the vicinity of the glans. The most common seat of blennorrhoea, on the contrary, is towards the end of the urethra, in the region of the prostate. M. Baumes is very explicit upon this point. However, blennorrhoea has been observed, in which the disease was less profoundly seated; there are some cases, even, in which the seat is the same as that of an incipient blennorrhagia; indeed, it happens that an urethritis becomes chronic in the same 90 VIDAL ON VENEREAL DISEASES. situation in which it has been primarily acute. Of this I am cer tain, for by the application of the nitrate of silver to the fossa navicularis, I have removed the most obstinate cases of blennor- rhoea. When the latter is symptomatic of stricture, it is generally towards the curve of the urethra that we find the most important lesion, viz. a thickening or induration of the sub-mucous cellular tissue. Sometimes it is difficult to decide upon the seat, the ana ■ tomical characters of blennorrhoea; in these cases, there is that disposition to mucous discharges of which I have spoken in treat- ing of the causes of the disease: the mucous membrane of the urethra may here preserve its natural appearance, like that of the nose, which presents nothing abnormal, even in a state of well- marked hyper-secretion. Symptoms.—The discharge in gleet is not always constant; sometimes there is a kind of intermission: it thus happens that the meatus urinarius is always moist, that the linen in contact with it is always more or less stained, or that the discharge appears more particularly at certain periods ; this may be in the morning, after slight exercise, or a repast. In some cases, it is only by pressing the urethra from behind forward, that the discharge is brought in this direction ; this is the case when it is deep seated in the canal. Then it is thick, viscous, and small in quantity; being carried away from time to time by the urine, it is rarely observed at the meatus, or if here perceived, it is only in the morning, when no urine has been passed during the night. If its seat be the fossa navicularis, we may in a manner produce the discharge at pleasure; we have but to press upon the glans, which is then often very sensitive to this pressure. It is a little en- gorged ; one or both lips of the meatus are sometimes of a violet color; and in separating the lips, the urethra appears of a violet red. If the seat of the discharge be more deeply situated, the lat- ter may be perceived without resorting to pressure, but for this a certain quantity of the discharge is necessary. Thus the quantity, consistence, viscosity of the humor, the more or less frequent dis- charge of the urine, may exert an influence upon the manner in which blennorrhoea presents itself to the observer. In every case, the different positions of the penis must, more or less, favor the appearance at the meatus of the gleety discharge. The humor may be entirely transparent and viscid, as described by Benjamin Bell, when it is supposed to be no longer contagious, it may be of grayish or milky white color; and the pus is more or less combined, or more or less separated from the mucus. The stains on the patient's linen are generally of a pale yellow color; sometimes scarcely visible; they are of a grayish white color; generally the central point is more deeply colored, the rest being very clear. Sometimes the stained linen has a sickly, sourish odor. Hunter maintained, that when the globules of pus, instead of float- ing in the serum, are suspended in a thready mucus, the discharge is no longer contagious. M. Baumes is less confident; according to the physician of Lyons, when the discharge is simply mucus, transparent, limpid, without color, thready, and glairy, it then less BLENNORRHAGIA OF THE URETHRA. 91 frequently possesses contagious properties, but even with these characters, when it would seem to be deprived of all purulent globules, the discharge may still be contagious; the only difference being that contagion under these circumstances is less frequent. Blennorrhoea, in general, is not painful; the sensibility of the urethra, however, is not normal; the patient complains of itching in the canal towards the perineum, or there is a feeling of weight or vermicular sensation extending from the urethra to the rectum, which the patient refers chiefly to the latter situation. Sometimes, indeed, it is on account of this annoyance, and not for any affection of the urethra, that we are consulted. Most generally he is of the opinion that he is troubled with ascarides in the rectum. I repeat it, that in blennorrhoea there is an absence of pain, properly speak- ing ; and when, as the result of excesses, it is present, it is felt in the vicinity of the gland, at the moment when the urine reaches the fossa navicularis, or when the last drops are voided. In such cases chronic inflammation exists in the anterior part of the canal. The same pains may exist when the urethra is inflamed at a greater depth, which is the most common seat of the lesion in cases of long standing. Then, in addition to pain, there is a frequent dis- position to urinate; the urine contains more or less of deposit, and there are symptoms of inflammation of the neck of the bladder. Diagnosis.—The diagnosis of blennorrhoea is generally not diffi- cult. The only difficulty is in distinguishing cases in which the discharge is from those in which it is not contagious. What may most confidently be asserted is, that when the discharge is entirely mucous, free from pus, contagion is least to be apprehended; but it is a more dangerous doctrine that when the discharge is of the above character, that for a long time it could not have been con- tagious. It is evident that many very obstinate cases of gleet, in which the discharge is thin and milky, and sometimes even colored, in all its shades and degrees of consistence, are entirely innocent, and that females have escaped after intercourse with those affected with every kind of gleety discharge. But notwithstanding these facts, which are very numerous, exceptions have been observed, which have given rise to much domestic unhappiness. I know of two cases of contagion from gleet; the disease was considered as of no consequence, and marriage, under the circumstances, was permitted; separations were the result. One of the infected women gave birth to a child, which succumbed in three months, covered with pustules. Thus the greatest uncertainty attends our means of distinguishing a contagious from a non-contagious case of gleet, and the practitioner should always inform the patient affected with it, who consults him upon the subject of matrimony, that the dis- ease is contagious.* * The judicious advice here given by our author accords, we believe, with the sentiments of the majority of the most experienced British and American practi- tioners. We have, however, nowhere seen this common sense view of the subject more happily expressed, than by Mr. Skey, in his Lecture on Gonorrhoea, in the Lond Med. Gazette, June 1839, p. 443. "Applications are frequently made for the Furpose of ascertaining at what period of the disease it ceases to be communicable. recommend you to be most cautious how you commit yourselves on this head, by 92 VIDAL ON VENEREAL DISEASES. Prognosis.—Blennorrhoea, being in the greater number of cases a chronic urethritis, the seat of which is in the deeper portion of the canal, where the openings of the seminal canals touch the prostate gland and neck of the bladder, we can understand how, from any excitement or irritating cause, this inflammation may extend to the vesiculse seminales, the bladder, and the prostate gland. Thus, it is not unusual to observe disturbance of the func- tions of the vesiculas seminalis, such as nocturnal or diurnal emis- sions, the consequence of the inflammation which has been propa- gated from its first seat, the urethra, to the adjoining parts. More than one vesical catarrh has been caused by an aggravated blen- norrhoea. Prostatic engorgements are often thus produced; a fact which is incontestable in the adult. In old men it may proceed, as is well known, from spontaneous hypertrophy, without previous inflammation of the urethra. But to maintain, as does M. Mercier, that urethritis has no connection with this hypertrophy, is more than is warranted by the facts of the case. I believe, on the con- trary, that in the prostatic engorgements of old men urethritis plays an important part. If, in our inquiries into the history of the case, it is not found, it is sometimes owing to the fact that it occurred before, or at a forgetful age, or that the patient is un- willing to admit certain details. The prognosis in blennorrhoea is therefore serious, as regards the connection of a female with a man thus affected, and the health and constitution of the children which may spring from such connection, and as regards the patient who is himself diseased. I have already alluded to the dangers of an urethritis when it becomes extensive; it is to be dreaded even when it is concen- trated on a limited space; for then strictures may result from the engorgement and condensation of the sub-mucous cellular tissue. A gleet, even when there are no apprehensions of contagion, and when it does not interfere with the functions of the genito-urinary apparatus, may exert a deplorable influence on the spirits of the patient. It seems difficult to comprehend how the appearance of a single drop of discharge, in the day, at the meatus urinarius can so affect the mind of the patient. Those who have often been consulted by persons affected with venereal disease, know the despair which is felt by certain patients, and must possess letters written by them, in terms most melancholy. Others, again, are perfectly indifferent to this disease; such are the most dangerous as regards the female sex. • Treatment.—In the treatment of this disease we should take into consideration all the causes which have been enumerated as con- cerned in its production. But our practice should be chiefly based upon the idea which I have constantly endeavored to keep in which, in case of failure, you render yourselves morally responsible for whatever consequences may ensue. In truth we know nothing about it. What is communi- cable to one person is incommunicable to another; and so long as we have no cer- tain evidence by which to draw the line, it is better to adopt the alternative of declining an opinion altogether, or of leaning to the side of good morals, by declaring that, so long as discharge exists, there is no exemption from the liability to con> municate it."—G. C. B. J BLENNORRHAGIA OF THE URETHRA. 93 view, viz. that we have to contend with an urethritis. Every practitioner acquainted with this fact, may calculate upon success much more frequently, and much more confidently than can he who is impressed with an opposite opinion. Thus, for my own part, the basis of my treatment of blennorrhoea is identical with that of blennorrhagia. In both affections it is the urethritis which I combat. Especially do I conform to this doctrine when blen- norrhagia has not been treated, or, in cases where it has been improperly treated, if antiphlogistics have not been employed in the first place, if hygienic rules have not been observed during the treatment, and. if the disease has not been improved. In cases where these measures have been employed, and these rules ob- served, I do not insist upon the use of antiphlogistics, but resort to direct astringents, to derivations, in fine to the means which are generally used to combat a blennorrhoea, not as a symptom of inflammation, but as a disease essentially catarrhal. This is not the place to prescribe the rules of treatment adapted to every constitution, to every diathesis. I will only remark, that when we have reason to suspect the rheumatic diathesis, a change of climate, a dry and warm residence, the vapor bath, aloetics, are calculated to produce beneficial results. It is particularly in pa- tients of this class, that we observe cases of blennorrhoea cured by horse-back exercise, the excitement of the chase, or a voyage to a warm climate, especially where a suppressed perspiration has been made to reappear, or a new one established. If the strumous dia- theses is suspected, we must resort to the preparations of iodine. In this category should be classed the patients who are cured by salt bathing, a remedy so highly extolled by Hunter. When blennorrhagia is complicated with a dartrous vice, and runs into an obstinate blennorrhoea, saline purgatives should be repeatedly em- ployed, an irritating regimen avoided, and all diffusible stimulants, without, however, prescribing tonics properly so called. When blen- norrhoea exists in a patient affected with eczema, or who has the mucous temperament of which I have spoken, I have recourse to the internal administration of ferruginous preparations: as for ex- ample, the pills of valette, or the saccharated ferruginous pills made according to my own formula. Each of these contains about one grain of the lactate of iron. At first, I give three in a day, and the patient may take as many as six or eight in a day if the stomach tolerate, and if there be not obstinate constipation.* De- * With Mr. Skey (Lect. cit. p. 443), we are satisfied that in many cases of gleet it is necessary to raise the standard of the circulation, and nervous power, by re- suming ordinary diet, and ordinary stimuli. " If," says this surgeon, " you treat a person habitually prone to large libations of drink, by entire desistence from his ordinary and necessary stimulus, he will have a protracted gleet; and this prin- ciple holds in all cases, catteris paribus, in which the depletion, whether positive or negative, has been needlessly persisted in; therefore, the first consideration applies to constitutional treatment, which is, at least, equally important to local. I re- cently had a man under my care, who, when in health, took per diem about one gallon of porter, in addition to an occasional glass of gin. He had been the subject of gleet for ten months, for which he had employed the usual catalogue of local remedies. I desired him to leave the gleet to take its own course, and resume his % 94 VIDAL ON VENEREAL DISEASES. rivatives, such as blisters, cauteries applied at a greater or less dis- tance from the urethra, should be preferred in cases complicated with the rheumatic or dartrous vice. Benjamin Bell greatly ex- tols the efficacy of bhsters applied to the perineum. Kecently this practice has been revived, even in the acute stages of an ure- thritis. In blennorrhagia they can be applied along the track of the urethra, in front of the scrotum. But as they have been used in conjunction with, or immediately after certain injections, it is difficult to decide upon their agency in effecting a cure. They should always be regarded as means to be employed after others which are less painful and attended with less inconvenience. If there be reason to suppose that blennorrhoea is a primary syphil- itic accident which has become protracted, or that it is a consecutive accident, the general treatment for syphilis should be pursued. Both the direct and indirect anti-blennorrhagics must necessarily be employed in the management of blennorrhoea; as for example, cubebs and copaiba. If the disease is the result of a marked blen- norhagia, that is to say, one which could not be cured, either from wrong or improperly-directed treatment, then after the application of leeches to the perineum, and along the course of the antiscrotal portion of the urethra, a combination of copaiba and cubebs in the form of the electuary already mentioned, may be administered. But a blennorrhoea cannot be removed like blennorrhagia, and these means continued for a length of time in the doses specified may singularly disturb the digestive organs ; in such a case the dose must be diminished, or the medicine must be for a time sus- pended, or turpentine substituted, of which the patient may take one drachm in the day. If the stomach is still intolerant, we must resort to injections. An immense variety of these have been em- ployed. Here I recapitulate the formulas which I have used in blennorrhagia: sometimes I inject 5 ounces of water with 8 grains of the sulphate of zinc and acetate of lead; sometimes I employ the nitrate of silver in the strength of 2 grains to 3 ounces of water. Injections should be more frequently repeated here than in blennorrhagia. In certain obstinate cases, we inject not only twice, or four times, but even more frequently during the day. My success in more than one case has been owing to the use of astringent injections thus repeated. I prefer, therefore, the injec- tions of the sulphate of zinc and the acetate of lead. Sometimes I have used cold water alone. We may also employ the follow- ing formula of Benjamin Bell: ft. Sulph Zinc, | ss. Eau. dist. | viii. usual drink. He perfectly recovered in a week, and has had no return of the discharge." Mr. Henry I. Johnson (op. cit. p. 103), after alluding to the fact that gleet is often cured by the most inconsistent treatment, remarks, that after all, these cases resolve themselves into the following formula :—that gleet, being a morbid action in the part, slight in itself, but sustained by habit, may be cured by any thing which excites a new action, and so breaks that habit.—G. C. B. BLENNORRHAGIA OF THE URETHRA 95 Or this: ft. Sulph. Alum, et Potass, grs. xv. to xxx. Eau. dist. § ii. Yinous solutions of vegetable astringent have been much em- ployed, according to the following formulas: ft. Yin. (heavy red) § ii. Tannin pur. gr. i. Yin. (heavy red), § ii. Quinquin, rub. 3 i. Macerate for 48 hours. It has also been proposed to act by injections upon the cause, the diathesis which protracts the blennorrhoea. In supposed scro- fulous cases, M. Eicord has experimented with injections of the iodide of iron (one grain to the ounce) ; then he has increased the strength to 18 grains to the ounce. Certain patients with a thick discharge, have been cured in four or five days. In others, these means have rekindled the acute stage; instead of a muco-purulent, there has been a discharge of bloody serum, and when the injec- tions have been discontinued, the blennorrhoea has been removed. Other patients have been irritated, and not cured. It is very pro- bable that these iodurated injections have acted simply as irritants, and not as specifics against a diathesis (antidiathesiques). The mildest injections may so irritate the canal as to oblige the practitioner to suspend them for awhile, and to resume their use after an interval of some days. If the irritation should reappear, and especially if in a severe form, injection must be proscribed, or at least the formula which has excited it. It often happens, when a preliminary treatment has been adopted, and the injection well selected, that the discharge is lessened, in which case we should continue its use until it has completely ceased. Even after this occurs, as many as ten have been employed, at intervals of from two to three days. Some- times, Avithout ^augmenting the urethral irritation, and reviving the inflammation, the first effect of the injection is to increase the discharge. Then, after four or five days use, they should be sus- pended. If, after this period, we observe a diminution of the weeping, the injections should be resumed, and it is very probable that they will be followed by complete success. I have already remarked, that caustic injections have been em- ployed not only in the acute stage in blennorrhagia, but in the chronic state in blennorrhoea. It then often happens that after the immediate and primary effects have passed, the gleet disap- pears. But be not deceived; the disease may then be only masked; there maybe a dry blennorrhagia, a urethral inflamma- tion without secretion, which, in subsiding, will reproduce its effects, which have only been postponed; for the cause being renewed, that is, the irritation of the urethra being brought back 96 VIDAL ON VENEREAL DISEASES. to its first condition, it Avill give rise to the same discharge, with the same, if not still more obstinate characters. I do not proscribe caustics in the treatment of urethral dis- charges, even where they depend upon an inflammatory condition, for analogy compels me to admit their use, and clinical observa- tion has furnished me with facts in support of this analogy: thus, a slight cauterization of the anterior, or deeper portion of the urethra, is a rational practice; for then we act only on the part affected; in certain opthalmic inflammations, for example, we in this manner modify the condition of the conjunctiva. When the part diseased in blennorrhoea is deep seated,_ it is difficult to ascertain its situation so as to attack it, and it alone. Before employing the porte caustique, we must explore the canal with the ordinary sound, or bougie. When the instrument comes in con- tact with the inflamed or indurated part, the patient experiences a severe pain, and the surgeon feels an impediment to the passage of the sound; it is irregular, encounters slight obstructions, and an uneven surface. I acknowledge that this exploration is not easy; it requires long practice, but it may be attained. M. Baumes, for example, constitutes it a guide to his practice. We must not confound the sensations mentioned, those on the part of the patient and the surgeon, with those produced at the moment when the sound passes through the curve of the urethra, or when it enters the bladder, reaching too far into its cavity. When once the irregular and sensitive point is felt by the operator, its distance from the surface should be marked upon the porte caustique, and the latter should be introduced within the urethra. The cup con- taining the caustic having been protruded, it should be turned rapidly upon its axis, so that it may act upon the circumference of the canal. The caustic is then withdrawn into the sound, and the latter is immediately removed. After this trifling operation, a bath should be directed, and should be repeated at intervals of two, three, or four days, according to the effect produced. Sometimes bougies are employed, which have been coated with an ointment more or less irritating, or sedative ; thus, an ointment of the nitrate of silver (1 grain of the nitrate to 1 drachm of lard), or of camphor, may be used. Now and then I have been success- ful with the following: ft. Ungt. Hydrarg., 1 part. Ext. Bellad. 2 parts. Occasionally the mercurial ointment, or the mercurial cerate, is relied upon alone. The naked bougie has also been employed; in this case, it acts as a physical agent, modifying the sensibility of the urethra, and tanning, as it were, the mucous membrane, and thus changing its mode of secretion. Sometimes I have adopted this practice with the greatest advantage; this was especially the case in two instances, where the patients in the higher ranks of society suffered so much from mental despondency as to consider life as a burden. I generally use the yellow wax bougie. Blis- BLENNORRHAGIA OF THE URETHRA 97 ters to the perineum, and the use of bougies, were regarded by Benjamin Bell as our most efficacious means of treatment. This. practitioner insists upon the employment, and prescribes rules for the use, of the bougie. According to him, we should select very soft bougies, which will slightly stimulate the parts, without excit- ing an inflammation; they are often extremely useful, not only in thus stimulating the weakened parts, but supporting them by their volume and their form; they are attended with less risk than injections, even when they stimulate beyond our expecta- tions, for the inflammation thus excited is always accompanied by a temporary discharge, which is well adapted to prevent any unpleasant consequences, which might otherwise result from their use. The bougie should be as large as the capacity of the urethra will admit. Benjamin Bell maintains that it is particularly essen- tial in this variety of discharge, that the bougie should be of a large size, for it is chiefly from the volume of the instrument that success in these cases is attained. We generally ascertain, in the course of a few days, whether the bougies are likely or not to be useful; nevertheless, we should not expect any lasting advantage unless their use be for a long time continued. In cases of long standing, they must be employed for ten or twelve weeks, and they should not be discontinued until the cure is complete. It is well, however, to observe, that when we have pursued this method of treatment for a reasonable length of time, it should occasionally be suspended in order to ascertain its effects. When bougies are daily introduced, it is impossible to decide whether the discharge proceeds from disease, or from the irritation excited by the instru- ments ; a bougie cannot remain for a length of time in the urethra even of a sound person, without being covered, when it is with- drawn, with pus or muco-purulent matter. It is better to use the bougies three or four times in the day, and not to leave them in the urethra more than ten or fifteen minutes. Sometimes, the discharge is not only increased by these instruments, but a true blennorrhagia is produced, especially when they are allowed to remain in the canal; in such a case, their use should be suspended; particularly, if they have given rise to fre- quent disposition to urinate, or io symptoms denoting an inflam- mation of the neck of the bladder. When the inflammation has been subdued, we should notice whether the discharge has com- pletely ceased. If it has not, Ave may resort to them again, though cautiously. Particularly should we guard against passing the' instrument too deeply, a practice of Avhich patients and young practitioners are often guilty. A gleet Avhich has resisted every kind of treatment, occasionally disappears in an unknown manner: sexual intercourse has pro- duced this effect. Finally, there are some cases Avhich resist everything, even time, and Avhich, after having been symptomatic of a form of inflammation of the urethra, are found at length to be maintained by strictures, disease of the prostate or bladder, or they are complicated with seminal emissions. The treatment, then, should be modified according to the complications of the case. VIDAL ON VENEREAL DISEASES. STRICTURE. As we are at present concerned Avith stricture only as one of the consequences of blennorrhagia, Ave shall not dAvcll upon other points in its etiology. Frequently there exists but a single stric- ture, though we occasionally meet with more ; thus, M. Lallemand refers to the case of a captain Foltz, Avho had seven ; Collot * met with eight, and John Hunterf six, in a single patient. As the lat- ter surgeons were deprived of our present means of exploration, we may reasonably doubt the accuracy of their diagnosis. No autopsy has ever revealed a large number of strictures in a single subject. Yet, it is well established, that in many cases, more than one exists. M. Leroy d'Etiolles asserts that in nearly one-half of those examined, two strictures are found, within about three lines of each other. Seat.—Differences of opinion have prevailed m reference to the seat of strictures. This has arisen from the different estimates formed of the length of the urethra, the result of different modes of measuring this canal. As a general rule, it may be stated, that the most common seat, is at the various points of projection of the canal, or in the vicinity of these projections, as for example, at the seat of junction of the bulbous and membranous portions of the urethra, and particularly at the commencement of the latter portion ; again, we find stricture occurring at the union of the lat- ter with the prostatic portion, and lastly, at the navicular fossa and meatus. They may exist at any of the intermediate points. Soemmering denies the existence of stricture in the prostatic por- tion of the urethra ; Hunter does not dispute such an occurrence, but remarks that it has never come under his observation. Prof. Lallemand is opposed to the views of Soemmering. Of 14 cases reported in the work of the former surgeon, allusion is made to strictures situated at the depth of six inches or more from the meatus; now, the average length of the urethra being from five inches four lines to seven inches three lines, we are compelled to admit the existence in these cases, of strictures in the prostatic portion of the canal. [The measurement of the urethra, as made by the following surgeons, twenty in number, gxiks an average of 7A to 9$ inches instead of 5£ inches to 7|-, as stated by our author. In. In. In. In. Lallemand, - - 7 J to 9£ Lisfranc, - - - 9 " 10 Meckel, - - 8 Malgaigne, - - 5^ " 51 Mercier, - - " " " Perreve, - - - 6 " 10 Sabatier, - - 10 " 12 Segalas, - - - 8 " 8 Velpeau, - - 5 " 7 Whately," - - - 7£ " 9£ Mr. Miller states in his Practical Surgery, (London ed., p. 519,) that the ordinary site of stricture is between six and seven inches * Traite de Toperation de la taille et des Suppressions (Purine, 17G2. f Traite des Maladies veneriennes, with Notes by M. Ricord. Amussat, - 7 to 8 Boyer, - - 10 " 12 Begin, - 7i " 9i Belmas, - - 10 " 12 Cloquet, L - 7i " 11 Cloquet, H. - - 9 " 11 Civiale, - - 5 " 7 Ducamp, - - 7§ " 9*1 Guthrie, - 8 " 11 Gross, - - 7 " 12 STRICTURE. 99 from the orifice, in front of the membranous portion of the ure- thra, which, with the estimates given above of the length of this canal, is far more liberal than that of our author. Indeed, accord- ing to the calculation of the latter, Mr. Miller would make the prostatic portion of the urethra the ordinary seat of stricture! That this portion of the canal is sometimes the seat of true stricture is positively asserted by M. Eicord, (Notes to Hunter, 2d ed., p! 217,) in proof of which he refers to the case reported and deline- ated by Mr. Crosse, to which, he observes, many others might be added. Doubtless it does occur, though rarely, at this point.__ Or. C. B.J _ The most common seat of stricture is a little in front of the junc- tion of the membranous with the bulbous portion of the urethra. The following results were obtained by Ducamp by means of his gradu- ated instrument: In 5 out of 10 cases, the stricture was encountered in from three and a half to four and a half inches, and to be more pre- cise, in 4 out of 5 cases it is from four inches ten lines to five inches seven lines, from the meatus. It is evident that this would bring it in the vicinity of the urethral curve, which, with the exception of the meatus, is the narrowest portion of the urethra. At the meatus, strictures are not uncommon: I have seen them produced by chancres, which had destroyed the frenum, or spent their ravages on the summit of the glans. Should the destruction by these ul- cers have been more complete, so as to destroy a portion of the penis, stricture occurs at the point where the urethra may have been divided. The meatus has likewise a tendency to become ob- literated, when chancre produces a perforation of the inferior wall of the urethra at the navicular fossa, by which a kind of hypos- padias is formed. Form.—A stricture occasionally presents the appearance of a slightly-projecting line, over which the mucous membrane seems only to have lost its elasticity and transparency; sometimes, on the contrary, the thickening of the parts is considerable; all the tissues Avhich enter into the formation of the urethra become in- volved, thus producing a decided tendency to its obliteration. The extent of a stricture may greatly differ, being from that of the thinnest fold of the mucous membrane, to one and a half inches (Lallemand, sixth case); ten to fourteen lines (Segalas) and one inch, nine lines; or two inches, eight lines (Hunter Chopart and Charles Bell.) V ' The longest strictures are generally found at the spongy portion of the urethra. Sometimes they are of considerable thickness, their dimensions in other respects being not very extensive. In such cases a stricture may be mistaken for a fold, a valve, or some morbid growth. This disposition is particularly frequent at the commencement of the urethra, in the vicinity of the glans; its direction is likewise more perpendicular to the axis of the canal. A case is reported in the Gazette Medicale, 1840, in which a valve existed in the ure- thra, its free margin being directed towards the bladder, thus causing an obstruction to the passage of the urine. The patient 100 VIDAL ON VENEREAL DISEASES. was sixteen years of age, and this growth was supposed to be congenital. A stricture, Avhich involves but a portion of the cir- cumference of the urethra, may be situated on its upper,_ lower, or lateral walls. The latter interfere less with the evacuation of the urine, because the opposite point being sound, is easily dilated; this variety is also most liable to exist a long time undetected, for it does not, except Avhen excessively developed, oppose the intro- duction of the catheter. No instances of a perfectly longitudinal stricture have yet been discovered. M. Amussat maintains that the urethra is never perfectly oblit- erated ; he asserts that a communication alAvays exists betAveen the parts anterior and posterior to the obstruction. Any inter- ruption to this communication, is, in his opinion, but temporary, and is caused by some foreign body. It was doubtless through inadvertence that Eicherand asserted, that of 10 cases of retention of urine, 8 are due to an obliteration of the urethra.* The truth is, that these obliterations have fre- quently been supposed to exist, when they were absent, or only caused by accidental circumstances; but cases have occurred which prove the possibility and actual occurrence of impermeable stric- tures. I admit, that the plates of Sir Charles Bell are overdrawn, but the case mentioned by Chopart f is conclusive, and accords perfectly with the dissection made by M. Delmas on a subject named Juniot, who died at the Hotel Dieu, from an extensive in- filtration of urine4 On this subject, the reader may likeAvise con- sult the case reported by M. Monod, and referred to by Cruveilhier in his great work, and Avhich is also noticed in the Annales de Chirurgie, 1842. I believe, that the obliteration did not take place until a fistula was established, through which the stream of urine was diverted. [Mr. Liston once boasted that he had never been foiled in intro- ducing a catheter with one hand, and it was not until some two or three years before his death that he encountered a case at the North London Hospital, which baffled him, and caused " the cold sweat to start in big drops from his forehead," (vide Lizars, on Strictures of the Urethra, pp. 18, 19.) Mr. Wm. Cadge, the pupil and friend of Mr. L., informs us in the Lond. Med. Times, Nov. 9th, 1850, that this distinguished surgeon, in the latter years of his life, abandoned his former opinion, that there are really no impermeable strictures. Mr. Syme, as is well known, still adheres to this opinion. In the very excellent Memoir on the Treatment of Stricture of the Urethra, &c, by Prof. Eve, of Nashville, (Nashville Journal of Medicine and Surgery, June 1853, p. 332,) this able sur- geon has reported a case in which, with all his well-known skill, he could not pass the stricture. After making an incision into the perineum, he '« drilled a hole through a hard cartilaginous mass occupying the membranous portion of the urethra." ° In a note, Prof. E. refers to another case, treated by Dr, Webb, of St. * Nos. Chirtirg. torn. iii. p. 470. t Traite des Maladies des voies urinaires, torn. ii. p. 323. £ These inaugurate, of M. Selles, 1824. Also Soemmering, p. 174. STRICTURE. 101 Louis. In this instance, Dr. W., after opening the perineum, could not find the urethra ; he then cut out a cartilaginous mass an inch in length, around which he supposed the urine must have passed. Prof. Eve, in view of the above facts, very pertinently asks, " Avould not this have proved an impermeable stricture, even to Mr. Syme, of Edinburgh," and, we would add, to M. Amussat himself? Impermeable strictures are distinctly recognized in the Treatises on the Urinary Organs, both of M. Civiale and Prof. Gross. —G. C. B.] Structure.—A knowledge of the structure of a stricture is abso- lutely essential to a just appreciation of the means proposed for its treatment. Laenncc, in his lectures, speaks of bridles formed of plastic lymph deposited upon the lining membrane of the urethra. The existence of this kind of stricture is denied on the grounds, 1st, of the slight tendency of mucous membranes to form plastic lymph; 2, the impossibility of the condensation of this lymph, owing to the frequent passage of the urine, by which it must ne- cessarily be removed. But one well-authenticated case is sufficient to destroy the force of these objections. Admit that the mucous membranes do not often secrete this lymph, still instances have occurred both in the intestinal canal and the laryngeal and bronchial tubes. Urine is not constantly passing through the urethra; the interval of the acts is sometimes sufficiently long, to permit the condensation of a layer of plastic lymph, which process is often very rapid. Lae'nnec deposited in the Museum of the Faculte de Medecine, a pathological specimen, in proof of his opinion : this I have not been able to procure. Besides, the preparation is now so old that one could not decide whether the stricture in this case was formed by a deposit of plastic lymph, or a thickening of the mucous mem- brane itself. The views of Lae'nnec were admitted by Ducamp, and similar opinions were entertained by Morgagni, Sharp, Goulard, and other surgeons; but further investigations on this question are to be desired. [This question has been definitely settled by the researches of that able surgeon, Mr. Hancock, of the Charing Cross Hospital, London. His recently-published work, " On the Anat. and Phys. of the Male Urethra, and the Pathology of Strictures of that Canal," contains more valuable practical information than we have ever seen embodied in so small a compass. We shall have occasion to refer to this work again in noticing the subject of spasmodic stric- ture. In speaking of the influence of adventitious membranes in the production of stricture, (p. 74,) he remarks, that he is con- vinced that the latter depends upon the former more frequently than is commonly supposed: " To gain as much information as possible upon this point, I have examined all the urethras I could get. I have examined the urethras of those who have died of other diseases, in whom the existence of stricture had not been sus- pected ; I have also, through the kindness of my friends, been enabled to examine preparations taken from those who had at one time suffered from this malady, and who were supposed to 102 VIDAL ON VENEREAL DISEASES. have been cured; I have also been enabled to examine those taken from patients who have died Avhilst laboring under the complaint. And the result of these examinations is the convic- tion that permanent stricture from false membrane Avithin the canal upon its free surface, is a common and frequent occurrence: and I am confirmed in this view by my friend Dr. Beith, Avho has rendered me great assistance, and Avho from his position at Green- wich Hospital, has had ample opportunity of studying these dis- eases, to Avhich he has devoted much attention." At pages 75-78, Mr. Hancock has detailed some of the autopsies which he has made, and Avhich prove incontestably the accuracy of his opinion. —G. C. B.] In the majority of cases, the mucous membrane seems the only- part affected ; its redness, consistence, and thickness are increased, and its elasticity impaired. When, at an autopsy, this lesion only is observed, Ave are surprised that it could have caused so serious an obstruction to the passage of the urine; but we forget the con- gested state of the subjacent tissues Avhich subsides after death, nor do we take into consideration the fact that this obstacle may have been increased by spasm. This is the most common form of stric- ture ; that through which, it may be remarked, the largest bougies are most readily passed. It should be remembered that the tissues subjacent to the mucous membrane are increased in thickness only by the temporary presence of a large quantity of blood, which is only temporary, being withdrawn at death, or which may be ex- pelled by well-managed external compression. Occasionally the mucous membrane is sound, and the subjacent tissues are alone affected. This does not imply that the former has not been dis- eased ; for it is to be supposed that it was primarily affected, the effects having here subsided, as in the case of certain alterations in the pyloric and cardiac orifices of the stomach, when these parts suffer from organic lesions. In proportion as the inflammation assumes the chronic form it becomes more profound, and the mucous membrane regains its natural aspect, whilst the subjacent tissues, especially the cellular, becomes indurated and hypertro- phied. Samuel Cooper was wrong in asserting, that when the mucous membrane is the seat of stricture, its color is Avhiter than natural: for the contrary is often the case, especially during the earlier stages of the disease. In my opinion, sufficient attention has not been paid to the morbid alterations in the tissues subjacent to the urethral mucous membrane. On this subject I beg the reader's indulgence, for its investigation may lead to important modifica- tions in the preventive treatment of strictures. The hypertrophy of the subjacent tissues is a fact well established, but it is produced in various ways: sometimes, it would seem that a deposit of plastic lymph had taken place in all the tissues of the part; whilst, in other cases, these parts seem to be thickened only. These are the strictures to which the term fibrous has been applied. Cru- veilhier believed that they are all of this nature. On this point the reader may consult the Annales de Chirurgie, t. iv. p. 129. STRICTURE. 103 However this may be, there is a projection into the canal as well as externally; by pressing the urethra a decided induration may be felt. This variety of stricture is ordinarily of considerable length, and is most commonly found at the spongy portion of the urethra. To this category belongs the case reported by M. Lalle- mand, in Avhich he speaks of a stricture of considerable extent, produced by the lesion of the walls of the urethra, and even of the tissues of the corpus cavernosum. After the death of the patient, on exposing the canal longitudinally, the indurated tissues pre- sented the aspect of a gun barrel split in its longest direction. A cartilaginous hardness has been spoken of in these cases. Some- times the length of these strictures is not considerable; they then form a band which surrounds the urethra, protruding both within and Avithout the canal. There are good grounds for believing that this kind of stricture is frequently the result of an abuse of cauter- ization. Nodosities form in the substance of the cavernous bodies, and diminish the calibre of the urethral canal, though the latter may not be directly affected; sometimes they do not in the least en- croach upon the urethra, but project externally.* Instead of becoming dilated and thickened, the cells of the sub- mucous tissues may contract and even become effaced. We then have, necessarily, a diminution of the calibre of the canal, and the formation of a contracted circular stricture as if caused by a liga- ture ; this is the variety to which, in my opinion, the term stric- ture pttrophy should be applied. It is met with most frequently at the bend of the urethra. It should be borne in mind, that inflam- mation, after having invaded the tissues, does not always leave them in the same condition ; not unfrequently these tissues seem to enjoy a new vigor and activity; but the contrary may happen, and hence the atrophy, and the development of that form of stricture to which Ave have referred. It is not, besides, the only instance in pathology where opposite effects are due to the same cause. We must likeAvise take into consideration the effect of the ab- scesses in the sub-mucous tissues which occur, either during or after a severe attack of blennorrhagia. Since my connection with the Hupital du Midi, I have found these very common in young girls. Noav Avhen these abscesses heal, a bridle. or depres- sion remains. Ulcerations of the urethra which were once regarded as the sole cause of strictures, have since been denied a place in their etiology. But modern researches have shown that they are only less frequent than Avas formerly supposed, their existence having been clearly established. M. de Selles observes in the Thesis already quoted, that Dupuytren during his lectures, exhibited several examples of urethral ulcerations. Some of these were superficial, others deep seated, and appeared as if cut out with a punch. They were * Roche, Sanson and Lenoir, Nouv. elem. de Path. Medico-Chirurgicale, 4th ed. torn. iv. p. 596. 104 VIDAL ON VENEREAL DISEASES. generally confined to a single point of the canal, in some instances, however, they occupied its Avhole circumference. Around and beneath these ulcerations, the mucous membrane was engorged and thickened. These characters Avere particularly noticed in the cases mentioned in a note Avhich I have received from my freind Dr. Goyraud, of Aix. It is obvious that the cicatrization of these ulcers must diminish the natural calibre of the canal, and the bridles formed resemble the cicatrices of burns. To this category belongs the stricture produced by cauterization either Avith caustics in a solid or diluted state. # Vegetations, which by the ancients were called carnosities, are by no means so common as they supposed, a fact first established by the investigations of Brunner and Mery, and aftenvards by those of Benevoli, Marini, Garengeot, Morgagni, Lafaye, Desault, and the more careful observations of modern surgeons. But Gir- tanner was Avrong in asserting that these carnosities have but an imaginary existence, for they were observed by Morgagni, Hunter, Ch. Bell, Dupuytren, and Baillie. I myself have met with them, and M. Mercier has reported a remarkable case. I have twice seen them on the cadaver; they are generally seated near the fossa navicularis. Wigelin and Lobstein have observed them behind the verumontanum. These, in my opinion, were cases of hypertrophy of the prostate or tumors of this gland. On this sub- ject Soemmering remarks : " The carnosities Avhich I have observed in the lacunae were of a violet color, hard, of the size and form of a lentil; they adhered by a kind of pedicle to the urethral mucous membrane; it is an easy matter to ligate or excise them Avhen they are not of too large size."* It is evident that Soemmering here refers to vegetations in the vicinity of the meatus. " But," he adds, " since these vegetations have been found to exist at both extremities of the urethra, why may they not occur at its middle portion?" He, however, never met with an instance of the kind: though the testimony of John Hunter, Benjamin Bell, Andre, and especially of Baillie, is sufficient to establish the fact of their ex- istence. More recently, together with M. Mercier, I have seen small vegetations along the whole course of the male urethra. I have also met with an instance where the urethra was rough throughout; it was that of a prostitute, who was under my care at the Hopiial du Midi. These vegetations were of a Avhitish color, soft, and bled from the most trifling cause. With the aid of a catheter,, and a finger introduced into the vagina, I detected their existence throughout the urethra. This girl was of a decidedly lymphatic temperament, and had no other symptoms of syphilitic disease; these vegetations were reproduced with a wonderful facility. Those situated most externally, I attacked with narroAV-bladed scissors; the others were cauterized with the nitrate of silver, Avhich was introduced to a great depth. Van Swieten refers in his Com- mentariesf to vegetations developed at the orifice of the urethra; * Traite des maladies de la vessie et de Vuretre. Translated by M Hollard rj 1 fi7 t Vol. v,, p. 453. ' V' STRICTURE. 105 these are not uncommon. It would appear that cancerous vegeta- tions may exist in the urethra. M. Lallemand has reported an example. But such an occurrence is exceedingly rare in the fe- male, especially as a primary accident. Cancer of the uterus may extend so as to invade the vagina and even the urinary appa- ratus. Nature.—The remarks which we have made upon the causes and pathological anatomy of stricture render any extensive observations upon their nature unnecessary. Thus, in the etiology, particular notice was given to wounds and inflammations. Both of these causes frequently lead to the same final result, viz. the fibrous condition of the parts. Thus, the cicatrix of a wound, and the condensation of the sub-mucous tissue arising from a protracted urethritis, produce the same anatomical changes, the fibrous or true stricture. As already stated, the inflammatory stricture is but the commencement of the fibrous, and it may also exist as a compli- cation of the latter variety. Is there a spasmodic stricture ? There is nothing in the struc- ture of the urethra, abounding as it does in erectile tissue, and surrounded as it is by muscular fibres, to forbid such an existence. Wilson's muscle alone may produce a constriction of the com- mencement of the membranous portion of the urethra. Spas- modic stricture, however, rarely exists alone, it is generally but a complication. In some cases, stricture would appear to be, at the same time, spasmodic, inflammatory, and organic. Suppose, for example, a chronic condensation at some point of the walls of the urethra, at which its natural calibre is diminished; yet, the blad- der retaining its contractile power, the urine is freely evacuated. Noav, let the subject of this stricture indulge in excesses, either at the table or venery, the obstacle to the passage of urine is soon increased; its strain, which before was scarcely distorted, is now arrested; but a bath, and the abstraction of blood, suffices to re- lieve the patient. It is evident, that the difficulty in this case arises from inflammatory congestion, and not from any permanent alteration in structure. The same patient is greatly excited by some accident; he has retention of urine at once; but it soon disappears, after some trifling remedy, or after his mind is restored to its accustomed tranquillity. We find, therefore, in the same subject, three kinds of stricture; at least, such is the case with those Avho admit this number, but it is obvious that but two of these are permanent, the spasmodic being but a complication of the other varieties. For the anatomical grounds on Avhich this opinion is based, the reader may consult the well-Avritten article of M. Gosselin, in the Archives de Medecine et Annales de la Chir- urgie. [The muscularity of the urethra, a doctrine advocated by John Hunter, Sir Everard Home, Bauer, Wilson, Howship and Samuel Cooper, is, at length, positively established by the more modern researches of Messrs. Quekett and Hancock, of London,* and Kol- * Op. cit 106 VIDAL ON VENEREAL DISEASES. liker, of Wiirtzburgh* But, it is to Air. Hancock that we are especially indebted for pointing out the practical bearings of the results of these investigations. It is now clearly demonstrated, that, as the urethra is muscular throughout its Avhole extent, spas- modic contractions may occur, independently, in any part of the canal, as Avell Avithin an inch of the orifice of the urethra as at its membranous portion. Indeed, it was a case of the former, Mr. H. observes, that first led him to examine the minute structure of the parts microscopically. We cannot too strongly recommend the work of the latter gentleman, to those desirous of becoming acquainted with the true pathology of strictures.—G. C. B.] Symptoms.—The stream of urine is diminished in size, length, and force; its course is altered, particularly in cases of lateral stricture; its form is flattened like the blade of a penknife, or spiral and twisted like a gimlet, frequently it^ is bifurcated, or forked, to use the language of Ambrose Pare ;f in some cases, one of these forked streams projects beyond the rest, which fall upon the patient's feet, or are scattered in all directions ; in these cases, it appears as if they issued from four or five small orifices in the glans, which seem as if perforated like the spout of a water-pot. Generally, in the normal state, the jet gradually diminishes in proportion as the bladder becomes emptied, and the curve which it describes is effaced, but in the case of stricture, this curve is, as it were, broken, and the stream is suddenly arrested. The blad- der is not completely evacuated; the desire to urinate is soon again urgent and irresistible ; however, a long time is required to empty even a portion of the contents of the bladder. It may be stated, that the patient urinates longer and more frequently than natural, and yet the bladder is never empty. A certain quantity remains behind the stricture, which oozes in drops immediately after the patient has finished, as he supposes, the act. Mental emotions, and changes of temperature, modify the extent of the resistance opposed to the passage of the urine. The retention of the urine in the bladder leads to an alteration in its composition. It becomes more ammoniacal, less aqueous; turbid, and sometimes a grayish deposit takes place ; it may be mixed with blood, pus, semen, and a glairy tenacious mucus, which, according to Sir Everard Home, indicates a lesion of the prostate gland. The emission of semen is obstructed, as well as of the urine. The slightest stricture interferes with its discharge, and it escapes after the erection has subsided. Sometimes the semen, instead of reach- ing the glans, takes a retrograde course towards the bladder. In- stead of a retention, we may have an incontinence of semen. Nocturnal pollutions are common in patients affected with stric- tures. The semen escapes, also, during a semi-erection, or during the act of defecation, without the consciousness of the patient; but sometimes he experiences severe pain after an emission, as if a needle were thrust into the perineum. This occurs particularly * MiJcroshopische Anatomie, 2> some cases, employs the gum catheter, which he allows to remain day and night. This induces suppuration in the urethra, after which a large-sized instrument may be introduced. The wax bougie is liable to bend upon itself, as represented in Fig. 1st. Fig. 2d, Porte Empreinte, an ex- ploring instrument. Figs. 3 and 4, coni- cal and fusiform bougies.—G. C. B.] I have already stated, that an instanta- neous dilatation has been highly extolled, and it is proposed to banish the practice of permitting sounds or bougies to remain in the canal* MM. Civiale, Leroy, A. Pasquier, approve of this method, with- out, however, excluding others. For example, M. Civiale permits the bougie to remain from two to three minutes to half an hour; whilst M. Pasquier never allows it to remain more than five minutes. It is evident, that certain strictures may be re- moved by the employment of a certain number of bougies, gradually increasing in size, which are introduced and withdrawn one after another, or which may be permitted to remain for five or six minutes; but, in my opinion, certain fibrous stric- tures can never be cured in this manner, believing, as I do, that the dilating agent must be alloAved to remain for a longer period in the u«thra. [Mr. Thomas Wakeley, of the Eoyal Free Hospi- tal, and Mr. Bernard Holt, of the Westminster Hospital, London, within the last three years, have published numerous cases in the London Lancet, illustrating the efficacy of certain instruments in the treatment of stricture, which they have devised and employed, and the object of which, like the method of M. Benique, is, in the language of Hun- ter, to act "like a wedge upon inanimate matter." Indeed, more than thirty years ago, Mr. Guthrie had a dilating instrument made by Mr. Weiss, for this purpose. At first, this consisted of three blades, which were gradually separated by the action of a screw which turned in the handle, but the same mechanism was afterwards applied to a two-bladed instrument. (Guthrie on Urinary Organs, Am. Ed. 1845, p. 76.) At page 77, he observes: "I thought I had now obtained an instrument which * Vide the last article of M. Benique. 112 VIDAL ON VENEREAL DISEASES. could not fail of fulfilling all my expectations, and was only disap- pointed by finding that it did too'muc h. The opportunity of dilating Avas in general too tempting to be resisted, and the consequence Avas, that it produced irritation in so many cases, that I was forced to give it up, having also fully satisfied myself that dilatation, to whatever extent it might be carried, could not cure the worst kinds of stricture." After noticing the dilating instrument of Air. Arnott, consisting of softer materials, and which is dilated by means of air or water, he adds, p. 78: " I do not noAV use instruments of this kind, either from their often failing, or being so troublesome, whilst they place the surgeon too much in the hands of the instru- ment maker, unless he has time and ingenuity to make them him- self, and they are after all unequal to effect a cure in the more ag- gravated cases of disease." At page 96, Mr. G. states that he gives the preference to a pliable hollow gum elastic bougie, of a medium size, perfectly smooth, and tolerably round at the point, so as to give as little uneasiness as possible. The method of M. Benique, to which our author has referred, is regarded by Messrs. Eicord and Acton as "pretty," but they observe that the idea emanated rather " from a mathematician than a practical man." (Acton, op. cit. p. 99.) However true the latter observation may be, as applied to M. Benique, this method has recently been most highly lauded by one of our own countrymen, who is both a mathematician and a practical man. We refer to the very able paper of Prof. Eve, to which Ave have already alluded.* This paper concludes with the following propositions: 1. " That while dilatation is the proper treatment for stricture of the urethra, this has hitherto failed to effect a cure, because in the ordinary mode of applying it, the seat of the disease has not been specially acted upon by the dilating instrument. 2. "To cure stricture, the orifice of the urethra must be so en- larged that the canal beyond ft may be dilated to its original size, which we ought to recollect is about twice that of the opening lead- ing to it. Instead, therefore, of being satisfied Avith introducing bougies of two lines in diameter through a restricted portion, they should measure four to five lines in thickness. 3. " There is no necessity to confine a patient to bed in treating stricture; once an instrument has been introduced, it has done all it can to expand the passage and should be Avithdrawn, that others larger in size may be immediately substituted. While this process ought to be cautiously and very gradually conducted; still the more rapidly and freely it can be applied, provided no pain is excited, the sooner the disease will be removed. 4. "By this method strictures maybe permanently cured in a few days, without suffering, inconvenience or exposure, to serious conse- quences ." The box of M. Benique consists of thirty-six pewter bougies, in diameter from one and one-third to five lines, cylindrical,of the or- dinary curve, and flexible. From two or three to seven or eight * On Treatment of Stricture of the Urethra by rapid and free Dilatation, <&c, die. STRICTURE. H3 may be introduced at each sitting, which if no irritation be devel- oped, may be daily repeated. If necessary to pass the large size, the orifice of the urethra may be enlarged with the knife. The trials yet made with these instruments, are not sufficiently numerous, we fear, to justify the unqualified praise of Prof. Eve. He has been able to furnish but two cases from his own experi- ence, Avhich he is compelled to admit are defective, especially in regard to time, and in one of these, certainly a desperate one, dila- tation Avas successful, only after the employment of the knife. Even after the external incision in the case, nineteen days were re- quired to pass a bougie measuring one-fourth of an inch in diameter. Prof. E. remarks, that when this patient returned home, so scep- tical Avere his friends as to the relief he had experienced, that they required ocular demonstration, " whereupon he, in true Western hyperbolical language, offered to aid any water-wheel deficient in power, if they Avould only let him mount a fence!" Perhaps subsequent experiments, on a more extended scale, may prove that these instruments, as well as those recommended by Messrs. Wakeley and Holt, like the contrivances of Mr. Guthrie, are capable of " doing too much." Mr. Wakeley's expe- rience, thus far, however, has been highly encouraging. In the dilatation of the female urethra, the vulcanized India-rubber appara tus of M*. E. E. Hodges, may be used, for a description of Avhich, together with those of Messrs. Wakeley and Holt, we Avould refer the reader to the excellent work of Mr. Fergusson on Practical Surgery (Am. Ed.), where may also be found some judicious ob- servations upon the methods of treatment to which we have here alluded.—G. C. B.] Cauterization.—Surgeons of the XVth, XVIth, and XVIIth cen- turies, among whom may be named A. Feri, A. Pare, Loyseau, and F. de Hilden, resorted to cauterization to remove urethral obstructions, which they supposed to be caused by vegetations, fungous growths, and carnosities within the canal. Hunter was the next whose name stands conspicuous in connection with this mode of treatment. In 1822, Ducamp (Traite des retentions d'urine) stamped upon it a character of certainty that caused it to take pre- cedence over all other methods in the treatment of stricture. There are tAVo kinds of cauterization, the lateral, and the direct or antero- posterior. Lateral Cauterization.—'This may be done with the porte-caustique of Ducamp, or of M. Lallemand. The modification of the latter instrument, however, as made by M. Segalas, by which the ad- vantages of Ducamp's and that of M. Lallemand are combined, is preferable to either. Antero-posterior Cauterization.—For this purpose, Ambrose Pare' employed coated bougies; Hunter, a porte-caustique stylet, which was introduced through a canula; Everard Home, an armed bougie. M. Leroy d'Etiolles has brought the instrument of Hunter to perfection. It now consists of a gum-elastic tube, Avith a fixed curve, at the extremities of Avhich are two ferrules, the external of silver, the vesical of platina. An obturator closes the orifice of 8 114 VIDAL ON VENEREAL DISEASES. the tube, while it is passed towards the seat of stricture. As soon as this is felt the obturator is AvithdraAvn, and a rod substituted, of which the vesical end is charged Avith caustic, the latter, nitrate of silver, being contained in a platina cup. Instead of the nitrate of silver, Ave may use the Vienna paste. The urethra should be cleansed of all mucosities before the caustic is applied. One Avord in reference to the comparative advantages of dilata- tion and cauterization. The advantages and inconveniences of both have been mutually exaggerated by their respective advocates. Thus, it has been urged, that by dilating a stricture we do not destroy it, on which account it is of course liable to return. Cau- terization, carried to a certain point, does, indeed, effect its destruc- tion ; but it cannot insure us against a relapse, and, in the opinion of some surgeons, this will assume a graver form, an inodular cicatrix is in fact produced, endowed with considerable retractile power, which property may aggravate the condition of the patient. The application of caustic requires extreme accuracy in the diag- nosis of stricture, both as to number, seat, extent, direction, &c. Noav this is impossible in practice, therefore Avifh caustic we must always operate in the dark, as is the case in the operations of incision and scarification, to which we shall soon refer. The caustic or point of the cutting instrument may be thrust into sound parts, by which, instead of benefiting we injure th% patient. M. Lallemand and his disciples rely exclusively upon cauterization, rejecting dilatation altogether, a course which, in my opinion, is attended with serious objections. The question is different if by cauterization, it is proposed merely to modify the vital action of the parts. The slightest contact is then sufficient, and of course, this superficial cauterization must be free from the risk of that which is more profound, as must be frequently practised by M. Lallemand and his folloAvers. There are cases, on the other hand, when the smallest sized bougie cannot be passed, though the patient may, after desperate efforts, succeed in voiding his urine. Again, there are case where neither a bougie nor the urine can pass, then direct, or the antero-posterior cauteri- zation may be followed, with the happiest results; for this purpose the instrument of M. Leroy is admirably adapted. [Prof. Gross notices an objection to the instrument of M. Lalle- mand, which is certainly of a serious character. He states that from the manner in which the cup is joined to the rod, it is liable to be broken; and he refers to the instance of a physician in Buffalo, who was in the habit of cauterizing himself Avith this instrument, and in which this accident proved fatal. (Treatise, p. 642.) To obviate this risk, Prof. G. now employs the instrument represented in Fig. 5; which he says is all that can be desired. It Fig. 5. r STRICTURE. 115 resembles a common silver catheter, straight or curved, according to the situation of the stricture. At its vesical extremity is an eyelet three-quarters of an inch in length and two lines in width, corresponding with the cup containing caustic, which is attached to a rod. The cup is partially' filled with tallow, soap, or extract of hyosciamus, and this is sprinkled with a thin layer of. the pow- dered salt, a much better plan, he asserts, than that of melting the caustic over a lamp. " To this method and this instrument," he observes, "am I in- debted for two of the most perfect cures I ever effected. I should not be surprised if cauterization should again become a favorite mode of treatment." For a favorable notice of this method the reader may consult the Practical Observations on Strictures, &c, by Mr. Eobert Wade, (Lon- don, 1853, pp. 79,181.) See, also, the Treatise of Prof. Gross.—G. C. B.] Incision.—Resection.—A variety of sheath-bladed instruments have been recommended by MM. Eicord, Guillon, Leroy, Amus- sat, Stafford, and others, for the internal division of strictures, but this method of treatment is liable to the same objections as that by cauterization. It must, however, be admitted, that in cases of valvular growths near the meatus, and in the prostatic portion of the urethra, it may be advantageously employed. Should com- plete' retention of urine occur we must then resort to the button- hole incision, (boutonniere), or puncture of the bladder. [Sir Benjamin Brodie has given the particulars of a very bad case, (op. cit. p. 41,) in which he resorted to a modification of Mr, Stafford's operation. In this case, a plaster bougie having been passed down to the seat of the obstruction, an opening was made in the perineum. The bougie was then Avith drawn and an instru- ment introduced in its place, which consisted of a straight silver tube, closed at its extremity, except a narroAV slit, through which a small lancet could be made to project by pressing on a stilet which projected from the handle of the instrument. " The round extremities of the instrument being pressed against the anterior part of the stricture, the lancet was protruded and the stricture divided." The advantages of this proceeding, he adds, consists in the fact that the free opening in the perineum prevents all danger from infiltration of urine; and the application of the finger to the posterior surface of the stricture serves as a guide for the lancet, by Avhich Ave can make an exact division of the stricture. Mr. G-uthrie, referring to Mr. Stafford's instrument, (op. cit. p. 92,) says, " it must ahvays be a two-edged tool, capable of doing much good and much mischief." We have often seen M. Civiale perform the internal division of stricture with the happiest effects, and if proper care be taken we are satisfied this operation will not often be pro- ductive of ill consequences.—G. C. B.] Button-hole Incision (Boutonniere).—A staff or catheter having been passed as far as the seat of stricture, is held by an assistant. The surgeon makes an incision along the raphe, and. seeks for the membranous portion of the urethra; by freely incising its inferior wall, he reaches the staff which the assistant withdraws a little. 116 VIDAL ON VENEREAL DISEASES. Figs. 7, Whilst searching for the continuation of the canal he directs the patient to urinate. A grooved staff or stilet is then introduced into the urethra, which serves as a guide in prolonging the incis- ion beyond the seat of stricture. A catheter is then introduced, which is allowed to remain, and the edges of the wound are brought to-. gether. [Mr. Fergusson says that he has been much pleased with the instru- ment represented in Fig. 6, in treat- ing slight strictures within an inch or two of the glans, or even deeper than an ordinary bistoury can reach. Figs. 7 and 8 is an ingenious instru- ment, manufactured by Tiemann, com- bining blades both for the lateral and antero-posterior incisions. Fig. 7 represent for lateral incision, Fig. 8 for antero-posterior.—G. C. B.] In my opinion, this operation is not justly appreciated. Its difficulties and dangers have been exaggerated, and I believe that it Avill become more general in proportion as surgeons be- come better acquainted with the anatomy of the parts, for then, if the staff fail to reach the point at which we propose to operate, we shall know where to find it. In such a case a knowledge of anatomy is our best guide. The stricture, in these cases, is almost always seated at the commencement of the membranous portion, and this is the point where the opening should be made; now, it is not very difficult to find the bulb of the urethra, nor to folloAV the course of the raphe, as in the incision for lithotomy. Guided by anatomy alone, the surgeon cuts down upon an artery,—Avhy should he not, in the same manner, cut for the membranous portion of the urethra, the position of which is far less liable to change than that of an artery ? If the mor-, bid alterations of the part have produced such a change it is an advantage to the operator, for this alteration is a dilatation, which renders this part of the canal more easy to be found and opened. There can be no comparison between the dangers of this operation and that of forced catheterism, or puncture of the bladder. It is limited to the perineum, remote from the deeper fascia, and consequently from the peritoneum. Strictly speaking, it does not affect the pelvic cavity, but only its walls. This operation places the male urethra in a condition similar to that of the female: the catheter has but a short distance to pass to reach the bladder, and if the prostate gland be STRICTURE. 117 not affected, this is readily accomplished. A staff, sound, or bougie, may also be passed through the stricture from behind forwards, to meet another introduced at the meatus. In the majority of cases, these instruments may be brought into contact, and may afford as valuable information as to the extent and the thickness of the stricture, as well as of other matters required to guide us in our treatment. [In 1849, Mr. Syme of Edinburgh, published a work on stric- tures of the urethra, &c, in which he attempts to prove (p. 58) that: 1st. " The division of a stricture by external incision, is suffi- cient for the complete remedy of the disease, in its most inveterate and obstinate form. 2d. " That, in cases of less obstinacy, but still requiring the frequent use of bougies, division is preferable to dilatation, as affording relief more speedily, permanently, and safely." Mr. Syme claims as the peculiarity of his operation, that instead of simply passing a staff, sound, or catheter down to the seat of stricture, a grooved staff is passed through the stricture before the incision is attempted, there being, in his opinion, no such thing as an impermeable stricture (p. 57). Of course, where this can be done, the operation must be greatly facilitated and rendered more free from danger. Thus performed, he states, it is "completely effectual." From the cases reported in the volume to which Ave have referred (p. 13), it would appear that Mr. Syme performed his fipet operation about the year 1838. Since that period, Ave believe that he has operated in upwards of sixty cases without a fatal result. He asserts that, if " correctly performed," the opera- tion is perfectly safe. Now, fatal cases have occurred to Messrs. Bransby Cooper, Cock, Gay, Coulson, Mackenzie, and Fergusson. These deaths occurred from phlebitis, hemorrhage, urinary infiltra- tion, &c, &c. In other instances, patients have had a very narrow escape. Noav, Ave think that few will be disposed to attribute the fatal results which occurred in the practice of the above-named surgeons to their inability to perform the operation " correctly." There can be no question, that even in the most skilful hands, it is not devoid of danger. The suffering, which the patients have long endured, on whom this operation is performed as a dernier resort, doubtless increases its hazards. If surgeons would resort to it at an earlier period of the disease, instead of aggravating the condition of the patient, by fruitless efforts at dilatation, Avhere dilatation is impossible, Ave believe that the operation would pre- vent much distress, and, in many cases, prepare the patient for a radical cure by the ATery means Avhich were before ineffectual. Mr. Fergusson recommends that it should not be practised indis- criminately ; and as he speaks impartially, and from experience, Ave cordially commend the remarks on this subject in the last edi- tion of his Practical Surgery, to those who propose to perform the operation. Professor Mussey informs us that, in a case in Avhich he not long since resorted to it, he was much pleased with the results. 118 VIDAL ON VENEREAL DISEASES. In the text, our author has spoken of the simplicity and safety of the old operation—the button-hole incision, in cases of imper- meable stricture. Mr. Fergusson states, in his Practical Surgery, that he has had two fatal cases in his oavu practice from this pro- ceeding, and Sir Benjamin Brodie (On Urinary Organs, 2d Am. ed., p. 40), alluding to an operation performed by himself, which consisted in laying open the Avhole of the contracted portion of the urethra, speaks of the difficulties connected with these operations; and the testimony of Professor Gross, who performed it some thir- teen years ago (op. cit), is to the same effect. The operation to which Ave now refer for impermeable stricture, and which has been performed and recommended by Collot, Petit, Wiseman, Bertrandi, Arnott, Shaw, Desault, Hunter, Cooper, and others, seems to have been almost universally mistaken for that claimed by Professor Syme, the peculiarity of which, as already stated, consists in cut- ting down upon a small grooved staff passed through the stricture. For a more complete account of the present state of the question, see Eeport of the proceedings of the Eoyal Medical and Chirurgi- cal Society, April, 1853, in the American Journal of the Medical Sciences, July, 1853, p. 226. M. Eicord, in noticing Mr. Syme's operation (Notes to Hunter, 2d ed., p. 259), merely states, that the cases reported would seem encouraging, but M. Civiale, as we were personally assured by him, never resorts to it; the old operation, hoAvever, he informed us, he frequently performs. The Irish sur- geons are decidedly opposed to it. During our recent visit to Dublin, Mr. Porter, the president of the College of Surgeons, de- clared to us, that he would venture to assert that it never had been performed in that city, and that it never Avould be !—G. C. B. [Urinary Abscesses.—Infiltration of Urine.—Under the head of blennorrhagia our author briefly referred to peri-urethral abscesses, which form during the existence of that disease. Among the con- sequences of stricture, we have likewise to note the development of abscesses, produced by the constant distention and irritation of the parts behind the seat of obstruction. In obstinate cases the continual straining of the patient is very likely to terminate in this manner. Ulceration may likewise ensue, and the urine be gradu- ally infiltrated into the adjacent loose cellular tissue. It forces its way slowly in some instances, in consequence of the adhesive inflammation which its presence excites; in other cases, from a rupture of the urethra, a sudden and extensive infiltration may take place, which shall result in the sloughing of portions of the urethra, or the entire canal, together with the glans penis and scrotum. The peculiar arrangement of the perineal fasciae, causes the direction of the effused urine to vary according to its seat. Fig. 9 shoAVS the tumefaction of the scrotum and perineum from infiltration of urine. If it occur in the membranous portion it passes under the sheath of the levator ani, laying bare the rectum; if at-the bulbous portion, it encroaches upon the deep-seated fascia of the perineum, and is arrested in its course opposite the anus, from Avhich point it may extend so as to involve the circumference of the penis, the scrotum escaping entirely, (Malgaigne.) It may URETHRORRnAGIA 119 also reach towards the groin and abdomen, infiltrating the cellular texture of all the coverings of these parts. Mr. Shaw, in his Notes to the Avork of Sir Charles Bell, on Diseases of the Urethra, (3d Lond. ed., p. 244,) has related an extraordinary example of the extent of the infiltration and suppuration which sometimes occurs. In this case there was sloughing not only of the coverings of the penis and scrotum, but of the loins and abdomen, as far as the um- bilicus, and in a doAvnward direction as far as the knee, and yet this patient finally recovered! At page 267, Sir Charles Bell has reported a case which proved fatal from delay; the swelling was on the left side of the pubes, and was mistaken for a hernia. When the urine is effused into the corpus spongiosum, and limited to this body, the penis may assume a semi-erect appearance, as in the case described by Mr. Earle, in the Lond. Med. Gazette, vol. ix. p. 736. In the same journal, p. 213, he relates a case where the ure- thra gave way about an inch from the external orifice; the under surface became enormously SAVollen, and a pouch or kind of second bladder was formed, which it was necessary to empty whenever the bladder Avas evacuated. It will be seen in Fig. 10, (from Sir Charles Bell,) that notAvithstanding the numerous external fistulous openings, there is but one communicating directly with the urethra. Treatment.—When no communication exists between the abscess and the urethra it must be opened in the same manner as Avhen seated near the rectum. If confined behind the deep-seated fascia the only indication of its existence may be a slight degree of ful- ness and deep-seated hardness in the perineum. The matter having been reached by the point of the bistoury, the opening may be enlarged by directing the instrument downwards and outwards, as in the operation for lithotomy. In many of these cases no time is to be lost; a free exit must be given to the matter or the most serious consequences may folloAV. The fistulous openings result- ing from these abscesses, of course, can be cured only after the stricture has been removed. When extensive sloughing of the parts covering the urethra has taken place, and the granulating process is insufficient for their reparation, recourse must be had to plastic surgery, on which subject the works of Mr. Earle, Sir Astley Cooper, Delpech, Dieffenbach, and Messrs. Eicord and Jobert may be consulted. The latter surgeon in particular has devoted especial attention to these operations, and in his splendid volume on Plastic Surgery the practitioner may find every desirable information.— G. C. B.] URETHRORRHAGIA Symptoms.—Nothing is more common than the discharge of a small quantity of blood by the urethra. It is not, strictly speak- ing, an accident, but only a symptom, Avhich I have noticed under the head of urethritis. Sometimes, however, it happens that the quantity discharged is sufficient to constitute a true accident, a hemorrhage. Thus Ave occasionally find that the blood Aoavs in a full stream, unmixed with urine or with a muco-purulent matter, 120 VIDAL ON VENEREAL DISEASES. and without any effort to urinate on the part of the patient. This hemorrhage may last for an hour, and weaken the patient to a surprising extent. Generally the discharge is not so abundant, and it is rare that a glass of blood is lost. In every instance the patient experiences relief, or a temporary improvement after this discharge. Severe cases occur in paroxysms, Avhich are sometimes excited by a walk, by imprudence, and occasionally occur Avithout any evident cause, even while the patient remains in the horizontal position and is submitting to anti-hemorrhagic treatment. If the hemorrhage be considerable, and often repeated, the relief of which I have spoken, is followed by syncopes and a prostration of strength which scarcely permits the patient to raise his eyelid. Causes.—Attempts have been made to establish the etiology of urethrorrhagia. Among the causes assigned are severe inflamma- tion, wounds, rupture of certain vessels, a hemorrhagic diathesis, and finally, a change in the mode of action of the cause which ordinarily gives rise to blennorrhagia. I believe that the etiology of this affection may be regarded under all these aspects, and we should not be exclusive in our views.. Thus it is evident, that in very severe cases of blennorrhagia, with the muco-purulent matter, mingled or separate, some drops of blood may be discharged which have oozed from the inflamed surfaces. There is a manifest solu- tion of continuity in the vessels in cases of rupture of the cord by a blow of the fist, by coitus or masturbation, which certain indi- viduals practice during a blennorrhagia even when most severe, either to gratify their passions or to cure the disease. In these cases the hemorrhage may be very abundant; it is of a bright red color and jets like arterial blood. These are the instances in which the discharge is followed by so much relief; it also hastens the sub- sidence of the inflammatory symptoms; but it is the harbinger of troublesome days to the patient, for at the point where the urethra was ruptured, an inodular stricture, the Avorst of all strictures, may after awhile be formed. I am not aware that an urethrorrhagia, the result of an hemorrhagic diathesis, has been really observed, but such a case is not impossible. An instance of which has come under my own notice, and of which M. de Castelneau has pubhshed the details in the Annales de la syphilis et des maladies de la peau, would seem to belong to this category; but the patient had suffered only from some trifling attacks of nasal hemorrhage, and there was nothing either in the antecedents or in what followed, to prove the existence of this diathesis. In this case the hemorrhage occurred in paroxysms, Avhich sometimes lasted for an hour. After each attack the patient was so debilitated that he could not raise his arm. This example of an urethrorrhagia so grave in character, I believe to be unique. There was this remarkable fact in connec- tion with it, that during its continuance, as Avell as the intervals between these attacks, the muco-purulent discharge was suppressed, and it did not return until the urethrorrhagia was completely cured. It was for this reason that M. de Castelneau conceived the idea of a change in the modus operandi of the cause; as it sometimes pro- duced a blennorrhagia, sometimes urethrorrhagia. This hypothesis, URETHRORRHAGIA. 121 which has been ably sustained by M. de Castelneau, is, however, after all but an hypothesis. Diagnosis.—Hemorrhage from the urethra may be easily distin- guished from that of the bladder. In the first case, the blood is not mixed with urine, and flows spontaneously; in the other, it is at the moment of, or immediately after micturition that it appears, and is always more or less mingled with urine. Very often, when a blennorrhagia is severe and deep seated, involving the neck of the bladder, with the last drops of urine may be noticed a clot of blood. In these cases the patient experiences severe pain when the stream of urine is voided, and vesical tenesmus. Sometimes the blood comes both from the urethra and the bladder; we see, indeed, as has been already mentioned, patients discharging blood mingled with muco-purulent matter, in the intervals of micturition, as well as during the act. Prognosis.—Urethrorrhagia is not serious in itself, but it gener- ally indicates the existence of an intense urethritis, and may give rise to unpleasant consequences, especially if there be a rupture at any point in the urethra. [Mr. South states, in his edition of Chelius (vol. i. p. 178, Am. ed.), that he once saAV an instance of enormous extravasation of blood, from the rupture of some vessel in the penis during the act of coition; the penis and perineum were greatly distended, there was a severe pain in voiding urine, the evacuation of which required the use of the catheter. In the course of two or three days extravasation of urine ensued, and the bladder was punctured through the rectum. Sloughing in the perineum and groins oc- curred, and the patient had a very tedious recovery.—G. C. B.] Life is not compromised by the loss of blood alone, and, in the most severe cases, the treatment consists simply in repose, and a milk whey diet, which suffices to arrest the hemorrhage. In the case already mentioned, after the hemorrhage had- ceased, the ap- petite was keen, and the patient soon begged to be discharged from the hospital. Treatment.—This should be based on the cause of the hem- orrhage, and the quantity of blood lost. Generally, repose, diet, slightly acidulated or demulcent drinks, are sufficient to arrest the discharge, when it arises from excessive inflammation or a rup- ture of the urethra. If the patient be young, plethoric, and the urethritis subacute, to repose I add blood-letting, or what is better, the application of fifteen or tAventy leeches to the perineum. Some practitioners, with Hunter, have employed copaiba. I have no faith in its efficacy, and am of the opinion that, in certain cases, this medicine might produce an injurious effect, by irritating the neck of the bladder, and thus, to the hemorrhage from the urethra, add a bloody discharge from the bladder, which is an unfortunate complication. When the quantity of blood lost threatens the life of the patient, the remedies to be first employed, are refrigerants along the urethra, the scrotum, and the perineum. Sometimes alone they do not suffice to arrest the discharge; in such a case, Benjamin 122 VIDAL ON VENEREAL DISEASES. Bell recommends compression of the urethra: it may be made from Avithout inwards, or vice versa, or in both directions at the same time. We may, indeed, by seizing the antiscrotal portion of the urethra between tAvo fingers, employ compression sufficiently long to arrest the hemorrhage, or with a truss we may compress the urethra in the perineum. The compression in front of. the scrotum may be effected by the application of little bands sur- rounding and compressing the whole penis. Should this be judged insufficient, we may resort to the use of bougies, or sounds which are to be introduced into the urethra; if of large size, they may of themselves arrest the hemorrhage. If in spite of these means it continues, we join to the excentric, concentric compress- ion ; we apply narrow bands circularly around the penis, or the perineal truss, according to the depth from which the blood pro- ceeds. But, I must declare, that I have never had occasion to resort to these mechanical means. I repeat, therefore, that in the great majority of cases, repose and soothing applications are still the best and the most speedily effectual means. Further, in mak- ing the two kinds of compression mentioned, we may often obtain a contrary effect to that which is desired. It is well understood, that when we have to treat a hemorrhage from rupture of the urethra, after its cessation, and that of the urethritis, with which it is complicated, we must dilate the urethra with bougies, in order to prevent the formation of strictures. URETHRAL PAINS. Symptoms.—All the symptoms of blennorrhagia may disappear, with the exception of the pain: this not only continues, but may become exasperated, and constitute the only disease. It may be seated in any part of the urethra which has been inflamed, from the fossa navicularis to the neck of the bladder, but more fre- quently it is situated in the vicinity of the glans. This pain is sometimes of a shooting character; it is constant, though occasion- ally exacerbated, and puts on the form of neuralgia; it may be, though rarely, intermittent, and the attacks occur at irregular in- tervals. The actual severity of the pain can be generally but little known to the practitioner, for this accident occurs chiefly in nervous subjects, who are sometimes more or less hypochondriacal, and Avho always exaggerate their sufferings. Occasionally the pain is reflected from the bladder towards the anus and the rectum, and there is a feeling of weight in the testicles. Causes.—It is evident that urethral pain is more likely to be observed as one of the consequences of a blennorrhagia which has been imperfectly or improperly treated. A neglect of hygiene is also an actual cause of this accident. Very excitable nervous subjects are those who suffer most from blennhorrhagia; but it must be acknowledged that, in certain cases, neither age, nor temperament, nor the intensity of the in- flammation, nor a neglect of hygiene, nor errors in treatment, can URETHRAL PAINS. 123 be accused. I have treated a patient avIio has been strict in his observance of hygienic rules, very precise in submitting to me- thodical treatment, and who was not of the nervous temperament: he suffered equally from urethral pains after the cessation of the discharge, and this pain resisted every plan of treatment. Treatment.—For a long period, antispasmodics, narcotics, and blisters have been employed. John Hunter highly extolled the latter remedy, which he applied to the perineum. To these have been added, cold injections of opium and perineal frictions with a pommade of laudanum. Hunter speaks of injection, of a slightly irritating character, which are to be employed from time to time; thus, we may use eight grains of corrosive sublimate to eight ounces of water. When these injections have produced a good effect, it has been but temporary. Bougies have also been employed, as Avell as sounds smeared with some particular ointment, or caustic. Thus, by the introduction of a large yellow wax bougie, I have sometimes diminished the irritability of the urethra. The bougie as it were toughens the mucous membrane of the urethra ; it seems to act like the bit in the mouth of the horse, of the presence of Avhich after awhile the mouth becomes unconscious. By means of the bougie belladonna ointment has been introduced. Finally, the urethra has been cauterized after the method and with the in- strument of Lallemand. I have seen all these methods fail in the most skillful hands, and in cases which have been permanently cured by very simple means, viz. compression of the penis. Author's Treatment.—Compression.—I have observed that patients suffering from urethral pains, either as the result of blennorrhagia, or from certain morbid conditions of the neck of the bladder, often compress the penis Avith their fingers, and they have declared that in this way they obtain true relief. Again, I had observed, as have other surgeons, that calculous patients compress the glans, that they stretch the penis, and thus strive to ease their anguish. From this I conceived the idea of employing constant compression. This I effect by the methodical application round the penis of little bands of diachylon plaster, as follows: each little band should not be more than 4 lines in width: its length should be sufficient to encircle the penis, so as to permit the ends to lap each other under the urethra. The dressing is thus rendered more solid, and the urethral compression more certain. The bands should overlap each other, the second covering a third of the first, and so on with the rest. The compression should be very decided, but not carried to an extent sufficient to prevent the patient from urinating. These bands should be allowed to remain as long as possible, until the pains have ceased at least for three days. We should not fail to renew them, as they may become deranged, and fail to effect the object for which they Avere applied. This method of treatment is chiefly successful when the pain does not extend beyond the limits of the antiscrotal portion of the urethra. When it is seated in the perineum, there is less chance of causing it to disappear. In such cases, it sometimes becomes permanent; generally it happens that 124 VIDAL ON VENEREAL DISEASES. it is only moderated, but occasionally it entirely disappears. We may know in advance, if compression will succeed, by making the patient attempt it with his fingers; if a momentary relief is ex- perienced, Ave have strong grounds for anticipating complete success. I should remark, in conclusion, that the pain may be caused by the remnants of an inflammation, in which case, leeching Avill be preferable to compression. In the Annales de la syphilis et des maladies de la peau, moreover, may be found facts recorded, Avhich favor the practice here recommended.* PERVERTED SENSATIONS IN THE URETHRA—ABSENCE OF SENSATIONS. Symptoms.—Instead of an exaltation of sensibility in the urethra which amounts to a pain, certain aberrations of this sensibility may be manifested as the result of blennorrhagia, which Benjamin Bell and M. Lagneau have denominated extraordinary sensations of the urethra. These sensations are also referred to the bladder, and in some instances to the testicles. Thus, after the cure of a blen- norrhagia and the cessation of the true accidents of this disease, there sometimes remains a modification of the normal sensibility of certain parts of the genito-urinary apparatus. According to M. Lagneau, it is a continual titillation, a pricking sensation of the urethra, the vesiculae seminales, the neck and even the body of the bladder. There is also a.kind of undulatory movement of the testicles (Benjamin Bell). Sometimes the symptoms resemble those of stone in the bladder. These abnormal sensations are oc- casionally felt not only in the genital, but in the pubic and hy- pogastric regions, and upper part of the thighs; sometimes the stomach itself, and the intestines become involved. It is not im- probable that in certain cases, these morbid feelings proceed from the stomach, particularly in hypochondriacal patients. Instead of an increased or perverted sensibility, it may be com- pletely wanting at some point of the urethra. Thus, after certain cases of blennorrhagia, there may be an entire absence of the voluptuous feeling, which coincides with the ejaculation of semen. What is quite remarkable is, that the patient may indulge in sexual intercourse as usual, and the erections may be complete, but the ejaculatory act is unattended by the least pleasure, and the completion of coition is only made known by the cessation of the erection. [We have recently been consulted in relation to a case of this kind. If the patient indulge in a second connection shortly after the first, the ejaculatory act is then accompanied with a slight sen- sation of pleasure.—G. C. B.] This condition has been observed without any appreciable lesion of the urethra, as well as with an indurated and thickened state of the walls of this canal. M. de Castelneau has published an interesting case which belongs to this last variety. The patient * T. ii. P. 135. PERVERTED SENSATIONS IN THE URETHRA, frss/r X<<4/y{/d/.), /tv// *//**t/rsyet ulcerated. Very extensive coagula Ave^found iMkw^rural vein, which Avas the seat of some inflammation. rffl|£ J^rnal saphena was destroyed as high as its origin. A^eHpitr coagula were here found, which explained Iftie ab^en^of hemorrhage during life. The stomach and intes- thj^EL yesented nothing abnormal, with the exception of a slight repress, and hardened faces in the cavity of the latter. Well- organized layers of fibrin adhered to, and were intenvoven with, the columnia of the ventricles of the heart. The cardiac muscu- lar fibres were a little pale and discolored, but not softened. There was a milky layer on the pericardiac surface. A slight hypostatic engorgement of the convex border of both lungs were discovered, but the rest of these organs crepitated perfectly, and presented neither purulent foci nor indurated nuclei. Lymphatic system. Both iliac fossa were the seat of a peculiar ulceration. The cellular tissue of these regions, especially that of the right side, was indurated, and studded with tumefied lymphatic ganglia of which some were filled with pus. These numerous masses of ganglia surrounded the internal iliac arteries and the termination of the aorta; they also embraced the thoracic canal as far as its termination, reaching even to the left subclavian vein. The thoracic canal itself presented at long intervals considerable no- dosities resembling in form the beads of a chaplet. On incising these nodosities, there were found within the canal lymphatic deposits resembling ganglia. The greater number of these, hard at their circumference, were soft in the centre, and had suppurated like those of the iliac fossa. The osseous system presented nothing abnormal." The third sub-variety is the serpiginous chancre. Instead of starting from a single point like the preceding variety, and ex- tending more or less circularly, encroaching upon the tissues which offer the least resistance, the serpiginous chancre follows circles, or portions of circles, more or less regular, like certain consecutive ulcerations, as the serpiginous syphilida. When cicatrization resists its progress on the one part, the chancre gains on the other. It may then be compared to a creeping plant. Sometimes cicatrization begins in the centre, and the ulceration is 204 VIDAL ON VENEREAL DISEASES. obselfed at its circumference; so that, in the middle of the ulcer, there is an inodular disk, which always increases in size, whilst the borders becqme likewise more excavated and enlarged. The serpiginous chancre most frequently coincides with the tubercular d^thesis and the dartrous vice. Sometimes the tuber- cular condition is' not manifested among the antecedents of the serpiginous chmcfeJmt only at an advanced period of the disease. Ihavfpital du Midi. With the history of chancre have been connected questions still involved in obscurity. By some, it is maintained that the indur- ated chancre alone is followed by syphilis, or that it is the start- ing point of the constitutional disease; others believe that it is principally this form of chancre which produces the pox. As I have shown that chancre is always more or less indurated, it is unnecessary to refute this proposition. Then again it is asserted, that the chancre must be strongly indurated, to be followed by consecutive accidents. To this I reply, that these accidents have been known to follow chancres but moderately indurated, and the speedy cicatrization of those which were regarded as non-indurated. Moreover, those who make of the indurated chancre a separate variety, admit that induration is not generally established until after the first week. Now, during this period, infection may take place, and generally it does not wait this term. In my opinion, instead of framing the question thus : Can the indurated chancre alone produce secondary accidents, or does it produce them more frequently than the other varieties of chancre ? I would rather ask, What connection exists between the indurated chancre and the constitutional disease ? Certain it is, that the general state of the system modifies the form of the chancre, and wherever we find an action which can be called syphilitic, the reaction must be greater. For example, when chancre is obstinate, when, from being moder- ately, it becomes much indurated, and seems to constitute a separ- ate variety, I believe that the syphilitic Atirus has then for some time already infected the system. The cause of the constitutional disease therefore exists, and the system is already infected. This degree of induration proves only that the diathesis is established: for the indurated chancre is really a consecutive accident, an ex- pression of confirmed pox. But the effect of the diathesis may be confined to this point; in other words, we may have an indurated chancre, without any other manifestation of the general infection. [We are satisfied that the majority of practitioners do not coin- cide with the views of M. Eicord, who would restrict constitu- tional infection to the true indurated chancre. Our own observa- tion has taught us the correctness of the doctrine inculcated by Mr. Lane, in his valuable lectures published in the London Lancet for 1841-2, vol. ii. p. 594. He thus observes: " The practical inference I wish you to draAV from these remarks is, that a mere principle, an excoriation, a vesicle, a pustule, a minute ulcer, one covered Avith a scab or not, a superficial ulcer, a raised ulcer, a deep one, one Avith or Avithout induration, a spreading ulcer, phagedenic or sloughing, a stationary one, a cicatrizing ulcer, ulcers varying in form, in color, size, or number, may contain, or have contained, the syphilitic virus, and, consequently, may be followed by the secondary or constitutional disease." Those en- gaged in the study of syphilis cannot do better than to consult CHANCRE. 207 these lectures by Mr. Lane, whose connection with the Lock Hos- pital, London, and Avhose vast experience in the treatment of syphilis, render his remarks of great practical value.—G. C. B.] Is it necessary to reply to the question: Can a patient have several different attacks of indurated chancre ? Is it true that a chancre, becoming developed after the indurated, will assume this form ? But this is a complicated question, since all chancres are more or less indurated; or, if we would speak of a strongly-indur- ated chancre, the expression of the syphilitic diathesis, the ques- tion becomes involved into this : Can a person have the pox more than once ? Experiment has already replied to this in the affirm- ative ; and the case observed by M. Boully, which we have quoted, leaves no doubt on this subject. I shall return to this question in treating of the consecutive venereal accidents. The indolent bubo, which should be the inevitable accompaniment of the indurated chancre, will be considered in the next chapter. 3d. The raised chancre (ulcus elevatum).—The base of this chancre is raised by a kind of vegetation of the form of a round or oval basin, of a fungous nature, and more or less raised above the skin. These chancres occur frequently on the edge of the prepuce ; they furnish a sero-purulent matter, are generally not painful, and their borders and base are but little indurated. When cicatrization takes place, it still remains for some time above the level of the skin, a flattened and whitened projection, which is slow in disap- pearing ; the cicatrix, after awhile, sinks to a level with the sur- rounding parts. Too much importance has been given to this form, not only in making of it a separate variety, but as giving rise to a pecuhar kind of constitutional disease. Fig. 1, plate 2, represents three raised chancres on the prepuce, and tAVO ordinary chancres on the glans. The latter are the result of inoculation with the matter from the former; they are therefore all produced by the same virus ; only those on the prepuce assume a fungous character, on account of the yielding of the loose cellular tissue of the part, which cannot occur on the glans. The subject of these chancres Avas in Ward 10, bed No. 13. Now, if we reflect on the^different forms of chancre, which I have described under the head of varieties, we find that they are the result of complications. Thus, the first variety is complicated with gangrene; another form, the diphtheritic, with hospital gan- grene, whilst the indurated serpiginous variety is connected with the tubercular diathesis. I believe that the raised chancre depends greatly on the locality; it assumes this form when it is seated on loose cellular tissue, as on the prepuce. I believe that this is the most important practical view of the subject, in our investigations into the causes of the deviations in the form of chancrous ulcers. Diagnosis.—In the majority of cases the diagnosis of chancre is not difficult. The practitioner Avho possesses a tact for observa- tion, need but glance at an ulcer to detect its syphilitic nature. I have already described chancre with sufficient minuteness to aid the young practitioner in forming a diagnosis. A round ulcer. with edges perpendicular and a little detached from the ^ 208 VIDAL ON VENEREAL DISEASES. gray or yellowish base, covered with little cells, induration, a violet-red circle, located on a part concerned in sexual intercourse, suspicious connection: these sum up the characters and circum- stances by which a true diagnosis may be established. But these elements do not always fully exist, and they are sometimes modi- fied and defaced: thus, both form and color may be changed, and the ulcer may be seated in an unaccustomed locality. Interest, false modesty, may lead to the concealment, or a misrepresentation of the antecedent circumstances. The uniform test with M. Eicord is the matter secreted by the ulcer: if, on inoculation, this pus produces a chancre, its syphilitic character is established, and the other elements of diagnosis are of no value. But, as there are chancres, the pus of which cannot always be inoculated, this test cannot always be trusted; and these are the chancres which present the most difficulties, and in the diagnosis of which inoculation Avould therefore be the most useful! _ Such, indeed, are the chancres of unnatural shape, caused by cicatrization or some other complication, such the deep-seated chancres, the chancres larves, for the diagnosis of which inoculation should be so important, yet these are precisely the cases in which it fails. (See my remarks on the nature of blennorrhagia.) As to other chancres, those which are open to view, and still progressing, unmodified by the process of cicatrization, inoculation is here use- less ; it is even dangerous. Thus, in doubtful cases, when.it is of importance to decide whether an ulcer is or is not a chancre, inocu- lation is insufficient. The differential diagnosis of chancre, _ in other Avords the distinction between primitive and _ consecutive ulceration cannot be established by inoculation, since I have demonstrated that both of these forms of ulceration may be inocu- lated. We must, therefore, in obscure cases, have an especial regard for clinical diagnosis; we must carefully collect the antece- dent circumstances and inform ourselves of the commencement of the progress of the ulceration, minutely note all the characters of the lesion, and pay especial attention to those furnished by the tis- sues in which the ulcer is seated. If there be an induration, and if the other circumstances are in favor, we may regard it as a syphilitic ulceration; for, in my optnion, every syphilitic ulcera- tion is accompanied with induration. There are cases in Avhich this is the only character on which we can fix: indeed, certain chancres of the fossa navicularis, or concealed beneath a narrow prepuce, are only discovered by the touch, which detects the indu- rated points. True there are other kinds of ulceration which are indurated, but then the concomitant circumstances are different, their progress is not the same, and they lack the circumstances that precede venereal diseases. Thus, cancerous ulcers have a more or less indurated base, but their entire history shows no connection with chancre. Sometimes it must be acknowledged, that notwith- standing the most minute attention to details, and the greatest poAver of grouping them in one assemblage which shall represent their diagnosis, the latter still remains obscure, and our doubts are removed only by the appearance of certain consecutive accidents. CHANCRE. 209 The young practitioner should therefore be very cautious in an- nouncing his opinion, especially in courts of justice. It is import- ant that he be forewarned not only that observation may lead to mistakes, but that he should also understand the errors which may result from experiment. He has been told that inoculation affords a test by which we may decide in medico-legal inquiries now, as it is Avell established that there are true chancres which are not inoculable, it therefore cannot possess a positive value. What would be thought of a test without a positive value, and of which the negative response is to be totally disregarded! Certain ulcerations are observed in the buccal cavity, which may be regarded as syphilitic ulcerations, and here I include those which are primary and secondary, as in a practical point of view, the difference is of no great importance. Mercurial may resemble venereal ulcerations. When mercury affects the mouth it produces ulcerations, the base of which is whitish, milky, and not gray or yellow, like the syphilitic ulceration; in fact, they rarely exhibit ruptured vessels. The circumference of mercurial ulcerations, instead of being like the syphilitic, of a violet red color, is pale, like the interior of the mouth. These mercurial ulcerations are found particularly within the cheeks, on the edges of the tongue, and especially behind the molar teeth; they are numerous, and their edges are neither indurated nor perpendicular. Syphihtic ulcerations may occur in the same situation, but they are most fre- quently observed on the palate, the tongue, tonsils, pharynx, and at the commissures of the lips; their edges are perpendicular; they are indurated and few in number, being sometimes three or more. Besides, in the mercurial ulceration there is a peculiar odor, Avith more or less salivation, and the patient complains of a metallic taste. Complications.—In speaking of the varieties of chancre I have asserted that in reality they depend on complications. There are two other complications or accidents, of sufficient importance to be separately described; these are phimosis and paraphimosis. As buboes may occur without a previous chancre, and as accidents completely primary, I shall treat of them under a separate head. This is an appropriate place for noticing a case which I believe to be unique. It is that of a chancre of the meatus urinarius, which so narroAved this orifice as to produce a retention of urine; a perforation of the bladder afterwards occurred which might have been regarded as a chancre, or a rupture arising from certain alterations which rendered it easily broken. The following are the particulars, as they were carefully noted by my interne, M. Codet. In connection with the report is a sketch of the pathologi- cal specimen. C. (I.), a water porter, aet. 26, temperament nervo-sanguineous, constitution robust. Admitted March 18th, 1852, Ward No. 10, bed No. 12, under the care of M. Vidal. Health always good. He ate heartily and drank much wine. Three years since he had a chancre in the burroav of the glans near the fraenum. After light treatment it healed in the course of three or four months. No 14 210 VIDAL ON VENEREAL DISEASES. enlarged ganglia in the groin or in the neck. The cicatrix of the chancre is smooth and soft as the parts by Avhich it is surrounded. Np consecutive accidents. Eighteen months ago he contracted a blennorrhagia; during this attack there Avas no retention of urine. Pain was moderate during micturition, and the latter was followed by slight hemorrhage, Slight pain in perineum. Orchitis on the right side soon followed; this was cured in fifteen days. The blennorrhagia lasted for three months. In the early part of February 1852, he had another attack of blennorrhagia, which appeared fifteen days after a suspicious inter- course. The discharge Avas very small, and there was but little pain in urinating. C. does not know whether at this time there were enlarged ganglia. A potion and injections were prescribed, but this treatment was very imperfectly followed, and at the end of five or six days it was abandoned, the patient resuming his usual habits of life, drinking to excess, and perhaps working more than ordinarily. He Avore no suspensory bandage; the discharge Avas slight, as were his sufferings. This state of things lasted until the 14th March, 1852. About the 13th of March, the patient experienced some diffi- culty in urinating; but on the 14th he was seized with an intense cephalagia, and violent pains in the flank. The urine was voided with difficulty, and its emission was accompanied with a trifling hemorrhage. Constant tenesmus, anorexia, bitter taste in the mouth, severe thirst. On the 15th, the desires to urinate were A^ery urgent. Micturition more and more difficult; slight pains in the epigastric region; spittle tinged with bile. This condition be- came aggravated, and the patient entered the hospital on the 18th March, 1852. 18th.—Difficulty in walking. He arrived in a carriage, and it was necessary to support him, Avhilst he mounted into the ward ; every movement, he stated, increased his suffering, which was in the sides. For three days he has passed but a few drops of urine. The complexion is a little discolored, and there is an expression of suffering on the countenance. The pain in the head and sides is very intense. Abdomen slightly distended; there is dulness for nearly an inch below the umbilicus, whilst above, there is tympanitic resonance. The pulse is feeble and frequent, the tongue slightly loaded, the mouth bitter, thirst severe. From time to time, the patient discharged some mouthfuls of bile. Ees- piration is a little accelerated. The prepuce, red and swollen, permits the meatus to be with difficulty exposed. On the part adjacent to the frenum, a chancre was found, of the existence of which the patient Avas unconscious, and whose base Avas a little indurated. The surface of the ulcera- tion is limited, it extending about a line into the canal. A little muco-purulent matter lies between the lips of the meatus ; pres- sure on the urethra does not increase the quantity. An examina- tion, per rectum, detected a slight enlargement of the prostate. The ganglia in the groins are slightly enlarged (for what length of time patient does not know). . The glans, hke the prepuce, is red. The CHANCRE. 211 meatus, very contracted, will not admit an ordinary silver cathe- ter ; a small, gum elastic instrument, a little larger than a raven's quill, introduced within a stylet, passes with facility. The pain is somewhat severe. Half a pint of urine was evacuated. Its flow was arrested (the eyes of the catheter having become obstructed). A second catheter of the same kind, introduced in the same man- ner, encountered some difficulties at fhe meatus, after which it passed with ease ; it gave exit to nearly a pint of muddy, highly- colored urine, which exhaled a decided ammoniacal odor. The urine issued in a jet. In withdrawing the sound, it was closely embraced by the canal. After the use of the instrument, some drops of blood appeared at the meatus. Some hours afterwards, I attempted again to introduce the catheter; it was arrested on a level with the bulb. A large cataplasm moistened with laudanum was ap- plied to the perineum (he had taken no bath at the hospital). In the evening the patient felt better; he passed his urine without the catheter. Abdomen still swollen, general condition same as in the morning. Laudanized cataplasms to the perineum, and to the abdomen. On the 19th, M. Vidal saw the patient. Condition same as yesterday. Examination by the rectum detected a slight enlargement of the lateral lobes of the prostate, which were sepa- rated by a slight furrow. This enlargement was not painful on pressure. No pain in the perineum. M. Vidal enlarged the meatus with a bistoury. A silver catheter then passed to the bladder without difficulty; nearly a pint of urine was evacuated. Cataplasms with laudanum; tAvo pots of whey ; twenty leeches to the perineum. In the evening, the catheter Avas readily passed. Eespiration more difficult than in the morning; fatigue increased. The urine deposited a sediment, having the aspect of blackish powder. 20th.—Passed a restless night; thirst troublesome; countenance somewhat changed from yesterday; abdomen more distended. The severity of the other symptoms has not increased. Bath; laudanized cataplasm. In the evening, the lips of the Avound assumed the aspect of a chancre. Patient is much worse; eyes holloAV; cheek-bones prominent;' naso-labial prominence very marked; pulse small, intermittent; pulsations from 110 to 120 in the minute; no chills; abdomen moderately distended, but little painful. Patient is troubled with vomiting of bile. 21st.—Bad night; delirium. Pulse very feeble, and intermit- tent, 130. Vomiting, almost constant, of pure bile; severe thirst; dyspnoea increasing. Abdomen tympanitic. Constant agitation of the patient in bed. Catheter passed readily, and brought away a little urine. When it reached the bladder, it seemed to be closely embraced by the neck of this organ, and its movements were limited. Apply one oz. of Neapolitan ointment to the abdomen; laudanized cataplasms. In the evening, the patient Avas a little better, and could urinate without the catheter. 22d.—The slight improvement of yesterday has not continued. 212 VIDAL ON VENEREAL DISEASES. Violent delirium during the night; anxious respiration; counte- nance rapidly changing; pulse thready and very frequent; con- stant vomiting of bile. Lungs perfectly sonorous, except poste- riorly, along the pulmonary depression, where the sound is a little obscured, and mucous rales are heard. The abdominal walls, constantly distended, were a little painful on pressure. Pain in the sides very severe. Catheterism; bath; continuation of the mercurial ointment; tilleul, two pots (the whey yesterday pro- duced a slight diarrhoea) ; laudanized cataplasms. In the evening pulse was almost imperceptible. Countenance of a yelloAv com- plexion ; features very sharp; lips dry; tongue coated; sides constantly painful on pressure; slight delirium; extremities cold. The catheter evacuated some spoonfuls of urine. 23d.—Patient was delirious the Avhole night. Constant picking of the bed-clothes. A small quantity of urine was passed by the instrument. Forty leeches to the abdomen; bath; laudanized cataplasms. Noon.—Abdomen less SAvollen; eyes convulsed; lips of a violet color; extremities cold. No pulsation at the wrist. Died at four o'clock in the afternoon. Autopsy, forty hours after death. Weather cold and dry. * The body exhibited no signs of putrefaction. Cadaveric rigidity very decided. The abdominal walls, having been opened by a horizon- tal incision below the umbilicus, were found infiltrated with a red- dish brown liquid, and were evidently softened. Adhesions, con- sisting of false gelatinous membranes, existed throughout the con- volutions of the intestines. The bladder adhered likewise to the parietes of the abdomen; it had mounted about an inch above the pubes. Its external surface was of a deep violet color. In order to expose the parts most involved, the urethra was divided through- out its entire length by its superior Avail; the symphisis pubis was also divided. An incision was made through the prostate from its pubic surface, and the bladder was opened by its anterior wall. It contained but little urine. Its internal surface was gen- erally red, particularly about the trigonem. On the right side of the bladder was found an ulceration about the diameter of a twenty centime piece; this ulceration penetrated through the whole thick- ■ ness of the organ; beneath it were false membranes themselves „ perforated, at two or three points, by which the bladder commu- nicated with the abdomen. (As before stated the original sketch has been reduced to one-fifth its size.) The edges of this ulcer were clearly formed, and round, resem- bling a cap surrounded by a well-developed vascular band; on this cap were seen small irregular Avhitish layers, which seemed to be sub-mucous and a little hard, like incipient vegetations; they were scattered over the whole internal surface of the bladder, but in much less number, than around the perforation. The prostate was but little enlarged; the volume of each lobe being about that of a small nut. Its substance was highly in- jected. The urethra was perfectly sound. At the meatus, the chancre was found, to which we have alluded. Testicles sound. The soft parts in the lowe* pelvis were softened and somewhat in- -> t d W-/^^^%» ^g<^dr./ />*'/> '-■a-d^d^z---/cp^'ddif: d< Blennorrhagia is less frequently the starting-point of bubo than \s» chancre, and when adenitis is developed, it is then said to be the ^ result of sympathy or extension of the irritation. A really syphi- > litic bubo^arising from the absorption of the virus, it is said can „" ^—"""only folio* a urethral chancre. This hypothesis I have already combatted, as I have shown that there may be a really syphilitic blennorrhagia without a urethral chancre. Bubo may also result from the physiological absorption of the virus; that is, without having been preceded by the three orders of lesion already indicated, viz. without inflammation, ulceration, or solution of continuity. This is proved by analogy, by authori- ties, and by facts. It is well known that a vast vascular netAVork covers the whole body; the virus penetrates this network ; it is so subtile that it may traverse the most external layer of the integu- ments, without any solution of continuity, and, as it is called, by imbibition. The network to which I have alluded sends out branches of lymphatics, which become loaded with virus, and bear it to the vessels and the glands. The whole of 'this route may be traversed without any lesion of the conducting vessels, because they do not react. But if the first network reacts, we ge- nerally have a chancre; if the vessel, a chancrous inflammation of the lymphatics; if the gland, a chancrous adenitis, a veritable syphilitic bubo. Some writers on syphilis do not fully admit this; they acknowledge only that a lymphatic vessel may be tra- versed by the virus without suffering the least injury. Now the same observation applies to the other tissues. Analogy, indeed, proves that the virus may pass from the skin to the ganglion without wounding any part, and the facts upon this point are con- clusive. Thus, when variola is not inoculated (and it is no long- er inoculated), how does the virus enter the system ? By the same avenues as the syphilitic virus, and no previous solution of con- tinuity is required. Does not the virus of glanders sometimes affect animals and man without any preArious solution of con- tinuity ? Is there not a glanders d'emblee ? Consult on this sub- ject the most weighty authority—Hunter. Now, Hunter admits the bubo d'emblee in the sense received by us. 'Twas particu- larly when treating of buboes that he pointed out the four surfaces by which pus may be absorbed: 1st, by an ulcer; 2d, by an in- flamed surface ; 3d, by a traumatic surface ; 4th, by a common, that is to say a sound surface. These three kinds of absorption are not merely theoretically indicated only. Hunter fully appre- ciated them, and studied them in view of facts. He clearly show- ed that absorption most frequently occurs by an ulcerated surface, and that by sound surfaces it is least frequently observed. On this point the English surgeon has shown an extreme distrust and the greatest hardihood. He advises, for example, that women should be avoided, as it is never known whether they are or are not'affected with blennor- rhagia ; he remarks that before an opinion is formed, they should BUBO. 237 be most carefully examined, and then we shall often discover that a small chancre is the cause of the infection, a circumstance that has more than once happened. " We should," he observes, "pay especial attention to every circumstance connected with a case of this kind." (j). 480.) Hunter, moreover adds, that every engorge- ment in the groins is not a venereal bubo. Thus, we here find a great genius, a keen and accurate observer, who admits the exist- ence of the primary bubo. We may assert that this doctrine is now becoming again in vogue, since this form of bubo is admitted not only by those who have always sustained this opinion, but by the disciples of M. Eicord; for example, by M. Eeynaud (de Toulon) and M. Gibert. M. Eeynaud declares very positively that he has treated persons who, after a suspicious intercourse, had fre- quently examined their penis, without discovering anything; and that they became affected with buboes which were followed by very decided consecutive accidents (p. 55). M. Gibert positively observed a case of primary bubo, the matter of which he success- fully inoculated. M. Eicord very simply objects to this, that M. Gibert deceived himself, or was mistaken. Observe that this reply, especially when politely stated, might be made to every observer; to MM. Lagneau, de Castelneau, Cazenave, Baurnds, &c. In the Avork of the last-named author, cases sixth and seventh leave no- thing to be desired on this subject, since they were inoculated with success. [During our recent visit to London, Mr. Lane very politely showed us, at the Lock Hospital, two cases of the bubo d'emblee. In one of these cases inoculation had produced the characteristic pustule. The brief notes of the case, as made under the supervi- sion of Mr. Lane, are as follows:—Thomas Hughes, aet. 22, admit- ted into the Lock Hospital, May 5th, 1853. Six weeks previously had last connection. At the time of our visit, 26th May, he had had a bubo for a month. No trace of a sore on the penis or any other point. Both Mr. Lane and myself, after diligent inquiry, could detect no other symptom. Matter from the bubo was inoc- ulated on the left thigh on the 21st May. On the 26th, character- istic pustule, which we saw, was perfectly developed, and Mr. L. directed it to be cauterized at once. Mr. L. informed us that cases of primary bubo not unfrequently came under his observation, but that this was the first instance in which he had produced positive results or inoculation. M. Eicord, in his Treatise (Am. ed. pp. 187, 190), has recorded eight cases of the bubo d'emblee ; and Dr. Judd, in his works on the venereal, has detailed several of the kind. M. Eicord, at pp. 74, 75, of his Treatise (Am. ed), has given us incon- testable proof of the existence of this form of bubo. He quotes authority after authority in support of what, in his Letters (XXV.), and his Notes to Hunter, (2d ed. p. 521,) he treats with ridicule; indeed, in referring to the successful inoculations of M. Gibert, he very complacently observes, that he either deceived him- self, or was deceived (M. Gibert s'est trompe ou a ete trompe)! Dr. Graves, in his Lectures (Dub. ed. 1848, vol. ii. p. 385), quotes from Dr. Eoe's Eeport of venereal patients treated in the 38th 238 VLDAL ON VENEREAL DISEASES. Eegimental Hospital, the following: "Buboes were often seen without any ulcers on the penis," &c. M. Eicord admits in his Treatise, p. 222, Am. ed., the devolopment of abscesses formed by the imbibition of matter from an adjacent chancre, yet, in his Let- ters (XXV.), he denies the possibility of such imbibition•!—G. C. B.] For my own part, I have seen several instances of the primary bubo. As I did not inoculate the primary accident, I waited the development of constitutional disease. In Ward No. 11 there was a case of double bubo, on a subject whose glans penis was quite uncovered; he had had these swellings for five days; he watched himself carefully; the buboes were positively the first manifestations of the disease; he had neither a discharge nor a sore. I was enabled to watch this patient for a long time, and. I saw a papular eruption developed. Another patient entered with a bubo still more recent than the first; there was nothing in the antecedent circumstances that could lead to the suspicion of any other primary symptom; only, he described perfectly a roseola which had disappeared. This I did not see. But a swelling after- wards appeared in the superior maxillary bone, which resulted in necrosis, and I extracted a fragment of bone to which were at- tached two of the teeth. The separation of the sequestrum, and the healing of the wound, were remarkably rapid, under the influ- ence of the iodide of potassium. Besides the buboes from absorption of the syphilitic virus, it is admitted that there are those produced by an extension of irrita- tion or inflammation, or by sympathy, independent of syphilis. The virus, having acted on the whole system,.may cause an en- largement of the glands and establish a consecutive bubo. In fine, bubo is said to be inflammatory or indolent, acute or chronic, according to the prevalence or absence of the phenomena of in- flammation. Still other divisions have been made; these it is un- necessary for me here to notice, as I am now considering these swellings in an etiological point of view. Symptoms.—L shall first describe the more general symptoms; in treating of the varieties, and especially of inflammatory bubo, I will complete the sketch. Bubo is occasionally preceded by febrile excitement; this ceases only after the appearance of suppuration. In corpulent subjects, especially females, fever sometimes exists for several days before a bubo is suspected, particularly when it is small. The tumor is generally of an oblong shape, its grand axis following the direction of the bend of the groin. In other situations, as the elbow and the axilla, it assumes a globular form. If the swelling consist of one gland alone, if it be already inflamed, it is of a reg- ular uniform shape; if, on the contrary, several glands are affected, and inflammation be still absent, the swelhng is more or less ir- regular in form. Sometimes the tumor is divided into tAvo segments —a superior, and an inferior; this disposition is observed when the very dense cellular tissue at the bend of the groin has resisted the development of the gland; it then produces in this situation a kind of strangulation, a depression, and the tumefaction takes bubo. 239 place on the side of the abdomen, or the thigh, where the adhesion of the skin offer the least resistance. Varieties.—Buboes have been divided into many varieties, ac- cording to the phenomena, and the symptoms which they present. I shall describe but two varieties; the inflammatory, and the non-inflammatory or indolent bubo, and in my description of these, I shall point out the characters of the sub-varieties. 1. Inflammatory Bubo.—Bubo is generally the result of the ac- tion of the syphilitic virus on a portion of the lymphatic system; it is the bubo from absorption. But this absorption may occur on an ulcerated, an inflamed or a sound surface. In the latter case, it is called primary bubo. I have already stated, that this kind of bubo was admitted by Hunter, that it was consistent with reason, and that it had been estabhshed by clinical facts, and by experiment. Whatever the surface of the absorption, the virus generally passes at once to the lymphatic glands, by their afferent vessels. These vessels are generally insensible to the poison which they carry; if they do re-act, a virulent angioleucitis is developed, which may be regarded as a bubo of the lymphatic vessels. It is well here to note the possibility of the virus passing through the lymphatic vessels without necessarily infecting the vessels them- selves, a fact admitted by those writers on syphilis who deny the existence of the primary bubo, and this too for the reason that the virus cannot penetrate our tissues unless by means of an ulcer! Now we here find this same virus traversing the lymphatic ves- sels, leaving them, for the most part, perfectly sound. It has been maintained, that in the bubo from absorption one gland only is affected, except in the case of very large chancres, which may communicate with a great number of lymphatic ves- sels. Nevertheless, there is in my service a patient affected with chancres on the penis; he inoculated himself with these chancres through a crack on his finger; at this point was a chancre almost imperceptible, and yet it was followed by a bubo at the bend of the arm, and in the axilla. We here see that the virus passed far beyond the first gland that it encountered. Another erroneous idea is, that when the virus is once beyond the lymphatic vessel and gland, it can be no longer inoculated, or transmitted. When once this virus has entered the circulation, it may still produce effects, even on the individual in whom it has been absorbed, but not on another person, for these effects, which are secondary acci- dents, cannot be inoculated, nor are they contagious. This serious error, against which clinical facts daily protest in vain, has been completely refuted by experiment. It has, indeed, been proved that a sound person may contract syphilis not only from the mor- bid secretions furnished by secondary accidents, but from the blood of the individual affected with these same accidents. Be- sides, who will say that the virus can reach the gland only by means of the lymphatic vessels? Every circumstance goes to show, on the contrary, that this poison may directly enter the cir- culation, and through the latter, reach every part of the system. Bubo may likewise occur independently of any specific syphilitic 240 VIDAL ON VENEREAL DISEASES. action; it is then maintained that the inflammatory radii from a chancre or an inflamed surface involve the glands; in which case it is called bubo from extension. The sympathetic bubo should be produced by an irritation reflected from the point primarily affected to the gland. We may remark in passing, that this sympathetic reaction has been singularly abused. That bubo may be produced during the existence of a chancre or an inflammation of the integu- ments from which lymphatic vessels arise leading to the affected gland, can be admittea according to our general ideas of morbid sympathies; but it is difficult, if not impossible, to acknowledge the sympathetic bubo without a starting point. For example, when buboes have been observed, without any previous lesion on the genital organs, without ulceration or inflammation, it has been pre- tended that they were sympathetic! But sympathetic of what ? Where is the starting point of this sympathy ? What directs it to the gland? They conclude by answering, coitus, a single act of sexual intercourse I This arises from denying the absorption of the syphihtic virus by a sound surface, in other Avords from closing their eyes to facts! However it may be, buboes by extension, sympathetic buboes, can only be, I repeat it, inflammatory accidents, and not syphilitic; compared Avith buboes by absorption, they may be regarded as benign, for they contain no virus, and are not inoculable, as is the case with buboes by absorption. It will be remarked that buboes by extension, by the propagation of the inflammatory foci, those that are regarded as the most common among benign buboes, occur precisely in those cases where chancre is but little inflamed, often when it is cicatrized, and almost never Avhen the ulceration is really complicated with inflammation. Observe what occurs after opera- tions on the penis, such as extirpations, ligatures, cauterizations of excrescences, cauterizations sometimes deep, incisions, excisions of the prepuce unmethodically made; now these lesions, each of which always produces an inflammation more severe than common chancre, are yet folloAved by no adenitis, by no bubo from exten- sion or sympathy; Avhence I conclude that there is nothing more rare than what is called benign bubo, that is, adenitis, a simply inflam- matory adenitis, either from extension or sympathy. I believe even that the last, having no starting point, is entirely hypothetical. I proceed to describe the several phases of inflammatory bubo. We shall find even here, sub-varieties which have been separately described by certain authors. Inflammatory bubo is sometimes preceded by a fever, Avhich continues Avhilst the swelling is in- creasing. We have then, as I have already stated, primary bubo. The patient complains of an unusual sensation in the region which is to be the seat of the inflammatory tumor; to this succeeds a pain, or rather it extends along the thigh; there is pain and diffi- culty in motion. The gland or glands are tumefied; at first they retain some mobility, which in a short time is lost. The phleg- monous period has already commenced; for, at the same time that the glands enlarge, in the majority of cases the cellular tissue becomes involved in the inflammation, the progress of which is BUBO. 241 then still more rapid. The tumor presents an elastic feel, which differs from the indurated thickening of glands and cellular tissue. The skin is of a deep violet red color over the centre and around the tumor. The pain is generally exasperated and shoots in dif- ferent directions, or it may remain unchanged. Its violence does not always correspond with the severity of the inflammation. In fact, we may yet hope to disperse these tumors and prevent sup- puration, especially if the most absolute repose be observed. The inflammatory phenomena are more decided and produce greater reaction when the glands affected are deeply seated; their enlargement is then prevented by aponeurotic layers which bind them down, and produce some symptoms of strangulation. If the inflammation continue, as is most frequently the case, pus forms, and then we have a suppurating bubo. In the majority of cases the matter forms in the cellular tissue, which becomes agglomerated; fluctuation is then easily and promptly detected, for the matter is more superficial and the abscess is unilocular. The skin is of a deep violet red color. When the suppuration, instead of being peri-glandular is intra-glandular, the pus may at first form several little foci in the organ; its presence is then difficult of detection on account of this circumstance, and because it is more distant from the surface. It afterwards becomes collected in a single cavity hollowed out of the gland, and beneath a certain thickening of the parts we may perceive fluctuation, which becomes more evident when the intra-glandular foci communicate with the pus of the cellular tissue surrounding the ganglion. When pus has formed and become collected, both general and local excitement cease, and the movements of the thigh are less difficult. But the skin becomes thin and bare, of a deeper color, and if in the first stage of suppuration, some hope may still remain that the tumor may disappear without any solution of continuity, this hope is now entirely lost; indeed, if the tumor be not opened it Avill open spontaneously. When the inflammation has been severe and acute the pus has the qualities of what is called good pus, phlegmonous pus; if the inflammation has progressed rather sloAvly, and if it has been, as it were, arrested from time to time, as often happens when glands are inflamed, the pus is then thin,. mal-assimilated, and filled with coagula. The pus may assume this double character when there has been a simultaneous suppuration of the gland and the cellular tissue by which it is surrounded. [n all cases it may be more or less mixed with blood, occasionally it happens even, that the cellular tissue, or peri-glandular tissues, contain nothing but blood. Whether we do or do not interfere, though the tumor be opened early or late, the solution of continuity may assume the characters of chancre; we have then what is called glandular chancre, Avhich may present the different aspects that have served to establish the varieties of chancre. Thus this solution of con- tinuity may have the aspect of common chancre, or it may be more or less indurated, and thickened at its base and borders, cor- responding to the indurated chancre; finally, mortified portions 242 VIDAL ON VENEREAL DISEASES. may be detached, the ulceration spread rapidly over one or several points, and resist all treatment: consequently, we should have the phagedenic chancre in all its different forms ; and here the same hygienic circumstances shall prevail, the same idiosyncrasies, the same therapeutic measures, which exerted an influence over the characters assumed by the ulceration, absolutely as I have de- scribed when considering the causes of the deviation in the form of what is called regular chancre. If the bubo be opened with a bistoury or lancet, if the opening be made at a proper time, and in the manner that I shall hereafter describe, there is a strong probability that the skin will contract its natural adhesions, and that the wound will soon become healed, without leaving any trace of deformity. If, on the contrary, we wait for the swelling to open spontaneously, if it be opened at too late a period, or in an improper manner, the skin will not become adherent, or it will be but imperfectly re-established: more or less of it will slough, and there will be a great loss of substance, or many openings, which will remain a long time fistulous. In both cases, the reparation of the wound will be slow, an unequal, de- formed, and strongly-marked vicious cicatrix will remain, to remind the patient of an event which, in the majority of cases, he would prefer should be unknown. 2d. Non-inflammatory or Indolent Bubo.—This generally consists of several enlarged glands, which are movable, not painful, and do not, at the commencement, present any phenomena connected with true inflammation, except the increased size. A great im- portance has been attached to bubo in forming the diagnosis of in- durated chancre: M. Eicord even denominates it the necessary companion of this disease.* But he must know that a similar glandular enlargement may be observed in strumous subjects who have never had a chancre ; it may exist in the other varieties of phancre, in that called regular common chancre, which is regarded as deprived of all specific induration; add to this, the fact that this same engorgement differs in no respect from consecutive bubo, since it exists in connection with indurated chancre, itself an indi- cation of the existence of the diathesis, being observed also, with the train of accidents called constitutional, and the value of the in- dolent bubo in. the diagnosis of syphilitic ulcerations is materially diminished. The indolent bubo, consecutive or primary, may assume an inflammatory character ; but its pus is not considered inoculable. Diagnosis.—We are now particularly concerned with inguinal bubo. Let us first exclude hernia, aneurisms, and abscesses, by congestion, the tumors produced by which are easily distinguished from bubo. The marks of some wound, or laceration, certain cutaneous inflammations, a furuncle at some point corresponding to the distribution of some lymphatic vessels leading to the glands of the groin ; the knowledge of these lesions will prevent us from confounding the glandular engorgements which sometimes result o Notes to Hunter, p. 652, 2d ed. BUBO. 243 from them, with syphihtic buboes. The difficulties are not great when, with the bubo, other syphilitic accidents coincide; if the latter are consecutive, the bubo is constitutional, indicative of the diathesis; if the accidents are primary, bubo might be indolent in the case of indurated chancre, or inflammatory in the case of regu- lar, common chancre. The difficulty is real, and not easy to be surmounted when we cannot discover the starting point of the inflammation which has invaded the gland, when there is nothing on the integuments to indicate that the virus has penetrated the system, when, in fine, there is a primary bubo. Some have thought that these difficulties might be obAaated by resorting to inoculation, which should produce a chancre, in the case of a syphilitic bubo, and which will fail if the contrary be true. But this proceeding cannot be adopted except where suppuration is already established; it is important to decide before this event has happened, and even when it has, inoculation is difficult and uncer- tain. Indeed, in the case of a true syphihtic bubo, suppuration may have invaded but the cellular tissue surrounding the gland, when it is supposed that the gland itself has suppurated. In such a case inoculation would lead to no result, for the pus of the gland alone ©ontains the virus. If we pass through the cellular tissue, and reach the suppurating gland, we cannot be sure of obtaining the virus, as the bubo may be composed of two glands, each of which may contain different kinds of pus; the matter obtained may come from the gland, Avhich does not contain specific pus, thence another failure of inoculation, and that, too, in a case where there is really a virulent bubo. Further still, we are not even certain of obtaining virus in extracting matter from a gland, the suppuration of which has been specific, for we may be too late, that is, at the time of reparation, when the pus secreted is no longer virulent. Inoculation, therefore, does not remove the diffi- culties ; it rather creates more. Clinical experience must furnish us with the principal information required to form a diagnosis ; it is the combination of certain constitutional and local symptoms, together with the antecedent circumstances, that can lead to prac- tical truth. In the last analysis, what tumor may be confounded with bubo ? The scrofulous. Now, the scrofulous, or, if it please, the strumous tumor, occurs in subjects who have had certain ante- cedents from infancy, from puberty, whose signification is known, and their systems have had certain marks which cannot deceive those who have studied the temperaments. Again, it is rare that there is the tumor in the groin only; but we find them in other regions, as the neck, for example ; and in the groin, even, we find an enlargement of more than one of the deep-seated glands, as well as in the pelvis; in fact, it is rare that the strumous bubo does not involve the supra-aponeurotic glands. In its development and progress, it resembles other strumous tumors. The engorge- ment begins in one or two glands, it forms slowly, and is attended Avith little or no pain. This indolent character remains for a long time, and the skin continues sound, not changing even its color. But under the influence of a physical cause, 244 VIDAL ON VENEREAL DISEASES. or some excitement of the system, sometimes Avithout any appre- ciable cause, the inflammation attacks the glands already engorged; the pain is now severe ; there is an erysipelatous redness of the skin, and thickening of the cellular tissue. These phenomena may be but temporary, and the tumor may thus be many times re- newed. It finally softens, and forms not one but several foci con- nected with the lobes of the different glands; and as the deep- seated glands of the groin and pelvis may be simultaneously affected with the superficial, the suppuration may be very pro- found. In describing the suppurating inflammatory bubo, it must have been remarked that it was attended by a different train of phe- nomena. The tumor, in this variety of bubo, is of limited size, its progress is acute, its suppuration rapid, and generally it forms but tfue focus of matter. After the bubo is opened, it does not present that successive degradation of strumous pus, which is at first thick and well assimilated, then demi-serous with flakes, and which always becomes more liquid and of a redder color. When the bubo is once opened, be it strumous or venereal, it becomes an ulcer which in both cases may possess analogous characters, but between which differences exist, which I will indicate. Both ulcers may have a fungous base, of a dull gray color. But in the ulcer from a venereal bubo, a false membrane covers the base, and we may remove it by gentle rubbing; then the color of the wound is of a more or less lively red. In the strumous bubo, the base of the ulcer, on the contrary, is formed by the gland itself, which is more or less fungous, and has the gray color, which can- not be made even momentarily to disappear. These glands more or less hypertrophied, sometimes rise above the level of the skin, which tends greatly to retard the healing of the ulcer. Further, the skin around the ulceration is thin, not red, but more or less livid. When the ulcer is venereal, there is always more or less inflammatory turgescence, and the cellular tissue of the base, that which lies under the skin, is more or less rigid; the gland does not so soon become exposed. Venereal ulceration, besides, makes too rapid progress in the commencement to be afterwards suddenly arrested, and then to march speedily towards reparation. The contrary is true of strumous ulceration, which is slowly established, which progresses slowly, and heals still more slowly. But, unfortunately, both the strumous and the venereal dia- thesis may be so blended, that the bubo having the characters of both, may render the diagnosis very difficult. Hunter very justly remarked: " There are buboes which are nothing else than a gland endoAved Avith a scrofulous disposition, in which the mor- bid action has been provoked by venereal irritation."* Occasion- ally we meet Avith a bubo which has been preceded by a chancre on the penis, or a urethral blennorrhagia has inflamed, suppurated, and opened in the same manner as a syphilitic bubo; the stru- mous engorgement then manifests itself, and it assumes the char- * On Bubo, chap. iv. BUBO. 245 acters which I have described. Here the venereal accident, on the part of the penis, has excited the scrofulous disposition of the glands of the groin, and has given to the strumous adenitis an active character, which did not belong to it before the venereal irritation was superadded. There are cases where the bubo is truly venereal; its onset, its progress, the ulceration which in vades the skin, all prove it; we then have evidently what is called a glandular chancre. But the scrofulous principle which, so to speak, had remained in its essence, began to act, and then it could produce two effects: it might complicate the venereal ulcer, cause it to be transformed into a phagedenic ulcer, which is a very grave affair; or, the venereal symptoms disappearing, scrofula gained the ascendency, the ulcer and the tumor assumed the characters which I have just assigned to the strumous ulcer of bubo.* From what I have stated, it will be seen that the difficulties in forming a diagnosis are real; and, in the present state of the science, it is not possible entirely to remove them. But the knowl- edge of these difficulties will cause the young practitioner to be at least guarded in announcing his opinion, to be prudent in his treatment, and to be discreet in his remarks before interested per- sons or in courts of justice. Thus, what we should here avoid is being too absolute, that is, when we come to the treatment, we should not persist in the administration of mercury when several courses of this mineral have not had a happy result. We should then remember the possibility of a strumous complication, and act accordingly. [In the Compendium de Chirurgie Pratique, of Berard and M. Denonvilliers, vol. 1st, p. 43, a case is reported which occurred at the Hopital du Midi, in 1812, and in which one of the internes opened an aneurismal tumor, supposing that it was a bubo!— G. C. B.] Prognosis.—This may be inferred from what I have stated in speaking of the different varieties of buboes and their complica- tions. The most terrible of all is the strumous complication which may convert the ulcer of a bubo into a phagadenic chancre. We then observe those extensive denudations of the groin, which invade even a part of the abdomen, and exhaust the unfortunate patient by his sufferings and the abundance of the suppuration. [Mr. South states, in the second volume of his edition of Chel- ius (p. 90), that he has known a sloughing bubo destroy life, by ulcerating the femoral artery.—G. C. B.] Treatment—Nicholas Massa recommended that buboes should be allowed to suppurate; he regarded them as a kind of emunctory destined to rid the system of the poison and to render the patient less liable to consecutive accidents, to the confirmed pox. This opinion, which others would call error, has always found sup- porters. Even at the present day we find in the work of M. Baumes, that subjects in whom buboes have suppurated, are less * Vide an article by M. Gabalda, in the Bull. Therapeut., Jan. and March, 1846. 246 VIDAL ON VENEREAL DISEASES. frequently troubled Avith consecutive accidents. To this it haa been replied, that suppurating buboes coincide with the common chancre which does not generally produce the pox. I have already shoAvn that this assertion is not true. [It is to be regretted that upon this, as on so many other doc- trinal points, the vieAvs of as Aveighty an authority as M. Eicord, should be so contradictory. For example, in his Treatise (Am. ed., p. 76), he remarks : " Experience having shown that buboes which do not inoculate are never followed by secondary accidents." Now in his Letters, (xxvii, p. 199.) he asserts that: " Every bubo which suppurates specifically, that is, which furnishes inoculable pus, is never folloAved by constitutional infection!" Which of these doctrines are we to believe? One thing we know to be true, viz., that constitutional infection sometimes occurs after a sup- purating bubo, whether such suppuration be specific or non- specific.—G. C. B.] For my own part, I will not here discuss the question, whether it is better to promote or to prevent suppuration in a bubo; for I believe it to be almost impossible by any of the ordinary means of treatment to obtain either of the results. The bubo that should suppurate, will suppurate, no matter what we do, and the bubo which should disappear by resolution Avill thus disappear in spite of the application of the ordinary suppuratives, except they be too violently used. Does it follow that I would dispense with the treatment of buboes ? No. I believe, on the contrary, that we have a preventive treatment; a palliative treatment, and a surgical treatment to employ. 1st. Preventive Treatment—Among subjects affected with chancre, there are those who greatly neglect hygiene, who do not observe repose, who labor, and who abandon themselves to pleasure; these are the persons in whom we most frequently meet with buboes. As to the frequency of this accident, there is a marked difference between the working population who frequent our hospitals, and the patients which we treat in private practice. This fact, to which I alluded in speaking of the etiology of buboes, should in- duce the practitioner to recommend hygienic measures to the pa- tient, and to insist that he avoid fatigue, and observe the most absolute repose. A well directed local treatment of chancre may prevent the formation of a bubo. M. Eicord advises that we should not irritate a chancre. I would remark that it is a practice with him to cauterize them, and to dress them with aromatic wine. 2nd. Abortive Method.—This consists in cold applications, the local abstraction of blood, and the use of compression. A kind of cau- terization with a solution of fifteen grains of the bichloride of mer- cury to an ounce of water, has also been employed. The skin is first removed by means of a blister. This painful and uncertain method is now abandoned even by those who recommended it. I shall again allude to this treatment, which is better adapted to the suppurating bubo. The glans have been incised subcutaneously. I know not the BUBO. 247 results thus obtained. Some have gone so far as to propose the subcutaneous division of the lymphatic vessels which pass from the chancre of the glands. To this I would reply: Avhen the glands are already infected, what advantage can possibly follow the section of the one or more of ihe lymphatic vessels ? Lf infec- tion had not taken place, then the incision might be preventive. But is this advisable for a disease which may not be developed ? Again, supposing that chancre is certainly followed by bubo, can we predict what gland will be affected, or on which side it will be ? Is it possible in all cases to strike upon the lymphatics of the glands which will be affected ? Is it exclusively the office of the lymphatics to carry the virus to the glands ? Further, to appreciate the value of tbe abortive method in general, we must ascertain the facts relative to the dispersion of buboes. Does this often occur? Clinical observation, on the contrary, teaches that bubo once formed, in other words adenitis once established with more or less inflammation of the surround- ing tissues, is very seldom observed to disappear in the rapid man- ner that resolution supposes. I assert that it is very rare; I do not maintain that it is impossible, for I have seen some exception- able instances of the disappearance of the suppurating buboes, but they were immediately followed by a phlegmonous inflammation of the cellular tissue of the scrotum, an inflammation which is known to be connected Avith mortification of the parts. In these cases it was a kind of metastasis. The proper treatment has reference to three varieties of buboes. 1st, the inflammatory bubo : 2d, the suppurating bubo : 3d, the chronic indolent bubo. 3d. Antiphlogistics.—In the treatment of inflammatory bubo, anti- phlogistics are plainly indicated. In some cases they may produce resolution, and frequently limit the extent of the inflammation, as well as the purulent cavity, if the inflammation become really phlegmonous, and terminate in abscess, if, in fine, suppurating bubo succeeds to the inflammatory bubo. As in every case of adenitis, Avhen the patient is young and vigorous, when the inflammation has decidedly an acute character, when the premonitory symptoms and the reaction are marked by fever of an inflammatory grade, it is Avell to begin with a^ general blood-letting, and afterwards resort to the apphcation of leeches. In the majority of cases, we rely on the local abstraction of blood. which is repeated and proportioned to the volume of the tumor, its tension, and the pain of Avhich it is the seat. We may apply from ten to forty leeches. The largest number should be applied at first; and when the leeching is repeated, a smaller number may be used. The mercurial ointment, not as ordinarily applied in small quan- tities, but in thick layers, as in the treatment of peritonitis, may produce a sedative and really antiphlogistic effect. But if we do not perceive a marked result on the first or second day, and if Ave find it necessary to continue the application, we are in danger of producing an annoying salivation. I therefore employ mercury 248 VIDAL ON VENEREAL DISEASES. only as a topical application, and do not believe that Ave should aim to affect the system by these frictions. I cannot believe that when we have to treat genuine buboes, we can cure them in four or five days by means of mercurial frictions, as Swediaur maintained. Our topical applications should be confined to rice or linseed cataplasms, or to those of .semoule, and of bread. When there is much pain they may be moistened with laudanum; in other cases, we may use Goulard's extract. Eest, a diet more or less rigid, soothing drinks, gentle laxatives, complete the treatment of in- flammatory bubo, of adenitis. Too often, notAvithstanding these means, and especially when they have not been employed, the tumor retains its volume; it becomes more and more tense, crepi- tating and of a deep red color. The fever continues, the redness in- creases, and soon a constant throbbing pain is felt. The patient is troubled with sweats, and the formation of matter can now no longer be questioned. When fluctuation is felt, should we open the tumor or leave it to nature ? 4th. Spontaneous opening of Bubo.—In all ages some practitioners have preferred to leave to nature the opening of the abscess and the evacuation of the pus. Swediaur, who especially taught this practice, maintained, that abscesses thus left to open spontaneously were more rapidly consolidated, and when cured left less deformity behind. Swediaur, however, is less absolute than is stated in books; he admits that there are cases in which the surgeon should dilate the natural opening, and in which he should even open the bubo with the knife. HoAvever it may be, SAvediaur stands at the head of the advocates for a spontaneous opening, and he has ad duced the strongest arguments in favor of the expectant method of treating buboes. As to the speedy consolidation, that is, the cure, Ave may reply, that in allowing the pus to remain Ave favor the exposure of the gland, and its suppuration in cases where the surrounding cellular tissue alone is inflamed, by permitting the cavity to increase, and the abscess, which is never simple, to be- come still more complicated, and. of course to retard the cure. As to the deformity I may be still more explicit; I may assert and can prove that there is a great difference between the natural and the surgical proceeding, such as I practice, be it well under- stood. , Indeed, in the majority of cases, spontaneous opening does not occur until the skin has been detached, and become very thin ; this perforation besides is but a form of mortification, and around this first loss of substance, there is more or less skin ready to mortify, and which most frequently does mortify; thence an enlargement of the first breach or rather other openings form. In the most favorable cases this skin requires a long time to become again adherent. If there be but one opening, it enlarges unequal- ly ; its thin, sharp borders, sink down towards the bottom of the abscess Should there be several openings, they often become converted into one large unequal breach, which is never completely covered by the surrounding skin, and an inodular tissue appears, an irregular cicatrix, depressed, stellated, and evidently deformed; if the openings do not become blended into one, the fistula to BUBO. 249 which they give rise are exceedingly difficult of cure. These re- sults are seen principally among patients who have received no care, who have worked and walked, and observed nothing like repose. The movements have then affected the diseased parts, and this, together with the chafing, has promoted the separation of the skin. It will presently be seen that the openings which I substitute for those which occur spontaneously, are not attended with such inconveniences, nor do they leave behind deformities. But, before describing my method, I must rapidly expose and 'judge those which have preceded it, and which are still preferred by other practitioners. 5th. Blistered surface dressed with bichloride of mercury—a method of which a wrong estimate has been formed, and which has been badly applied, especially at Paris, is that of M. Malapert. This physician proposed to open thoroughly the suppurating bubo by means of a concentrated solution of the bichloride of mercury; but he proposes to act particularly upon the cavity, so as to modify it specifically ; he supposes, also, that he thus acts on the whole system. M. Malapert, therefore, proposes to fulfil a double indication, and his treatment is intended to produce both a local and general effect. M. Eeynaud, of Toulon, who has most fre- quently and perfectly employed the method of M. Malapert, does not apply it for the purpose of opening and evacuating the bubo to more advantage than the other methods. It is only in this point of view that I judge it, for I believe that medicines to coun- teract a diathesis should be administered internally. The follow- ing is the proceeding : When suppuration is first detected in the bubo, a blister of the size of from a fifty centime to a franc piece, according to the vol- ume of the tumor, is to be applied to the point of fluctuation. The vesicle is opened, and on the denuded dermis is placed a pledget soaked in a solution of the bi-chloride of mercury, of the strength of fifteen grains to the ounce of liquid. Tavo hours afterwards an eschar is already formed ; should it not be completely formed, the application is to be renewed, and then an emollient cataplasm. Thirty-six or forty-eight hours after the formation of the eschar, and as soon as it is detached, a purulent liquid exudes from the fissures. The discharge is more abundant in proportion as the eschar becomes detached at several points ; after it has fallen off, the cavity is sometimes entirely emptied. During the discharge of the liquid, the walls of the cavity contract, and the cavity itself is soon effaced. It is obvious that a cauterization of this kind can be rationally employed only in the case of a superficial and very limited sup- puration, and even when the abscess is subcutaneous, we occa- sionally find it necessary to return to a second application of the caustic pledgets, which renews the pain. In employing the pro- ceeding of M. Malapert, we must therefore wait until the suppura- tion has been for awhile established, for there is then more or less detachment, more or less denudation of the skin ; it is likewise not Uncommon to see the eschar A'ery rapidly separated, and the open- 250 VIDAL ON VENEREAL DISEASES. ing which it leaA^es becomes enlarged by the mortification of the integuments, which were at first only attenuated. In fine, this method is liable to the inconveniences Avhich folloAV the spontaneous opening of the tumor. If the abscess be deep seated, and the pus be situated within the gland, the difficulty, and even impossibility of reaching it by a very superficial cauterization, can be appre- ciated. Add to this, if the pus be contained in more than on& cyst, a part only can be evacuated, thence the necessity of renew- ing the blister and' the pledget; in other Avords, to inflict double pain to finish the matter, if we finish it at all. It will be seen that the supposed advantages of this method are: 1st, to empty the abscess gradually so as to permit the cavity to contract upon itself; 2d, to stimulate the interior ofthe cavity, and thereby promote the adhesion of its walls. The first I believe to be a real advantage; but I think that it can be more easily, more surely, and less painfully obtained by the method of punc- turing which I will describe. As to the second advantage, I will say that the interior of the ca-yity is always sufficiently excited to produce an adhesion of its walls; when it does not take place, it should be attributed to every other cause than inertia. 6th. Instead of perforating with the caustic solution, M. Eeynaud often employs small sized cauteries, which are heated to a white heat, and with which numerous punctures are made. This is not a new method; for a long time it has formed a part of the thera- peutics of abscesses in general, especially of cold abscesses. Its object is to open the purulent cavity, and, at the same time, so to modify its walls as to promote their approximation and adhesion. This method is more rapid than that by blisters; it is painful, but the pain is not repeated as in the method by the caustic solution. Still, even by these little cauteries, a loss of substance is produced, by which a breach is left, which is increased by the sloughing of the surrounding skin. Thus we do not avoid the deformity or deformities which attend the cure. Moreover, M. Eeynaud, of Toulon, who has extolled and much employed this method, frankly acknoAvledges, that after these trifling cauterizations, this separation and destruction of the skin, he has observed solutions of continu- ity sometimes complicated with hospital gangrene. Although it may be more easy to manage these little reeds than the solution of the bi-chloride of mercury, we can never accomplish with them what can be done with the point of a bistoury or a lancet; thus, with the actual cautery we cannot penetrate deeply, and still less obliquely. 7th. Potash.— Vienna Paste.—Other caustics, potash alone, and the Vienna Paste, are employed for the purpose of freely opening the cavity, of modifying it deeply, and for destroying a portion of the skin over the glands that has been a long time affected. It is par- ticularly in cases of indolent buboes with a strumous complica- tion, that these caustics have been used. Long and deep sinuses form, which fill up with difficulty, and the traces which it leaves behind are very apparent. Now a mark of this kind, in such a region, is a stigma, which may become of serious importance. It BUBO. 251 must not be supposed that the elegant man, or the coquettish female, is the only person Avho has a dread of such traces, of such souvenirs ; among the masses, and in classes apparently the most indifferent to such matters, we occasionally find individuals who are sadly mortified Avhen compelled to carry a deformity claiming such an origin. 8th. Incisions.—Excisions.—In all ages, the knife has been substi- tuted for the cautery; incisions, more or less extensive, have been performed, and portions of skin so altered as to retard cicatriza- tion, have been excised. These extensive incisions, with or with- out the removal of portions, have for the most part the inconve- niences attached to the cauterizations which I have described. But the knife is more easily managed than the caustic, and I prefer to extirpate a detached portion of skin, of little vitality, or a gland which presents an obstacle to the hearing of the parts, than to act upon them with the Vienna paste. Besides, as with the knife we may give to the wound a certain regularity, we may expect a cicatrix less irregular, less deformed, than after cau- terization. 9th. Simple and multiplied punctures.—Proceeding ofthe Author.— As may well be supposed, I do not here raise the question of pri- ority for the purpose of deciding it in my favor. I write for the practitioner, who, perhaps, cares but little for the hand that offers him a therapeutic measure. What he chiefly wishes to know, is its efficacy, and how it is to be employed. I will only remark, therefore, that in the first edition of my work on surgery, I recom- mended small incisions, punctures with the lancet, and I claim only to furnish arguments in favor of this practice, and to teach it more in detail than others. I pass, then, at once to the modus faciendi, to the proceeding that constitutes the basis of my practice. We commence, if possible, by shaving the tumor. As it is sel- dom that a bubo has not had at least one plaster applied, we should remove its effects. The instrument required for the punc- ture is a straight, sharp bistoury, the blade of which is not larger than a penknife ; or Ave may use a lancet. If the suppuration be not extensive, and the abscess recent, we make but one puncture, or one incision, of a centimetre in extent, over the fluctuating point. We sometimes find that but a single gland has suppurated, and it is then emptied of the pus which it contains ; the other and adjacent glands are only engorged; should they afterwards sup- purate, they should be treated like the first. We may thus open, and successively puncture, as many as four glands. It is especially among scrofulous subjects that this peculiarity presents, and which must be treated by successive punctures. When suppuration exists within the gland, it is more difficult to be detected, because more deeply seated; we must then extend our incision to a greater depth in order to reach the cavity. This is another argument in favor of the knife over the caustic, as with the knife we may reach any desirable point, and the instrument may assist us in our explorations. 252 VIDAL ON VENEREAL DISEASES. Should the purulent collection be of greater extent and more superficial, and the skin more or less detached, we must make several punctures at the same sitting. But instead of making them at the most fluctuating point, we must avoid the centre of the tumor, and regions where the skin is thin ; instead of being direct, they should then be sub-cutaneous, so as to reach the pus by a circuitous route ; it is, therefore, towards the circumference of the tumor that we should enter the knife, the point of which is di- rected towards the centre of the cavity. In this manner, the skin is divided where it is inherent, intact, and in possession of all its vitality. When punctured Avhere it is thin, denuded, and pos- sessed of but little vitality, the opening is likely to become en- larged from mortification, Avhich is hastened by the puncture, an enlargement of the openings is thus produced, the result of which is a general communication. A large breach of continuity is now formed, to which the air has access, placing the bubo in the unfa- vorable circumstances of those that have been freely opened by the caustic or the knife. In making the punctures at the points indicated, if the tumor be not compressed (it should not be com- pressed for a few days after the operation), it is gradually emptied, and the cavity is, in a measure, filled by the contraction of its walls. The cure is then much more rapid, and it leaves no un- pleasant traces behind. The cicatrices of these punctures, indeed, resemble those of leech bites; and, like the latter, they finally completely disappear. The punctures thus made, obliquely and towards the circumference of the tumor, excavate passages of which the walls sometimes contract too speedily on themselves, whereby they become obliterated before the pus is completely evacuated. But, as several openings are made, and as it is rare that all are obliterated by compressing the tumor slightly once a day, the cavity may be discharged through the openings that re- main. It will be remarked, that I here advise compression which I so recently proscribed; but it will doubtless be remembered, that it was for the few days following the operation, when the pus is still abundant, and the openings perfectly free, that I recom- mended to abstain from compression. Sometimes all the openings have a great tendency to close speedily. I formerly tried to keep them open by means of a tent of charpie; I now prefer to let them close, after which, if any pus remain, I make one or two more punctures. Sometimes what remains becomes absorbed, and there is, of course, no necessity for repeating the punctures. The advantages of this method are obvious; 1. It is of easy and rapid application; 2. It is less painful than the others; 3. It pro- duces more speedy cures; 4. It leaves no deformity. I know what objections may be urged against it. It may be said that it is really advantageous only in the case of sympathetic buboes, or those which result from the extension of the inflammation, or from irritation of the genital organs, in other words, when the abscess is of a simple character; it may be urged that in the case of really syphilitic buboes it has not the same advantages, as the little open- ings will become inoculated and transformed into so many chancres, bubo. 253 which may become united and confounded into one, constituting one vast ulcerated breach of continuity. In the first place, the roof of the inoculation of these little punctures is very difficult to e found; and if I should reckon syphilitic suppurating buboes by the number of those which having been thus opened, were inoculated, I should find that there were but a small number of buboes in my service which had that nature. I have not witnessed this inoculation • more than three times in a year. But I would observe, that when a bubo is established I adopt general treatment. Others will say that this goes to show that many buboes, even syphilitic, produce a pus that is not inoculable. They may explain the fact as they please. It may also be said that I do not often penetrate the substance of the gland, and that I reach the surround- ing cellular tissue only, which is possible. What I maintain, for I treat the question in its practical bearings only, is, that in adopt- ing my proceeding buboes are sooner cured and without deformity, which cannot be claimed for the other methods. I have stated that I have rarely observed the inoculation of the trifling wounds thus made; I will add, that I have seen one or two instances in which some of the wounds became invaded, the others remaining unaffected. But if all the wounds did become inoculated, thus forming one vast chancre, it would then possess the inconveniences of the other methods, of the free incisions, and cauterizations which I know are exposed to the action of Adrulent pus. The students who have followed my visits, and who have been attached to my service, have been able to observe and compare the results obtained by this method with those that have followed the others, and they can appreciate its value. M. Caillant, one of my internes, has collected a very considerable number of cases which deserve publication. 10th. Puncture with Injections of Iodine.—M. J. Eoux, of Toulon, and Marchal (de Calvi) have proposed simultaneously to inject the purulent cavity with the combination of iodine, employed in the radical treatment of hydrocele. In the first place, we empty the abscess _ by a puncture, and with a small syringe, introduce into the cavity the tincture of iodine diluted with equal parts of water. This mixture then takes the place of the pus, comes in contact with the Avails of the cavity, stimulates and so modifies them as to promote the adhesions which should obliterate the cavity. The iodine acts also as a resolvent on the engorged glands, which is of great advantage in cases of strumous complication. 11th. Compression.—Compression has been proposed both as an abortive means, and consequently to be employed at the com- mencement of buboes, and as a resolvent means, to be used in the case of chronic indolent buboes. In speaking of the abortive treat- ment, I have already stated that it is impotent, and among the abortive means I include compression. But, if it be well supported and continued for a long time, if the surgeon knows how to resume its use Avhen the tumor has a tendency to be reproduced, very good effects may be derived from compression in the case of strumous buboes, especially if, at the same time, we administer internally 254 VTDAL ON VENEREAL DISEASES. medicines adapted to the nature of the case, and to the diathesis under the influence of which these tumors are developed. The preparations of iodine are here suitable, as are the mercurial, when the indolent bubo is a consecutive accident, or one of the effects of Best is an excellent auxiliary to compression; the patient should observe it as much as possible. We may compress with the spica bandage, under which may be placed graduated compresses; or we may use a hernial truss, the pad of which should be adapted to the volume and form of the tumor. At the Hopital du Midi, a little apparatus has been successfully used which was invented by a former externe. It is a little oval pad covered with leather It is fixed by a strap which, being attached to the extremity of the pad, at the internal part of the inguino-crural fold, passes around the thigh, reaching on its external surface, an iron loop attached to the external surface ofthe pad passes through it, and having been reversed is passed around the pelvis, gaming the opposite side of the body, then arriving at the anterior wall of the abdomen it descends obliquely towards the compressive pad, and passes through a buckle on its internal side, by the aid of which the apparatus is tightened at pleasure. An apparatus is required for PflOil S1Q.G [Another method of pressure has been recently recommended by Dr. J. H. Clairborne, in the Stethoscope and Virginia Medical Gazette. He states that in his hands it has proved incomparably superior to any other discutient. It consists in the application of Collodion, which, when applied too thickly, he has known to con- tract so tightly as to split the epidermis, in fissures around the borders. He recommends its application in thin layers, allowing one layer to dry before another is made. The above account we gather from the Nashville Journal of Medicine and Surgery for June 1853, p. 351.—G. C. B.] . 12th. Various Combined Methods.—-It is rare that m the treatment of bubo, especially its chronic form, different means are not resorted to and that these means are not alternated, and in a certain manner combined. Thus, in the treatment of bubo, which M. Eicord regards as the necessary accompaniment of the indurated chancre, local mercurial frictions, the plaster de Vigo, and general treatment, should go hand in hand. According to the same practitioner, a combination very often efficacious in the treatment of non-specific indolent bubo consists in the employment of blisters, mercurial ointment and cataplasms, as long as we obtain an amelioration; but if it remain in statu quo, the bhster is allowed to dry in order that Ave may resort to compression, which in turn is continued whilst it produces a diminution, and is abandoned if it produce no effect for the blister; and thus in succession these means are employed until a complete cure is obtained, f I have been desirous of noticing this combined treatment as it was proposed by M. Eicord himself. The * Ricord, Traite pratique des maladies veneriennes, p. 588. f Ricord, Traite, &c, p. 588. VEGETATIONS. 255 obscurity of the formula will perhaps be noted at once as well as the difficulty of its execution. In conclusion, I still advise the general treatment adapted to the nature of the tumor; this is the best of all resolvants. CHAPTER VII. VEGETATIONS. These are parasitic growths appearing on different parts of the integuments, and which resemble certain vegetables. Situation.—In the male, they are observed most frequently on the mucous membrane, covering the glans and lining the prepuce; in the female, at the entrance of the vagina; we may find them, and not unfrequently, in the vagina itself; I have seen them on the neck of the uterus and surrounding the nipple. In both sexes they occur in the Aticinity of the anus, in the urethra, especially at the entrance of the canal; they are met with also in the genito- crural fold, at the umbilicus, on the lips, mouth, and base of the tongue. I once saw them on the mucous palpebral lining, in a subject that had suffered from blennorrhagic ophthalmia. Varieties.—All seem to penetrate the dermis, and to be more or less expanded. Their mode of insertion and expansion, their pedicle, and color, present differences which have caused them to be compared with warts, cauliflowers, leeks, strawberries, and raspberries. Some are sessile, having no pedicle—they are small, and their surface is fissured: these are the paler vegetations called warts. When there is a kind of stem, of one or more lines in length, with a swelling of a deeper color, in the shape of a fur- rowed head, it is called the leek. If the stem give rise to many branches, which shoot off so as to form several united bouquets, then we have the cauliflower excrescence. There are other vegeta- tions with protuberances strongly marked, of which the shoots are less distinct, the prominences less decided; they are quite red; they have been denominated strawberry excrescences or raspberry excrescences, according to the depth of their colors. ( Vid. plate 4, fig. 1.) The form of the vegetations occasionally depends upon the seat Avhich they occupy: thus, in a prepuce somewhat narrow, they are pressed between this envelope and the glans, and assume more or less the form of the crest of the cock (fig. 1, plate 4); the same sometimes occurs when they are seated betAveen the nates. Structure.—All of these vegetations are more or less vascular, and especially the last-named varieties. By prolonged maceration all that part above the level of the skin becomes discolored and reduced to a whitish pulp, Avithout any regular organization, and resembling coagulated albumen ; it is easily removed by scraping. ThroAvn on hot coals, this matter desiccates, hardens, turns yellow, and emits an odor like that of burning horn, or other productions 256 VIDAL ON VENEREAL DISEASES. of the epidermis. In fact, M. Sibert has discovered, by means of the microscope, that these vegetations contain only cells of the epidermis and a vascular element * The point at which they are inserted into the integuments appears to be somewhat thicker than in the normal state; it is redder, and traversed by numerous vessels, some of which penetrate the vegetation. The dermis seems also to be a little thickened. The epidermis is not perforated, but rises with and covers the vegetation. Sometimes the vegetation is but a disease of the mucous or cutaneous follicle, preceded by a little black spot on the skin ; the secretion of the follicle becomes more and more concrete, the follicle itself suffers a kind of extro- version, and presents a granulated base, on which are seated rough projections in the form of a leek. Symptoms.—Frequently the appearance of the vegetations is not preceded by any modification of sensibility. The patient some- times experiences a slight pruritus at the point where the vegeta- tion is about to shoot forth ; this pruritis increases, and there is a sensation of pain until the production appears. Once developed, it is often indolent or only painful when chafed. At other times, it is painful even without the application of any irritating cause. There are cases in which it may be said that there is no pain in the vegetation, but the latter may be the exciting cause of it: for example, when numerous and voluminous vegetations are enclosed within a narrow prepuce, they are a source of irritation, and in- flame the lining membrane of the glans, as well as of its envelope; they distend, and stretch the latter so as to produce severe pains, Avhich cease on the division of the prepuce to a sufficient extent to expose the morbid mass. In these cases, especially after they become exposed to the air, they assume the color of the raspberry. A discharge is now secreted of a very disagreeable odor. The vegetations themselves may be the seat of a congestion bordering on inflammation. Sometimes they slough, and this is one method of cure. But as this mortification is but partial, the cure is not com- plete ; roots always remain, from which the vegetations may be reproduced. Complications.—Accidents.—The venereal accidents which I have regarded as the starting point, the cause of the vegetations, may also exist as complications; thus, chancres more or less advanced, a blennorrhagic inflammation, mucous tubercles, according to their seat and volume. Vegetations may themselves give rise to acci- dents, and interfere with important functions ; as of the urethra, the vagina and the penis. The possibility of a cancerous transformation of the vegetation is generally admitted. I am inclined to believe that those which have been regarded as cancerous transformations, were primarily of that character; in other words, that the venereal vegetation did not exist. Diagnosis.—This is easy when observed on their first appear- ance, and when their development has been watched. But, under the opposite circumstance, it is more difficult. The vegetations * Physiologie pathologique, t. i., p. 23. VEGETATIONS. 257 on the glans and prepuce furnish the most frequent examples of difficult diagnosis. Thus a vegetation incarcerated within a narrow prepuce in a state of phimosis, may be very difficult of detection. It may be regarded as an indurated chancre, a calcareous concre- tion, or a deposit of sebaceous matter, according to its volume, consistence, and insensibility. At a clinical trial of the concours of the central bureau, a patient was submitted for examination who had a congenital phimosis. This patient, already advanced in years, for a long time had had a tumor within the prepuce. By pressing through the skin, this tumor was insensible and very hard; the introduction of a probe produced no pain, and gave exit to not the slightest particle of blood. The majority of the jurors remained doubtful of the nature of the tumor, and in this uncer- tainty the candidate participated. An incision of the prepuce, afterwards made, revealed the existence of a very old vegetation which possessed but little vascularity. Lately there was in _ my service a young man who had within his prepuce a very decided induration, clearly representing a vegetation; the appearance of an eruption (roseola) disclosed the fact of the existence of a chancre, with a very indurated base. But the cases most obscure, and those in which the diagnosis is really of great importance, are those of old degenerated vegetations, which invade and cover the glans, and which present a cancerous aspect. The morbid masses, in these cases, exhibit softening at certain points, and at others indurations ; some become mortified; hence, they have a grayish aspect, an unequal consistence, and are the seat of a sanious fetid discharge. If to this condition, we add the emaciation of the subject, the pallid countenance, the ef- fects of a prolonged suppuration, and it must be admitted, some- times of treatment, it will be perceived how easily these vegeta- tions may be confounded with cancer of the penis, and we need not be astonished that such errors have been committed ; the mis- take may be so complete, as to induce the practitioner to ampu- tate the penis. This error, sometimes, is not removed even after amputation and dissection of the parts. The cause of this is the atrophy of the glans caused by the compression of the vegetating mass; this is occasionally so great that the glans seems to have disappeared. But when the diagnosis has been clearly established, when the vegetations alone have been removed, the glans gradu- ally recovers its form, and almost its ordinary volume. The diag- nosis, I repeat, is here very obscure, and we are deceived in a double sense Indeed, in certain cases, true vegetations have been mistaken for cancer, and vice versa. The first mistake was com- mitted in my service, by one of my former internes, Avho has writ- ten on venereal diseases, and the other by surgeons who quickly decided to sacrifice the organ. Besides their microscopic charac- ters, vegetations are to be distinguished fr©m cancer, after their removal, by their great vascularity, which causes them in a short time after separation to diminish one half in size. During life, the diagnosis is much more difficult, especially if the early develop- ment has not been seen. If observed at the onset, it will be 17 258 VIDAL ON VENEREAL DISEASES. found that cancer does not at first appear as a pimple, but as an ulcer; and it is surrounded by more or less induration. Vegetations seldom exist alone; they first appear by several shoots, and the surrounding tissues are soft, except when they spring up on the induration around a chancre. Age, also, should be taken into consideration. Thus when the subject is young, there is greater probability that induration may exist. We should also have a regard to glandular engorgements ; thus, in the vegetations which do not succeed to a chancre nor to a blennorrhagia, there is no glandular enlargement. When cancer of the penis exists in its early stages, there is almost always a very hard and indolent en- larged gland, before it undergoes the process of softening. But here, as in all other cases, this circumstance should be noted, with- out attaching to it too great importance. Glandular enlargements are among the most common causes of mistakes in diagnosis. Causes.—Blennorrhagia, balano-posthitis, and chancre, are the principal causes of vegetations; thus they may shoot forth at a point of the integuments only, that has been inflamed, excoriated or ulcerated; in fine, vegetations may be the first as well. as the last symptoms of contagion. We see vegetations succeeding im- mediately to posthitis, we know that they may shoot forth on the cicatrix of a chancre, and they may appear on the glans without inflammation or previous ulceration; the same may occur at the anus. As a consecutive accident, they may occur at any period of syphilitic infection. I have now in my service, three patients with vegetations around the anus; one of them is young, and has acknowledged unnatural connexion; the second, for three months has had a chancre on the penis; and the third has also had a chancre on the same organ; but for five years his sys- tem has been fully infected, and the vegetations have been the last to appear. Vegetations may, therefore, belong both to the primary, and the consecutive accidents. Nature.—It has been maintained that they are not of venereal origin. According to some writers on syphilis, they are but parasitic growths generated under the influence of the irritation excited by a blennorrhagia or chancre, or produced by some other irritating cause, as for example, the irritating discharges secreted by the genital organs of the pregnant female. I deny that any irritating cause may give rise to them ; there are cases, indeed, in which they shoot forth, without any previous irritation. We never find a vegetation appearing without an antecedent, without venereal accidents, without some preceding inttmate connection. Thus irritation of the glans and the prepuce without sexual inter- course is not uncommon in very young boys ; vulvar inflamma- tions are often observed in young virgin girls ; yet we never find vegetations occurring at this age, nor after this kind of inflamma- tion. But if the subject has had connection, the case is different; then, vegetations may shoot forth from the slightest irritation. Again, the syphilitic nature of the vegetations is incontestable, when they appear as consecutive accidents, long after the chancre that preceded them. There is another argument against the doc- VEGETATIONS. 259 trine that these vegetations are the result of simple irritation; and that is, their very decided tendency to reproduction. Transmissibility.—This is now placed beyond doubt, by the ob- servations of the majority of writers on syphilis, and especially of MM. Baumes and Eeynard (of Toulon). The latter thus remarks: " Incontestable facts prove that the form of syphilis which I am now considering (vegetation), without being so uniformly conta- geous as chancres, are capable of being directly transmitted."* I am at present treating a young girl who had connection for the first time with a man affected with vegetations on the corona glandis; she has vegetations on the vulva, and these have been preceded by no other symptoms. I should remark, that the vege- tations on the young man grew on the cicatrix of an indurated chancre, but the chancre had been completely cured for two years. Treatment—This is both general and local. Those who pretend that vegetations are not caused by the syphilitic virus reject the general treatment, and proscribe mercury. Those, on the contrary, who believe in the specific character of these morbid growths, re- commend a general treatment. The remedies indicated may be inferred from the circumstances in which they are developed. I have shown that they may appear in all stages of syphilis, and that they may be the first apparent symptom of infection. Now when they appear during the existence of a diathesis, they are rarely alone, but are accompanied by other accidents requiring a general treatment; hence all doubts of the propriety of the latter are removed. Sometimes, they appear after all the other accidents, and then general treatment has in most cases already been adopted, and this has consisted either of the preparations of mercury or of iodine. Constitutional remedies may now produce no effect: the vegetations have become localized, they no longer have deep roots, but are a kind of remnant of the disease. Topical treatment, trifling surgical operations, should now be preferred; for if entirely extirpated, they do not return, as is so often observed under other circumstances. When vegetations are primary, when they constitute the first ap- parent symptom of the infection, we should still pursue a general treatment, if we would not expose the patient to the liability of frequent returns, and if we desire to prevent complications. More- over, facts go to show the efficacy of a general treatment; a re- markable instance may be found in the work already mentioned of M. Eeynard (of Toulon).f Under the influence of the concen- trated syrup of sarsaparilla, with the addition of the corrosive sub- limate and the extract of opium, in fifteen days well-marked vege- tations Avill become softened within, and drop off, no more to re- turn. I shall never forget the case of a young girl I found in the ward of St. Louis when I entered on service at the Lourcine. Both the labia majora and the labia minora Avere covered Avith small vegetations which produced an intolerable pruritus, and even severe * Traite pratique des maladies veneriennes, p. 310. f P. 312. 260 VIDAL ON VENEREAL DISEASES. pain. All kinds of powder and ointments had been employed; some of the vegetations had been removed with the knife, but had reappeared, whilst the others remained. No general treatment had been undertaken; mercury had not been administered, perhaps because the young patient was feeble and of a lymphatic tempera- ment. I thought best, however, to prescribe Dupuytren's pills, and in less than twenty days the vegetations began to wither, and' by degrees they fell off spontaneously. I have observed other cases of the kind, but truth compels me to admit that vegetations most frequently remain in spite of general treatment. We must therefore resort to topical treatment, to the ligature, and to excision. There are numerous topical applications which have been greatly multiplied on account of nervous patients who dread anything like an operation. Saturated solutions of opium, crude opium, iodide of iron, sulphate of copper, and calomel, have all been used. The most successful method is the following: ^. Savine, 3 i. Alum,Cale, 3 i. Reduce to a very fine powder. Wash tlve vegetations twice a day with red wine; cover them afterwards with a thick layer of the powder. In the course of three or four days the vegetations become feeble, and the patient may begin to remove them with his finger nails. After each separation, there is a slight bloody discharge, which may be arrested by the vinous lotion, after which tlie powder is reapplied. When the vegetations are not very numerous, and have not a large base, this method is successful, and the patients are delighted to operate on themselves, and to cheat as it were the hands and knives of the surgeon. Some practitioners prefer cauterization; for this purpose, the nitric and the hydrochloric acids, the nitrate of silver, and the butter of antimony, have been employed. That most used at the present day, and which is the most efficacious, is the nitrate acid of mercury. A vegetable, silk, or silver ligature has also been used, but this method, tedious in its effects, equally painful with cauterization or excision, is now generally abandoned by surgeons. Some patients still submit to it; they gradually tighten the knot, and as they themselves operate, and can suspend its action when they please, they actually suffer more than they would under the hands of another. But topical applications cannot reach the root of the vegetations; if with ligature or caustic, Ave act to such a depth, we should produce most violent pain, and of longer duration than that resulting from excision. A cutting instrument should therefore be preferred when we have reason to suspect that the roots of the vegetations are not very deep, when their base is large, and when, in fine, we would pre- vent a return. A forceps may be used to seize the vegetation, and it may be excised with flat curved scissors. When it is some- what large, but little prominent, as we often find on the genital organs of the female, it is sometimes difficult to seize it, it glides MUCOUS TUBERCLE. 261 between the blades. I use small forceps (a dents de rat), which will embrace the quantity and only the quantity of the mucous membrane required to be removed around the vegetation, and this is extirpated without being torn. My rat-toothed forceps are much employed by oculists in their operations on the eye-lids and the eye. Some surgeons cauterize the wound left by the opera- tion ; but it is unnecessary if the limits of the skin have been sur- passed ; if they have not been passed, then the extirpation has not been well performed; if we resort to caustic, then we inflict two operations. It is better to seize the whole thickness of the integu- ments, and not be too saving of the parts removed. Especially should this rule be followed, if the integuments be more or less altered and thickened, either by the venereal affection on which the vegetation has sprouted, or by its age, which by long irritation of the skin, has developed on its tissue a hypertrophic action. After the operation, blood often flows in great abundance, especially when the excrescence is seated on the glans. Cold ap- plications should be applied at first, and the parts should after- wards be dressed as in the case of a simple wound. It should be well understood that extirpation is not to be attempted, if there exist chancres which have not healed, for the wound may then be inoculated. As a general rule, we should not operate until all complications are removed. However, there is often around the vegetations an irritation, an inflammation even, that subsides only when these excrescences have been removed. CHAPTER VIII. MUCOUS TUBERCLES. These are also called, according to their aspect and form, flat pustules, fiat tubercles, mucous pustules, mucous patches or papules, [and condylomata.—G. C. B.] They consist of elevations of which we may have a very correct idea if we imagine the application of disks more or less perfect, or portions of a disk, to the integuments. Situation.—These tubercles form on the mucous membranes and portions of skin Avhich, either naturally or from disease, resemble mucous membrane: thus, the skin on the genital organs, on the parts adjacent, and at the bend of the thigh. In the female, they are more frequently observed on the vulva; whilst in the male, they are found at the margin of the anus. The scrotum, penis, perineum, are also frequently affected. They have been observed at the genito-crural fold, at the umbilicus, in the external auditory canal, and behind the pavilion of the ear, in the axilla, the mouth, the commissures of the lips, on the tongue, the internal surface of the cheeks, on the tonsils, and the walls of the palate, at the en- trance of the nostrils, the alae of the nose, the base of the toes, around the nails, the nipples, and the neck of the uterus. These 262 VIDAL ON VENEREAL DISEASES. tubercles may occupy nearly all of these regions, on the same subject, and assume all the forms Avhich I shall soon describe. At present (March 16th, 1852,) there is in my service a man forty years of age, who has tubercles on his ears, nose, lips, tongue, right axilla, at the genito-crural fold, on the scrotum, perineum, anus, and between his toes. Causes.—Mucous tubercles are more frequently observed in females, owing perhaps to the extent of the mucous membrane lining their genital organs, and the delicacy of their skin; children and lymphatic subjects are also strongly predisposed. Want of cleanliness is favorable to their development: indeed, a female seldom comes to tlie Lourcine from the country, in whom mucous tubercles do not exist. Corpulent persons, whose acrid perspira- tion accumulates in the genital fold, the irritation produced around the margin of the anus by prolonged walking, and especially by constipation, are among the causes which favor the development of those venereal accidents. The surface of the integument fre- quently exposed to the action of the matter discharged in blennor- rhagia, is sometimes covered with mucous tubercles. It is ad- mitted, that chancre may be transformed into a mucous tubercle, and this too at the moment when a chancre is healing, but healing irregularly ; in such a case, the tubercle is only a transformation ofthe chancre. The truth is, that a tubercle may appear even at the point where a chancre is seated, as it may appear on a surface simply inflamed; such sometimes being the result of a balano- posthitis. It may therefore be regarded as a consecutive accident, but it may, likewise, be altogether primary; in other words, it may be the first accident observed to follow a suspicious con- nection. In females, the mucous tubercle most frequently exists as a primary symptom; in the male, on the contrary, it is generally found to follow a chancre on the penis and urethral blennorrhagia, whilst it is itself followed, some time afterwards, by the same dis- ease at the anus. This, moreover, is one of the accidents which most compromises the classification of diseases, the syphilitic acci- dents, into primary and secondary, if we attach to this classification a doctrinal and absolute sense. Symptoms.—The mucous tubercle may appear one or two weeks after coitus, and often during the existence of chancres, or of blen- norrhagia. Sometimes there is a period of incubation of two or three months, and even longer. Occasionally they appear at once (d'emblee); they then constitute the first symptom of the pox. They resemble disks, or portions of a disk, glued on the surface of the integuments. Sometimes they have an oval form. The smallest are simple papules which increase to the size of a lentil; the largest, the true clusters, seldom exceed the size of an Ameri- can {lime (fifty centime piece). When several pustules come together and become confounded into one, they may be of very large size. Instead of remaining in the state of patches adhering by one entire surface, these excrescences, especially when of long standing, ;% • *V Fill. Fi§ 2 ?- ^> /d / jd/t/<-<> a/">" '/ t///Vt W. jrss'.r. d:l. I L' inciair Lith v- ? ' 3C t -* •n • . WO \ MUCOUS TUBERCLE. 263 become now and then detached and pediculated, assuming the form of the vegetations in condyloma. Thus, in the patient to which I have alluded, who was almost covered with tubercles, those in the axilla and the genito-crural fold strongly resembled the vegetations of which I have spoken. When seated on the mucous membranes, the color is more or less of a lively red, whilst on the skin, in the majority of cases, they are brown. Around them the coppery areola of the syphilitic eruptions is often observed. The surface is sometimes smooth, slightly fungous, and sometimes presents a macerated appearance. Occasionally they are completely fungous, and of a violet color. In persons of a brownish color, even when they grow on the skin, they are fissured, and appear as if irritated. They may have an eroded and even ulcerated surface, resembling that of chancre, especially that form known as the ulcus elevalum. They generally secrete a serous like, or sero-purulent fluid, which has a peculiar and repulsive odor. The pus becomes more strongly marked as the ulceration is established and the pustules are irritated. Seldom do the mucous tubercles exist alone, especially about the anus and the vulva. They may be extremely numerous, and as I have already stated, occupy several regions; generally they occur in groups, or are arranged in order, on a line more or less curved: thus, they will appear on the edge of one of the labia, or on one side of the nates. Then, in the majority of cases, if the person be careless, we observe on one of the labia or nates, tuber- cles precisely like those on the opposite side. It is not uncommon to find two, one of which seems moulded on the other, to such a degree as to resemble the valves of a shell. This resemblance of two tubercles, situated on organs adjacent to each other, is another argument in favor of the contagion of this form of syphilis. (Vid. Plate IV. Fig. 2.) In this symptomatology I have particularly dwelt on the charac- ters of those most known, viz. those on the genital organs and around the anus. There are others less known, either from their infrequency, or because they are so situated as never to lead to the suspicion of their existence, or, in fine, because their characters are less marked, and probably, also, because, up to the present time they have not been described. I proceed to point out the appear- ances by which they may be known, which will complete the general sketch and facilitate their diagnosis. In the nasal region they may be found either without or within the nostrils, and at first resemble those at the angles of the lips; they are seated in the groove that separates the cheek from the ala of the nose. They are of smaller size than those on the hps, being occasionally not larger than the head of a pin. Sometimes we find in the groove ab,ove mentioned an elongated scale, which is very thin, ulcerated, and transformed into a fissure. After this has healed, there remains a dark red shade, which cannot deceive the observing physician, and which may become a precious sign in forming a diagnosis. Within the nostrils, or at their entrance, these 264 VEDAL ON VENEREAL DISEASES. layers are less frequently observed; they generally form a swelling with crusts, the fall of which exposes a red and gray surface, then the crusts are renewed until a cure is completed. The cure is retarded by the excoriations produced by the patient in his efforts to relieve the itching. On the toes and around the root of the nails, the tubercle has nearly the same characters. Almost always the patches are ulcer- ated and resemble rhagades of the anus. The most prominent portion is of a bluish color and round between the toes. They are elongated at the root of the nails and follow the direction of their base. The ulceration differs in the two cases. Around the nails, they are irregular fissures, with edges more or less turned over on the nails. These layers are painful and emit the most fetid odor, when the patient does not observe cleanliness. They are very speedily affected, and are quickly cured. In the aural region, it occurs at the junction of the concha with the mastoid region, around the auditory canal, and assume the form of the swelling which we find at the entrance of the nostrils. It may also be found even in the auditory canal. On the neck of the uterus, it is often of a reddish gray color, very round, distinct, and a little larger than a lintel. It has been seen, at the same time, on both the upper and lower lip. At the umbilicus, the patch occupies in part or entirely the um- bilical depression; it is ordinarily prominent, of a reddish-gray color, humid, and of a sickening odor. Sometimes there is pruritus, but rarely pain. Around the nipple we sometimes find an excavation, lined by a layer which somewhat overlaps it; it has a grayish aspect, is humid, smooth, and there is an oozing of muco-purulent matter. In the buccal region, the mucous tubercle is constantly seated on the external border of the lips, at the commissures, and on the internal surface of the cheeks; on the edges of the lips are little projections, generally, of an elliptical form, varying in number and covered with crusts. They frequently exist undetected, and often disappear but readily return. These patches almost always co- exist with a similar condition of the throat and the genital organs. At the labial commissures it is of a granulated aspect; there are at least two of nearly equal size, one on» the superior, one on the inferior lip; one fissure separates them, a fissure that remains after the removal of the patches. These are likewise very often undis- covered. We see nothing but the fissure which is regarded as being independent of syphilis. On the tongue, we find patches on the apex, the base and borders, They are very large, of an elliptical form, and sometimes ulcerate. In the female these patches almost always coincide with a similar affection of the vulva. On the velum palati and tonsils, mucous tubercles are of frequent occurrence, especially on the latter. They often escape detection at their origin, for then they are not prominent; they are round, multiple, sometimes confluent, and almost always of a grayish- white color. ^Occasionally they ulcerate at the centre, or at other MUCOUS TUBERCLE. 265 points of their surface. The tonsils are often enlarged and of a red color, which spreads to the surrounding parts. With the patches in this region there exists symptoms of angina, pain in the throat, exasperated by deglutition, catarrh, and a little coryza. In the axilla, where pustules are rare, they are sometimes seen prominent and a little pediculated.* Diagnosis.—The description which I have given constitutes a true diagnosis. The ulcus elevatum alone can be confounded with the tubercle in question. But this form of chancre generally ap- pears on the edge of the prepuce, where tubercles are not common, and it is preceded by a true ulceration; besides, it requires a much longer time for its cure. [There is one point connected with the diagnosis of the mucous tubercle to which for a moment we solicit the reader's attention. Waller, who is at the head of a large venereal hospital at Prague, has reported, among other cases, that of a nurse named Watzka, who became affected by suckling a syphilitic child. In describing the mucous tubercles which formed on this nurse's breast, he states that the one on the right breast was of the size of a bean ; that on the left of a pea, and that they rested on a broad base. M. Eicord would impeach the accuracy of Waller's diagnosis, on the ground that they rested on a broad base, and asserts (Letter xxix., p. 221) he knows not Avhat may be regarded as mucous tu- bercles at Prague; but at Paris, those described by M. Waller would be considered as very excellent specimens of indurated chancre with a broad base! The nurse's nipples became affected from mucous tubercles on the child's lips. Now let us examine a few French authorities upon the subject of this broad base of mucous tubercles. In the Bibliotheque du Medicin Praticien, vol. vii, p. 260, it is stated that " mucous tubercles vary in breadth from the simple papule, the size of a lentil, to a tubercle as large# as a half dime or dime piece. Again, at page 261, quoting from MM. Baumds and Eeynaud, we find that their volume varies from that of a small lentil to a dime piece." M. Eayer (Lond. Ed. by Dr. Willis, p. 812) observes, " that these tubercles attain a size but little less than that of a shilling" (Eng- lish). At p. 813 he remarks, that when situated on the breast they sometimes ulcerate to a greater extent than they are ever ob- served to do in any other part of the body." M. Cazenave (Bulkley's 2d. Ed. from Transl. by Dr. Burgess, pp. 303, 304) states that " these tubercles are occasionally as small as lentils, at other times thick, of a deep livid red color, and as large at the base as a shilling'''' (English). M. Simon (Gustav.) in his work " On the Diseases of the Skin, as elucidated by Anatomical Investigation," Berlin, 1848, (Med. Ghir. Review, April, 1849, p. 357,) says, "thediameter of the broad condylomata (mucous tubercles) varies from that of a lentil to that * Vide, a memoir of MM. Deville and Davasse in the Archives generates de medi- cine. 266 VIDAL ON VENEREAL DISEASES. of a groschen (in size equal to the American quarter eagle, or $2.50 gold piece). M. Eicord's contempt of the diagnosis made by M. Waller in the above case, arises solely from the fact of his (M. Eicord's) op- position to the doctrine of the transmissibility of secondary acci- dents, and all who do not join in his faith must suffer from his un- sparing sarcasm and ridicule.—G. C. B.] Contagion.—Inoculation.—The contagious character of the mu- cous tubercle; in other words, its transmissibility from one indi- vidual to another by intimate contact, is generally admitted, since it is almost universally acknowledged that it may be a primary accident. M. Eicord is, with but few exceptions, the only writer on syphilis that denies its contagious nature. Nevertheless we find certain doubts expressed in his work, certain contradictions which would place him among the contagionists. However this may be, those practitioners who have the opportunity of seeing both together, know what credit to attach to the contagiousness of these pustules. They will see on the left side of the scrotum a flat tubercle resembling that on the right side of the vulva with which the man had had frequent connections. I retained for a long time in my service a patient affected with the mucous tuber- cles at the margin of the anus, of which I have had a sketch taken; those on the right nates seem moulded on those of the op- posite side, as represented in plate 4, fig. 2. The following is a report of the case made by Mr. Pellagot, one of my internes. This case shows not only the remarkable relation existing between the tubercles on both sides of the anus, but it is an excellent example of the multiplicity ofthe syphilida on the same subject. G. (Alain,) set. 25, currier by trade, of bilious temperament, and good constitution. Admitted 3d Nov. 1851, into Ward 9, bed No. 7. 1845. Blennorrhagia, which lasted six months. Treated by copaiba. 1849, (Sept.) Blennorrhagia and chancre on the prepuce. The former lasted two months, and was treated by cubebs. The chancre was cauterized by the nitrate of silver. At the end of about fifteen days it was cicatrized. No other treatment. 1850, (October.) Blennorrhagia, chancre on the glans, suppurat- ing bubo in the right groin. The patient Avas treated at the hos- pital at Nantes. For a month he took a fluid which he believed to be a solution of iodine. 1851, (August.) A warty excrescence was developed on the skin of the penis, at the very place where a chancre had pre- viously existed. Two others, smaller than the first, grew on the edge of the prepuce. They appeared four or five days after the last coitus. Eight or ten days after the appearance of these vegetations he had a urethral blennorrhagia. The patient is positive that there was no abrasion on the glans; for fifteen days he has observed absolute continence. Six weeks after the vegetations, three weeks after the urethritis, MUCOUS TUBERCLE. 267 mucous tubercles appeared on the scrotum and at the anus. Balanitis, followed by phimosis. At the same time an exanthe- matous syphilitic eruption. Finally, twelve days since, there was a lichenoid eruption and alopecia. On the 3d Sept., at the time of his admission, in addition to the vegetations on the prepuce, the urethral and balanitic discharge, the patient still presented various kinds of eruptions. On the lower extremities, and the arm, copper-colored spots without elevation, having had at first a rosy color for the extent of a franc piece. These spots are parti- cularly remarkable on the legs, where they are more numerous and larger than elsewhere. On the chest and the forehead lich- enoid eruptions; on the neck squamae of psoriasis, and on the whole side crusts of the pustules of ecthyma. Finally, on the scrotum, and at the anus, mucous tubercles abound. At the anus, especially, these excrescences assume a re- markable disposition. There is indeed the closest resemblance between the tubercles on the right and those on the left side. The patient declares that their appearance was not simultaneous, but that there was some days interval. On the 5th he was placed under the influence of pills of the proto-iodide of mercury, and in three months the patient left, cured. (Vide Fig. 2, Plate 4). For a long time experiment has corroborated the results of ob- servation, and Wallace repeatedly inoculated the mucous tubercle from a diseased to a sound subject with success. And yet, not- withstanding our frequent and easy communication with Dublin, attempts have been made in France to conceal the results obtained in that city! Wallace denuded the skin, by a blister or other- wise, and applied to the denuded surface portions of the mucous tubercle, or charpie impregnated with the matter secreted; he thus produced, almost at pleasure, tubercles which varied in form, but which belonged to the class of accidents called secondary. M. Bouley, a hospital physician, whose attention was aroused by my experiments in inoculating syphilitic ecthyma, undertook with M. Schneph some bibliographical researches and experiments, which form a part of an elaborate memoir published in the Annales des maladies de la peau et de la syphilis, (vol. iv., Oct. and Nov., 1851.) This memoir contains the report of numerous cases, copied from the work of Wallace; they leave no doubt whatever of the transmissibility of the mucous and of other tubercles belonging to the class of accidents called secondary. The memoir is invaluable, particularly on account of a case reported under the supervision of M. Bouley, by M. Schneph, interne at the Lourcine. This case, Avhich cannot be too frequently studied, itself resolves two questions of the highest importance, for it proves: 1st, that the mucous tubercle may be inoculated; 2d, that a subject that has been completely infected with syphilis, and passed through all the different stages of the disease, may have a second attack. The following is a synopsis of the report: Patient, a female, at the Lourcine (service of M. Bouley). Had suffered from constitutional syphilis, as was manifested by disease of the fibrous and osseous systems; she had gummy tumors and 268 VIDAL ON VENEREAL DISEASES. necrosis. A blister was applied to the arm, and, after the removal of the epidermis, for three days it was dressed with charpie im- pregnated with the secretion of mucous tubercles on another pa- tient in the same hospital. On the fifth day after the inoculation, the blistered surface had healed; but on the seventeenth day, lenticular pimples, of a copper color, covered the blistered part; on the twenty-seventh, crusts appeared, and the eruption was pro- nounced ecthyma by M. Cullerier, which by M. Cazenave was re- garded as syphilitic. A second blister, dressed simply, and not inoculated, promptly dried, and was followed by no eruption. There was here, therefore, as in other cases of inoculation that I have known, a long incubation. It lasted seventeen days. A constitutional syphihtic accident afterwards appeared, but in a form less profound than the patient had already experienced; since the accident inoculated was a syphilitic eruption, a cutaneous affection, whilst the others involved the fibrous and osseous sys- tems. Further, forty-eight hours after inoculation, there followed a syphilitic fever, connected with the new infection. There was intense cephalalgia, the crusts of the ecthyma remained, and there was an appearance of tumors in the subcutaneous cellular tissue, together with a kind of imperfectly-defined nodes, like those on the female from whom the matter was taken for inoculation. This new syphilitic excitement was advantageously modified by mer- cury, although it had resisted the iodide of potassium. Thus, I repeat, this case at once destroys two dogmas:—1st, that of the non-transmissibility of syphilis in its secondary form; 2d, that which proclaims that syphihs cannot affect an individual but once during life. Waller, physician to the hospital at Prague, has inoculated by another proceeding: instead of removing the skin by a blister, he scarified the parts. The subject inoculated was a young lad who had never suffered the slightest venereal symptom. The matter of inoculation was taken from a subject affected with mucous tubercles. Charpie was impregnated with the secretion of these pustules, and applied to the little wounds already made on the thigh of the young lad. The whole was secured by dressing, par occlusion, that prevented the contact of any other substance than the charpie saturated with the morbid secretion. There was at first a little inflammation, or, to speak more properly, some red- ness, which disappeared at the end of four days; finally, it Avas not until the twenty-eighth day from the inoculation, that tuber- cles and papules appeared at the place of inoculation, and symp- toms of general infection. There were, in this case, at first, inflammatory phenomena, which were soon extinguished, an eruption which aborted, and, some time afterwards, the effects of the virus were produced in the most incontestable manner. We may often meet with analogous cases; the eruption which first appears may abort, and after this the true syphilitic eruption is observed to follow. [There is abundant proof, as we have already shown, that inocu- lation with the matter of chancre does not always produce the MUCOUS TUBERCLE. 269 same invariable result, the so-called characteristic pustule; and such, as might be expected, is the case with that of secondary acci- dents—ag; for example, the mucous tubercle. We have mentioned the fact that Dr. Skae, of Edinburgh, in four out of thirty-six in- oculations of the matter from mucous tubercles, produced positive results, but, "in the only cases in which my inoculations suc- ceeded, the effect took place within one or two days," (Cormack's Lond. and Ed. Month. Journal, July, 1844, p. 620.) " In all of these, the first appearance presented in the seat of the inoculation was a pustule on the second or third day, as in inoculating from a chancre. At length a scab formed, which appeared to be seated on sores depressed below the level of the adjoining surface, but without the elevated or hardened edges, or the defined circular form of chancre. These continued to increase in size, preserving the same appearance and covering, until they met each other and coalesced. On the 14th day, these crusts became detached, and a fungoid excrescence, having all the appearance of a condyloma, shot up from the sore." We quote from the abridged account of Dr. Skae's article, which originally appeared in the Northern Jour- nal of Medicine for April, 1844.—G. C. B.] Whoever peruses the remarkable work of Waller,* may see with what rigorous precision he has selected the elements of cer- tainty, when, from his own clinical observations, he remarks: " Strongly as the above cases show the great probability of the contagious nature of secondary syphilis, I could not and would not rely on them alone; I sought, certainty, and believed that it could be found only in inoculation. The following is the princi- pal instance of inoculation: " Durst, aet. 12, No. 1396, for several years was affected with tinea favosa, of the head, a disease for which he had been several times treated in the institution; his health is perfectly good, and he never had an eruption of any kind, nor was he ever troubled with scrofulous affections. As his disease compelled him to re- main for several months in the building, and as he had never had syphilis, he was considered a proper subject for inoculation: which was performed on the 6th August, 1850. A scarificator, perfectly clean, was applied to the anterior surface of the right thigh, and into the Avounds thus made, still fresh and bleeding, pus from mucous tubercles was inserted. For this purpose, a narrow wooden spatula was employed, together with charpie saturated with pus, which was gently rubbed on the surface of the wounds, and Avhich was afterwards there deposited and secured. The mat- ter for inoculation was taken from a woman (named Nemee), who, indeed, presented the cicatrix of a chancre, but who, at the time, had no primary sore. On the labia majora and minora there were mucous pustules, covered with an exudation partly croupy, partly purulent. These croupy exudations, besides, existed throughout * De caractcre contagieux de la syphilis secondaire, by Dr. Waller, translated into French, by M. Axenfeld, in the Annales des maladies de la peau et de la syphilis, April, 1851, and Gazette des Hopitaux, for the same date, by M. See. 270 VIDAL ON VENEREAL DISEASES. the throat, and in the commencement were attended with an ulcer- ation of the tonsils; an eruption of blotches covered the Avhole body. This woman, at the same time, had a vaginal blennor- rhoea. " On the next day, August 7th, and the following days, the wounds made by the scarifier and the intermediate skin, Avere slightly inflamed; but at the end of four days the wounds were all closed: there was no trace of inflammation, and the whole sur- face in general resembled that which has healed after scarification. " On the 15th August, I remarked at the seat of inoculation, some red spots, and on the 30th August, consequently twenty-five days after inoculation, I discovered fourteen cutaneous tubercles, the majority of which had arisen even in the cicatrices of the wounds. These tubercles were almost all confluent; four only situated on the edges were isolated; their base was large, their size that of a lentil, in many that of a pea; hard to the touch; most were of a deep red, some of a deep yellow color; their form was perfectly round; on some there was a slight desquamation; nothing abnormal in the other parts of the body—(no treatment). On the following days, the tubercles still increased in volume, and became blended together ; they then represented a patch about the width of a dollar (thaler), were soft, projecting half a line above the level of the skin, and covered Avith grayish scales, which be- came thickened and finished by forming the large crust common to tubercles. In cleaning this surface Avith hot water, the crust became detached, and the tubercles then appeared under the form of flattened elevations, slightly excoriated, but which were promptly covered with new, thin, dry, and grayish scales. " The 27th September, twenty-seven days after the appearance of the tubercles, and fifty-two after inoculation, a maculated syphi- litic eruption appeared on the skin covering the lower part of the abdomen, chest, and back. " These spots were for the most part united, some were a little prominent, isolated, of the breadth of a millet-seed or a lentil, of an oval and elongated form, some of a pale yellow, others of a reddish-gray tinge, without areola, itching or pain, completely dry, without crusts and scales. The next day, and the follow- ing, the number of these spots prodigiously increased, and the whole body was covered. There was no febrile disturbance nor was there any symptom of catarrh, &c. In the early part of Octo- ber, some of these spots became elevated into pimples, others into tubercles, and altogether had a physiognomy so characteristic, that without inquiring into the antecedents, any physician would at once have pronounced them to be syphilitic. There was no affec- tion of the throat; but as this papular and tubercular eruption sufficiently proved the success of the inoculation, I now feel jus- tified in giving publicity to the case." I still repeat that there was here, between the inoculation of the secondary accidents, and the true results of the infection, a period which is not observed to follow the inoculation of chancre. And I would here especially remark, that the wounds for the inocula- MUCOUS TUBERCLE. 271 tion were dressed with charpie, and that they were thus guarded against any other fortuitous inoculation. When I come to treat of ecthyma, I shall detail the facts con- nected with the inoculation of this secondary accident, which will present the same peculiarities. Occasionally nothing appears on the point inoculated for a long time, the true syphihtic eruption being the first to manifest itself The case which I am about to relate, in detail, the particulars of which were carefully collected by my former interne, M. Pella- got, differs from those which have been published by the experi- menters whom I have quoted. We here find the morbid secre- tion of a mucous tubercle producing in the first place a most abundant and most fetid suppuration, then an ulceration, and lastly, a patch analogous to a mucous tubercle. As it has been retended that the bhstered surfaces, which after the inoculation ecame transformed into tubercles, were nothing more than vege- tating bhstered surfaces, I was careful to make the counter proof; on the right arm, indeed, we observed a bhstered surface, which on being irritated for four days with strong blistering ointment, desiccated, healed without ulceration, or papules, whilst the same surface dressed only twice a day with the morbid secretion, be- came the seat of the most active inflammation, of an ulceration, in fine, and of a patch analogous to mucous tubercles. In addi- tion to the students who ordinarily attend my visits, the subject of these experiments was seen by Drs. Morel, Chausit, Auzias, Tur- enne, and M. Gosselin. P. aet. 19, tinsmith, temperament lymphatic, constitution very good, was admitted, July 17th, 1851, into Ward No. 10, bed No. 1, service of M. Vidal. Had had no previous venereal disease; Four or five months since had a chancre on the corona glandis. This chancre lasted a month, after which it cicatrized. An indu- ration remained in the situation of the chancre. Itchings begin to be felt about the anus, and mucous tubercles to appear. Present condition.—On the glans, Avhere the chancre was seated, the mucous membrane is red, thickened, and unbroken. Between the glans and the prepuce, there exudes a very thin scanty sero- purulent fluid. Tavo inguinal glands much developed, on the right side, a small one on the left. The whole are indolent. The sub-maxillary and anterior cervical glands enlarged. Posterior cervical glands not visible. About the anus are three mucous clusters non-ulcerated. Up to the present time has submitted to no treatment. On Thursday, July 24th, a small blister was applied to the left arm. It Avas covered with a watch-glass. Pills of mica panis. Friday, July 25th, first dressing. The epidermis raised by the blister is removed. A disk of blotting-paper covered with cerate, with an opening in the centre, of one and a half centimetres in di- ameter, is so applied to the wound as to secure the margins. The central part is dressed Avith carded cotton saturated with pus taken at the moment of dressing from mucous tubercles about the anus of a patient, in bed No. 38, of Ward No. 8, service of M. 272 VIDAL ON VENEREAL DISEASES. Puche. The whole is covered with a watch-glass, and secured by straps of diachylon plaster* Saturday, July 26th. Second and last dressing with the same pus as before. The old dressing is removed. Suppuration con- siderable. The odor resembles that from mucous tubercles. The wound is converted into a whitish diphtheritic-like pellicle, with black spots at certain points. In removing this pellicle, which ad- heres, and is torn by pulling, a slight bloody exudation is pro- duced. The edges of the watch-glass have cut the skin and pro- duced at its upper part a superficial excoriation which is distinct from that produced by the blister. Sunday, July 27th. The solution of continuity which was be- fore superficial, is deepened and has assumed the form of an ulcer, the edges of which are perpendicular to the base. The latter is of a yellowish-white color, and secretes a large quantity of well- formed pus, but of an intolerable fetor. In wiping with a compress the surface of the wound, we remove in part the false membrane that covers it, and then there is a little bloody exudation. The excoriation, produced by the edges of the watch-glass is converted into a deep notch which suppurates abundantly. The watch-glass is no longer used. Simple dressing with cerate. 28th. The ulcers remains the same. It secretes an enormous quantity of pus always very odoriferous. The edges are red, per- pendicular, and the base of the sore yellow. No enlarged glands are felt in the axilla. Simple dressing with cerate, and renewed twice a day. 30th, 31st. The wound retains the same characters; the sup- puration always abundant and nauseous. Dressed night and morning. August 1st. A blister similar to that on the left is applied to the right arm, and like the latter is covered with the watch-glass. 2d. The blister on the left arm remains in an ulcerated state; that on the right is dressed for the first time. The epidermis is removed, and a round shield of blotting-paper covered with blis- tering ointment is placed upon the wound. It is covered with a watch-glass. The left arm dressed with simple cerate. 3d. Left arm.—Flesh granulations begin to appear on the base of the ulcer which is partly cleansed, and is now of a coppery-red color. The suppuration is still very considerable and disagreeable. Dressing, simple cerate. Right arm.—The blistered surface has copiously suppurated; its surface is red, and the granulations not diminished. The watch- glass has produced a complete circular notch. Dressing of blis- tering ointment; watch-glass no longer used. * The following was the diagnosis of M. Puche, in reference to the accidents on the patient that furnished the matter for inoculation. Indurated chancre on the edge of the prepuce for four or five months, treated by an apothecary and healed. Mucous tubercles on the scrotum of fifteen days' standing. Mucous tubercles at the margin of the anus. Roseola nearly effaced. Ulceration on the right pillar of the velum palati. Rheumatic pains. No other symptoms. The pus for inoc- ulation was taken from clusters about the anus. MUCOUS TUBERCLE. 273 August 4th. Left arm.—The fleshy granulations have multiplied. The base of the wound is now on a level with its edges. The su- perior ulcer, caused by the watch-glass, does not yet seem inclined to cicatrize. Simple dressing. Right Arm.,—The blistered surface is of a rose color, and is not depressed. The circular notch produced by the watch-glass is effaced and replaced by a superficial excoriation. Dressing, blis- tering ointment. Aug. 5th. Left Arm.—The ulceration is replaced by a red layer, from two-fifths to four-fifths of a line in height, surface of a cop- pery red, and irregular. The circumference of this layer is quite limited and not hard. All around it, that portion of the blistered surface which has not been in contact with the specific dressing is red, without granulations, and covered with thin crusts formed by concrete pus. The wound produced by the watch-glass healed without granulating. The suppuration is someAvhat less bift always fetid. On wiping the wound with linen, it produced but a slight bleeding. Dressing of simple cerate. Right Arm.—The Avound presents the same aspect; it is of a rosy color, granulated, and not ulcerated. Dressing with the blis- tering ointment. Aug. 6th. Both blisters dressed with the cerate. 9 th. Left Arm.—The notch made by the watch-glass has healed. The diameter of the fungous growth is somewhat less, and it still projects from two-fifths to four-fifths of a line above the level of the surrounding parts. It is circumscribed by a reddish-brown circle, and its surface always presents the same irregularity, soft- ness to the touch, still furnishing a little pus somewhat less odorifer- ous. Simple dressing. Right Arm.—Nothing special. Cicatrization has commenced. Aug. 11th. Left Arm.—The wound is as large as a franc piece, and distinctly circumscribed. The granulations covering it are united together in such a manner that the surface is less unequal; it is of a pale red and somewhat copper colored, soft to the touch, and a little bloody when chafed by the linen. The suppuration, however, is now small in quantity; it still has an odor. Simple dressing. Right Arm.—Completely cicatrized. No dressing. Aug. 23d. The left arm has been dressed every morning during the visit of M. Vidal. The cluster has not changed its aspect; it is always about four lines in diameter, rising above the level of the surrounding tissues which have resumed their natural color. The surface is covered with soft fungous growths, not bloody, of a yel- low color, and furnishes a certain quantity of pus. 27th. No change. 29 th. There is an inflammation which appears as if inflated. Above this is an ulceration which is hollowed on a rose-colored protuberance, coA'ered with a cicatrix thin and transparent, Avhich has been produced in the twenty-four hours 30th. The rose-colored tubercle, in the centre of which the wound existed, has disappeared. The ulceration is now on a level 18 274 VIDAL ON VENEREAL DISEASES. with the surface of the skin; it is superficial, of a yellow color, and always of the same extent. The patient left the hospital. Nothing on the penis. The muc- ous tubercles about the anus are dry and have almost entirely disappeared. No eruption on the skin. During his stay in the hospital discovered no roseola. In the second week of September, the patient, who resided at Versailles, came to see us. He exhibited the arm inoculated, and in the centre of the blister we found an elevation, resembling a waistcoat button. It was dry, and of firmer consistence than the tumefactions which we have already observed at the same place; in fine, it resembled certain mucous tubercles that form on the skin of persons of dark complexion. Such is the case as reported by M. Pellagot. It may be objected, that, in this case, the blister on the left arm, was but the exciting cause of the accidents observed on that limb, as the subject inoculated was fully infected with syphilis, and had mucous tubercles at the anus. But why did not the second blister, that on the right arm, produce the same effects ? An ulcer, with a yellowish base, folloAved the active inflammation of the inoculated blister, and on this base a papule was developed. It may be urged that this ulceration was a chancre, and the papule a transformation of this chancre, which remained susceptible of the change. At first, the glands, in the vicinity of the points inocu- lated, were not enlarged, I am perfectly aware that we may have a chancre without a bubo, and yet I note this circumstance. Fur- ther, it is of but httle consequence whether this was a chancre or some other form of ulceration, for I do not pretend by inoculation to reproduce the same form of lesion as that which furnished the matter for the purpose. This is not the question; but the prob- lem is, to know whether a syphilitic affection can be communi- cated by the product of papular eruptions. Some may go so far as to say that I took the matter from a chancre, instead of a papu- lar eruption. To this, I reply, that Mr. Puche made the diagnosis impartially. These facts leave no longer room for doubt: the mucous tu- bercle may be inoculated and is contagious. I have already stated that M. Eicord stands almost alone in denying its contagiousness. But even by his own words, we may compel him to acknoAvledge the contrary. Indeed, at page 182 of his Traite pratique des mala- dies veneriennes, we find these words which I transcribe: " But ■ contagious by some incomprehensible vital action, and which cannot be explained, the mucous tubercle cannot be transmitted by inocu- lation." Thus, M. Eicord is evidently a contagionist, and he makes a distinction between physiological inoculation, which is contagion, and experimental inoculation. The latter only he rejects. MM. . Baumes, Eeynard (of Toulon) and other Avriters on syphilis who regard the mucous tubercle as contagious, do not admit its trans- missibility by inoculation. In a practical point of view, this re- jection is of no importance if we admit its contagiousness. But it is probable that if the writers on syphilis who deny the seconc MUCOUS TUBERCLE. 275 mode of propagation, had adopted the proceedings of Wallace; if they had repeated to a sufficient extent his experiments ; if they had not formed their conclusions until the required period of in- cubation had passed, a very long time when secondary accidents are inoculated; if these writers had properly performed their ex- periments, they would have observed results analogous to those witnessed by Wallace, M. Bouley angl all those who are aware that the chcumstances are different in the case of inoculation with the matter of secondary accidents, from those which attend the same proceeding with that from primary accidents. Treatment.—Begarding the mucous tubercle as a consecutive syphilitic accident, it may be stated that it is one which soonest appears and disappears. Eest and cleanliness are often sufficient to cause its disappearance from the genital organs and the anus, and this, too, in the course of twenty days, especially when they are not of long standing, nor complicated. Patients in my service affected with tubercles about the anus or the genital organs, take a hip-bath daily, except on the day of using the general bath. By these repeated, washings, and rest in bed, the tubercles shrink, and rapidly disappear. M. Baumes adds from one to three drachms of corrosive sublimate to the hip- bath. He applies a lotion of pure chloride of sodium, if the tuber- • cles are not ulcerated and surrounded by an inflammatory areola. When these complications exist, it is better to dilute the chloride with a certain quantity of water, so that it may produce only a slight smarting sensation, and not a real pain. The following is the formula of M. Baumes: ^. Chlor. Calc. vel Sod. § vi. Aq. dist. § xvi. This solution may be changed for that of the acetate of lead, sulphate of alumina and potash. Some practitioners prefer corrosive sublimate. From three to fifteen grains may be dissolved in two ounces of water, according to the susceptibility and irritability of the parts. We have then in vieAV not only the local treatment, but a certain influence on the diathesis, which I believe to be an illusion. The nitrate of silver is the substance that should be pre- ferred. It not only hastens reparation, but it is the agent which most promptly subdues the pain, relieves the smarting sensations, and the pruritus with which the patient is harassed during the night. The tubercles about the anus and perineum, which are more or less ulcerated, and the secretion of which inflames the sur- rounding skin, are those Avhich produce the greatest suffering Belief is afforded by the following application: R-. Nit. Argent. 3 iss. A([. dist. 3 iiiss. This may be repeated every three days, until the tubercles are evidently modified. 276 VLDAL ON VENEREAL DISEASES. After each cauterization, the hip-bath is to be used, and the parts should be washed with a decoction of poppy-heads, or a dilute solution of opium. They may also be touched with a crayon of the nitrate of silver, especially when we wish to limit the action of the caustic, as in cases of superficial ulcerations, or if the tubercles assume the form of condyloma; we may then, by cauterizing a httle more thc$oughly, gradually destroy the excres- cence, to the extirpation of which by the knife the patient may be opposed. The crayon is especially to be preferred in treating those tubercles which grow in cavities or on the uterine neck. Those in other regions may be sprinkled with some inert poAvder, such as amidon, or calomel (d la vapeur). I have never been an advocate for the use of ointments, either of mercury, the oxide of zinc, or of the iodide of sulphur. I have always found that their application only irritates the parts. Some practitioners employ them after the cure of the tubercles, in order to remove the stains that are left behind. M. Baumes places a high value on the following ointment: JJ. Calomel, 3 iiss. Axung. § viss. At the commencement of my remarks on the treatment of the mucous tubercle, I stated that this accident is one that most readily disappears, either from cleanliness or from the treatment which I have already mentioned. I should also add, that it is one of the accidents that most frequently returns, and that is most speedily and surely reproduced, either under the same or some other form, when the above measures only are adopted. We should, therefore, administer a general mercurial treatment, which should be commenced at the same time with the local, or after some days of repose, especially if there be marked irritation, or inflammation. The latter is the course which I generally pursue. In the case of inflammatory complications, when the subject is young, I begin with blood-letting from the arm ; this depletion is employed for the double purpose of subduing the inflammation, and of preparing the way for the action of the mercury. M. Baumes recommends the corrosive sublimate according to the formula of Van Swieten, or in pills. I prefer the proto-iodide, which I administer as stated in speaking of the treatment of con- firmed syphilis. I give the pills, when the tubercles exist with other accidents which show that the syphilitic diathesis is estab- lished. On the other hand, when we have reason to regard the tubercles as primary, the corrosive sublimate should be preferred. PART SECOND, CONSECUTIVE VENEREAL DISEASE (VEROLE). The diseases which form the subject of our present investiga- tions have been called consecutive, because they generally follow those considered in the previous section, and because the syphilitic virus has so acted on both the fluids and the solids as to create a special constitution, for which reason these consecutive affections are also called constitutional; writers also speak of a syphilitic diath- esis or confirmed verole, or simply the verole. I shall treat of these diseases in two different chapters. In the first, I shall consider them in general; I shall thus pass in review their characters, the period and order of their appearance; I shall inquire into the causes that produce them, and shall consider the syphihtic fever, and the state of the blood during the verole; I shall afterwards discuss the question, whether it is possible to have syphilis more than once, and shall conclude with an import- ant chapter, viz., the treatment of syphilis. In the second chap- ter, I shall treat of consecutive venereal diseases in particular. CHAPTER I. GENERAL REMARKS. SECTION I. CHARACTERS. The title of this chapter indicates what I have already stated, that the diseases which Ave are now investigating appear after those which have been studied in the preceding section. But I have not been absolute, and by my reserve I wish to show myself faithful to the principles which I have advocated in considering the subject of physiological absorption, which is the introduction of the syphilitic virus into the system, without ulceration, and with- out pre\dous inflammation of the surface to which it is applied. 278 A'IDAL ON VENEREAL DISEASES. Virus absorbed by a sound surface may produce precisely the same effects upon the system as that which has given rise to the so-called primary accidents, the diseases of this second section may therefore be primary; they may appear at once (d'emblee), and be the first manifestations of syphilis. But they are com- monly observed after a longer or shorter interval from the first syphilitic impression; they are apt to appear at several points, and in different regions at the same time, or successively, and may extend over a large surface; on this account they are called gene- ral affections. The syphilida, which may be seen growing at all points of the cutaneous surface, present a remarkable example of this form of venereal disease. On the contrary, the lesions most frequently primary are generally confined to the narrow sphere of contagion, hence they are called local. All the tissues may be invaded by syphilis, from the epidermis, the dermous and cellular, to the fibrous, osseous, and parenchyma- tous tissues. The lesions assume the most varied forms, from the simple pimple, to the largest sized tumor. Their color is of a reddish, coppery tinge, peculiar to the majority of these diseases; it is so characteristic, that it has been called the syphilitic tint. As a subjective symptom, nocturnal pains often exist; they are so inseparable from certain consecutive lesions, that their existence alone leads to the suspicion of syphilitic infection. Their progress is generally slow; we do not observe those severe inflammations which attend the primary accidents. They are rather alterations, which are slowly destructive ; for obstinate ulceration seems to be the characteristic of syphilis Avhen left to itself, and it infallibly produces this effect in bad constitutions, and where complications exist. If the influence of specific treatment in primitive venereal disease may be questioned, such is not the case here, for nature, in the majority of cases, is impotent, and simple measures are of no avail. On the contrary, in certain of the syphilida, the mercurial treatment, and in certain tumors the iodides of potassium, exert sometimes so prompt, so direct an influence, that it is impossible to deny their efficacy- But even here, we should not exaggerate the power of therapeutical agents, and undervalue that of the vix medicatrix naturae, which alone may cure the worst cases, when heroic means have failed. We will only observe, that such are very exceptional cases. SECTION n. PERIOD, AND ORDER OF APPEARANCE. When several consecutive accidents occur, they generally appear at different epochs. This fact has been noticed hy every observer. It has even been assumed, that they appear in a certain order. But these periods have not been definitely fixed, and this order, as is proved by observation, is not completely regular. According to Hunter, the period at which consecutive accidents appear, varies according to the susceptibilities of the parts in- PERIOD, AND ORDER OF APPEARANCE. 279 volved. In this point of vieAv, there are parts of the first order and parts of the second order. Those of the first order, that is, the most susceptible, are the skin, tonsils, nose, throat, internal surface of the mouth, and sometimes the tongue; in other words, the skin and certain mucous membranes. Those of the second order are the periosteum, the aponeuroses, and the bones. Hunter attrib- uted great influence to the air as a determining cause of constitu- tional affections, believing, as he did, that the morbid action was exerted more directly on the integuments, in consequence of the contact of the air producing there a greater susceptibility. Ap- plying the same theory to the evolution of diseases affecting the second order of parts, Hunter showed that the parts of the skele- ton nearest to the skin, were affected before the deeper seated bones; thus the bones of the head, the tibia, the ulna, the ossa nasi, become more frequently and more quickly affected than those of other parts. He also supposed that the susceptibihty might depend on the structure of the bones; it therefore depended both on the proximity ofthe skin and the hardness of ihe osseous tissue. Hunter, moreover, acknowledged that this order might be inverted, and he admitted the possibihty of the lesion of the parts ofthe second order, the first having'never been affected, that is to say, Hunter ha-ving a mind eminently disposed to generalize, lost no opportunity of so doing; but as he was at the same time a profound observer, the exceptions did not escape him, as he was sometimes sufficiently candid to acknowledge. Hunter, besides, never spoke of immutable laws, as he was too well acquainted with the nature of disease; he was well aware, that it is particularly during the existence of disease that laAvs are not constant. Thus in adopting the philosophic views of Hunter, and receiving his theory at its proper value, we may admit and sanction, to a certain extent, the two orders of lesions he established, and this too from undoubted analogies and proof the most direct. Indeed, when the s}Tphilitic virus is applied to the riving tissues, every part does not react equally against it, or rather, is not similarly affected at the same time. The integuments, as a general rule, are the first affected, or furnish the first manifestations of the im- pression they have received. This is not peculiar to the syphihtic virus; all morbid agents of this class produce analogous effects ; indeed, the virus of rubeola and of variola manifest their first effects on the skin by exanthematous and pustular eruptions, which are irritated by the syphilida; for the rubeola and the variola are repeated by roseola and jlcertain form of ecthyma. The parts belonging to the second order, Jfccording to Hunter, are the fibrous and osseous tissues of a much lower grade of action and vitality than the skin and mucous membranes; consequently, when morbid changes occur it is only after they have manifested them- selves on the integuments. The* skin, besides, being exposed to vieAV, its slightest changes of color and stains are seen even from the commencement, whilst analogous phenomena, passing in the subcutaneous tissues, the periosteum and bones, cannot be known, for there the lesions become appreciable only after a tumor has 280 VIDAL ON VENEREAL DISEASES. formed, when in fact they have existed for a much longer period. Thus, whatever view be taken of the matter, it will be seen that the cutaneous affections must be observed, before those more deeply seated. This has been noticed by the most simple ob- servers, but those who know how to interrogate nature completely, . will admit it as a general though not an absolute rule. M. Eicord adfcpts the division of Hunter, and denominates the diseases which anlct the parts belonging to the first order, secondary accidents, and those of the second, tertiary accidents, because he places at the head primary accidents. Syphilis may therefore be completely embraced in the following summary : 1st, Primary Accidents. * 2d, Secondary Accidents. 3d, Tertiary Accidents. This division is .an old triade ; for we find it complete in Thierry de Hery, and it has been traditionally handed down by every writer who*has followed him.* M. Eicord has rejuvinated it, has rendered it popular, by descending from his high philosophical position, and*by representing it as based on experiment. This, too, has been done at a time'when this method Avas much in vogue, and it has been represented as being capable of simplifying the study of syphilitic diseases. It is, therefore, greatly admired by certain minds, which are satisfied with a superficial investigation of mat- ters, and which have not the time to sift them to the bottom. Those, however, who like a thorough investigation, discover in this classification, serious and very grave objections. But as most of its opponents Avere not convinced of the utility of resort- ing to experiment, as they believed in its dangers and judged it immoral, they are disposed to neglect and even censure this means of popularity ; hence their little success compared with those who attach so much importance to this method of investigation. How- ever, among these opponents, there are some, who relying chiefly on observation, still know the value of experiment, and believe that when employed within certain limits, it may be advan- tageous to science, and that it does not violate the laws of morality properly interpreted. They therefore experiment more philo- sophically ; that is, without losing sight of observation, and not satisfied in addressing the mind alone, they speak also to the senses, and it was especially by means of experiments, that they * " Thierry de Hery. La Methode cuMtoire de la maladie venerienne, p. 133. Several symptoms or accidents are commo!rHo this disease, some of which precede, others follow, and others again supervenefpn these. Those which precede are ulcers of different kinds: ardor urince, buboes, which being said to precede, though they may be equivocal, and may or may not arise from contagion, do, nevertheless, most generally precede, and may serv^as precursors of the disease. The others, which we call consecutive, are pustules^and ulcers on all parts ofthe body, princi- pally on the private parts, the fundament, the mouth, the throat, the forehead, and the emunctories. In like manner, there is also a falling off of the hair commonly called peloda, articular pains, often also wandering, but seldom nodosities. " The latter which we call superadded or extraordinary, which appear after im- perfect cures, . Decoct, rad. Marsh mallow, § vi. Laud, of Sydenham. 20 to 30 m. Whatever may be the modus operandi of the direct means em- ployed to arrest sahvation, as they can act only temporarily on the local irritation without modifying the cause producing it, we should, according to M. Lagneau, consider them only as accesso- ries to other anti-sialagogues which have a tendency to displace this irritation or to render the mercury incapable of maintainihg it by causing it to undergo, if we can believe some authors, new combinations. At the head of these indirect means must be placed cathartics. They transfer the irritation to the intestines, and may thus prevent ptyalism, and their continued use is an excellent cu- rative means, when salivation has been produced. In the latter case it is an established principle that they must be administered much more frequently. Purgatives often promptly arrest the pro- gress of a salivation in the course of five or six days. Sometimes, however, it is not suppressed under from fifteen to twenty days. But even their purgatives are not without their advantage, for they may prevent the aggravation of the buccal irritation, even if they are insufficient to arrest its progress. It is customary to prescribe an ounce of the sulphate of soda or magnesia, to be taken in three glasses of chicory water, or a bottle of the solution of the citrate of magnesia. M. Lagneau recom- mends a pill of soap and aloes according to the following for- mula: IJ • Sapon. Offic. § ii. Pulv. Rhei. § i. Aloes. Pulv. (fine) | ss. Make into pills of one grain each, of which from three to six are to be taken in the day. Hot baths are frequently employed in cases of sahvation. Their efficacy is explained by the cutaneous excitement diverting the Atital forces which act too violently on the salivary apparatus, in which case their action may be compared to that of purgatives or other in- direct irritants. Foot baths may have the same effect, and may be used with benefit; the latter act especially as derivatives, if to them we add mustard powder or two ounces of hydro-chloric acid. Eecourse has also been had to the abstraction of blood by cupping, or to dry cupping, to rubefacients and dry frictions, in order to transfer the irritation to organs remote from the salivary glands. For this purpose even blisters have been used. They are especially useful when the salivation is disposed to continue very obstinate; for it sometimes happens that ordinary means fail, and we are obhged as a last resort to employ those of a severer nature. 314 VIDAL ON VENEREAL DISEASES. Bhsters like the cups may be applied to one or both arms; but the nucha of the neck is the place generally selected on account of its proximity to the parts. Mussa Brassavole, who wrote in 1551, believed that salivation was produced by mercury reaching the mouth in its metallic state. He recommends that the patient should constantly hold in his mouth a piece, or ring, of gold, in order that the mercury may combine with it, and thus lose its sialagogue properties. These experiments have been repeated by the most skilful chemists of our day, but they have never been able to detect a single atom of mercury on the gold. [The evidence upon this subject, afforded by the carefully-con- ducted researches of Dr. Samuel Wright, of Birmingham, England, is not without its value, confirming, as it does, the conclusions of Devergie and others, who have failed to detect any portion of mercury in the saliva of those affected with stomatitis. In his lectures on the physiology and pathology of the saliva, published in the London Lancet, Sept.,1842, p. 803, he remarks: "As far as my own experience is concerned, and I have operated largely, and with much patience, I can offer no evidence in favor of the presence of mercury in the saliva of people suffering from mercurial ptyalism. I have employed all the most eligible and delicate pro- cesses recommended by Christison, especially the galvanic test and destructive distillation, but not in one instance have I succeeded."— G. C. B.] The affinity existing between sulphur and mercury having long since been remarked, this simple substance was early recommended for the purpose of arresting the progress of salivation. It is given in substance, in the form of lozenges. Some advantage has been supposed to be derived from this agent notwithstanding our igno- rance of its manner of acting on our organs. Perhaps it is a derivative. It may also act as a stimulant to the alimentary canal, and by increasing the activity of the functions of the skin. M. Lagneau, who seems to be an advocate for the use of sulphur, reproaches it as well as other anti-sialagogues, with not constantly fulfilhng the expectations of the practitioner, but as its employment is sometimes followed with good effects, he recommends it more strongly, as it is very innocent and does not prevent the simulta- neous use of purgatives, of gargles, and other appropriate means. This practitioner has seen sulphur thus administered, three times arrest a ptyalism during the same treatment, in a subject whose • mouth became constantly affected by the slightest dose of mercury. Pearson observed the efficacy of sulphuric acid administered as a beverage, a sufficient quantity being used to give it an agreeable acidity. M. Lagneau, who has used both the mineral and vegeta- ble acids, speaks of it in the highest terms. I have thus noticed briefly as possible most of the means which have been employed in the treatment of salivation, but I should remark that all are not possessed of the same degree of efficacy. Slight cauterization with hydro-chloric acid or the nitrate of silver, and the use of purgatives, constitute the basis both of the direct THERAPEUTICS. 315 and indirect treatment. The other means are accessory, with the exception of local or general depletion in young and plethoric subjects, and when there is manifest congestion of the mouth. It should De well understood that first of all, the administration of mercury is to be suspended. Cholic and Diarrhoea.,—Mercurial Tremor.—At the present day perhaps mercury produces more frequently morbid effects upon the intestinal canal, than it does salivation, for it is almost always administered internally. Diarrhoea, and especially cholic, occur in certain patients after every dose of mercury, and continue during the day and following night. This accident is more frequent in females, and is much more frequently observed after the administration of the proto- iodide, than the bi-chloride of mercury, either because the latter is administered in smaller doses, or perhaps on account of its more frequent combination with opium; for the formula of Dupuytren is very much used. It is especially in cases where the mercury is thus administered that we observe constipation. It is not very rare, indeed, that hospital patients who are treated for primary accidents, with the pill of Dupuytren are thus affected. But this is an inconvenience of much less importance than diarrhoea and cholic; in the latter case the mercury should be either discon- tinued or its dose so diminished as no longer to produce abdominal trouble. In all cases it is better to combine it with opium. Mercurial tremors I believe to be very rare. I have observed them but in three instances, once in a gilder, and once in a-patient who for a long time had made use of frictions. There is at present in my service a patient in whom this accident has followed the administration of mercury in baths. As facts of this kind are rare, and as the cases are generally wanting in details, the circum- stances connected with this case besides seeming to possess a real interest, I here insert the particulars which I have been able to collect in regard to this patient. L. (Alf.) set. 19. Admitted March 15th, 1852, into Ward 9, No. 1. He has several times been affected with blennorrhagia. The last attack was in 1848. The treatment prescribed was yery irregularly followed. The patient suffered but little; the inguinal glands Avere indolent. During the latter part of 1849 (L. was in the hospital of Dijon) the discharge ceased at the moment of the appearance of a cutaneous affection, which the practitioner regarded as psoriasis. The patient made use of corrosive sublimate baths for three weeks, one every day. The quantity used in each bath is unknown. After the tenth bath, L. felt slight pains, accompanied with mus- cular contractions, especially in the arms. Soon a little tremor folloAved Avhich was but of short duration. The patient lost his appetite and suffered constant cephalalgia, with profuse perspira- tion. There was constipation as well as considerable debility, without much emaciation. During the twenty-second bath, L. had violent attacks with foaming at the mouth, and was insensible for two hours. There 316 VIDAL ON VENEREAL DISEASES. was convulsive rigidity of the extremities. With returning con- sciousness, he was seized Avith a general tremor so violent as to render walking very difficult. Five or six days aftenvards, the patient's condition began to improve, and in the course *of three weeks, the legs and arms alone remained affected with the tremors. He then left the hospital at Dijon. His disease diminished under the influence of simple baths ; the tremors became intermittent; he rarely, however, passed an entire day without an attack, having from one to twenty during the day. (Their duration was gener- ally from three to ten minutes.) Stimulating drinks, and strong mental emotions, exerted an influence in producing their attacks. The baths of corrosive sublimate effected no change in the con- dition of the cutaneous affection, which was not cured until two months afterwards. Notwithstanding this affection of the nervous system, the pa- tient indulged in sexual intercourse, and contracted a chancre, for which he came under our care. This chancre, of a serpiginous form, was very painful; he had also intense cephalalgia. The tremor, confined to the limbs, diminished under the influence of baths and mild purgatives. Of course I refrained as much as possible from the use of mercury when I commenced the general treatment. The above is an example of epileptiform mercurial tremors. As to the morbid affections of the skin and the kidneys, de- scribed in some books as the results of mercurial treatment, I am not aware that such have been carefully observed, and if they really deserve to be called accidents. If the reader have noted our remarks upon the morbid effects of mercury, he will have be- come convinced that this medicine produces those of a grave char- acter only when it has been improperly administered. By avoid- ing those proceedings which suddenly introduce into the system too large a quantity, as, for example, frictions, and by moderating the doses for internal use, we may almost always prevent, not only the slight inconveniences of the mercurial treatment, but the morbid effects which may be regarded as the accidents of this treatment. In conclusion, briefly, we would state, that the bi-chloride in small doses for the primitive accidents, the proto-iodide in little larger doses for the secondary accidents, are the two forms under which mercury renders most service in practice. IV.—IODINE. The introduction of iodine into the treatment is a recent and most happy event. It may, therefore, be of some interest to know how it occurred. In 1821, Coindet announced that an addition had been made to our therapeutics of a new resolvent, a precious discutient, viz., iodine. At the same time, a revolution was going on in England against mercury ; and France became converted to the opinions promulgated by Broussais. Mercury became unpop- THERAPEUTICS. 317 ular, not only because it failed to cure venereal diseases, but be- cause it provoked or aggravated the consecutive accidents. The innovators, therefore, proscribed mercury from the therapeutics of syphilis, and employed only soothing remedies, and anti-phlo- gistics, in other words, the means authorized by the physiological school. But the inefficacy of these means, in many cases, soon became apparent. Mercury they would not reinstate, for that would be a recantation, but they sought a new specific. Iodine arrested their attention, and to this remedy they resorted. Thus, in 1823, we find Bichond-Desbrus prescribing this metalloid in cases of bubo and blennorrhagia; in England the advocates of the same doctrine entered the same path, and iodine was pro- claimed an anti-syphihtic. V.—IODIDE OF POTASSIUM. Pure iodine is too difficult to manage, its effects are too diver. sified, too opposite even, for symptoms of intoxication are some- times observed after very small doses, whilst in other instances very large doses may be taken with impunity. It has, there- fore, been deemed advisable to combine this metalloid with other substances, and Buchanan, of London, was the first to unite it with amidon. He obtained an iodide of amidon, which was employed with the iodide of iron, both in France and London, as an anti- strumous, anti-syphilitie remea/, but this was done without method, and, it must be confessed, not with full confidence. Then (1836) appeared the famous lectures of Wallace.* This was the inauguration of the iodide of potassium as an heroic remedy against syphilis. One hundred and forty-two cases of venereal disease attested the virtues of the new medicine. And we must not omit here to mention that Wallace employed a formula which even to this day passes for one of the best. It is as follows: ]J. Iod. Potass. 3 ii. Aq. § viii. A tablespoonful to be taken four times in a day. In this manner the patient takes nearly half a drachm of the iodide in the day, which quantity, it was asserted, in the majority of cases, is sufficient to overcome the worst cases of syphilis. Soon Wallace had followers both in Germany and France. Cullerier, M. Eicord, and other practitioners still, experimented, and extolled the iodide of potassium in such a manner as to excite a real enthusiasm. They did not, however, go so far as to pro- scribe mercury, but the latter was compelled to co-operate with the neAV agent, and M. Eicord took upon himself to make the fol- lowing distinction in the treatment, viz., tertiary accidents were to be treated by the iodide of potassium, and the secondary by mer- cury. This gave rise to objections, which I shall make known. * The Lancet, March, 1836. 318 VIDAL ON VENEREAL DISEASES. The iodide of potassium has many arguments in its favor: first, the truly admirable cures obtained by it, in a short space of time (as I shall hereafter show), the facility of its administration, and the absence of all real danger, which is not the case with pure iodine and the other preparations. Further, the iodide of potas- sium being very soluble in water, it may be taken in all kinds of vehicles and drinks. Its action being infinitely less irritating than that of pure iodine, it may be administered in very large doses : a practitioner in Paris, indeed, having given an ounce, and even more, in a day. It may be used in as small a quantity as one and a half grains. There are but few substances capable of being ad- ministered according to so great a variety of formulas, and under so many different circumstances of age, taste, convenience, and even caprices of the patient. The dose may also be proportioned to the degree and nature of the accidents; for I shall, in another place, show that the iodide of potassium may fulfil a double indication. I shall not here insert all the different formulas which have been proposed for its administration, for, as has been stated, they are innu- merable. I shall mention only the principal and most important. M. Eicord employs the following : ]J. Iod. Potass, gr. iss. Syr. Papav. | i. Aq. dist. | iii. The dose is to be increased every five days about eight grains, until we reach one and a quarter ounces in the day, a quantity which should rarely be exceeded. A year afterwards, the same practitioner taught that we might commence with fifteen and even thirty grains a day, and that the patient would always tolerate two and two and a quarter ounces in the day. Finally, in his notes to the second edition of Hunter, M. Eicord observes : " When tertiary accidents alone exist, the most success- ful treatment consists in the use of the iodide of potassium. We may commence with forty-five grains in the day. This is to be taken in three doses, in three glasses of the decoction of sarsapa- rilla, of hops or soap wort. Every five days the dose is afterwards to be increased from fifteen to thirty grains, which I rarely exceed." The two following formulas shows how large is the quantity given by M. Puche: HOSPITAL FORMULA FOR THE SOLUTION OF THE HYDRIODATE OF POTASSA. ]J. Iod. Potass. | iii. Aq. _ § xii. « Cochineal, q. s. f. rose-colored solution. To be used in cases of chronic syphilis and tertiary symptoms, such as ecthymatous ulcerations, tubercles, periostitis, exostosis, and caries. Dose, from one to four ounces in a pint of bitter or sudorific tisane. To be taken at six different times at regular intervals. THERAPEUTICS. 319 SYRUP OF IODIDE OF POTASSIUM. IJ,. Iod. Potass. 3 v. Anisette of Bordeaux, § iss. Syr. Sacch. § xiv. Cochineal, q. s. Dose, from one to four ounces a day in half a pint of cold water. The wlwle to be taken in four doses at regular intervals. N.B.—The dose of the hydriodate of potassa in this syrup may be in- creased to three ounces. I employ the iodide of potassium both as a tonic and an anti- syphilitic. I never give more than fifteen grains to fulfil the first indication, and rarely exceed one drachm for the second object. Let me explain : I beheve that almost all cases of syphilis may be sucessfully treated by mercury, if this medicine be properly man- aged ; but sometimes the system is antipathic to it, and then, instead of producing curative, it produces morbid effects: thus, patients who are excessively debilitated, cannot be treated with mercury, which evidently depresses the ■vital forces, since it is called a hyposthenisant. I give, in these cases, the iodide of potassium, in doses from one to one and a half and fifteen grains, but never in larger quantities. With these doses I do not propose to act upon the diathesis; I aim not directly at the virus, but I endeavor to act upon the system, to strengthen it, and to place it in the best possible condition to resist the intoxicating agent, and at a later period to tolerate the use of mercury. The iodide of potassium is not, therefore, a specific, and when it cures, it does so indirectly, by a contre-coup. The stomach regains its tone under the influence of these minute doses, the .appetite becomes keen, nutrition active, the strength re-established, and it is not uncom- mon for the patient to acquire a certain embonpoint. But some- times the venereal affection continues obstinate. If the case be one of the superficial syphilides, it does not disappear; it may even become aggravated ; uoav is the time to interpose the use of mercury, which may be employed alone, if the patient's strength be restored, or its use may be conjoined with that of the iodide of potassium. At a later period of the disease, when the fibrous, osseous, and deeper-seated tissues, are involved, it is of great im- portance to give specific doses, those which act directly on the malady. We may commence Avith half a drachm, and the same week increase the dose to one or one and half drachms a day. The following is my formula: ]J. Iod. Potass. 1 ss. Aq. dist. | viii. A tablespoonful to be taken morning and evening in a glass of hop or soapwort tisane. The dose may be gradually increased to six spoonfuls, and as, accoi'ding to this formula, each spoonful contains fifteen grains of iodine, we give, therefore, one and a half drachms a day. I do not ordinarily prescribe the latter quantity. 320 VIDAL ON VENEREAL DISEASES. At the Hopital du Midi, the bottles containing the iodide are marked with transverse lines on their sides, so as to make divis- ions, each of Avhich contains a tablespoonful of the solution, or fifteen grains of the iodide ; the whole bottle contains eight spoon- fuls. I have them made containing sixteen spoonfuls. It is evident that the iodide of potassium, in a large dose, acts directly upon the diathesis; first, by the beneficial modifications which it produces on the disease in an incredible short space of time, and before the general health appears to be the least im- proved ; 2d, by the failures which occur when less than fifteen grains have been administered, and the success obtained by in- creasing the quantity in precisely the same cases. I have known a young literary character, who had a chronic ulceration at the base of the tongue sufficiently deep to lodge the extremity of the finger. This patient was treated without success for six months with the iodide, which was not given in larger quantities than eight grains in the day. He had been treated in the country. On his arrival at Paris he came under my care, and I commenced with thirty grains a day; this quantity was increased to one drachm a day during the first week, and in thirty days the ulcer had completely healed. [There can be no question that the iodide of potassium is often administered in doses too feeble to derive all the benefits that this remedy is capable of affording. Dr. Graves recommended thirty grain doses three times a day. During our recent visit to London we saw some inveterate cases of syphilis, which had re- mained for many months in the hospitals, and we ascertained that they were taking but two grains three times a day! But can the iodide of potassium cure even the tertiary stages of syphilis ? We beheve not, and such we find is the opinion of many experienced practitioners whom it has been our privilege to meet not only in Europe but our own country. As remarked by Sir Benjamin Brodie (Lect. in Lond. Lancet, Feb. 17, 1844), " You may remove slight symptoms by giving it for a time, and severe symptoms, by exhibiting larger doses ; but in the latter case, so far as I have seen, it does not make a permanent cure, for the symptoms return again. As a prophylactic, it is not to be compared with mercury." In a letter recently received from Mr. Langston Parker, he says, " I believe the curative effects of iodide of potassium have been over-rated. It suspends disease, but often fails to cure. Iodic cachexia, which is common from its prolonged use, is worse than any symptom which mercury produces. I have known it taken by patients for three, seven, and in one case (a surgeon) ten years ; it always kept the disease in check, but when discontinued the symptoms became Avorse." In this view of the subject, as we have been personally assured, Drs. Mussey, Willard Parker, and John Watson, coincide. At the Dublin Lock Hospital, we were informed, that in cases of much debility, they employed a combination of iodine and soda instead of the potash. It is administered in ten-grain doses three times a day. For a full account of the evidence in favor of iodine THERAPEUTICS. 321 and its compounds, we would refer the reader to the elaborate article of Dr. Hocken in the Ed. Med. and Surg. Jour. vol. lxi., and the work of Dr. Dunglison on New Eemedies, last edition. —G.C.B.] The iodide of potassium may also produce a prophylactic effect; it may assist the mercury in preventing the formation of the last stages of syphilis. Thus I often give it in small doses, after a complete mercurial course, in the treatment of primitive or sec- ondary accidents, which have exhibited an unusual degree of ob- stinacy, especially when the patient is feeble. I then dissolve the iodide in the syrup of fumitory, or of burdock, of which a table- spoonful is to be taken two or three times in the day in a glass of hop tisane. I have already shown that the use of the iodide is not to be restricted to the tertiary accidents, but that it has been used dur- ing every period of the anti-syphilitic treatment. If we examine the list of cases reported by Wallace, we shall find that it con- tains those of secondary accidents, and of late this medicine has been proposed not only in the second stages of syphilis, but even in the first, the so-called primitive accidents. MM. Payan* and Bazinf- have published facts, going to shoAV that this powerful agent may in certain of these cases produce happy effects. I am far from wishing to dispute these facts, for I possess those of an analogous nature, having experimented with this medicine in every stage of syphilis. I have seen chancres and secondary cutaneous affections cured during the employment of this remedy; but its therapeutic action has never appeared so prompt and weh defined, as when it is employed in the treatment of very chronic tertiary affections; in fine, I have never been able to satisfy my- self beyond a doubt of its efficacy in the other forms of the dis- ease. In these new applications the cure may doubtless be re- ferred to the iodide, but we should not overlook the efforts of nature, for in almost all a sufficient time elapsed to permit such a result. [The recent memoir of M. Melseus " On the Employment of Iodide of Potassium as a Remedy for the Affections caused by Lead and Mercury," has attracted considerable attention. He main- tains that, after its absorption into the blood, it combines with the metallic poison, and forms with it a new and soluble salt—liberates the poison from its union with the injured part—dissolves it out, so to speak, and sets it afloat in the circulation. Thus free, as supposed, in the form of a double iodide of mercury and potas- sium, it escapes through the kidneys, in combination Avith any ex- cess of iodide of potassium that may be present, and both remedy and poison are cast out together. Dr. Wm. Budd has given an analysis and translation of this memoir in the Jan. Number (1853) of the Brit, and For. Med. Chir. Eeview, and another notice of it by Mr. Parkes, Clin. Prof, in University College, may be found in * Vide Journal de la Societe de Medicine de Bordeaux, 1844. f Gazette des Hopitaux, 1843. 21 322 VIDAL ON VENEREAL DISEASES. the April Number of the same Journal. Dr. Budd has appended numerous remarks corroborating the vieAvs of M. Melseus. Some twenty years ago Mr. Judd, in his Treatise on the Venereal, p. 564, thus remarked: " After mercury has produced ptA'alism, broken down the general health, and begun to bring scrofula into action, iodine then appears to act in a far more salutary Avay than in cases wherein no mercury has been taken. Is it not possible, nay even likely, that under these circumstances the iodine (espe- cially the hydriodate of potash) being taken into the system, forms an Hydriodate of Mercury in the living blood ? Seeing that Bin- iodate of Mercury, in a solution of Hydriodate of Potash, formed a crystalline triple salt, I attempted to procure similar crystals from the blood after a course of mercury and Hydriodate of Potash, but failed." He then resorted to other experiments, from which he concluded that both mercury and iodine were present in the blood. The perusal of Mr. Judd's remarks upon the subject has satisfied us, that to him is due the credit of first promulgating the views now broached by M. Melseus. To those engaged in the investigation of this subject we would recommend the perusal of the interesting Essay of our esteemed friend Dr. J. W. Corson, entitled " Canes testing the Iodide of Potassium, as an Antidote to the Injurious Effects of Mercury, and corroborative ofthe Experiments of M. Melseus," published in the New York Journal of Medicine and Collateral Sciences, Sept. 1853.—G. C. B.] ACCIDENTS ATTRIBUTED TO THE IODIDE OF POTASSIUM. Strictly speaking, these are not true accidents;. they are, in the majority of cases, pathogenetic effects which subside on the dis- continuance of the remedy, and which never assume a serious importance. These effects are manifested on the mucous mem- brane of the nose, eyes, mouth, stomach, and intestines; they may likewise be observed in the urinary organs, the skin and nervous system. The most prompt and common effect is upon the pitulary and ocular mucous membrane. The majority of patients are attacked at the commencement of the use of the iodide of potassium, with coryza which is sometimes very acute. At the same time well- marked symptoms are observed of catarrhal opthalmia, with more or less decided serous chemosis and oedema of the eye-lids; some- times this amounts but to a simple redness. It is rare for both mucous membranes to become the seat of a muco-purulent secre- tion. I have seen a patient at the Hopital duMidi, whose conjunc- tiva at first became tumefied, after which followed a sanguineous effusion into the cellular tissue of the eye-lids, which absolutely discolored them like an ecchymosis. The patient, seen at a dis- tance, seemed to wear large glasses of a violet blue color. I treated him for a chronic engorgement of the testicle; he Avas very much debilitated; he took only fifteen grains of the iodide of potassium. Salivation frequently occurred; it resembled that of pregnant women, consisting of a kind of regurgitation of a saline saliva, of THERAPEUTICS. 323 a metallic and bitter taste. To a certain extent it was like a mer- curial salivation, for in some patients an erythematous, cedematous tumefaction of the gums occurs; but this congestion never amounts to an inflammation as in the case of a mercurial ptyalism. Fur- ther, it is never accompanied with ulcerations of the lining mem- brane ofthe mouth; it has neither the peculiar odor nor fetor of the breath. According to M. Payan, chemistry has been able to detect the presence of the hydriodate of potassa in the saliva.* In the majority of cases the digestive organs tolerate well the use of the iodide of potassium, and we often observe an increase of the appetite, especially when it is administered in small doses; but sometimes patients complain of a pain and uneasy sensation in the region of the grand cul-de-sac of the stomach. This pain sometimes resembles that of pleurodynia. This did not escape the attention of Wallace; he speaks of a cough and difficulty of respiration. But the pain in these cases is more profound than in pleurodynia. In certain cases the thirst is increased, although generally the appetite alone is augmented, and nutrition promoted, so that the patients soon acquire a degree of embonpoint. Some- times, but more rarely, vomiting and diarrhoea are observed. M. Payan mentions the case of a scrofulous child, in whom the iodide of potassium produced a chronic gastro-enteritis, which required nearly a month for its removal. A. chronic gastro-enteritis, how- ever, which soon subsides, I must say is an accident of very little importance, and I would add, that M. Payan attributes the dis- ease in this case to faulty nutrition. Symptoms of bronchitis have also, though rarely, been noticed. Certain affections of the skin may also appear; these most gener- ally assume the form of acne, and ecthyma, with very small pus- tules. I treated a patient in town whose face was covered with an eruption which resembled the first appearances of variola, and this occurred on the next day after the commencement of the administration of the iodide of potassium, if we exceeded fifteen grains at a dose. It is still more rare to meet with the spotted malady of Weslohl. M. Payan cites an example in his memoir. The patient was of a lymphatic temperament. He had taken the iodide for two months. Spots appeared on both legs resembling ecchymosis resulting from a contused wound. The urinary organs are very much affected in certain subjects, and the secretion of urine greatly augmented in the majority of cases. M. Payan has seen a patient who voided seven pounds of urine in twenty-four hours. He took eighteen grains of the medi- cine in the day. It should be stated, however, that this patient had a chronic affection of the bladder, and perhaps of the kidneys. The circulation, apparently, is not affected. According to the Italian school, the frequency of the pulse is diminished. M. Payan assures us, on the other hand, that it is accelerated. The cases of hemorrhage, which have been very rarely observed, have been * Vide a work by this physician on the employment of the iodide of potassium, etc., p. 221. 324 VIDAL ON VENEREAL DISEASES. regarded, sometimes as passive, sometimes as active. I have seen a patient affected with nasal hemorrhage, after having taken thirty grains of the iodide in two days; he was excessively feeble. As to the nervous system, says M. Eicord, some patients experience what is called an iodic intoxication, and which is characterized by an impairment of the voluntary movements, twitchings of the muscles, a sense of weight in the head, a kind of mental inactivity, and occasionally by slight disturbance of the intellect. " The iodide of potassium has been accused of producing atro- phy of the glands, particularly the mammary, and the testicles. It is indeed one of the most powerful resolvents with which I am acquainted, but it affects only the diseased parts, the atrophy of which it may sometimes produce, but this is not its only oper- ation."* VI.—IODIDE OF IRON. The iodide of iron is sometimes employed in the treatment of the last stages of syphilis. According to M. Bouchardat, the phy- sicians at the Hotel-Dieu have for ten years been accustomed to administer this heroic agent in large doses, for the removal of syphi- htic accidents of long standing, and which have resisted the prepa- rations of mercury. I am satisfied that the iodide of iron is a therapeutic agent of certain power; but I am confident that in cases where mercury has proved ineffectual, the use of the iodide of potassium will be followed by the greatest success. The iodide of iron is particularly adapted to cases where a de- cided syphilitic cachexia exists, and a state of anemia, or of debil- ity complicated with scrofula. M. Baumes has observed, in cases of imperfect plasticity of the blood, and of obstinate ulcerations, the most prompt and remarkable effects from pills of the proto- iodide of iron. The formula is M. Bouchardat's formula: ]J. Iod. | iiss. Fer. I \\. Aq. | iiiss. Subject the whole to a temperature of 60°, until the liquid is discolored; pour off, and rapidly evaporate in an iron mortar. When the water is nearly evaporated, add : Mel. 3 ii. Pulv. G-um. and Marshmallow. q, s. Make one thousand pills, each of which will contain about one and a half grains of the proto-iodide of iron. Dose, four, to be gradually increased to twenty and thirty a day. This is a very convenient form for administering the proto-iodide of iron. But it should not be forgotten, that the patient will not * Notes to Hunter, 2d ed. THERAPEUTICS. 325 tolerate the quantity here indicated, except when the salt contains red iodine in a free state. The physicians at the Hotel-Dieu have often remarked to M. Bouchardat, that they could not administer the same quantities to patients in private as in hospital practice. This chemist attributes the difference to the presence of free iodine in the pills made by ordinary chemists. According to him, this inconvenience may be obviated by the following formula: IJ,. Proto-iodid. Fer. 3 iiss. Carl). Pot. Mel. aa gr. 1£. Pulv. Gum. and Marshmallow. q. s. Make one hundred pills. From one to ten to be taken in the day. What answers still better, is not to increase the doses of the proto-iodide, and for the reason, too, that it is necessary to act upon the system a long time before a cure can be really effected. I employ most generally the syrup made according to the fol- fowing formulas: 5. Proto-iod. Fer. 3 ii. Syr. Sacch. § xvi. M. Dose from five to six tablespoonfuls in the day. $. Syr. Sudorif. § xvi. Proto-iod. Fer. 3 i. M. Dose, two tablesmpnfuls daily; may be increased to six spoonfuls. VII.—GOLD, SILVER, AND PLATINA. Gold in the form of powder, or combined with oxygen, anti- mony, silver, or amalgamated with mercury, has been employed as an anti-syphihtic. Ucay, in his Nouveau traite de la maladie ve- nerienne (1699), remarks: " The virtues of this remedy cannot be too highly praised." Ucay was not the only admirer of this reme- dy at this epoch; silence, however, soon usurped the place of these pompous eulogies, and it became buried in complete oblivion. At a later period (1811), Chrestien prescribed gold as a new reme- dial agent in the treatment of venereal and lymphatic affections. Serre (of Montpelier) experimented with silver, and platina. Chrestien employed especially equal parts of the hydrochlorate of gold and of soda, in the form of powder; he also made use of the oxide pre- cipitated by tin or potash or metalhc gold, in a state of minute di- vision. " These three preparations succeeded completely, no mat- ter what the nature of the venereal symptoms for which they were prescribed."* The powder was administered according to the method of Clare, by making frictions on the gums, the internal * Lagneau, t. ii., p. 193. 326 VIDAL ON VENEREAL DISEASES. surface of the lips and on the tongue. Chrestien also employed the following pills: R> Hydrochlor. Aur. et Sod. gr. i. Ext. Daph, Mezer, gr. xii. Syr. Sirup, q. s. f. pill 15- Dose, one in the day ; to be gradually increased to three or more daily. Gold has always retained its advocates at Montpelier, especially with the members of Chrestien's family. Experiments have been made, with every precaution, at Paris, by M. Legrand, and at Toulon, by M. Eeynaud. Eemark how it has been employed and judged by the latter surgeon. I will afterwards mention the opinions formed of this agent by some other writers on syphilis, and, in passing, will also allude to their estimate of silver and platina. M. Eeynaud used the same combination as did Chrestien: one grain of the salt and two grains of the iris powder, or lycopodium, moistened with water and alcohol so as thoroughly to mix; the. whole being divided into twelve equal parts. One of these was rubbed on the tongue and internal surface of the cheeks every morning. The patient moistened the right index finger with saliva, dipped it into the powder, and made frictions on the tongue from five to ten minutes; the end of his finger was thrust against the cheeks. The latter point is selected for the frictions, if from any cause it cannot be made upon the tongue. They may be used upon the gums, but then it Avould be difficult to guard the teeth against the action of the gold, and to pre^nt the disagree- able dark color which it produces on their necks. A copious se- cretion of saliva follows, this should be entirely swallowed, as it is loaded with particles of the salt. After this first series of frictions, M. Eeynaud resorted to a sec- ond, dividing the same quantities of the medicine into ten parts, and afterwards a third ^ series, the powder having been divided into eight parts, a fourth into seven, a fifth into six, a sixth into five, a seventh into four, and the eighth series into three parts. In the more inveterate cases, he made several experiments with the third and fourth diAdsions, so as nearly always to administer more than Chrestien, and sometimes to reach as high as from twelve to fifteen grains of the auriferous salt. According to M. Eeynaud, from six to nine series of frictions were ordinarily required, in other words, from six to nine grains of perchloride of gold and soda were used. Often, especially in the worst cases, this practitioner conjoined the use of the oxide of gold in the form of pills, which were combined with the extract of the bark of mezereum, but most commonly with the extract of cicuta, or of the woody nightshade, in the proportion of one grain of the oxide of gold, to nine grains of either of the extracts which was made into ten pills, each contain- ing a tenth of a grain of gold. Two of these were given in the day, morning and evening, and the latter either an hour before or THERAPEUTICS. 327 an hour after eating, in this manner from eight to ten or twelve grains of the oxide of gold were administered Tisanes of soapwort, of chicory, or sarsaparilla, are prescribed as accessory means. Of course proper attention to hygienic meas- ures is to be observed. M. Eeynaud remarks that he has never observed the disorders of the mouth and the gastro-intestinal affections which some authors have attributed to the influence of the preparations of gold, and he has employed them at least in a hundred instances. Fre- quently they produce no appreciable effect upon the system, some- times they give rise to a little general excitement, and in a few cases only, is this excitement accompanied by a slight cephalalgia or febrile reaction, which the temporary cessation of the remedy causes soon to disappear. M. Eeynaud observes in conclusion, that almost always, under the influence of this treatment, he has seen the tertiary accidents of the syphilis gradually diminish, and finally become completely cured.* It Avill be remarked that I have not commenced the exposition of the opinions entertained in regard to the efficacy of gold, with any expression which can be regarded as malevolent. It has been my desire, rather, to give the views of an author, who may be regarded as its advocate. But I cannot refrain from remarking that M. Eeynaud is also a great partisan of the iodide of potassium, a remedy which, as is known, overcomes the same accidents which M. Eeynaud seeks to combat with the preparations of gold. The great advantages attributed by Chrestien to the latter aroused the attention of the Socieie de Medicine, and Cullerier (the uncle) was charged to make experiments with them at the Hppital du Midi. These were not favorable to what was then called the new method. Thirteen patients were submitted to this treatment, and thirteen entrusted to the vis medicatrix naturce. The lesions in all were the same, and the results were identical.! According to M. Ei- cord, gold has always been ineffectual as a general method in the treatment of primary affections, and in that of the general con- secutive accidents, it is medicine of a most doubtful reputation. The majority of cases cured by this remedy are far from being in- contestible cases of syphilis, and when it has been administered in those of an unquestionable character, after the use of other means and of mercury in particular, it proves, according to M. Eicord, not the virtues of the new medicine, but the advantages of suspend- ing for awhile an injurious treatment. The preparations of silver in all their forms, and after the indi- cations pointed out by M. Serres (of Montpelier), have seemed to M. Eicord still more uncertain than those of gold, both in the treatment of primary and of confirmed syphilis. They were ad- ministered at first in small quantities, and gradually increased to the enormous doses of from fourteen to sixteen grains daily. M. Eicord observes that these doses produced only irritation of the * P. 398. f Vide, the detail of experiments in tome ii., p. 195, et suiv, of M. Lagneau. 328 VIDAL ON VENEREAL DISEASES. digestive organs, which rendered it necessary to discontinue its use. M. Cazenave and Biett experimented Avith the preparations of gold. According to these practitioners, the results have always been so doubtful as to give them but little confidence in the value of these agents. As to the preparations of silver, in twenty cases treated with the cyanuret, the chloride, iodide, and the phosphate of silver, in none were they crowned Avith success. But, Biett and M. Cazenave did not treat the primitive symptoms which may dis- appear under almost every form of treatment, but their cases were those of secondary accidents, those which are called symptoms of confirmed or constitutional syphilis. It is already apparent that the experiments of Cullerier, Biett, MM. Eicord and Cazenave, are far from according with those of Chrestien. To these practitioners may be added numerous others, who have arrived at the same conclusions. M. Payan having examined these facts and opinions, thus concludes : " The treat- ment with gold cannot be established as a general method; it should be reserved,—1st, for those cases in which mercury has failed; 2d, where a decided intolerance of the mercurial prepara- tions forbids its use; 3d, for those where the inefficiency of mer- cury is to be attributed to a strumous complication ; 4th, for those where the symptoms depend less on syphilis than on a mercurial hypersaturation which may engender accidents perfectly analo- gous to those of tertiary syphilis." For my own part, I believe that our therapeutics are not so rich as to permit us for a slight cause to reject any means, especially when accompanied with the honorable testimony which has been awarded to gold; but it Avill be remarked that those who wish to retain in practice the preparations of gold, have especially em- ployed it towards the latter stages of the disease, after mercury has been sufficiently used, or after it has failed. Now this is the period of the disease, during which, at the present day, the iodide of potassium is chiefly used, the advantages of which cannot be questioned. What then remains for the preparations of - gold? The cases alone which are refractory to the iodide of potassium. VIII.—DOUBLE SALTS. In speaking of the iodurets, I have already alluded to a double salt, employed by M. Puche, viz., the iodhydrargyrate. Others were used very anciently; that which has been handed down to us, and which has always maintained a certain degree of reputa- tion, is the soluble mercury of Hahnemann. M. Cazenave goes so far as to say that it is one of the most useful preparations in the treatment of the syphihtic eruptions. It is of easy management and toleration, which renders it particularly adapted to delicate and feeble subjects. The activity of soluble mercury is not great, but it suffices in cases of superficial eruptions; and in those of long THERAPEUTICS 329 standing, it may perhaps be used with advantage. In severer cases it is better to resort to the proto-iodide of mercury. The soluble mercury of Hahnemann is composed of 92.2 Protoxide of Mercury. 1.9 Ammoniac. 5.9 Nitric acid. As this salt is readily decomposed, Hahnemann preferred the form of powder, after the following formula: POWDER OF THE SOLUBLE MERCURY OF HAHNEMANN. Soluble mercury. Opium, aa. gr. i. Powder of tragacanth or liquorice, 5 to 10 grains. M. Cazenave employs the following pills: Soluble mercury: Thridace, aa. § ss. Make forty pills : one to be taken morning and evening. M. Cazenave is reported to have given as many as four daily. IX.—SUDORIFIC WOODS. These woods, which at one time had so great a reputation, have now fallen into the most complete disrepute. Even guaicum, which nearly dethroned mercury, is now regarded but as an acces- sory means, or as a vehicle for other remedies. "VVe know that this wood was first brought from St. Domingo by the Castilians, who used it medicinally. Leonard, Poll, and especially Ulric of Hutten, who owed it a certain debt of grati- tude, extolled it beyond measure. The following tisane of guaiac is still employed conjointly with the preparations of mercury: ]J. Guaiac, (rasped), § iv. Aq. Com. 2 quarts. Macerate twelve hours, reduce it to one half, then add: Rad. Glycyrrh. § i. Sarsaparilla is still used in the form of decoction during the administration of mercury, especially in the treatment of the con- secutive accidents. With some practitioners, it is from custom rather than from any conviction of its utility, that it retains its place. It enters besides into the composition of certain tisanes and syrups, as we shall hereafter show; as for example, in the tisane of Arn'oud, and the syrup of Cusinier. The simple sarsaparilla tisane is prepared according to the follow- ing formula: 830 VIDAL ON VENEREAL DISEASES. R,. Sarsapar. 3 iv. Aq. Com. 2 quarts. Macerate twelve hours, and afterwards bruise the roots in a marble mor- tar, and reduce to one half the quantity. The tisanes of China root, of sassafras, and other sudorific woods, are prepared in the same manner. The roots of lobelia and astra- galus are no longer used. As to the soapwort, its leaves are much used at the present day, in the preparation of a tisane in which the iodide of potassium is dissolved. X.—COMPOUNDS, PARTLY MINERAL, PARTLY VEGETABLE. If with an unprejudiced mind we carefully examine the majority of these compounds, we shall soon become convinced that their efficacy depends on the mineral substance they contain. Thus, the syrup of Cusinier alone possesses no efficacy, but united with corrosive sublimate it then becomes a powerful remedy. The tisane of Eittmann is of therapeutic value only on account of the proto-chloride and the sulphuret of mercury that it contains; that of Feltz is due to the sulphuret of antimony, and thus it is with all the tisanes, all the compound syrups, and all the robs; when uncom- bined with other agents they have but a moderate action. I give the formulae for two ofthe compounds which have enjoyed the greatest reputation, and the absence of which might here be regretted; I refer to the syrup of Cusinier and the tisane of Feltz: SYRUP OF CUSINIER. IJ. Sarsapar. g>i. Aq. Com. B>xii. Macerate for twenty-four hours, and reduce to four pounds. Having decanted the liquor, subject what remains to the same operation twice. Mix these three decoctions, and add: Flowers of borage, | ii. • White Roses, § ii. Aniseed, f ii. Senna, § i. Boil until reduced one half; add: Sugar, fti Honey, g>i. Dose, half a glass three times in a day, with the sarsaparilla tisane. This is the syrup of Cusinier, of the first, second, and third boil- ing, that is after we add one, two, or three grains of the bi-chloride of mercury to each pint of the syrup, according as we wish to SYPHILITIC ERUPTIONS. 331 increase, or more properly speaking, to reahze its anti-syphihtic virtues. . „ M. Baumes prescribes, morning and evening, with two or lour tablespoonfuls of the syrup of Cusinier, half a tablespoonful, or a whole spoonful of Van Swieten's liquor, the dose of which is gradu- ally increased. , . , In the place of the deuto-chloride we may introduce into the syrup of Cusinier, the cyanuret of mercury, which is less easily decomposed. But M. Baumes observes that we must then atten- tively watch the administration of the syrup when this addition has been made, its action on the digestive organs bemg severe: FELTZ'S TISANE. * ]J. Sarsapar. 1 "• Icthyocol. 3 jjss. Sulph. Ant. (washed,) § iii. Aq. ftiv. Evaporate to one pound. A glassful to be taken daily. The sulphuret of antimony is ordinarily washed in boiling water. M. Eayeiv who employs this preparation, very frequently re- marks that we thus remove a large portion of the arsenic contained in the sulphuret of antimony, by which its efficacy is partly de- stroyed. But as the proportion of the arsenic contained in the tisane is sometimes too considerable when the antimony is not washed, M. Eayer often prescribes, in the place of the tisane of Feltz, the folloAving: M. RAYER'S MODIFICATION OF FELTZ'S TISANE. * 5,. Decoc. Sarsapar. 5 xvi. Arsen. Sod. gr. ~. CHAPTER II. ON SPECIAL CONSECUTIVE VENEREAL AFFECTIONS. SECTION I. SYPHILITIC ERUPTIONS. Syphilida. — Syphilides.—Syphiloderma.—When the syphilitic virus has infected the system in a certain manner, various eruptions are produced upon the skin. They assume almost every element- ary form of cutaneous disease, but have certain peculiarities which reveal their nature. 332 VLDAL ON VENEREAL DISEASES. So common and grave were the affections of the skin in what was called the epidemic of the fifteenth century, that they did not fail to attract the special attention of observers. From that epoch to a period nearer our own, every syphilitic eruption Avas con- founded under the name of pustules. In calling these eruptions syphilides, Alibert rendered a double service to science: he created a happy and precise denomination, and contributed to destroy the false idea to which the word pustule, used as a generic term, gives rise. But it is to Biett and his pupils that we are indebted for the proper application of Willan's method to the study of the syphil- ides, and for a classification based upon the elementary lesions of the skin. No one can deny the advances here made by this school; but it is equally true that much yet remains to be learned in the study of these eruptions. . , I.—GENERAL CHARACTERS. I proceed, in the first place, to describe the general characters of the syphihtic eruptions; I shall afterwards classify them, and study each variety according to the divisions established since the school of Biett. > :s The syphilitic eruptions present a physiognomy that cannot be mistaken when once the attention has been fixed upon them. This physiognomy consists in the color, form, chronicity, and marks which they leave behind. Color.—The color of these eruptions, the ham-c'olor of Fallopius, the copper-color of Swediaur, has always arrested the attention of observers. It is still regarded as the most characteristic feature, that on which the differential diagnosis of these eruptions is based, that which distingushes them from simple eruptions or those of any other nature. And yet the value of this test has been dis- * puted and even denied! It is true, that after certain ulcers, cer- tain simple eczematous eruptions, especially on the legs, we ob- serve the skin to assume nearly the same tint; sometimes, also, the spots of purpura, before they disappear, become of a faint red color; but the slightest inquiry into the circumstances preceding the first stages of the disease will remove all doubts. Instead of a well-marked tint, there sometimes exists a shade difficult of detec- tion. Fallopius was the first to remark: non enim ruber, non albus, non pallidus. There are cases, says M. Cazenave, where the red- ness is but shght, the tint varying from this to a gray color. Again, the shade may depend upon the period of the disease as well as other chcumstances: thus, at the moment of the erup- tion of roseola, of the papular form of the disease, the color is of a bright red, which becomes darker as the eruption becomes more distinct, as is represented in plate 5, fig. 1. Is this owing to the vascular congestion in the first period masking the alteration of the chromatogenous apparatus ? or is it rather owing to the fact that this apparatus is not yet modified ? There are cases in Avhich we may distinguish the two colorations: thus, in certain tuber- SYPHILITIC ERUPTIONS. 333 cular affections, by pressing with the finger and emptying the ves- sels, we may cause the redness to disappear; but the copper color remains, because it depends upon a matter which is combined with the layer of the skin. In the last stages of certain lenticular squamous syphilitic eruptions, we observe the coppery red pass into an obscure grayish yellow, which is called the dirty coppery yellow. The quinine tubercles and pustules leave behind livid spots of a dark red color, like the ecchymosis of purpura. But even then, if we carefully examine the whole surface of the skin, we shall find places exhibiting the coppery-red color. Sometimes, instead of being effaced by the long standing of the disease, the redness continues and becomes more distinct. Thus, we occasionally find red spots long after the eruptions have disappeared. Cold appears to affect the color of certain of the syphihtic eruptions; roseola is one of those which it renders more apparent. The persistence of the color of these eruptions, their chronicity, and the impossibility of causing them to disappear by pressure, seem to prove that the affection, in these cases, is seated between the epidermis and the dermis, in what is called the rete mucosum— in other words, in the chromotogenous apparatus, of which the secretion has been altered. I have already spoken of the varieties of tint which are peculiar to the period of eruption ; I should add, that on the base, to speak classically, there are individual shades, which depend upon modi- fications in the integument, and its vascularity. Thus, in certain subjects Avith a fine white skin, the redness is lively in roseola, and lichen, and especially as I have already stated at the commence- ment of these eruptions. Towards the termination, in males whose skin lacks transparency and Atitality, the color is always duller; often it is violet. In persons of a bilious temperament, the red- ness assumes a brownish shade. In those of a cachectic habit, the tint approaches that of a venous injection, being livid. I have now under my care a corpulent patient, of a very lymphatic and apathetic temperament; he has had an indurated chancre, and this has been followed by livid spots upon the skin, which I should never have regarded as syphihtic, had I not seen the development of all of the phenomena. It is in such subjects that the cicatrices of the syphilitic eruptions Avhich ulcerate, have a blueish appear- ance. In conclusion, the coppery tint is one of the best signs, for it seldom occurs in other than syphilitic affections; it may of itself, in certain cases, establish the diagnosis, but it must then be very decided, so as not to be masked by any comphcation with other diseases. In every case we should observe all the features which complete the physiognomy of a syphilitic eruption. Form.—The most important symptom, next to the color, is the form of the eruption. It is generally curved, circumscribing por- tions of a circle, or entire circles, or roundish spots. This is ob- served not in isolated places only, and limited to small portions of the surface, but whole groups of vesicles, of tubercles and scales are thus surrounded. True, this feature is wanting in certain of 334 VIDAL ON VENEREAL DISEASES. the eruptions, as in the papular form, and it is found in some cutaneous affections than the syphilitic, for simple herpes may assume the circular form. But there are eruptions which do not exhibit this character, except when they are of a specific, of a syphilitic nature: thus, the elements of the tubercular eruption grouped together, are surrounded by a circle more or less complete, more or less perfect. What is remarkable is, that we see, occa- sionally, the circle formed partly by one and partly by another organ: thus, in the horny syphilitic eruption, we sometimes ob- serve a segment of a circle on the palmer surface of the finger, whilst the other segment is inscribed upon the adjoining finger. I have under treatment a patient who is affected with herpes cir- cinnatus on the genital organs ; one-half of the circle exists on the root of the penis, the other upon the scrotum (plate 6, fig. 1). For a long time this singular disposition of syphilitic eruptions has attracted the attention of observers: thus the term corona veneris is a very old one. Chronicity.—A syphilitic eruption being essentially a chronic affection, we find that the sensibility of the parts is but little modi- fied ; thus, there is neither acute pain nor pruritus, even in those forms assumed by the eruptions which, in their simple state, are sometimes remarkable for their intolerable itching. Heat is a symptom which is also absent. However, even here, we must not be too absolute, and deny any changes of sensibility or of the temperature, in every stage of the eruption. Thus, of seventeen patients, M. Legendre remarked that thirteen suffered not the slightest pruritus, but three complained of it a little, while in the fourth, it was very severe. During the first stages of a tubercular eruption, it is not uncommon to hear patients say that they feel an itching sensation in the evening, when they begin to get warm in bed, and facts are not wanting to show that a true febrile excite- ment has preceded a syphilitic eruption. The chronic character of these affections is due, not only to the absence of alterations of the sensibility in the majority of cases, but to the slow pathological processes which are observed in cer- tain forms. Thus, in the pustular form, we sometimes observe a large indurated base, surmounted by a small suppurating point; in the vesicular variety, we find the vesicle remaining unbroken, and preserving its transparency for four, five, or six days, sur- rounded by an areola, the redness of which soon fades. Ulcerations.—These are much more frequently observed as sec- ondary lesions of the syphilitic than after ordinary eruptions, for herpes zoster and ecthyma alone offer this peculiarity. The exca- vated ulcer of the syphilitic eruptions is generally of a regularly- roundish form, with reddish, perpendicular edges, with a grayish and sometimes a bloody base. These characters are especially to be seen on the loAver extremities. Occasionally the ulcer assumes an oval form; sometimes its edges are irregular and scalloped; then a group of small "ulcers is confounded into one of larger dimensions, the edges of which involve a portion of the circum- ference of the constituent ulcers: in this manner it is enlarged by SYPHILITIC ERUPTIONS. 335 the process of ulceration. There is another method, Adz., mortifi- cation : thus, at some point of the circumference, the dead skin and the separation of the eschar produce a loss of substance which enlarges the ulceration. I shall return to this phenomenon in describing the serpiginous ulceration. Most generally the ulcer increases regularly in all directions, and is arrested only when it has attained a certain diameter: thus, M. Legendre remarks that he has never seen a cicatrix of an isolated ulcer present a diameter of more than a five-franc piece. The ulceration of a syphilitic eruption has a much more decided tendency to reparation than that which supervenes on other cutaneous affections^ It remains but a short time stationary, and tends rapidly to hesp whilst non- syphilitic ulcerations of the extremities remain unchanged for two and even three years. But, most frequently, during the cicatriza- tion of a syphilitic ulcer at one point, another is progressing at another point; or, if but one ulcer exist, whilst one portion of it is undergoing reparation, another is enlarging its dimension^: the ulcerations losing nothing in this contest with the reparative forces. Thus, taking the syphilitic ulcer altogether, we see that a very long time is required for its cure. I treated, in Ward 11, Bed 26, a barber, who was affected with both forms of the serpiginous ulceration to a truly incredible ex- tent, and in this case I obtained extraordinary success from dress- ings Avith the vigo cum mercurio. This patient had an indurated chancre on the penis, several superficial eruptions, ulcerations in the throat, and syphilitic engorgements of the testicles ; last of all, he had large ecthymatous pustules, which ulcerated to such an extent, that on the 15th December, 1851, the right inferior extrem- ity presented two enormous solutions of continuity, which nearly came in contact with each other; one was situated on the external border of the right thigh, reaching from the knee towards the trochanter, being nineteen centimeters six and one-third inches in length, and three and one-third in breadth; the other commenced immediately below the patella, occupied the external, anterior, and somewhat of the internal surface of the leg, extending towards the foot, and was five inches in length, and six and two-thirds in breadth. On the external surface of the knee, these tAvo ulcers were not more than some two-fifths of a line distant from each other. Three smaller ulcers were scattered on both lower ex- tremities ; on the left calf of the leg, and the popliteal space, there were two, one of which was of the size of a five-franc piece, the other of double the size. The patient was in a very serious con- dition, being exhausted by the suppuration. Internal and exter- nal treatment had failed. I then applied the dressings with little bands of the vigo. They were made to overlap as in the dressing by occlusion; they were reneAved every three days, and at each dressing there was a decided improvement, so that in less than a month, reparation was complete. The patient regained his embon- point, and his general condition was very satisfactory. Sometimes under the influence of this treatment, the patient became affected 336 VIDAL ON VENEREAL DISEASES. with a mercurial ulceration on the alveolar border of the lower jaw, and there Avas the commencement of a salivation. This case is highly instructive. We here see a patient who had been subjected to various external and internal measures: 1st, simple cerate, opiated cerate, dressings of aromatic Avice, repeated cauterization, emollients, solutions of iodine ; 2d, combinations of mercury and iodide of potassium; simple mercury, iodide of po- tassium alone, the preparations of iron, cod-liver oil, all failed. I employed the dressing already mentioned, and this measure was crowned with speedy success. Was it owing to the physical, local action of the plaster, or was it the result both of the local and the general action,? I have stated that the mouth became affected as during a mercurial treatment, and we know that the vigo con- tains mercury, and that it was applied to very large surfaces. In this case, then, a feeble subject, in the last stages of syphilis, was cured by the external application of the mercury ! Cicatrices.—The cicatrices left by syphilitic eruptions generally present the following characters; they are circular, and more or less depressed; when recent, they have a bronze color, and some- times their tissue is slightly prominent; beneath the epidermis, we see the superficial vessels broken; at a later period these be- come effaced, and a kind of internal absorption seems to be estab- lished ; they lose their violet tints, become white and more de- pressed ; their surface, of a dull white color, is also tense or corru- gated, shining or swollen, and sometimes furrowed with hard and prominent bands. Under certain circumstances they are white from the first, but of a blueish white ; they are then surrounded by a coppery areola which tends constantly to diminish, and the color of which is gradually lost in the surrounding skin. Syphil- itic cicatrices may present bands similar to those following exten- sive burns; they sometimes degenerate and become covered with a kind of keloides. This phenomenon has been noticed particu- larly to occur on the cicatrices of certain cases of rupia, and of the serpiginous tubercular variety. When I come to treat of this form, I shall relate a very remarkable example of this cicatricial degeneration. II.—VARIETIES Having described the general character of the syphilitic erup- tions, I proceed, in the next place, to study them in particular. Following the example of M. Cazenave, I shall establish seven varieties: 1. Exanthematous. (Fig. 1, pi. 5.) 2. Papular. (Fig. 2, pi. 5.) 3. Squamous. (Fig. 3, pi. 5.) 4. Vesicular. (Fig. 1, pi. 6.) 5. Bullous. (Fig. 4. pi. 5, et fig. 2, pi. 6.) 6. Pustular. (Fig. 3, pi. 6.) 7. Tubercular. (Fig. 5, pi. 6.) **A -' d ;*V'" '■••v- Kg 1- ,ij? . 0 • # 0 # ,,« 2 Efi. 3 |^F , i &^/„. Kg* -^' ^ 6*U** Kg-* ^V^ 1 * td PI Fn! ■Qf\ 0^ Q />> fuCl fit Fitf. 5. t.Q - t-S/r rfAtv f'/'f'V // teuse, of M. Sestier, p. 88. AFFECTIONS OF THE MUCOUS MEMBRANES. 397 hemorrhage before assistance could be had to secure the vessel. He also exhibited preparations in his lecture, showing the neces- sity, in some cases, of resorting to tracheotomy in these distressing cases.—G. C. B.] The treament is similar to that of the consecutive affections of the buccal cavity; but if the affection continues obstinate, remain- ing long after the subsidence of the tertiary symptoms, we must then resort to the use of iodine. In some cases even in spite of this remedy, the disease seems to continue, but it is then main- tained by a necrosis, the dead portion acting as a foreign substance, and though the syphilis be cured, the patient is far from being saved. V.—MUCOUS MEMBRANE OF THE EAR. The mucous, or rather the semi-mucous lining of the ear, may become affected by constitutional syphilis. In treating of mucous tubercles, I mentioned a case in which the patient's whole body was covered; they occupied both auditory canals; in one, was seen the raised papula, accompanied with a slight discharge; in the other, there were ulceration of a dark brownish color, and a true otorrhoea. Hearing was not impaired. I have read, however, and we may find in the work of M. Baumes, that consecutive dis- charges from the ear coincide almost always with more or less dul- ness of hearing. True, the physician of Lyons intends his remarks to apply to greenish-yellow discharges. Those which I have ob- served consisted of a dirty, offensive serum. Cases have been de- scribed in which the ulcerations had the character of those belong- ing to constitutional syphilis; they were seated both at the en- trance of the auditory canal, and at a greater depth, the latter being discovered only by the aid of the speculum auris. In such cases there is necessarily more or less of a discharge. According to M. Baumes, during the continuance of the discharge, soft, fung- ous, pediculated vegetations are to be seen in the auditory canal. I believe that these are most commonly mucous tubercles, at least such is the result of my own observation, and that the matter dis- charged proceeds from these tubercles. I have never seen any- thing in the ear that could be compared to true pediculated vege- tations. Of course, I do not include polypi in these remarks, as they have nothing in common with syphilis. When I have been called upon to treat mucous tubercles of the auditory canal, I have administered the proto-iodide of mercury internally, and have confined my topical applications to cleanli- ness. Lotions with diluted Goulard's extract, or with a dilute solution of the chlorides, and the insertion of cotton in the canals, may prove of service. VI.—MUCOUS MEMBRANE OF THE ANUS AND RECTUM. In speaking of blennorrhagia, in the first part of this work, I stated that anal discharges were most frequently the result of con- 398 VIDAL ON VENEREAL DISEASES. secutive affections. These discharges generally proceed from con- secutive mucous tubercles; but the most abundant source of the matter is particularly the mucous membrane surrounding these tubercles, which is the seat of a consecutive blennorrhagic inflam- mation. The vegetations, and especially the mucous membrane by which they are surrounded, may also secrete more or less mat- ter. These vegetations, in the great majority of cases, are consecu- tive affections. They may invade the mucous membrane to a much greater height than the mucous tubercles, which are always developed on the margin of the anus, and rather encroach on the nates, where they spread and multiply. On the contrary, the vegetations form high in the rectum, even on the lining membrane of this portion of the intestine, as may be seen by the speculum, or when the patient makes strong bearing-down efforts, as in going to stool. These ulcerations of the rectum, and particularly of the anus, are of frequent occurrence. In the majority of cases, they assume an elongated form, and are known by the name of rhagades. They have a grayish-yellow base, with edges more or less indurated and irregular. They may be seen completely when the patient forces down the parts, as in going to stool. They are much less painful both to the touch and during the act of defecation, than is the fissure of the anus, and we do not observe that disposition to syn- cope which is common to the latter affection. There is another kind of ulceration which is more superficial; it is observed in blennorrhagia, and is rather an excoriation, like that of balanitis. M. Baumes has met with greenish discharges from the anus, con- joined with other syphilitic symptoms. He examined with the speoulum, and found the mucous membrane red and thickened, and as if granulated at certain points, without ulceration. But generally, with the puriform discharge there is ulceration, the lat- ter may occur without previous engorgement or induration of the mucous membrane. According to this writer, they may be found in large numbers very high in the rectum. The general treatment of the consecutive affections of the anus is that Avhich has been recommended for the same morbid condi- tions in other mucous membranes. The local treatment consists particularly in the observance of cleanliness. Hip-baths should often be used. The anus should be filled with charpie or carded cotton. That portion of the mucous membrane which admits of being exposed, may be cauterized with the nitrate of silver. In- jections of Goulard's lotion, or a solution of the nitrate of silver, may be used when the affection extends to any great height. We should avoid injections containing laudanum. I have seen poison- ing produced which threatened the most deplorable consequences, by injecting a solution containing sulphate of zinc and a large proportion of Sydenhams's laudanum. DISEASES OF THE EYES. 399 SECTION rv. DISEASES OF THE EYES. In the first part of this work, I have already described a serious affection of the eyes, which commences in the more external mem- brane, the conjunctiva ; it is one of the so-called primitive venereal accidents, a form of conjunctivitis. A consecutive conjunctivitis has been mentioned, or rather it has been supposed, for what has probably been regarded as a manifestation of secondary syphilis in the ocular mucous membrane, was probably a chronic conjunc- tivitis succeeding to a blennorrhagic ophthalmia, or it may have been the latter in a protracted state, or a conjunctivitis dependent on some other diathesis which cannot be determined. As to the lesions of the other tissues of the eye, they are still more problem- atical, or if they have indeed been observed, it was in severe cases of iritis with extension of the inflammation, or, more properly speaking, in complicated cases. Thus, writers speak of a complete disorganization of the globe of the eye resulting from syphihtic iritis. 'Mackenzie alludes to this accident, and I have now in my service, Ward 11, a patient Avho has passed through all the stages and demi-stages of syphilis: he has a sunken eye. It was not long after this profound lesion that we saw him, so that we were able to note the starting point of the ophthalmic affection. We obtained sufficient proof that he had not blennorrhagia at the time when the eye became affected, so that the eye was not in this case lost, as is observed in a severe case of blennorrhagic ophthalmia, but it was the result of a lesion occurring during the development of various consecutive accidents, or, probably, of an accident itself of this nature, but of a much more serious character than that which is most commonly observed, viz., syphihtic iritis. The his is indeed most commonly affected when the virus has infected the whole organism ; and this lesion alone is noticed by some writers on venereal diseases. I will devote a paragraph to it. SYPHILITIC IRITIS. M. Eicord, in his Notes to Hunter, thus remarks: "There is a secondary accident to Avhich Hunter has not alluded, because it escaped the laws which he had established, or what is very probable, because he was ignorant of the disease." I quote verbatim.* Causes.—Syphilitic iritis is so intimately connected with the affections of the skin, it occurs so frequently in their train, that it may be regarded as one of the accidents of the syphilitic eruptions. It is for this reason that I treat of this disease immediately after the affections of the skin and mucous membranes. * Hunter, 2d Ed., Note by M. Ricord, p. 648. 400 VIDAL ON VENEREAL DISEASES. Attempts have been made to determine what form of syphilitic eruption is more frequently followed by syphilitic iritis. Accord- ing to M. Legendre, it is the papular and the pustular varieties, {Thesis already quoted^ Mackenzie states that his experience has shown that the pustular and squamous eruptions on the face and trunk should take the first rank, Avhilst the second should be assigned to the syphilitic affections of the throat. " The pustules on the face," says Mackenzie, "which I have observed to coincide with syphilitic iritis, were often voluminous, hard, and penetrated the skin so deeply that they almost deserved the name of tubercles. The squamous eruptions on the face sometimes resembled the areolar form of lepra. On the body, Avhere the eruption had gene- rally a more acute character, it appeared under the form of numer- ous circular elevations, of a brownish-red color, about half the size of a pea, and terminating by a succession of thin pellicular desqua- mations of the epidermis."* M. Eicord admits three degrees of syphilitic iritis. According to this writer, if the patient is affected with the syphihtic exanthe- mata, rubeola, the iritis coincident with this form of eruption, with other things being equal, aaqII be less intense, forming what is known under the name of erythematous iritis, and which some oph- thalmologists call serous iritis. There is another iritis accompany- ing the papular form of eruption; in this variety, under certain circumstances, vegetations are observed, which Beer has compared to condylomatous vegetations; but most frequently, says M. Eicord, we observe on the iris genuine papules, more or less prominent, of the size of a grain of millet seed, and of a copper-red color. Finally, Avhen the iritis co-exists with a vesicular or a vesico-papu- lar eruption, we discover on the iris true vesicles, vesico-pustules, and we may even say, small ecthymatous pustules. Each principal form of cutaneous eruption should therefore have its prototype on the iris. Such is the opinion of M. Eicord. Thus we have not only a syphihtic iritis but several varieties corresponding to the several syphihtic eruptions. And yet M. Eicord concludes by doubting the existence of syphihtic iritis; he seems to reject the disease, as a distinct variety, after having described three different forms! In the same note, by the same syphilographer, we read as follows: "In the absence of all pathognomonic signs, we are justi- fied in asking, as in certain cases of pemphigus in the infant, whether syphilis does not here act like any other common cause."f So that after all, syphihs in these cases acts like cold, or any other non-specific exciting cause; and this, too, for the reason that this iritis has not a specific character by itself. As if the antecedents, the progress of the malady, its relations with other concomitant circumstances, such as the syphihtic eruptions, and the Avhole pathological history of iritis, were not equal to an anatomical character in establishing its nature! * Mackenzie, Maladies des yeux, p. Z11, translated into French, by MM. Langier and Richelot. t Vid. Notes to Hunter, p. 682, 2d ed. DISEASES OF THE EYES. 401 [Among the Avriters who first described syphilitic iritis as a dis- tinct disease, were Prof. Schmidt, of Vienna,'and Mr. Saunders, of London. Although the highest authorities of the present day, such as Messrs. Lawrence, Jones, Hilton, and Mackenzie, as did Mr. Carmichael, regard it as a specific affection of the iris, there are others, as observed by our author, who'can see in it nothing to entitle it to such a distinction. Mr. Porter objects to the term iritis, believing, as he does, that all, or almost all the other'struc- tures participate in the disease. " T have seen patients, become blind long after every symptom of the 'iritis' had disappeared, and I have witnessed the unpleasant situation in which a surgeon was placed, who had, under such circumstances, pronounced his- patient cured. I prefer, therefore, that name which tells us and keeps constantly before us the fact, that all the deeper structures of the eye are engaged—deep-seated syphilitic ophthalmia," (Lect. in Dub. Med. Press., April, 1847.) Mr. Morgan believed, and this is the doctrine, if we mistake not, of Mr. Travers, that the form of iritis under consideration is due to the conjoint agency of syphilis and mercury, but Mr. LaAvrence has quoted a number of Cases in which mercury had been given in some quantity, for the cure of the primary sore, in about one-third of the whole number; very httle, in about another third, and no mercury at all in the remain- , ing third, and yet iritis supervened. Similar results followed the non-mercurial practice of Messrs. Eose and Thompson.— G. C. B.] ' Symptoms.—Diagnosis.—In the first place, I should remark, that iritis, Avhatever may be its cause and nature, may present the fob' loAving characters: 1st. A particular vascularity of the,opaque cornea and even of the iris; 2d. A modification in the motions and form of the pupils; 3d. A production of lymph, of a more or less purulent fluid, and adhesions; 4th. Impaired vision and pains in the eye and around the eye, and even beyond this region/but A always confined to the head. • Thus, we have what is called Zonu- lar sclerotitis, that is, very fine vessels, which run like rays towards the margin of the transparent -cornea. The color of the iris is changed by an abnormal vascular development, or the production of lymph, in its substance, or on its posterior surface. If it is naturally blue it becomes green, and if of a red disk' color it changes to broAvn. The pupil contracts and its motions are im- paired or destroyed. The lymph of which I have spoken may be effused in the posterior as well -as the anterior chamber of the eye. This same lymph may become organized on certain portions of the membranes, forming bridles and producing adhesions ofthe margin of the pupil to the capsule of the crystalline lens, and sometimes, though more rarely, to the cornea. These morbid productions may assume the form of tubercles, or of pustules; we then have, in the majority of cases, abscesses in the iris. Finally, there are subjective symptoms relating to vision, Avhich is more or less dis- turbed and sometimes destroyed, and there are circumorbitar pains, which may be nocturnal. These characters are not observed in 402 VIDAL ON VENEREAL DISEASES. all cases of iritis, but they may be met with from Avhatever cause the disease may occur.* The Germans, at the head of whom stands Beer, describe among the characteristics of a specific iritis, a peculiar distortion of the pupil, and the development of what are called condyloma on the iris. The first is produced by a gradual contraction of the pupil from without inwards; instead, therefore, of being in the centre of the iris, it is much nearer its superior internal border, thus causing a deformity, a laceration of the pupil, converting its grand axis obliquely from below upwards, and from without inAvards. This distortion may certainly occur during the existence of syphihtic iritis, but it is also observed during that of rheumatic iritis. Fur- ther still, by folloAving the different phases of syphilitic iritis, we may observe both this distortion and that in the opposite direction. This character, therefore, is governed by no law; it may depend upon the adhesions to the crystalline lens and the effects of bella- donna so frequently employed in the treatment of iritis.. If the adhesions no longer exist at the time when the belladonna is em- ployed, the pupil will dilate equally in all directions, presenting not the slightest deformity. If, however, adhesions still exist, the dilatation of the pupil will then be irregular, and then only do we perceive distortions of the pupil; they result from the action of the belladonna, dilating the portions of the iris free from adhe- sions, whilst the position of those which are adherent remains un- changed ; thence the distortions, whieh are hot constant, and con- sequently cannot be regarded as pathognomonic. M. Legendre has twice seen the contracted and circular pupils dilated by the action of belladonna, and assume an oblique form from beloAV up- wards, and from within outwards, a direction the opposite of that which is regarded as pathognomonic; in another case, the pupil was vertical and lozenge-shaped; and, finally, in other instances, it could not be made to assume any particular figure. The distor- tion of the pupil, accidentally produced by the belladonna, is repro- duced, but ma permanent manner, by the cure ofthe iritis. Indeed, Avhen the circular coarctation ceases on the disappearance of the disease, the pupil has a'tendency to reume its natural shape ;■- but if, during its contraction, adhesions form, and the unadherent portions Only should become dilated, a permanent distortion then results. As to the condylomata, according to some of the best ophthal- mologists, they are but abscesses which occur more frequently in syphilitic than in other forms of iritis. We should therefore take into.consideration the chcumstances of their existence, especially if they co-exist AA-ith a syphihtic cutaneous eruption, as they will then be of more value in establishing our diagnosis." Mackenzie alludes to a rusty color of the iris near its pupillary margin: a phenomenon, he observes, which is sure to be met with in syphilitic iritis. But M. Desmarres has seen this color in cases of iritis, without any special comphcation. * Vid. in my Pathologie externe the different forms and degrees of Iritis, t. iii. p. 18, et suiv, 3d ed. DISEASES OF THE EYES. 403 The progress and the character of the pains in syphilitic iritis deserve the greatest attention. ; Its progress is slower and less acute than that of traumatic iritis, which very frequently terminates in the rapid and complete obliteration of the pupil. The cause of traumatic iritis being entirely local, its effects seem to be limited to the eye affected; nothing, on the contrary, is more common than to see the other eye attacked in syphilitic iritis, and scarcely does the inflammation subside before it reappears, and so it pro- ceeds, until several relapses have occurred. It is frequently the case, that false membranes are not formed until after several attacks of inflammation in the same iris, and they rarely produce an obliteration of the pupil, even when the disease is abandoned to itself. Disorganizations of the eye, and staphylomas, very sel- dom result from this specific iritis. Pain in syphilitic iritis evidently occurs in paroxysms; these paroxysms are nocturnal, and, if pain exists during the day, there is always an exacerbation at night. It seldom occurs before eleven o'clock at night, and most generally at midnight, or at one* o'clock in the morning. These pains are seated not only in the globe of the eye and orbit, but the corresponding side of the head; some- times it extends towards the occiput. I am perfectly aware that other forms of iritis are attended with nocturnal pains—as, for ex- ample, the rheumatic, and even simple iritis; but I beheve that this phenomenon is much more decided in syphihtic iritis. I attach much more importance to it than to condyloma, for these I have rarely observed, whilst the nocturnal pains have never been absent in cases of iritis where the disease has been at all severe. I should add, that the sulphate of quinine exerts a powerful influence over these pains; the hour of the accession of the paroxysms may, therefore, be changed, and finally they may be entirely removed by this potent agent. None of the anatomical and physiological characters of iritis, taken separately, can be regarded as proof of its syphilitic nature, > But, united, they possess a real value in forming a diagnosis, and this is especially true of those relating to its progress and the na- ture of the pains. First of all, the skin should be examined, if we would establish a sure diagnosis. I have already attempted to show the intimate connection existing between the syphilitic eruptions and iritis. It is such, that I consider the existence of syphilitic iritis impossible Avithout the cutaneous eruption. Indeed, we shall find, almost invariably, some of these eruptions, or traces ■ of them, and if not yet developed, it soon will-be, before the iritis -•' can have made much progress. In cases where the skin appears- ■>- to be perfectly sound, we shall probably find on the mucous ;£ membranes in the buccal cavity, the .anus and genital organs, le- sions analogous to the syphihtic eruptions. Certainty of diagnosis, therefore, is established by taking into consideration circumstances unconnected Avith the symptomatology of iritis. But this is no reason Avby we should attach but slight importance to the elements which the symptomatology may furnish, for they may lead us to 404 VTDAL ON VENEREAL DISEASES. an examination of the cutaneous surface, which might ofherAvisO haAte been neglected. I shall not here attempt to establish the varieties of syphilitic iritis. I have already stated that M. Eicord has assigned a form of iritis to each variety of the eruption. He recognizes an ery- thematous, a papular, and a pustular iritis. The mildest form should therefore correspond to the milder forms of the eruption, and vice versa. I will only remark, that I have observed Arery slight and perfectly erythematous forms of iritis, with the graver forms of the cutaneous eruption. Thus the subject of the squa- mous eruption represented in plate 5, fig. 3, Avas affected Avith the mildest form of iritis, which was cured in eight days, and yet the eruption on this patient was very obstinate; the testicles became affected, his constitution deteriorated, and finally the constitutional infection was very complete. Prognosis.—The gravity of the prognosis does not depend upon that of the syphilitic iritis itself, for, hke the inflammation of the iris, it is perhaps one of the least compromising as regards vision. One circumstance Avhich should render the prognosis very guard- ed, is the evident tendency of this disease to return. But the danger arises principally from the changes produced in the sys- tem, by the establishment of the syphihtic diathesis. Indeed, the iritis almost always supervening on constitutional syphilis, and after other manifestations of the disease, the patient is generally debilitated, and consequently intolerant of antiphlogistic and other debilitating remedies which form the principal part in the thera- peutics of iritis. „ Treatment.—Blood-letting is frequently indicated. Monteath in- sists upon the absolute necessity of this measure, especially in par- ticular cases; he opposed his experience to those who place all their confidence in the use of mercury, to the exclusion of all other-means, such as blood-letting, blisters, .&c. This practitioner has seen, indeed, syphilitic iritis running rapidly into a dangerous hypopion, notwithstanding mercury had produced its Complete effect, and yet its progress was at once arrested by repeated vene- section in the arm, and the application of a blister to the nape of the neck. Mackenzie, who quotes and coincides Avith Monteath, states that he has been obliged several times to repeat venesection in the arm, besides resorting to the application of leeches, before he could affect the disease so as to derive advantages from the use of mercury.* Unfortunately, syphilitic iritis often occurs in subjects whose constitutions, greatly debilitated, Avill not tolerate the abstraction- of blood. Applications are frequently made to parts adjacent to the orbit, and to the eyelids, for the purpose of mitigating the pains, and preventing contraction and obliteration of the pupil, and they are either of an antiphlogistic character, or have a ten- dency to overcome the diathesis. Opiated frictions are commonly used to relieve the nocturnal pains; they should be applied about * Maladies des yeux, p. 378, Frenoh Translation. DISEASES OF THE EYES. 405 an hour before the expected attack. The eye may afterwards be covered with a folded compress which has been previously warmed before a fire. Whenever the paroxysms threaten to return, and this generally occurs about midnight, these frictions, with opium should be renewed. Opiated mercurial ointment has also been employed, or the tincture of tobacco, according to the circum- stances of the case and the judgment ofthe practitioner. The ex- tract of belladonna, in the form 01 an ointment, is much used ac- cording to the following formula: R. Ext. Bclladon. grs. xv. Axung. § i. An application of a mixture of one part of extract of belladonna and one of mercurial ointment, is also employed ; but precautions should be taken when belladonna is used in large quantities. It is proper here to allude to a phenomenon which has often been observed, and which is noticed by M. Yelpeau. The extract of belladonna is generally employed for the purpose of preventing the contraction of the pupil and promoting the laceration of the false membranes which may have been developed in its vicinity*. But it has been remarked, that in cases of intense iritis, the pupils- does not dilate under the influence ofthe belladonna; it was only' after the inflammation had subsided, and the congestion dimin- ished, that dilatation was produced, and the laceration and separa- tion of the very thin grayish newly-formed adhesions were effect- ed. This shows the necessity of resorting to antiphlogistics before we use the belladonna. Every evening the belladonna should be freely rubbed over the eyebroAvs and on the eyelids. After the cessation of the acute symptoms, Ave may drop several times in a day a filtered aqueous solution of this substance on the conjunc- tiva. The medicine should be used regularly for a month at least when the pupil has not completely regained its natural mobility. Mercury, hoAvever, is the best of all means. It is on this medi- cine, says Mackenzie, that we should chiefly rely to arrest the progress of syphilitic inflammation of the iris, and to remove the morbid changes which may be produced in this membrane and in the pupil. It should not be administered in small doses as an alterative, but the system must be fully impregnated and the mouth evidently affected. In many cases, it is only after a copi- ous salivation is established, that any beneficial effect is observed from its use., I employ frictions' twice in the day on the eyelids and the eye- broVs, Avith a pommade composed of tAvo-thirds of Neapolitan ointment, and one-third of the extract of belladonna; afterwards I apply the Neapolitan ointment alone under the angles of the max- illary bones. In addition to the above, I administer internally two pills of the proto-iodide of mercury, daily. The mouth soon becomes affected, even severely, producing an abundant discharge of saliva, and a rapid resolution of the iritis. I know of no treat- ment more rapid and effectual. 406 VIDAL ON VENEREAL DISEASES. Mackenzie alludes to a case where the medicine was thrown aside by the family physician ; having been resumed, it produced but little benefit; the patient, finally, having taken ten grains of calomel and five of opium, daily, for several successive days, the mouth became suddenly affected, and the iritis disappeared as if by magic. This Avas a case of genuine syphilitic iritis, the pa- tient's body being covered with« copper-colored eruption. Mackenzie strongly recommends the combination of calomel and opium. A pill composed of one and a half grains of the former, and from one-third of a grain to one or one and one-third grains of the latter, may be given morning, noon, and evening, for some time, until the gums become decidedly affected; afterwards two pills a day may be continued for awhile, and when the sahvation is of longer standing, we may diminish the quantity to one a day, to be taken in the evening. This combination is adapted to the severer cases, and when Ave wish to speedily arrest the progress of the malady, to prevent the effusion of lymph in the pupil, and to produce its absorption when already deposited. In the milder forms, Ave may rest satisfied in giving, to begin with, one pill morning and evening. Mercury, especially the proto-iodide, should be administered for a long time, not only that the iritis may be checked, and its con- sequences removed, but for the purpose of curing the constitu- tional infection, as Ave cannot infer the cure of the syphilis from the cessation of the iritis, and we should remember that the gene- ral disease often appears to be cured, though much still remains to be done, particularly with mercury, in order that the eye may be thoroughly cured of the iritis and its consecutive effects. I come now to speak of a means which has been highly praised, viz., turpentine. Carmichael of Dublin has reported cases in his memoir, presenting incontestable proof that this, medicine has sometimes cured a form of iritis regarded as syphilitic. After the effusion of lymph in the pupil, and the formation of condyloma on the surface of the iris, he has succeeded in restoring these parts to their natural state. Carmichael Avas led to administer turpen- tine in iritis from the known influence of this remedy in cases of peritonitis, and the analogy existing between the morbid products m the two diseases, since in both a serous membrane is the part affected, and in both adhesions are produced between surfaces destined to be separated. This medicine, which, moreover, I have never administered, may be of service in some cases in Avhich, from various circumstances, mercury cannot be employed. The oil of turpentine is given in drachm doses three times in a day. Its disagreeable taste, and the nausea which it produces, may be avoided by taking it in the form of an emulsion. Lf strangury supervene, the mfedicine should be for awhile suspended, and an infusion of flax-seed or camphorated julep be given. To prevent burning sensations in the stomach, Ave may add from four to five grains of camphor to eight ounces of the emulsion, containing one ounce of the turpentine. Conjointly with all these means, and even with the opiated frictions already mentioned, we should ad- DISEASES OF THE TESTICLE. 407 minister the sulphate of quinine, in cases where the nocturnal pains are severe. A pill containing one and a half grains of the quinine may be given when the patient retires, and another one hour before the expected paroxysm. SECTION Y. DISEASES OF THE TESTICLE. In the first part of this work I have described an affection of the testicles peculiar to the so-called primitive venereal diseases'; this affection is orchitis, a lesion which is almost always of an acute nature. The disease noAV under consideration follows other syph- ihtic manifestations; it is one of the most remarkable forms of consecutive syphilis; it is the syphilitic sarcocele or the venereal tes- ticle, a malady essentially chronic. SYPHILITIC SARCOCELE, OR VENEREAL TESTICLE. This chronic engorgement of which Astruc had a faint glimmer, and which Benjamin Bell seems to have in view, was but imper- fectly known before the investigations of Dupuytren and Sir Astley Cooper. It is to modern writers that we must refer for the history of this affection, and several obscure points yet remain to be eluci- dated. / - [Among those who have most contributed to promote our knowl- edge on this Subject, by pathological evidence, the names of Cus- ack of Dublin, and Dr. John Watson of New York, deserve a con- spicuous place. The paper of Mr. Cusack in the 8th vol. of the Dublin Jour, of Med. Science, Nov. 1835, though brief, is valuable, inasmuch as his remarks are based on the evidence afforded by eight pathological specimens. It is strange that neither Sir Astley Cooper nor Mr. Curling' never had an opportunity of dissecting a syphilitic testicle (Curling on Testis, Am. Ed., p. 348.) Sir Ben- jamin Brodie refers to a case in which he examined a testicle thus affected, but the morbid appearances observed by him did not differ from those seen in chronic inflammation. (Lond. Med. Gazette^ Arol. xiii., p. 379.) The preparations presented to the Surgical So- ciety of Ireland by M. Cusack, exhibited the changes produced by the disease " in all its stages of progress, from a small circumscribed tubercle in an otherwise sound testis, to the contracted, indurated, and completely disorganized gland," which changes Avere analo- gous to the products of scrofulous disease. The several examina- tions made by Dr. Watson led him to conclude that the primary seat of the affection is in the fibrous envelope forming the proper capsule of the testis, Avhich occasionally becomes enormously thickened, whilst the proper tissue of the testis remains healthy. 408 VIDAL ON VENEREAL DISEASES. The tubule seminiferi, Avith their continuous vessels of the epididy- mis were atrophied, pale, and immersed in serous effusion. In one case, there Avas a deposit of a large yellow mass, irregular in shape, broadest in front, and apparently connected with the fibrous en- velope of the testicle, and extending backAvards in the direction of the corpus highmorianune. This mass, by its pressure, produced atrophy of the tubuli seminiferi. ( Watson on Syphilis, New York Journ. of Med. & Collat. Sciences, Nov., 1845.—G. C. B.] As I have already stated, syphilitic sarcocele is one of the most remarkable forms bf consecutive syphilis; it is also that affection which at its commencement perhaps furnishes the strongest argu- ment against the systematic arrangement of the syphilitic accidents into three divisions. In fact, the same tumor may be a secondary, a successive, and a tertiary accident; for we see syphilitic sarcocele developed during the existence of chancre, and the eruption which is Earliest manifested, or even when not preceded by syphilitic cutaneous eruption, and again it appears only in connection with the more profound and tardy forms of the eruption; finally, it may not occur until the last stage of syphilis, with the exostosis; then it is tertiary. I had in my wards for a long time three patients affected with this disease, and in Avhom existed these three connec- tions with other accidents. Symptoms.—If Ave would remove the obscurities surrounding the history of venereal engorgements of the testicle, it is necessary to establish tAVO varieties. 1st Variety.—A blennorrhagia has existed, and may still exist, but it is rarely alone, the patient most frequently having been affected with chancres. The tumor almost always commences in the epididymis; at a period, generally advanced, of the disease, we may detect an effusion of greater or less quantity of serum, in the tunica vaginahs. Sometimes the testicle is affected simultaneously with the epididymis; it may constitute the largest portion of the tumor, which is generally of considerable size; it is ordinarily larger, more unequal and painful than in the second variety. It is in this variety especially, that the tumor is the seat of lancinat- ing pains like those of cancer. When the disease is of long stand- ing, we find both sides affected; then when we imagine that we are treating an ordinary orchitis, which shifts from one testicle to , another, as is of frequent occurrence, Ave are frequently mistaken, for whilst orchitis ordinarily disappears on one side Avhen the other testicle becomes affected, we here observe the tumor on one side increasing whilst that of the opposite side does not diminish. This is the engorgement of the testicle Avhich M. de Castelneau re- gards as a chronic orchitis, and which other AAriters on syphilis consider to be a syphilitic testicle, and which, in my opinion, is both. Perhaps it would be more proper for me to say, that it is an orchitis complicated with syphilis, a circumstance which gives it a decidedly chronic character. Thus, in this first variety, syph- ilis invades a testicle already diseased, already inflamed; it attacks a testicle affected with orchitis. 2d Variety.—This is observed in patients who have never been DISEASES OF THE TESTICLE. 409 affected Avith blennorrhagia, who even have never had any disease of the genital organs, since I have seen a case of syphilitic sarco- cele in a patient where the only antecedent disease had been a chancre on the lip. Generally, there has been a primitiAre ulcera- tion on the penis, and this has been followed by a syphihtic erup- tion. In the majority of cases, there are no premonitory symp- toms and it is only by accident that the patient discovers that there has been any alteration in his genital organs, or perhaps he may feel a sensation of Aveight, and inconvenience, and of dragging. It is rare that a dull pain in the loins, occurring chiefly during the night, precedes or accompanies this variety of syphilitic engorge- ment. The tumor is generally smaller than that in the first variety. Sometimes the epididymis is not involved in this augmentation of volume; it seems perfectly atrophied by the compression which it suffers from the abnormally-developed testicle. The gland be- comes gradually indurated in patches, in zones; these multiply and finally become united, the testicle only, enlarged without being sensibly altered in form, is of remarkable hardness. Both sides are affected more frequently than is imagined, but generally one is larger than the other, and this alone arrests the attention of the observer. If but one testicle is really affected at first, the other soon becomes involved. According to M. Eicord, the parenchyma of the testicle, after having suffered this syphilitic attack, becomes transformed into fibrous, cartilaginous, or osseous tissue; it may undergo even a malignant degeneration. Sometimes the tumor ulcerates ; according to the same writer, this would then constitute a gummy tumor, Avhich should be opened independently of the testicle, it being seated in the cellular tissue of the scrotum. Atrophy may be one of the consequences of this affection of the tes- ticle, but it is not constant. I have seen, in more than one in- stance, both testicles which had been completely affected with this disease, restored to their normal state and afterwards perfectly fulfil their functions. I have seen it followed even by hypertrophy of the testicle; a case came under my observation, where the testicle on one side had been removed, and the other was affected.Avith the disease under consideration, and yet this patient after he was cured, indulged to excess in coition. I shall refer to this fact in another place. This second variety, AArhich affects especially the seminal gland, may occur even where no antecedent chancre has been observed; it may result from syphilitic blennorrhagia. It is to cases of this k kind that most of the obscurity connected with the history of the disease in question is to be attributed ; for the advocates of chronic orchitis, Avho almost always reject this second variety, attach greatjl importance to the antecedent blennorrhagia in estabhshing this same chronic orchitis. Generally, the tumors on both sides are not painful, when they belong to the first or second variety. Lf pressure be made some- what firmly, it produces the same amount of pain that it Avould if made on a sound testicle. This pressure may be productive of no sensation Avhatever. When pain does exist, if on one side, it is 410 VIDAL ON VENEREAL DISEASES. rather towards the inguinal region, and in the majority of cases, it is then caused by the weight of the tumor, when the latter is of large size. As I have already stated, I am now treating of chronic affec- tions. Their progress is slow, and they may continue for several years. If Ave observe a certain tendency to assume an acute char- acter, it is in the first variety, and affects the epididymis. In the great majority of cases, there is a decided alteration in the func* Sons of the testicles. Sexual desire is diminished, and in some instances completely destroyed; erections are then less frequent, and sexual intercourse, less sought after at first, at length becomes impossible. The secretion of semen is lessened, and is proved by the smaller number of animalculse which is in all cases observed. These lesions in function become much more decided when the disease involves more particularly the parenchyma of the testicles, and when both are involved. The second variety in this respect, is more grave than the first. I shall return to this subject when I come to speak of the prognosis of the disease. Diagnosis.—The diagnosis may be greatly simplified by observ- ing the general rule mentioned in a memoir which I read to the Academy of Medicine. I have stated that when there is a chronic engorgement of both testicles, the affection is necessarily benign; it cannot belong to any of the forms of cancer, nor to the category of tumors caused by tubercles which are found at the same time in the internal organs. Syphilitic sarcocele, therefore, can be con- founded only with the chronic engorgement of the testicles, which is also regarded as a tubercular affection, but which is of a benign \ character as the viscera are sound. It remains, then, to distinguish h syphilitic sarcocele from this chronic engorgement, or, if it be pre- ferred, from these benign tubercular tumors. Here the antece- dents and the concomitant symptoms afford us great assistance. The tumor, besides, in the second variety, is less irregular, than in the strumous affection, and the induration involves the testicle • itself, whilst in the strumous disease the. testicle retains its normal elasticity. The first variety, that which was first described, may more readily be confounded with the engorgement in question, and so much the more easily as among the antecedents of both tumors a blennorrhagia may oe found. But the strumous tumor is much more irregular; there are portions of it which frequently become softened, and suppurate; it is rare that the patient, at some period'of the disease, does not experience pain, and pressure, even when slight, produces it. Syphilitic sarcocele, on the con- trary, may pass through all its stages, without ever being the seat of the least pain, and, in some instances, even pretty strong press- ure does not excite it. Treatment may throw some light on the diagnosis; the iodide of potassium, indeed, in large doses, produces a prompt and de- cided effect on the syphilitic tumor, while the same medicine, administered in strumous cases, is long in exerting its influence, and its action is felt in the tumor only after the whole system has been thoroughly modified by this agent. True, the prompt and DISEASES OF THE TESTICLE. 411 manifest action of which I have spoken is produced only in the first variety, and it is rare to "observe these effects produced when the iodide is employed in the other forms of syphilitic sarcocele. But this A-ariety is very favorably influenced by mercury, used both externally and internally, while the effects of this agent are injurious in the strumous affection. Prognosis.—I have already indicated my opinion as to the prog- nosis in syphilitic sarcocele, when I classed it among the benign tumors of the scrotum. The prognosis is therefore favorable, especially since the iodide of potassium has been introduced into the therapeutics of certain forms of syphilis. There is no diversity of opinion on this point. The patient, then, has nothing to fear in general; but what effect has the disease on the functions of the organs ? This is a serious question, which I have attempted to discuss in a paper read before the Surgical Society of Paris. A testicle affected with Avhat is called syphilitic sarcocele doubt- less suffers profound modifications in its structure. I have already stated, that the organ may become of a fibrous or a cartilaginous nature, or its parenchyma may become the seat of calcareous de- posits, in Avhich case it becomes atrophied. Nutrition in the sub- stance|pf the organ is impaired, the organ itself is diminished in size, and after the cure of this kind of sarcocele, it remains more feeble and of smaller size. Atrophy of the testicles, therefore, is a condition so frequently produced by syphilitic sarcocele, that we are authorized in assigning it a place among the general characters of the disease. But I believe that those Avho regard atrophy as an inevitable termination of syphihtic sarcocele, entertain an opin- ion not warranted by facts, or, more properly speaking, by well- authenticated facts. The consequences of atrophy of the testicles, as regards their functions, may be imagined, since if it exist to any great extent, if it involve the parenchyma of both organs, it is equivalent to castration. Unfortunately such a condition some- times happens. Thus, I was consulted by one of my confreres, who had Avatched the wasting of his testicles under the influence of syphilitic disease; a portion of the epididymis only remained on either side, and these remnants of the organs were exceedingly sensitive ; impotence in this case was complete. This was an ex- ample of atrophy Avith its most serious consequences. The most common result of the disease is to diminish the size of the testicle in its ensemble only, and to render it irregular and of unequal- consistence. The extent to which virility is impaired, does not appear to be always in proportion to that of the destruction in the organ pro- duced by the disease: indeed, we meet with patients no longer capable of an erection, or in Avhom the seminal discharge is very diluted, and small in quantity, and yet who have lost but a small portion of the parenchyma of the testicle. These differences de- pend upon the age of the patient, the use or abuse he has made of his virile powers, and the state of his mind. In connection with the latter point, melancholy cases are sometimes observed; they occur in that class of society capable of comprehending the nature 412 VIDAL ON VENEREAL DISEASES. of atroplr^ of the testicles and its effects on virility. These un- fortunate individuals have learned the nature of indurated chancre and its consequences, of syphilitic sarcocele and its results: they remain a long time under the influence of disease; they imagine an impotence with which they are often not affected; they are afraid of marriage, regarding themselves as ruined men, and they remain in a state of celibacy the most melancholy and complete. If certain considerations, family or self-interest, lead them to con- tract marriage, at the moment of attempting the conjugal rite, their courage fails them, and they sink into the deepest despair. I knew a person placed in the above chcumstances, and who after- wards became a father, after having been persuaded that even when both testicles are diseased, provided the patient be placed under proper treatment, virility may be preserved. This fact of itself is calculated to impress upon our minds the importance of the subject now under consideration. [These remarks of our author will doubtless recall those made in another place on Syphilophdbia.—G. C. B.] For my own part, I believe, not only that atrophy followed by impotence are not the inevitable consequences, even when Avhat we call syphilitic sarcocele is cured, but I am acquainted Avith facts Avhich led me to think that, in certain cases, the testicle thus affected may, after a well-directed treatment and cure, preserve its vigor, and be completely restored to its normal anatomical and physiological state. A rare exception is where the same syphilitic influence, exercised on the same individual, produces completely opposite effects in each testicle; one will become atrophied, the other hypertrophied. I shall soon relate a case showing this double effect of the syphilitic action. I have already published the details of one of the strongest cases to show that virility may survive a profound syphilitic affection of the testicle; this case is related in my work on surgery, and 1 shall repeat it'when I come to the subject of the therapeutics of this disease. The patient was a soldier, from whom an army surgeon removed one testicle, supposing it to be affected with malignant disease; in investigating the previous history of the "case I found that the patient had had symptoms of syphilis. I prescribed the iodide of potassium in what. I call sufficient doses. The testicle soon returned to its normal state, with the exception that it remained somewhat larger than natural. I ask the atten- tion of the, reader here particularly to the last part of the report, which thus concludes: "The patient is constantly inclined to sexual indulgence." I am convinced of the truth of this by the fact that I have been called upon to treat this soldier twice for blennorrhagia since he left the hospital. Here we have a patient Avith only one testicle, and that affected Avith what is called sarcocele; the previ- ous history of the case, the characters of the tumor, the good effects of the iodide of potassium, all go to prove the fact; yet this testicle, after the disease is removed, was not only not atrophied, but seems to have been hypertrophied; his virility was not destroyed, for he DISEASES OF THE TESTICLE. 413 indulged in sexual excesses, the penalty of which was repeated attacks of blennorrhagia! In the month of August, 1847, there was in my service at the Hopital du Midi, a carman, who presented an analogous case to that just described. This patient had never lost a testicle, but one was not developed; it was the right testicle, and was situated near the external opening of the inguinal canal, where the only trace of it to be found was the epididymis, which was scarcely the size of a common bean. This carman left my service cured; he after- wards contracted a chancre at a house of prostitution, communi- cated it to his wife, who became pregnant and gave birth to a child, which died shortly after its birth, covered with a syphilitic erup- tion, similar to that which I observed on its unfortunate mother. Here, again, was a subject with only one testicle, and that evidently syphilitic, and yet his virility was not affected, since it was mani- fested both in lawful and illicit intercourse, and by the birth of a child bearing the marks ofthe paternal disease. The following case would seem to prove that a syphilitic affection involving both testicles, may produce atrophy in one alone. M. Eicord asserts that this atrophy is consective to an actual disease of the testicle, of the existence of which we may be ignorant, since it does not augment the volume of the organ. For my own mxt, I consider it of but little consequence whether the atrophy is pMi- tive or consecutive; what I maintain is, that there may be atrophy of the testicle on one side, and hypertrophy of that on the other. On the 19th July, 1845, there Avas admitted into my service a man named B., ost. 50, a road-laborer, and of good constitution. Twenty years before he contracted a chancre, which was followed by a suppurating bubo in the left groin. At the end of ten days the chancre became cicatrized, but the patient Avas confined to his bed awaiting the cure of his bubo. He took pills, but does not know whether they contained mercury; he never had an eruption on his skin, nor sore throat. Six years since he suffered, without any apparent cause, pains in his head, neck, and extremities, which lasted only fifteen days. Three months since he contracted a new chancre on the anterior part of the reflection of the prepuce; the only treatment was cauterization, and it cicatrized in the course of fifteen days. This patient never had a blennorrhagia. Some two months before the appearance of the last chancre, the left testicle began to enlarge, and this enlargement was unattended with pain. It is only during the last month that Jhe patient has experienced shooting pains, which are more frequent during the night than the day. The left testicle at present is of the size of a large hen's egg, j it is hard, heavy, of pyriform shape, and presents slight inequali- ties. The epididymis "cannot be felt, but appears to be confounded with the testicle. The spermatic cord is someAvhat larger than natural, and the veins ofthe same side are also unusually developed. Pressure produces but httle pain. A month and a half since a small tumor appeared on the external and superior part of the left thio-h, Avhich suppurated. The Avound Avas not completely cica- trized until about eight days since; a very large reddish cicatrix" 414 VIDAL ON VENEREAL DISEASES. remained, analogous to those left by'cutaneous tubercles. The right testicle is atrophied, being reduced to half its size. This - diminution in size was not preceded by any tumefaction, and occurred about two months after the left began to enlarge, and at a time when discutient plasters had been applied to the latter, lead- ing the patient to suppose that the atrophy of the right testicle had been produced by the plaster. ~ July 12th. The iodide of potassium was administered to the extent of half a drachm daily. Eight days afterwards the pains had ceased, and there was a marked diminution- in the size of the testicle. 28th. The left testicle, which was the largest, is reduced to nearly half the size it presented on the patient's admission. In- durated nuclei are felt much more distinctly when the testicle is made to glide beneath the skin under the fingers; the consistence is less. The epididymis is readily distinguished from the rest ol the gland, and the spermatic cord has regained its normal size. There is no .longer pain even on pretty firm pressure. The nor- mal sensibility seems to be diminished. For some days past the patient has been troubled with dimness of vision. The vessels radiating from the sclerotic are slightly injected; there is photo- phobia, with lachrymation. The patient also complains of buzzmgf irnRis left ear, but this has existed for several years. Aug. 8 th. Vision is now perfect, and the eyes have resumed their natural appearance. The buzzing in the ear continues. The indurated nuclei in the left testicle are less numerous and painful. The consistence still diminishing. 22 d. The left testicle has regained its normal shape. It still remains larger than natural. The right is always small—that is, it is reduced one-half. I saw this patient again one month after his cure; he came to consult me in regard to a blennorrhagia which he had Contracted. Here, then, we have three cases estabhshing the fact that both the testicle and its functions may be preserved in their integrity after the termination and cure of a syphihtic sarcocele. They jus- tify me in placing hypertrophy of the testicles in the same cate- gory. I Avill not conceal the objections Avhich may be urged . against my conclusions, objections drawn from the cases them- selves which I have quoted. In the first place, it may be said, that ' hypertrophy of one testicle in the absence or imperfect develop- ment ofthe other, is a fact in the organo-genesis well known; that the hypertrophy preceded the syphihtic infection. • Syphilis, there- fore, did not give rise to it; it resulted in obedience to that law of compensation, by which the materials destined for the nourish- ment of an absent or imperfectly-developed organ, are carried to its'felloAV organ, which thus receives an unaccustomed supply. It may be objected, perhaps, that in the cases above mentioned, - syphilis has found the testicles hypertrophied, and that if after its cure, the testicles remain of their natural, or of an unnatural size, if they still retain their functions, it is no proof that these organs have not suffered^ certain degree of atrophy, for an organ which DISEASES OF THE TESTICLE. 415 is equal to one and a half may very well suffer a substraction, and remain still equal, if not a little more larger than the other. The case of the carman furnishes the strongest argument in favor of this view of the subject; he was born with but one perfectly-de- veloped testicle, whilst the situation of the other was indicated only by a portion of the epididymis. There may therefore be some ground for believing the perfectly-developed testicle, in this case, had become considerably enlarged before it became diseased. When attacked by syphilis it became reduced to less than its na- tural size: the hypertrophied organ here became atrophied, and the hypertrophy was at the expense of the cure. These arguments, to which I cannot refuse a certain Aralue, do not destroy the fact of one testicle retaining its natural size, with a volume even more than natural, preserving its functions, and this, too, after it has suffered from the disease called syphihtic sarcocele. I do not know precisely what was the condition of the left testicle in the carman before it became attacked by syphilis; what I affirm is, that, after the cure, it was found of larger size than the same organ in another subject of the age and strength of that patient. I will also state, that this carman, who had begotten no child before his disease, did so after his cure. The same objections, perhaps, may be advanced against the case" of the soldier in whom one testicle had been extirpated, and who, after being cured of syphilitic sarcocele in the other, preserved thev latter in an hypertrophied and very active state, for there Avas an interval of two years between the castration of the one, and the. syphilitic attack in the other. During this period, it may be said,' the testicle which was left had the benefit of the nutritive mate- rials destined for the other as well as for itself, and may have thus become preternaturally developed: constituting an hypertrophy, which may have prevented the atrophy from producing its effects." To this I Avill reply, in the first place, that the tAvo years' interval above mentioned, Avas too short a period for an organ to become so hypertrophied as to resist the atrophy produced by syphilis. Further, as the Avhole history of this soldier's disease, a history which may soon be read, proves to me that the amputated testicle was not cancerous, but syphihtic; and, as it Avas the same venereal disease Avith which the first Avas affected that invaded the latter, I submit whether a subject, completely infected with syphihs, under< the influence of a principle the tendency of which is to produce atrophy of the testicle, could, under such circumstances, have one x of these organs hypertrophied. I believe, further, that the altera- tions of tissue constituting the tumor, called syphilitic testicle, or syphilitic sarcocele, may vary, and that the mode of reparation is not always identical; in proof of this, I will offer the case which I have fully related. It shows, indeed, that under the same syphili- tic influence, one testicle becomes atrophied without becoming tumefied, while the other tumefies, actually forming a tumor, and remains, to a certain extent, hypertrophied. These facts and these inferences are, in my opinion, of a nature to merit the attention of practitioners, for they relate to an important question in pathologi- • 416 VIDAL ON .VENEREAL DISEASES. cal anatomy, and to the question of sterility in the male—questions of very serious importance,' in many points of view. Treatment.—The treatment is the same as in confirmed consti- tutional .'syphilis, modified, however, according to the variety of the sarcocele and the other circumstances already indicated. We should Remember that syphilitic sarcocele does not always occur at the same period of syphilis. I have asserted, at the commence- ment of this article, that the tumor may appear shortly after the first manifestation of syphilis, simultaneously with a premature eruption on the skin, or without this eruption, that it has-been observed during the period of transition, and that, in fine, it may occur among the latest symptoms, such as periostosis and the exostosis. , The practitioner should take these circumstances into consideration. The sarcocele which appears before this profound alteration of the organism, Avhich contra-indicates all depletory treatment, may be advantageously affected by mercury. It was this variety of sarcocele, which I will call premature, that was cured with mercury alone, by Dupuytren, Boyer and other practitioners, who, before they decided to perform castration, subjected to a mer- curial treatment patients affected with chronic enlargement of the testicles, which assumed certain of the characters of cancer. Thus, more recently, with the pills of the proto-iodide of mercury, I have removed a double syphilitic sarcocele, which had preceded the' squamous eruption. Mercury, therefore, and even mercury alone, may radically cure certain syphilitic sarcoceles, and I be- lieve that it is well "to commence with it, Avhen Ave have a concom- itant superficial eruption, and the patient still retains his strength, ' and his constitution is not profoundly altered. It is, in iny opin- ion, the means, fo;r preventing relapses. But it is evident that cerr • tain sarcoceles, especially'those of the-second variety, cannot be / affected by mercury, no matter how it may be administered. This remedy, therefore, may have its dangers, and it is principally '$' when the disease is late in its development, when it occurs in' the. last stages of syphilis, when the syphilitic cachexia is already es- tablished. These are the sarcoceles which Avere formerly re- moved by castration; they were regarded as of a cancerous na- . ture, because they'resisted the influence of mercury. This period , is not very remote from our OAvn, and I have seen, quite re- Ncently, some of the great masters whom I have mentioned remove testicles which might have been saved by the iodide of potas- sium. ' [Dr. John Watson refers in his Essay to an instance where, in consultation, he opposed, but unsuccessfully, the. operation of cas- tration, for syphilitic sarcocele !—rG. C. B.] This, therefore, is the remedy to be employed in severe cases, "when the constitution has become, compromised; in the second variety, then, it will produce very prompt, and at first, very -de- cided effects. Its eihployment even need not be confined to the "■latter variety; as a general rule, it should,be associated with mer- cury in the treatment of the first variety. The following is a re- port of the case to Avhich I have alluded; it is calculated to make DISEASES OF THE TESTICLE. 417 the surgeon reflect in similar cases, and to cause the surgeon who performed the operation to regret the deed. \ Great enlargement of the left testicle. Ablation ofthe organ by an army surgeon who regarded the tumor as a hydro-sarcocele. Similar enlargement of the right testicle. Cure by the iodide of potassium.— B., set. 29, gunsmith, occupying No. 24, Ward 10, admitted 11th of March. Not very robust, and of a scrofulous aspect. He states that from his childhood he has never been ill. His parents are healthy, and are very vigorous. On his neck and face, however, are cicatrices which have resulted from scrofulous ulcerations. Six years since, he had a blennorrhagia, Avhich lasted eighteen months; this was never painful, and was cured spontaneously. Six months afterwards, long after'he had indulged in sexual inter- course, ulcerations appeared on the prepuce and glans. The patient submitted to a mercurial treatment. After this, he had an eruption on the skin, which the physician did not regard as syphi- litic, according to the'patient's statement, and there was an enlarge- ment in the left axilla, without any abrasion or wound of the cor- responding extremity; perhaps it was a scrofulous bubo, and it was treated by maturatives and an incision. The patient states that there Avas a syphilitic ulceration in his mouth, which his hysician repeatedly touched with the nitrate of silver, and which ealed several times only to break out again. At length, the left testicle began to enlarge (the patient being at this time in service); in the course of four months it acquired an enormous volume; hard at the commencement, it became softer and softer ; more or less frequent shooting pains were felt in the tumor, extending even to the kidneys. For four months the patient remained in military hospital. Finally, in April 1841, the tumor was removed by operation. The Avound, at the end of six weeks, had completely cicatrized. The man resumed his occupation as gunsmith. Two years afterAvards, the right testicle became enlarged. In the month of August, 1843, this enlargement had acquired the volume of the two fists. It was hard, particularly at its inferior part; it was the seat of severe lancinating pains, which deprived the patient of all repose. His physician prescribed the repeated application of a large number of leeches to the tumor, frictions with mercurial ointment, and the plaster of Vigo. Six weeks af- terAvards there Avas a great improvement; but the patient led an irregular life, and was addicted to excesses. Although deprived of one testicle, and the other was diseased, he had strong sexual desires. After his indulgences, his pains returned with still greater severity. He then resolved to place himself under my care, and he Avas admitted into the Hopital du Midi. The tumor was much larger than the fist; it was hard at its posterior and lateral parts; someAvhat soft anteriorly, and there was a sense of fluctuation for the extent of about one inch; its shape was oval, its upper extrem- ity the largest, and it had much the appearance of the swelling in hydrocele; but it Avas much heavier than the latter. As I have already stated, this tumor was the seat of severe lancinating pains. The particular hardness of this tumor, the nature of the pains, the 418 VIDAL ON VENEREAL DISEASES. circumstance of the ablation of the other testicle, seemed to shoAV that it was a true sarcocele, a scirrhous or encephaloid tumor which might lead to a fatal termination. But having carefully learned the history of the disease, on his admission, I placed him under the influence of the iodide of potassium; he had taken only about two drachms before the pains had nearly ceased. At pres- ent, A£>ril 15th, 1844, the tumor is reduced one half in size, and the pfiin has completely subsided. The part ofthe tumor presenting an obscure fluctuation has not enlarged, but there is still a sensation of a fluid of this consistence, as if it might be the product of ramollisement. On the 2d of May, 1844, the indurated portion had diminished in extent fluctuation was more evident, and the whole-tumor was less than half its orig- inal size; on the 19th of May, it was scarcely double the volume of an ordinary testicle. The administration of the iodide of potas sium was suspended. Frictions Avere made on the tumor with an ointment ofthe iodide of lead. Finally, the* testicle resumed its normal state, and the patient left the hospital on the 15th of June. He is always strongly inclined to sexual indulgence. We here see a tumor presenting many of the characters of ence- phaloid disease; an obscure fluctuation, lancinating pains, debil- ity pallor of countenance, one testicle amputated, a testicle which was similarly affected, and yet the iodide of potassium in this case was triumphant! Did it cure a cancer, or was it a case of benign tumor, a syphilitic sarcocele ? The latter appears to me the more rational hypothesis. SECTION VI. DISEASES OF THE CELLULAR TISSUE. In describing the affections of the skin and mucous membranes, we have frequently alluded to a simultaneous lesion of the cellular tissue. Thus, the deep-seated syphilitic eruptions, the tardy lesions ofthe velum palati, ofthe pharynx and tongue, are attended with more or less congestion of the subjacent cellular tissue, and at the same time it is observed in the affections of the external and in- ternal tegumentary coverings. It is the diffused syphilitic indu- ration of the cellular tissue; it may occur conjointly with the le- sions of the skin. In this case, the cellular tissue seems to become affected by the extension of the cutaneous lesion, or by that of the mucous membrane by which it is covered. At other times the cellular tissue becomes thickened, and indurated without any pre- vious affection of the skin, which may then remain for a long time and forever, in a normal state. . Instead of this diffused or vaguely-circumscribed induration, we may observe partial engorgements, Avhich gradually assume the form of a nut, tubercle or knot. They may be condyloma^ DISEASES OF THE CELLULAR TISSUE. 419 and then they occur especially about the anus; or they have re- ceived the names of gumma, nodes, gummy tumors, and are found beneath the skin, the deep cellular tissue, and even in the sub- stance of certain organs, and of muscles. This affection of the cellular tissue is observed when constitutional syphilis has deeply undermined the system. The most frequent seat of these tumors is on the external surface of the extremities, in the subcutaneous cellular tissue, where it is lamellar and dense ; there they may for a long time preserve a certain degree of mobility and for a decided prominence ; they have been seen of a pediculated shape. These tumors may occur in the cellular tissue of the scrotum; they may then be confounded with syphilitic sarcocele, a mistake of no great importance, or they be confounded with genuine can- cer, an error of much more serious consequence. They may also occur in the deep-seated cellular tissue, and even in that which unites, or separates the fibrous or the muscular system. Thus they frequently invade the tongue, which then appears as if covered with small hazel nuts. M. Eicord mentions a remarkable case of the kind. It is in such cases that it is especially hable to be con- founded with cancer. Generally, there are several of these tumors, but they are not all developed simultaneously. Months, and even years, may there- fore be required to effect their cure, no matter what the treatment pursued. At first, they are small, but little sensitive, hard, adhe- rent to the skin, but free and movable beneath. They are slowly developed, increase slowly, and are unattended with pain. Some little inconvenience in the part, or accident, leads to their discovery by the patient. They vary in size from that of a hazelnut to a walnut. For a long time hard, they finally yield to pressure, pre- senting a slight sense of fluctuation, which afterAvards becomes quite evident. Then, if they are in the vicinity of the skin or the mucous membrane, their envelope becomes thin, of a violet reddish- brown color, and they burst, presenting perforations similar to those which folloAV the opening of an anthrax. A badly assimi- lated pus, a kind of gummy matter, of organic debris, issues by the openings which become enlarged: a deep ulceration forms; the gummy tumor appears to be evacuated, leaving a kind of cavern, bounded by a shell, or cyst, which must be destroyed and cast out, before complete reparation can occur. The cicatrix that fol- lows is depressed, and irregular like that succeeding to a deep burn. M. Eicord observes that the ulcerative destruction which sue- * ceeded to the tumors on the tongue, in the case before mentioned, "was horrible, and to eyes unaccustomed to such sights these ul- cers might have appeared horrible cancers."* We should remember, that all deep-seated syphilitic tumors are not formed by the cellular tissue, or at least by this tissue alone. Thus, in describing the tumors of the muscles, I shall soon speak of one formed by a particular degeneration of the muscular fibres * Traite des Maladies Veneriennes, p. 660. 420 VIDAL ON VENEREAL DISEASES. themselves. In complex cases, the tumor may be composed both of cellular tissue and the parenchyma of organs. The affections of the cellular tissue, of whatever form, are neces- sarily grave, as they occur at a period of syphilitic infection char- acterized by a profound alteration of the organism. The gravity of the prognosis, besides, depends upon the seat of the gummy tumors. Thus, those situated beneath the skin on the extremities, are of a much less serious character than those which are devel- oped in the substance of the tongue, or of the velum palati; for when they ulcerate, they may commit vast ravages, and compro- mise important functions. The treatment must be adapted to the nature of the affection, and the period of syphilis in Avhich it is observed. Mercury can seldom be administered with propriety in these cases, on account of the profound alteration of the organism coinciding with these tumors. The practitioner should therefore avoid this and all other hypothenisants, and trust to tonics, and such other means as may invigorate the system. At the head of these means, stands the iodide of potassium. If the subject tolerate it well, and it be ad- ministered in due season, we shall see these tumors rapidly disap- pear. Some have advised the apphcation of blisters to these tumors, and that they should be opened, and even extirpated. It is evident that these proceedings cannot be resorted to except in certain cases, where the situation of the tumors renders them ac- cessible to the means indicated. Cullerier treated these tumors by blisters dressed with the bi-chloride of mercury, as is recom- mended by M. Malapert in the treatment of buboes. The opening of these tumors is but a palliative remedy, and their extirpation should not be attempted except when general treatment has been exhausted, and a satisfactory trial given to the iodide of potassium. Should, however, we attempt to extirpate them, we should do it thoroughly, for the suppuration will be rendered very protracted if any portion of the cyst be left behind. Sometimes the opening of the tumor, whether spontaneous or made by the surgeon, is fol- lowed by a very active inflammation. We must then resort to topical emollient applications. In the majority of cases, dressings with charpie, steeped in a mixture of two-thirds water and one- third tincture of iodine, should be preferred. We may afterwards employ dressings with the vigo cum mercurio, which will here be found a very useful apphcation. SECTION vn. AFFECTIONS OF THE MUSCLES, TENDONS, AND APONEUROSES. These organs of locomotion frequently become affected in the last stages of syphilis, and yet, until recently, the study of these lesions has been almost entirely neglected. Astruc merely alludes AFFECTIONS OF THE MUSCLES, TENDONS, &o. 421 to this manifestation of syphilis; according to this writer, when the substance of the muscles becomes infiltrated with the virus, we have ganglions, and hard tumors; he speaks of rheumatic pains. Petit Bad el properly characterises it "a retraction rebelhous to treatment." M. Lagneau seems to have observed analogous cases, and he regards the syphilitic contractions as chronic inflammations of the muscles, arising from the syphilitic infection. MM. Ph. Boyer and Eicord have clearly described these contractions, especially those seated in the flexor muscles of the fore-arms; they place • beyond doubt the syphilitic nature of this lesion, and its connec- tion with the tertiary symptoms. I have more than once observed the contraction of the brachial biceps, and have seen a tumor seated in the rectus femoris. The particulars of this case I will soon relate. Finally, M. Bouisson has treated, ex professo, this question of the syphilitic tumors of muscles and their appendages, in a memoir published in the Gazette Medicale of Paris, 1846. I have availed myself of this memoir in the present article. Causes.—The last effects of the diathesis are manifested by numerous local affections. It is the duty of the practitioner to discover the existence of this diathesis, and to assign to it its pro- per place in the etiology of these affections. Nothing is better established than its manifestations in the osseous and fibrous tis- sues, in what is called the tertiary form of syphilis, and these manifestations are generally produced by the influence of syphilis alone, without the intervention of any local or appreciable exter- nal cause. The syphilitic tumors of the muscles, and tendons, come under the same category; they become developed in the sub- stance of these organs, independently of any particular exciting cause. Symptoms and Pathological Anatomy.—The principal symptoms are, pain, contraction and tumors. 1st. Pain.—Pain is more especially observed when the syphilitic infection is inveterate, and in patients who have been exposed to the influences of cold and moisture; these predisposing causes are not essential. This accident has been described under the name of syphilitic rheumatism.- The pain is felt along the course of the muscles, tendons, and the aponeurosis of attachment or envelop; it is of a character similar to that felt in osteocopes, but is less pro- found, and is exasperated by muscular contraction ; it differs from ordinary rheumatic pain by its relation to accidents evidently syphilitic, and it yields to specific treatment. 2d. Contraction.—The muscular contraction is sometimes the result of syphilitic rheumatism, of which it is but a higher degree; at other times, it is slowly manifested, and coincides with a more or less advanced state of the disease. The muscles of the superior extremities and more especially the flexors of the fore-arm, are most frequently affected Avith this contraction. M. Bouisson speaks of a syphilitic contraction of one of the motor muscles of the eye. According to this surgeon, if he were to name the seat of election of these contractions, it would be the sphincters. "WeknoAv" he observes, "how common are permanent con- 422 VIDAL ON VENEREAL DISEASES. tractions of the sphincter ani, in subjects affected with syphilitic eruptions in this vicinity, and Avith fissures of the anus. We also frequently observe active and painful contractions of the vagina, in women affected with ulcerations in the vicinity of its vulvar opening. Now, if in certain cases, these spasms are provoked by the presence of ulcerations, independently of any specific influence, Ave do not violate the laws of analogy, in assigning in other cases, contraction of the sphincter muscles, a place among the accidents • of confirmed syphilis, and in regarding it as a veritable venereal contraction," (loc. cit.) I know not precisely whether M. Bouisson does depart from the laws of analogy, but judging from my own observations, he abuses them. 3d. Tumors.—Tumors developed in the muscular system and its appendages are deserving especial attention. I will first speak of the tumors of the appendages. The tendons and aponeuroses are more frequently the seat of syphilitic tumors than the fleshy part of the muscles. The tendons, like the periosteum, notwithstanding their feeble vascularity, par- ticipate in the effects of confirmed syphilis, and are especially liable to become the seat of partial thickenings, or of small tumors called nodes, Avhich are sometimes hard and filled, sometimes fluctuating. The pathological susceptibility of the aponeuroses, is here less marked, but different observations, and particularly those of Hun- ter, leave no doubt of the part which they take in this class of affections. It cannot, however, be denied that all the reports of •hese cases are brief and unsatisfactory, and that they merely indi- sate their existence without affording us full details; it is even probable that in many of the cases where tumors have formed in these tissues from the effects of syphilis, and which have fallen under the notice of different observers, their real nature and causes have not been suspected. M. Bouisson has furnished the details and facts, which, as far as possible, have rendered the study of these affections complete. These tumors are sometimes solid, and appear to be produced by a circumscribed hypertrophy of the fibrous tissues of the tendons, with effusion of a serous and plastic fluid m their interspaces; they are accompanied with pain more or less acute, which is increased during the contraction of the muscle to which the tendon is attached. The cadaveric examination exhibits this tendon of its natural color, or presenting only slight traces of injection; but it is enlarged either by the thickening of its fibres, or by the addition of an albu- minous and demi-sohdified matter. Lf the affection be long pro- tracted, if it does not terminate in suppuration, ossification occurs, and sometimes invades the Avhole length of the tendon, as was observed by M. Bouisson in the tendon of the psoas parvus muscle; at other times it is limited to the part diseased, forming a kind of sesamoid bone. Syphilitic tumors occur both on the surface and in the centre of tendons. The first is the more common seat; the tumor then forms an abrupt prominence along the course of the tendon, and ii it terminate in suppuration the continuity of the fibrous cord is AFFECTIONS OF THE MUSCLES, TENDONS, &a 423 respected. When it is situated in the centre of the tendon, the newly-formed matter separates the fibres of the tendon and causes the tumor to assume an ovoid or fusiform shape. M. Bouisson has given an illustration of a tumor of this kind, taken from a preparation in the Museum of Pathological Anatomy of Stras- burgh; it was situated in the substance of the tendon of one of the flexor muscles of the fingers. Fluctuation could be detected through the fibrous envelope, and the tumor presented nearly the form and size of an almond. According to M. Bouisson, the affection described by Lisfranc under the name of white nodosities of tendons was only a form of the syphilitic nodes found on tendons; the case was that of a large tumor developed in the substance of the tendo-Achilles, in an opera dancer. It resisted every kind of local treatment; but the iodide of potassium internally administered, aided by compression and certain antiphlogistic measures, produced a complete cure. It is to be regretted that Lisfranc has not furnished us with the previous history of the case; but it is difficult not to assign this tumor a place in the category of those produced by syphilis, when we take into consideration not only the analogy between the situation and symptoms, but that in the effects derived from treatment. The iodide of potassium, the efficacy of which is well established in the accidents of confirmed syphilis, was pre-eminently the remedy if not the exclusive means of effecting a cure in Lisfranc's patient. The muscular tumors resemble those of the tendons. The essay of M. Bouisson contains several interesting facts relative to these muscular tumors, which have also come under my own observa- tion. It is sometimes difficult to determine whether this alteration has its starting point in the muscular fibre, or in the interposed cellular tissue. Analogy, observes the professor of Montpelier, would lead us to believe that the cellulo-sclerous tissue which unites the fleshy fibres, or which forms theh sheath, is the part first attacked. But when the lesion is advanced, when it has manifested one of its modes of termination, either in suppuration or induration, all the anatomical elements would seem to be in- volved, and according to the more or less advanced state of the morbid action, the muscular fibres seem immersed in neAvly-formed matter; or, they become softened or destroyed, or transformed into indurated sub-cartilaginous and even osseous tissue. Such are the different conditions in which I at least have observed syphilitic muscular tumors. M. Eicord has dissected those taken from the tibialis posticus and from the ventricles of the heart, and in these cases they Avere evidently formed by the muscular fibres themselves. M. Bouisson divides into three degrees the modifications which the muscular tumors undergo. In the first degree the muscle is the seat of a circumscribed local tumefaction, of a consistence exceed- ing that of oedema. A section of the diseased part displays some discolored muscular fascia, surrounded by a plastic effusion of a grayish color (a tumor of the gluteus maximus was of this kind). This state may be indicated by a sub-acute inflammation, which 424 VIDAL ON VENEREAL DISEASES. causes the morbid secretion which is to pass through further transformations. In the second degree, the effused matter becomes softened. H the inflammation continue with its original chronic character, the gradual elaborations of the effused product are transformed into a thready viscous fluid, similar to a solution of gum. Should an acute inflammation supervene, or there be a constant pain from the commencement, with an increase of the temperature of the part, true pus has then formed in the centre of the muscle, the softened fibres are destroyed, or are more or less considerably shattered. According to M. Bouisson, some cases of intra-pelvic abscess, arising from psoitis or destructive inflammation of the internal iliacus, may be the result of a syphilitic inflammation of the mus- cles in this region. In support of his opinion, he mentions the case of a soldier, affected with an inguinal bubo consecutive to an indurated chancre. Whilst in the hospital, this patient was seized with a chronic inflammation of the psoas and ihac muscles of the left side; a tumor of considerable size formed in the pelvis, and protruded on a level with Poupart's ligament, and when opened by the bistoury, it discharges an enormous quantity of matter. The patient being subjected to an anti-syphilitic treatment com- pletely recovered. In the third degree, the non-suppurating syphilitic tumors become indurated. By successive stages of organization, they pass through the sub-cartilaginous, the cartilaginous, and osseous transforma- tions. The latter transformation is that Avhich has most arrested the attention of pathological anatomists. M. Bouisson has seen in the Museum of the Faculty of Medicine, of Strasbourgh, an osse- ous mass of very considerable size, and which was developed in the body of the quadratus femoris. The ossification of the muscles and tendons often coincides with exostosis in different parts of the body. Prof. Dubreuil is in the possession of the skeleton of an Arab who Avas affected Avith syph ilis. In addition to numerous exostoses, there is ossification of a large number of muscles at their point of insertion. The osseous productions on this skeleton are of a styliform. laminated shape, or of various other configuration, according to the disposition of the muscles participating in the alteration. The seat of these muscular tumors is very variable. M. Bouisson has observed them in the gluteus maximus, the trapezius, the sterno-mastoideus, vastus externus, and some other muscles of the lower extremity ; he has also seen them in the pectoralis major, on a subject at the same time affected with a syphilitic perichondritis of the costal cartilages. Finally, the same surgeon has observed, in the muscles of different regions, traces of ossification which might reasonably be traced to the effects of syphilis. I have already stated that M. Eicord has met with one of these tumors in the tibialis posticus. The following is an example of a muscular tumor, situated in the rectus femoris. It will be observed that it appeared after a deep-seated syphihtic affection of the extremities, with which there existed an exostosis. AFFECTIONS OF THE MUSCLES, TENDONS, Ac. 425 July 24th, 1845. L., aet. 38, was admitted into the Hopital du Midi. He was by occupation a groom, and of a sanguine tempera- ment. Six years before, he contracted a blennorrhagia, which lasted nine months. Three years and a half ago, he was under the care of M. Puche, for a left inguinal bubo, which appeared twelve days after a suspicious connexion; he states, that on the day following this connexion, he discovered a slight abrasion, which disappeared in the course of two or three days. The bubo Avas very large; it was opened, and suppurated but little. It was afterwards treated by compression. The patient was subjected to internal treatment, and remained two and a half months in the hospital. When he left, the tumor was very small, and it finally disappeared. Two months since, no accident had yet manifested itself; but at this time, pustules formed on the legs, especially on the left; the patient states that they were about as large as the end of the finger; these soon broke, and from that time there were ulcerations at the various points which the pustules had occupied. At present these ulcerations are small, round, and ap- pear as if cut out with a punch; they are situated on both sides of the leg, and number some six or eight; the surrounding skin is of a violet-red color. Some are situated on the right arm, on a level with the epitrochlea. At the time of the eruption, the pa- tient suffered pains in his limbs, more particularly in his legs, and about fifteen days afterwards, he discovered a prominence on the middle of the crest of the tibia; this became the seat of a dull pain, which was more severe during the night. A physician who had probably mistaken these syphilitic for varicose ulcers, recom- mended the use of a laced-stocking; but its application produced severe and intolerable pain. At present the tumor on the tibia is of the size of a walnut, of the hardness of bone, and painful on pressure; the skin covering it is sound. Since the patient's ad- mission into the hospital, the pain has completely subsided; and it is particularly when he becomes fatigued that it is rendered more intense. One day he discovered an indurated tumor on the anterior sur- face of the thigh; it was painful on pressure, and when the patient extended his leg, the pain increased and became immovable. This tumor, which Avas about a quarter of an inch in diameter, could not be attached to the femur, as it was movable, nor to the skin, for it glided readily beneath it; it appeared to belong to the rectus femoris, near the point of its insertion into the tendon uniting it to the patella. On the 26th of July, the patient was put upon the use of the iodide of potassium (half a drachm daily). For four days after commencing the use of this remedy, he was troubled with frequent sneezino- and a considerable discharge of mucosities from the nose, accompanied Avith a severe obstruction of the passage. August 10th, the induration on the thigh had sensibly decreased. August 15th| the ulcerations on the legs, which had been covered with the plaster of Vigo, Avere cicatrized, and the enlargement of the tibia Avas diminished one-half. From this time, forty-five grains 426 VIDAL ON VENEREAL DISEASES. of the iodide were given daily. August 30th, the tumor of the thigh as well as that of the tibia had disappeared; the pain had ceased and the patient left cured. When the muscular tumors are somewhat voluminous, every contraction produces pain, and the latter, if it had previously ex- isted, becomes exasperated. Sometimes the affected muscle is re- tracted, as we have seen in the case of the psoas and iliac muscles. The tumors are movable or fixed, according to the state of relax- ation or repose of the affected muscle. If in a state of rest, the tumor may readily be examined; it may be moved in various di- rections, thus distinguishing it from adherent tumors, and at the time we may appreciate most of its other physical characters. When the muscle contracts the tumor immediately becomes fixed, according to the duration of the contraction, and this condition may also affect its degree of resistance and sensibility. The consistence of these tumors varies according to their du- ration and their mode of termination. Of a very moderate degree of hardness during their first stage, they present signs of fluctua- tion if the matter by which they are formed is converted into pus or a gummy matter; at length they become quite hard, and if resolution be not effected, they are frequently attacked with a sub- acute inflammation. They are ordinarily of a globular form, their size varying from that of a small nut to that of an orange. The color of the skin remains natural, nor does the skin adhere to the tumor. There is no unusual heat, unless inflammatory accidents are manifested; the lymphatic glands are sometimes enlarged in the vicinity, as we have seen in cases of tumors of the lips. The muscles of the tongue, lips, and of the movable portion of the palate, are affected Avith these tumors ; but pathological anatomy has not yet enabled us to distinguish those produced by a kind of muscular degeneration of tubercles which become developed be- tween, and separate their fibres, tubercles which by their elimina- tion, leave profound ulcerations. The different muscles of the larnyx itself, so often attacked in its mucous and cartilaginous elements, may hkewise become involved. Finally, says M. Bouis- son, if it be true that the uterine tissue participate in the characters of muscular tissue, may we not comprise in the class of tumors under consideration, certain congestions of its cervix which result from the influence of venereal disease ? Long ago, I hinted at the connection existing between the tumors or tumefactions of the uterus and confirmed syphilis. On this subject, the reader may consult my remarks in my work on surgery.* Finally, the heart may be attacked by tumors analogous to those found in the muscles of animal life, at least this may be in- ferred from the report and illustration of a case in the Iconographie of M. Eicord. At the autopsy of a venereal subject who died suddenly, M. Eicord discovered in walls of the venticles several points of a tu- berculiform alteration consisting of a hard yellow matter, creaking * Traite de pathologie externe et de medecine operatoire, t. v. AFFECTIONS OF THE BONES AND PERIOSTEUM. 427 under the knife, not vascular, of a scirrhous consistence at some points, at others, analogous to that of tubercular matter in process of softening. In a word, says this writer, we there found the char- acters of syphilitic nodes or tubercles, tertiary accidents which are often observed in the subcutaneous or submucous cellular tissue. But in this case even the cardiac fibres were involved. I shall re- fer to this case in describing syphilitic affections of the viscera. Treatment.—The affections of the muscular system and its ap- pendages appear at an advanced stage of syphilis, and as I have already stated, conjointly with the deeper-seated cutaneous affec- tions, and especially with the lesions ofthe periosteum and bones, that is, at an epoch when, as a general rule, the system is debili- tated and but little disposed to tolerate the effects of mercury, which, besides, in the great majority of cases has been repeatedly employed. On this account we should discard this agent, or if we do resort to it, we should administer it cautiously, and carefully watch its effects. Iodine is the remedy generally indicated, and of all the preparations the iodide of potassium is to be preferred. It should be given in large doses. We have already described the mode of employing it; the formulas Avhich have received the most general approbation. We may dissolve half an ounce of the iodide, in eight ounces of water, and of this, a spoonful may be given in a glass of hop tisane tAvice a day, by Avhich half a drachm of the iodide Avill be taken daily. The quantity may be increased to six spoonfuls, that is to one and a half drachms, daily. But, I repeat, it is seldom that I exceed forty-five grains in the day. At the same time, we may prescribe Bareges' baths, or vapor baths, especially the latter, if the patient is not too feeble. M. Bouisson states that he has advantageously employed, in some cases, the preparations of gold. I should prefer, in cases of great debility, and when the iodide of potassium has been administered for a long time, the ferruginous preparations, and afterwards resort again to the iodide of potassium, for it is always the best remedy in the last stages of syphilis. Local treatment is seldom indicated. Of course, when the mus- cular tumors are painful, and when this pain is aggravated by motion, and muscular contraction, repose should be observed, and local emollient applications prescribed. In other cases, resolution may be promoted by applying flying blisters, which should be repeated, and at the same time we should resort to the use of iodine ointments. SECTION VITI. AFFECTIONS OF THE BONES AND PERIOSTEUM. The bones and periosteum are so inseparably connected in their structure and diseases, that I shall consider them both under the same head. These affections, besides, resemble those of the skel- 428 VIDAL ON VENEREAL DISEASES. eton resulting from other causes. Here, as in all diseases of the bones, we have pain, inflammation, tumors, necrosis, and caries. But Ave most generally observe certain peculiarities in these pains, and a certain progress, and consequences of the inflammation, which, with other accompanying symptoms, give them a special character ; and finally, the effects of our treatment afford us aid ti establishing the unity of their nature, for the same agent equally affects each variety. These shall be studied separately, and their treatment described. I—OSTEOCOPES. These pains accompany the lesions which I shall soon describe, but as they do sometimes exist when these lesions are not observed at the same time, they are separately described by many authors. If I conform to this custom, it is only that this symptom may be the more carefully studied. I do not, in fact, believe that this modification of sensibility is a separate disease, independent of any material lesion. When there is no external appearance of this lesion, it is because it has not yet completely formed, or rather that it is developed in a cavity formed by bone. Thus, the syphilitic disease, instead of being limited to the more superficial layers of the bone and the periosteum, may involve the deeper layers, the medullary membrane in the bones of the extremities, and the dura mater in the bones of the cranium and spine. In the latter case, the bone may continue for a long time, and even always diseased, without exhibiting any material external mani- festation; and especially may this be the case, when only the internal membrane of the bone is affected. This is proved by the autopsies, which expose material alterations of the dura mater, exostoses of the inner table of the skull, without any external tumor. In my work on Surgery, I have given a representation of the frontal bone, in which two exostoses from the inner table of the skull projected into the cavity ofthe cranium, without any external protuberance whatever. This is what I call exostosis* and it is an affection which may produce the most atrocious pains, and even fatal cerebral compression, without its existence being suspected, unless the previous history of the patient be known. I shall necessarily return to the consideration of these internal tumors and their consequences. When the osteocopes continue after the disappearance of the apparent exostosis, there is reason to suspect that there has been, at the same time, an internal and an external exostosis, and that the latter alone has disappeared, while the first still remains. I repeat, an osteocope is but a symp- tom of an affection of the bones, and not a distinct disease. [In the London Journal of Medicine for October, 1852, (vid. also, Ranking's Abstract, &c, No. 16, p. 128,) Mr. Henry Lee, one ofthe * Traite de pathologie externe, &c, t. ii., p. 395. AFFECTICNS OF THE BONES AND PERIOSTEUM. 429 surgeons of the Lock Hospital, London, has published a paper, showing that long-continued pain in bone may depend, among other causes, upon the deposition of solid material, arising from the poison of syphilis. In the treatment of this affection, he re- commends the operation of trephining. This idea was suggested to him by a case which occurred at the Lock Hospital during his connection with it as house-surgeon. A young and delicate woman died after severe and protracted suffering from pain in the right thigh. On examining the bone, its cancellated structure was found occupied at different parts, by a morbid deposit of a light- brown color, of a moderately firm consistence, and which was dis- tributed in irregular patches. The parietes of the bone were greatly thickened, and a kind of cancellous structure had been developed between the original outline of the bone and the newly- formed portion. On the 29th of May, 1849, he operated on a woman, in whom the pain and swelling were confined to the im- mediate neighborhood of the knee-joint. As the epiphysis ofthe bone appeared to be the original seat of the disease, he trephined at this part. " As soon as the outer shell of bone was perforated, the cancellous structure was felt to give way under the press- ure of the instrument, and some minute and separate flakes of white matter were observed to escape with the blood by its side. On the 24th August, her health was quite restored; she could raise her leg without any pain or inconvenience, and had expe- rienced no return of the ' old pain' since leaving the hospital." On the 19th October, 1852, Mr. Langston Parker read a paper before the Medico-Chirurgical Society of Birmingham, " On the Nature and Treatment of some painful Affections of Boned In this, he states that the medullary membrane is liable to become in- flamed in the tertiary stages of syphilis, and owing to the un- yielding nature of the walls by which it is surrounded, this in- flammation produces at times the most atrocious pains. In a case of this kind, he perforated the medullary cavity with a trephine, and the hole thus made was kept open by a tent of lint changed every morning. The relief to pain was complete; whilst previous to this operation, it had resisted all the usual remedies in such cases, blisters, opiates, iodide of potass, &c, and had at times been so excessive that she had frequently importuned me to amputate the limb." In gratefully acknowledging our obligations to the author for a copy of this interesting essay, we would observe that he recommends the trephine in cases of inflammation of the medul- lary membrane arising from scrofula, rheumatism, and wounds.— G. C.B.] It is difficult to give a perfect idea of the character of these osteocopes. Sometimes, at the commencement, they seem to be wandering, the whole skeleton being painful. They are then often profound, that is, they come, in the language of the patient, from the marrow of the bones. In the majority of cases, they are fixed, yet not very clearly seated at any particular point of the skeleton. They are then acute, and lacerating; the patient feels as though the bone were strongly pressed in a very narrow space, 430 VLDAL ON VENEREAL DISEASES. and as though it were being bored. Pressure in some instances does not increase the pain, whilst in others, it is aggravated by the slightest contact; in this case, it is probable that there is peri- ostitis, or superficial ostitis. The most remarkable peculiarity of this pain is its nocturnal tendency. Indeed, it is sometimes com- pletely absent during the day; at others, it is slight, and wander- ing, but it becomes aroused, fixed, and exasperated with the twilight, and is mitigated or subsides with the morn, which brings sleep to the sufferer. The pain is most severe during the first three hours of the night, and the paroxysm generally at its height about midnight. As these pains occur at the hour for retiring, and when the patient is warm in bed, this has been regarded as the exciting cause, and it is said that bakers who turn day into' night, suffer from this pain during the day, that is, when they are in bed. But it should be remembered that bakers suffer more from heat when employed than they do in bed. Besides, instances have occurred where venereal patients have awakened, and remained in the open air, or have rode in a carriage during the night, and yet have suffered the same when the fatal hour arrived as when reposing in their warm couch. The diagnosis of these pains may be attended with difficulties. They are certainly more fixed than those of a rheumatic nature already described; they return in the same place at each paroxysm, which is not the case with those belonging to the earlier stages of syphilis, and they are ordinarily exasperated by pressure, which generally relieves rheumatic pain. But these characters are not always so well marked, and I have already stated that there are wandering osteocopes, and some are not aggravated by pressure. True, the latter does not relieve them. Besides, the patient may have both rheumatism and osteocopes at the same time, for we know that all the stages of syphilis are not perfectly distinct, and the accidents called secondary may occur simultaneously with the tertiary. It is not, indeed, very rare to observe a superficial cutaneous eruption, with an affection of the bone or periosteum. Still further, it is not always possible to distinguish syphilitic from rheumatic pains, for cases of osteocopes are observed in which the pain is exasperated during the day, and relieved during the night, and vice versd. Again, it is not very unusual for a patient to be affected both with rheumatism and syphilis, a circumstance which renders the diagnosis so much the more complex. Such cases have been observed among soldiers affected with the venereal disease who have contracted rheumatism in bivouac with washerwomen and hosiers. Thus, we see that pain alone may deceive the practitioner. The value of this symptom must be duly appreciated, but not exaggerated, and we must learn the previous history of the case, and examine the concomitant symptoms which may exist on the skin and mucous membranes, for we know that it is common to observe syphilitic eruptions or blotches during the existence of osteocopes, and it is not rare to find ulcerations in the buccal cavity, ulcerations mani- fested only by functional lesions of but little importance, and which may pass unobserved. • AFFECTIONS OF THE BONES AND PERIOSTEUM. 431 I am still compelled to add one word in relation to that error which attributes the osteocopes to mercury. This error has here assumed a serious character, for it is true that we may find mer- cury in the bones, and it is reported that M. Bretonneau has observed these pains in patients not affected with the venereal dis- ease, but whose systems have absorbed much mercury. As to the cases of M. Bretonneau, I have been unable to find them; I can- not therefore judge of their value. Mercury has been discovered in precisely the bones which have never been the seat of any pain. It is known that workmen who are constantly exposed to mercu- rial emanations, do not suffer from osteocopes, and on the other hand, venereal patients who have abstained from mercury, have suffered in their bones and have had exostosis. Finally, these osseous pains and lesions have more than once been cured by mercury; for before the introduction of the iodide of potassium, it was particularly by mercury that these accidents, peculiar to the last stages of syphilis, were combated. However, in order to omit nothing, I should add, that in a syphilitic patient who pre- sented cerebral symptoms, and who died after having taken much mercury, this metal was detected in the cerebral substance, (vid. the work of M. Eeynaud, p. 407.) II.—PERIOSTITIS AND OSTITIS. Periostitis, unaccompanied by ostitis, must be extremely rare if it does really exist, for the periosteum being but the envelope of the bone, it is difficult to comprehend how it should not participate in the affections of the latter. The same regions, the same portions of the skeleton, are most generally affected both by periostitis and ostitis; thus the tibia, clavicle, ulna, radius, cranium, sternum, metacarpal bones, and the portions of these bones nearest to the skin. [According to Mr. Stanley, the osseous node does not occur upon the cranium. " So far does the pericranium differ from peri- osteum in its actions under the influence of disease, that under no chcumstances does its tissue become ossified. When, from syphi- lis, isolated portions of the pericranium inflame, circumscribed swellings arise, which are hard and painless, when consisting only of the thickened pericraneum, but soft and tender when produced by serous or purulent effusion, either beneath the pericranium or into the cellular tissue covering it. In the latter case they have received the expressive designation of soft nodes." (Stanley on the Bones, Am. Ed., p. 271.)—G. C. B.] PERIOSTITIS. The tumor formed in inflammation of the periosteum, periostosis, appears simultaneously with the pains already described, sometimes a feAV days after their first manifestation. This tumor, which 432 VIDAL ON VENEREAL DISEASES. • grows on the portions of the skeleton just mentioned, is not dis- tinctly circumscribed; it is rather an engorgement, the most promi- nent part of which is round, and the boundaries of Avhich are insensibly lost in the adjacent tissues. The color of the skin is at first unchanged. Sometimes, there are several periostosis on a single bone, on the tibia or on a flat bone; they are then smaller, there is a doughy feel around them, and yet the color of the skin is unchanged; their progress is ordinarily, but not always, rapid, and, most generally, the pain which is severe, is still exasperated by pressure and by every movement of the corresponding bone. The tumor or tumors are much less distinct, much more difficult of diagnosis than when they spring from a bone deeply covered by muscular layers, as is the case with the femur. If the tumors are more superficial, so that they may be directly examined, we find them of a doughy feel; then we detect a certain degree of fluctuation; the skin at first sound, and movable over the tumor, finally adheres to it, becomes changed, and ulcerated if the disease terminate in suppuration. But this is far from being the most frequent result; periostosis, on the contrary, may termi- nate in complete resolution; it may also lead to the formation of exostosis, and this is a frequent result; this is the variety which I shall describe under the name of exostosis epiphysaire. According to M. Eicord, periostosis may present itself under three different forms: 1st. The first variety, often of a very indolent nature, but rapid in its development, is generally of long duration, and terminates in complete resolution. The tumor contains a serous, or a sero- albuminous fluid, resembling, in some instances, scrofulous pus, and in others, synovial fluid. 2d. The second variety pursues the course of inflammatory tumors ; it is acute, and well marked, or it is sub-acute. Suppura- tion sooner or later occurs, and it is rare then that subjacent bone is not primarily or secondarily affected. 3d. The third variety, of slower development, is, nevertheless, frequently very painful on pressure, and even when it is not touched. The tumor then consists of interlamellar plastic effu- sions, which may be the rudiments of exostoses, which we shall presently consider. [The degree of hardness of a node, says Mr. Stanley, does not with certainty indicate its composition. He states that he, has examined those which, from their hardness, were supposed to be osseous, but found them to consist of indurated periosteum.— G. C. B.] I have already spoken of lesions of the periosteum and bone, of which there are no external signs, and which may produce the pains which I have already described. These internal tumors, when developed within the cavity of the cranium, cause disorders of a still more serious character, and here the dura mater, which is the internal periosteum, may play an important part. M. Eeeve, in a work entitled, Syphilitic Meningitis, has reported a case which would seem to belong to this class. It is as follows : AFFECTIONS OF THE BONES AND PERIOSTEUM. 433 " Case.—M. F., in July, 1847, was attended by another surgeon and myself, for a paralytic affection: the rapid progress of which, together with other cerebral disturbances, alarmed the patient. He Avas unable to stand on his feet long enough to remove his pantaloons. His articulation was very imperfect, the combination of his ideas very defective, as well as his memory, and vision in both eyes considerably impaired. Some years before, this patient had been treated for secondary syphilis, which was manifested in the form of obstinate ulcers on. the face and extremities. Shortly afterwards, he became affected with amaurosis, which continued to increase rapidly until it had terminated in the general paralysis, from which he was suffering when he came under our notice. "From an examination of the patient, and an inquiry into the previous history of the case, I was led to suppose that the symp- toms might depend upon a compression of the brain, produced by syphihtic tumors developed on the dura mater; but to satisfy my- self more fully, I concluded to administer mercury in such a man- ner as to obtain its prompt and decided action. I directed that the whole scalp should be shaved, and covered with a bhster, to the surface of which a drachm of strong mercurial ointment was to be applied twice a day. I Avas, however, alarmed by threatened coma, and the consequent prospect of a fatal result. " Eight days afterwards, I met the surgeon above mentioned; he informed me that our patient became rapidly cured, and that he could now ascend and descend a very steep flight of stairs. To my great surprise, I one day met our patient in the street, in good health, vision perfect, and it was difficult to believe that it was the same person who had consulted me some three weeks before. He had completely regained the power of motion, sight, and articula- tion, and was in the perfect possession of aU his faculties." The author expresses the opinion that the preceding case would certainly have soon terminated in death, had it not been for the administration of mercury. Such is his confidence in this agent, that, in a similar case, he should indulge the strongest hope of suc- cess, notwithstanding the most decided exhaustion in the state of the patient. It is a remarkable case of cure by mercury. The editor of the Gazette Medicale, from which journal I have copied the above report, states, that the preparation of iodine would have a still more decided effect in cases of this kind. I do not under- stand how such could be desired. OSTITIS. Syphilitic ostitis attacks the bones already mentioned as the seat of the nocturnal pains, viz., the tibia, clavicle, sternum, cranium, ulna, and radius. I have stated, that it is difficult to admit the existence of periostitis without ostitis; indeed, the superficial layer of bone is always, or nearly always, involved in periostitis, and, most generally, it is the part first affected; an effusion then occurs between this layer and the periosteum, by which the latter be- 431 VIDAL ON VENEREAL DISEASES. comes detached, and forms a tumor which may be detected if the bone be thinly covered. Instead of invading the superficial por- tion ofthe bone, ostisis may attack its parenchyma, and be there- fore deeply seated; this is particularly the case, when it has ex- isted for some time without furnishing any external indications of its presence, of Avhich pain is the only symptom. Ostitis, Avhether involving the external portion, or the parenchyma of the bone, may be circumscribed—sometimes very limited, while, in other in- stances, it may be more extensive, invading the whole or nearly the entire bone. The bone, at first; presents here and there stains of blood, its vascular canals become developed, and contain red blood and a transparent fluid, resembling osseous substance ; fur- ther, these remarks apply to all cases of incipient ostitis, whatever may be their nature. A thicker fluid, resembling that of callus, is next secreted; sometimes it is an organizable plastic matter, like that in certain cases of periostitis. The tumor, resulting from san- guineous congestion, and the products mentioned, often manifest themselves after the patient has complained of nocturnal pains ; at first it is very limited, and diffused; there is no decided protru- sion, except in cases of circumscribed ostitis, and when a true ex- ostitis is about to form. Syphylitic ostitis is generally of a slow, chronic progress ; some- times it assumes a very acute form. A word as to the treatment of periostitis and ostitis. It is par- ticularly in cases of the former, of course external periostitis, that we may resort to topical applications and to certain operations. Thus, there are cases of exostosis evidently inflammatory, of an acute nature, and in which the patient still retains his strength; we have then a formal indication for repeated local depletion by leeches. This first indication having been fulfilled, we may resort to the use of blisters. When the character of the tumor is less decidedly inflammatory, and the subject debilitated, the blisters may be employed without resorting to the local depletion by leeches. Their surface should be dressed with mercurial ointment. Periostitis may also be treated by incisions. These, which have particularly been recommended in acute periostosis, by Crampton, MM. Velpeau and Maisonneuve, should not be made except when the tumor is situated on a superficial bone, and when the iodide of potassium has been already administered internally, without effect. We may then reasonably infer that the resistance offered by the fibrous tissue to the expansion of the parts affected pro- duces a kind of strangulation, which may be relieved by the in- cisions which are then debridements ; but, I repeat that, first of all, the iodide of potassium should be tried, for in some instances the relief thus affected is equal to that produced by the incisions themselves. The treatment of ostitis, especially of superficial ostitis, does not differ from that of periostotis above indicated. Here we must par- ticularly avoid incisions, until we have administered internally a means the efficacy of which is so universally acknowledged, viz., the iodide of potassium. AFFECTIONS OF THE BONES AND PERIOSTEUM. 435 [The testimony in favor of the iodide of potassium, as remarked \ by our author, is indeed universal, especially when the acute stage of periostitis has passed. "It rarely fails," observes Mr. Stanley, j " to stop the progress of the disease, and, in much the largest pro- portion of cases, completely cures it. This statement of the reme- dial agency of iodide of potassium is to be taken in its most com- prehensive sense. Whether it be the inflammation of periosteum adjacent to an exfoliating bone, or investing an enlarged bone, or that which is the consequence of scrofula, syphilis or rheumatism, there has not appeared to me to be any difference in respect to the influence of this remedy upon the disease. And, with respect to the suitable doses of it, I have but to repeat the statement already made, that my impression is in favor of administering it in doses of two or three grains, three times a day, in either decoction of sarsaparilla, or a bitter vegetable infusion, or camphor mixture" (op. cit. p. 275). Our own experience would lead us to rely rather on larger doses of the remedy; we do not give less than five grains three times a day, and sometimes this quantity is in- creased to ten and even fifteen grains for a dose.—G. C. B.] III.—EXOSTOSIS. A tumor actually exists in periostitis and ostitis, but the term exostosis is applied especially to the termination of these inflam- mations in induration. Indeed, instead of disappearing by reso- lution, suppuration, or mortification, the tumor formed by ostitis becomes the seat of excessive nutrition, of abnormal ossification. But periostitis or ostitis is not always necessary to the formation of an exostosis; sometimes, indeed, we observe hypertrophy in- dependent of any previous inflammation; sometimes a plastic substance is deposited throughout the whole osseous substance, even in the medullary canal, a substance exactly resembling that mentioned when I Avas describing the syphilitic affections of the muscles. Varieties.—As in other forms of exostosis, the syphilitic may be divided into two principal varieties; the parenchymatous, and the exostosis epiphysaire. 1. Parenchymatous Exostosis.—This occurs, especially, in cases of profound ostitis. The abnormal ossification may assume the character of areola, or of compact tissue. In the first case, it may consist of layers, between which are areola, constituting what au- thors denominate cellular or laminated exostosis. In the second case, it is the compact tissue, and according to Albers of Bonn, the cortical substance which constitutes the exostosis. H the osseous layers suffer a divarication, an osseous matter without any distinct organization has been deposited between them, and the volume of the bone becomes increased, but its weight and density have also undergone a marked increase. We have now the eburnated exos- tosis, suitable for making scalpel handles. 2. Exostosis Epiphysaire.—This results particularly from perios- 436 VIDAL ON VENEREAL DISEASES. titis. Albers of Bonn, calls cases of this kind osteophytes, that is, new formations independent of the bone Avith which they are con- nected (at least for a certain time), since they can be removed without injury to the bone. Albers mentions an osteophyte (in the Museum of Bonn) situated on the middle of the femur of an adult; it is of an oval form following the great diameter of the bone; it has a compact envelope, and internally it is cellular. These are epiphyses, superadded bones, which, like all epiphyses, finally become incorporated with the bone ; at first they are sepa- rated by a cartilaginous or osseous layer, which disappears when this abnormal epiphysis becomes incorporated with the body of the bone. We meet with cases, also, in which epiphytal exostoses are engrafted on those of the first category, on a parenchymatous exostosis. According to M. Eognetta, the epiphytal exostoses have a structure similar to that of velvet, that is, they are com- posed of fibres perpendicular to theh surface of implantation. Whatever may be the variety of exostosis, its form will be more or less hemispherical; it may be conical, flattened, elongated, or even almost pediculated; sometimes it is a crest similar to that formed in certain of the annular syphilitic eruptions; an example of this singular form is represented in the Iconographie of M. Eicord. The epiphytal exostoses are the best defined, and form the decided prominences. Exostosis, particularly when large, may interfere with the func tions of surrounding organs ; and singularly alter their forms. In my work on surgery there is a representation of an exostosis of the superior maxillary bone, eleven inches in circumference, and which rendered the appearance of the patient hideous.* Some- times, then, only trouble is in the adjacent organs which may be- come displaced and atrophied; thus, the exostosis of the superior maxiUary bone to which I have alluded, at first interfered with the movements of the lower jaw, and ended in its dislocation. An exostosis may destroy the regularity in the movement of a limb. By compressing vessels, it may produce oedema at a greater or less distance from its seat, and by its pressure on nerves it may modify the sensibility of the parts, producing pain which must not be con- founded with the special pain seated in the exostosis itself. The effects of this compression are particularly severe, when the ex- ostosis springs from a bone entering into the formation of a cavity enclosing organs of great importance, as for example, the cranial cavity, or spinal canal. The compression of the nervous centres in these cases affects both the general and special sensibility, as well as the powers of motion, and the intelligence of the patient. A cranial exostosis may produce agitation, somnolency, para- lysis, convulsions and delirium. Amaurosis is sometimes the re- sult of an exostosis of the sphenoid or some other bone at the base of the cranium; this ocular paralysis is not very uncommon, and we may remark in passing, that when it does depend upon * Traite, depathologie externe, ™der these circum- nated ^ « nt ^f GXaC% as if she wer* in a* unimpreg- te^t^^W0^^^^ al^8^e»" ^observes, "have oref nan? w. ° ^ °f ^ ^rgeon who dreads to give the Kefnedt Z°Tf ^^J' are chimerical." Drs. Beattyf Every, and a h^ftwfe' raamtai\that • 'abortion may be prevented durino-™ 7 Hd ^SUred' b^ a J^ioious mercurial treatment during pregnancy." (Egan, op. cit. p. 291.)—G C B1 . Ihe father should be treated precisely in the same manner that is in accordance with the principles of therapeutics Zch I'have laid down. The question on which writers on syphilis are divided is whether in the absence of all evidences of the disease, the father should be subjected to treatment simply because the mother mav have miscarried. It is necessary to distinguish here, if the father has really had syphilis, if the foetus bears marks of this diathesis there should be no hesitation in submitting the father to treatment- for we know that the disease may remain for a long time latent as is proved by the relapses after long intervals. Indeed, between the two manifestations of the disease, we see persons enjoying the best of health, and bearing on their body no traces ofthe diathesis; but the latter does not the less exist; it will probably reappear at a later period on the same individual, his child or his wife. We should be guarded when the father assures us that he has never been syphilitic, except when we know that he has some particular object in deceiving us. In such a case, the shrewdness of the physician, and the confidence which he knows how to inspire in the mind ofthe father, may be of great service to the family. When a child is born of syphihtic parents, should the father be treated ? No, if there are no marks upon him of the disease; for it has been proved that venereal parents have begotten healthy children, Avhich have been raised, without even showing the least symptom of syphilis. But children of such an origin°should be carefully watched, in order that they may be properly treated upon the very first manifestations of the disease. They should not suckle their mother, for, Avhatever may be the opinions entertained as to the alteration of the milk, it is acknowledged that it is better that they should be nourished by a woman free from the disease. Indeed, if the mother's milk is not syphilitic, if it is impossible for it to infect the child (which, is not established), it may suffer some other change, from the contamination ofthe system, so as to afford imperfect nourishment to the child, or favor the development of a diathesis, the germ of which might have been destroyed by a more healthy aliment. There are mothers, who, from economy or un- easiness of their child, use the sucking bottle instead of committing it to the care of a nurse. This, especially in cities, is bad practice. Children, I repeat, of such an origin, should be carefully watched, and placed in the best possible hygienic conditions. Now, as ali- mentation is here the basis of hygiene, a good nurse should be selected for the child. Should the child be born with symptoms of syphilis, or if these symptoms appear shortly after birth, it must be subjected to treatment, for, as I have already stated, if we do 482 VIDAL ON VENEREAL DISEASES. see adults become rid of unquestionable symptoms of constitutional syphilis, without any specific treatment, it is not the case with children of a tender age. Under the influence of hygienic care, the symptoms may completely disappear; but they are certain re- peatedly to return, after longer or shorter intervals, and with more or less intensity until a fatal termination, which is then sure to be the result. In my opinion, mercury is our proper remedy, and it should be administered directly. 1 fiud that in this view of the subject, M. Cullerier, the son, coincides. This practitioner has pubhshed an article in the Bulletin Therapeutique, from which I have profited. But as this mode of administration is not adopted by all practitioners, let us discuss the advantages of the direct and the indirect employment of the remedy. The indirect treatment, or that through the medium of the nurse, has been recommended by many writers on syphilis, or accouch- eurs, who, fearing the effects of mercury on constitutions so feeble and delicate as those of infants at the breast, and exaggerating the gravity of the possible accidents, beheve that they can avoid these effects by medicating the milk of the nurse, which is thus made to serve, at the same time, for nourishment and medicine ; those who are afraid of the action of mercury on the mother or the nurse who present no symptoms requiring its use, cause it to be given to goats and asses, on the milk of which the child is fed, Astruc, Fabre, Burton, Eosen, Faguier, Doublet, and Levret, declare them- selves the advocates of this method of treatment. " Seeing," says M. Cullerier, " such great confidence in the in- direct treatment, it is very natural to conclude that it is not the result of reasoning alone, but that it is based on researches show- ing the presence of mercury in the milk of the females or animals to which it has been given. This, however, is not true, and the theory of the passage of the mercury into the milk has long been regarded as merely an hypothesis, for a truly serious chemical analysis has never been made. Many absurd notions have indeed been admitted in reference to the action of mercury on the system, and if it were possible to believe in its presence in different parts of the system, or in the secretions, we might, without proof, admit of it in the milk. But let us glance at the authors who have re- ported cases of the kind, and see with what confidence they inspire us. Thus, Petronius speaks of a syphilitic patient treated by mer- curial frictions, in whose urine numberless globules of mercury were seen to float; Mussa-Brassavole having seen a patient on whose arms and thighs mercurial frictions had been made, attacked with vomiting, was astonished at the weight of the matter rejected, and, looking in the vessel with the expectation of finding a collec- tion of thick phlegm, saw nothing but a large quantity of mercury which had been vomited; Gabriel Fallope, who asserted that mer- cury is found in quantities in the saliva of patients affected with mercurial ptyalism, and declares that the way to arrest salivation is to hold a gold ring in the mouth, to draw off the mercury. Assertions still more serious have been made, and authors of some renown, as, for example, Teller and Buchener, declare that they INFANTILE SYPHILIS. 435 memZ ™,^i /' ' T 'M-flu,t M- Colson, in a well-written attempts, could not succeed in detecting it" (S ka\ The question here rested, and chemical analysis had as vet de- tected nothing m the milk, when M. Peligot commenced S re- searches on the subject In the Journal des connaissances medlo- chirurgicules, for November, 1836, he published a memoir on the chemical composition of the ass's milk, and in a passage where he is treating of the mercurialization of this milk, he remarks- I have made numerous essays for the purpose of detecting the presence of mercury at first in the milk of an ass which had taken five grains of corrosive sublimate daily, and afterwards in the milk of the goat to which twelve grains were given daily, without any unpleasant results. Notwithstanding the utmost care, and the variety of methods employed, I could not detect the presence of the mercury. It cannot, however, be positively affirmed that it may not be found in the milk of these animals; for the best pro- ceedings for detecting small quantities leave much to be desired." M. Cullerier also made experiments, and took the most favorable position for detecting the presence of mercury in the milk of the female, and of goats to which he administered this metal. He was aided by druggists, and chemists, MM. Lutz, Eeveil, Per- sonne. He did not succeed, notwithstanding the utmost persever- ance, in discovering but infinitesimal quantities of mercury, after analyses made in the best manner possible. After these experiments, need we be astonished at the want of success, and the fickleness of authors, Avho, at one time have con- demned the direct treatment, preferring that of the nurse, and who have subsequently returned to the former method. Thus, Faguier and Doublet, who at first greatly lauded the indirect treat- ment, afterwards retracted their praises, and Avithout hesitation ad- ministered mercury to infants. It should be stated that these physicians were at the head of a hospital established for the ex- press purpose of carrying out the indirect method of treatment. It was the Yaugirard, opened in 1780. At this period, there was a diversity of opinion in reference to the best mode of treating children at the breast, and no dQubt was entertained as to the transmissibility of secondary accidents from the nursling to the nurse. In this hospital were admitted only nurses who were in- fected or pregnant women equally syphilitic who were near their accouchement; these Avomen, therefore, could suckle strange chil- dren affected with the disease, without risk, and could supply them with milk medicated by means of the treatment which they themselves were obliged to findergo. Bertin, who had charge of the department allotted to nurses in 484 VIDAL ON VENEREAL DISEASES. the Hopital des Capucins, was for a long time inclined to the indi- rect method of treatment; but it is evident that his confidence sometimes wavered, and he even acknoAvledges that, under this mode, the symptoms were only mitigated or made to disappear, with a certainty of reappearing. He goes so far as to express his regret that he had not more frequently resorted to the direct treatment, for he had had reason to approve it. As if completely to contradict theories in favor of the indirect* treatment, some writers still recommend this method, at the same time that mercury is administered to the child, as though such a compromise, says M. Cullerier, were not sufficient to settle the value of this indirect method. As to the treatment with the mercurialized milk of asses or of goats, which might be supposed to be more efficacious on account of the larger quantity of mercury thus administered at once to these animals, the researches of M. Pelligot and of M. Eeveil, by which no traces of it could be detected, are certainly well calcu- lated to dissipate such a fallacy (Cullerier). For my own part, I have never doubted the passage of a small quantity of mercury into the. milk, both of the goat and of the nurse. But my reason for rejecting the indirect treatment is the impossibility of regulating the quantity, or of giving sufficient doses. Now, in young infants, the progress of syphilis is very rapid. We see children born of syphilitic mothers, having the appearance of the most perfect health, in the course of four or six weeks they are attacked with characteristic symptoms, which, in a few days, assume a very serious aspect, and, if the disease be ne- glected, soon terminate fatally. What confidence, in such cases, could Ave repose in the indirect treatment, when the milk of the nurse contains so insignificant a proportion of mercury, and even that only some days after its administration. I repeat, the pro- gress of the disease is very rapid. The treatment, therefore, must be energetic. The best method is to give the mercury to the child itself, Avithout any apprehension on account of its enfeebled state. It may be objected, says M. Cullerier, that the digestive organs of these little beings are likely to suffer from the preparations of mercury, so that their doses cannot be increased. But then, in- stead of giving it internally, it should be administered according to the endermic method, by frictions and by baths. Mercury, taken internally, has rendered great services; it has been recom- mended by practitioners too reputable, and is still thus adminis- tered by those of too high standing, not to inspire confidence in the results they profess to have obtained; but surely this method can be indicated only in cases in which the progress of the malady is less rapid than usual, and when the constitution is not yet be- come too far undermined, or when, indeed, the disease, having been arrested by the endermic method, there is some obstacle to its continuance, the further administration of mercury being still indispensable. Corrosive sublimate is the preparation generally employed, and it may be given in milk, syrup, or honey, in the dose of a sixteenth, a twentieth, or the twenty-fourth of a grain. INFANTILE SYPHILIS. 435 In the second division of this work, I have already shown how ieeole is the action of mercury on the mouths of children, either wnen administered internally, or applied to the skin; but the cniet risk to be apprehended from its internal use, is its deleterious enect upon the stomach and intestinal canal. Children have been seen to be attacked with very obstinate vomiting after shght closes, and what, according to M. Cullerier, is the predominant anection is enteritis, which destroys most of those thus treated. ihe following is the endermic method of employing mercury- lhe infant should be bathed several times with water for the purpose of allaying any excitement that may exist, and to render the skm more favorable to absorption ; fifteen grains of the Nea- politan^ ointment is to be rubbed on the sides of the chest, towards the axilla, the application to be made on one side to-day, and on the opposite to-morrow. These frictions should be gentle, so as not to irritate the skin; and they should be prolonged for several minutes. TAvice a week they should be suspended, during which the child should take a hot-water bath, to Avhich from half a drachm to a drachm of corrosive sublimate has been added. In children from two months to one year of age, the above treat- ment is generally sufficient, though it may be necessary to in- crease the quantity of the mercurial ointment or the corrosive sublimate ; but when they have passed this age, the ointment may without inconvenience be increased to half a drachm, and that of the sublimate in the bath to one and a half drachms. M. Cullerier has but one objection to these baths, and this is a proof of their efficacy, viz., that when daily employed they cause the symptoms to disappear too rapidly, and that, both in hospital and in city practice, the parents seeing no longer any evidence of disease, are too ready to believe that the cure is perfect, and they discontinue all treatment, in spite of the instructions they may re- ceive. Well, Avhat then happens ? Why, that in trying to re- move the symptoms in too great haste, the specific principle is not destroyed, and we have relapses of a malady, of which, as it were, we have only skimmed over the surface. It is very rare that frictions with the mercurial preparations above mentioned, give rise to erythema or a vesicular 'eruption; besides, it is obvious that in making them on the sides of the chest, Ave act on a broad surface, and thus avoid the irritation likely to be produced when made on the legs or thighs, with which urine or fecal matters may come in contact. When there are mucous tubercles, or ulceratious secretions copi- ously on the genital organs, or about the anus, (a circumstance not unfrequent,) it is well to touch them occasionally Avith a solution of nitrate of silver, of the strength of one and one-half or two drachms to eight ounces of water. If the discharge is moderate, or the tubercles are dry, lotions Avith bran, marsh mallow, or elder water, will suffice; Ave may sprinkle the surface Avith starch, farina, or lycopodium, (club-moss,) and isolate them as much as possible with dry lint, or charpie. When the face is attacked, and facial syphihtic impetigo is com- 486 VIDAL ON VENEREAL DISEASES. mon, the same lotions should be employed. The parts being now exposed to the air, desiccation is rapid, causing very fine chaps and fissures, which are very painful when the child cries or nurses, on Avhich account we should cover them as frequently as possible with some greasy substance, cucumber ointment, simple cerate, or cerate containing opium or calomel. M. Cullerier thus concludes : " The indirect treatment, or that through the medium of the nurse, is insufficient, in consequence of the small portion of mer- cury contained in the milk, it is dangerous from the loss of pre- cious time in a disease of rapid progress, and which may speedily terminate fatally. " The direct treatment only is effectual; it may consist in the internal administration of mercury, of frictions, with Neapolitain ointment, or corrosive sublimate, baths, means best suited to the condition of the digestive organs." Since I have described the symptoms of purulent ophthalmia, it is proper that I should here allude to its treatment. This does not differ from that of the same affection in the adult; that is, we must act directly on the parts, by the most energetic means, such as the nitrate of silver in substance. Before resorting to this powerful treatment, a great variety of more moderate measures have been adopted, many of which have been attended with success, thus showing that there are ophthalmic affections which are not of a very serious nature. As before stated, the nitrate of silver is still the sovereign rem- edy, if we really possess a remedy entitled to this name, in the treatment of a malady which is occasionally of a very grave char- acter, and which terminates in the destruction of the organ. The cases reported to the Medical Society of Dublin by Drs. Kennedy and Ireland, tend to inspire us Avith still greater confidence in this remedy. These cases are very ndmerous, and show that this oph- thalmia is always cured in two or three days, by the following col- lyrium, applied three or four times in the day: ^. Nit. Argent. 3 iii. • Aq. Ros. 1 viii. Antiphlogistics may be employed at the same time: thus there are cases where the active nature of the congestion, and the strength of the child, require the application of leeches. Sometimes one will suffice; if applied to the upper lid, at a point where the ves- sels are much congested, it will discharge blood copiously. Hygienic measures should not be neglected, cleanliness being, in these cases, absolutely essential. We should, frequently inject water between the lids, for there is nothing more irritating than the matter secreted by an inflamed mucous membrane; the contact of this fluid with the cornea, is one of the most common causes of its disorganization. I am convinced, that if we can interpose and maintain, without inconvenience, some soft substance between the globe and the eyelids, we may prevent, in many cases, the destruc- INFANTILE SYPHILIS. 487 tion of the eye. Thus a child affected with this disease should be frequently visited for the purpose of removing this matter which tends to adhere to the globe of the eye; occasionally a hernia forms m consequence of the tumefaction of the exuberant mucous mem- brane, and the wound is cauterized; at first it produces severe pain, as manifested by the cries of the infant, but it finally subsides, and the inflammation disappears soon after the reduction of this hernial projection. PART FOURTH, PROPHYLAXIS OF VENEREAL DISEASES. I do not think that, at the present day, an author is justified, in a moral point of view, in teaching the methods of preventing the contagion of the venereal disease. On the contrary, he should beg the indulgence of the reader for the precepts which, under this head, he may inculcate. What, indeed, does he propose? To instruct the reader in the means of preventing infection. Now, if we sum up the whole of our science, disinterestedly, there is but one advice to give, and that is to avoid the source of the poison. It is evident that this advice cannot always be followed. We must therefore seek other counsel, less certain, but more easy to be ob- served, and with this view a private and a public prophylaxis have been instituted. » As to the prophylaxis, in general, it may be said that folly, wis- dom benevolence, and charlatanism have vied with each other in the effort. Some measures may be found which it would be pru- dent to follow; others, again, are absurd and useless, or even haz- ardous. I shall notice only those which possess some utility; some there are to which I will merely allude, whilst others will be passed in silence, for I am not writing a satire. CHAPTER I. PRIVATE PROPHYLAXIS. Two persons are here concerned; one fearing to communicate the disease, or distrusting himself; the other is exposed to infec- tion and would prevent it. In the first case, that is, to place such person in circumstances least favorable to contagion, he should observe the utmost cleanli- ness. All the parts should be most carefully washed. Here, the chlorides, soaps, in fine every measure capable of acting chemically or physically in altering or remoAring the morbid secretions, should be employed. The parts should be scraped (decaper), to use an expression now in vogue in speaking of syphilitic prophylaxis. PRIVATE PROPHYLAXIS. 489 In the second case, that is, when a person is about to expose Himself to risk, precautions should vary, before and after the con- summation of the act. Before the act, the parts should be minutely examined to ascer- tain whether there is any solution of continuity. The least fissure surprisingly promotes contagion. Previous to coition repeated lotions with soap are injurious, as they deprive the parts of the protection of the smegma and mucosities, and render them com- pletely naked, thus placing them in a condition most favorable to contagion. Those practitioners who disapprove of these lotions before the act, do not regard in the same light those made some time previously with solutions of alum, acetate of lead, and parti- cularly Avith aromatic wine alone or combined with tannin. These astringents are preferable to fatty substances alone, such as tallow and lard, which still enjoy much reputation with those who are much exposed to the chancres of infection. An intermediate sub- stance, still more efficacious, is the condom already mentioned in speaking of blennorrhagia ; it is a small sack made of gold beater's skin or the cgecum of certain animals, in which the penis is en- closed. It should be well washed, new, and perfectly sound. The condom, however, leaves the root of the penis, scrotum, genito- crural fold, and pubes, exposed, and the pus of a chancre may reach, and inoculate these parts; but it prevents, to a certain ex- tent, blennorrhagia, and affections of the glans produced by its contact with the neck of the uterus, which, in my opinion, is the most frequent point of infection in females. The condom, there- fore, is one of the best measures of prevention ; but its cost, and the calmness of mind required for its application, are frequent causes of its neglect. Directions have likewise been given as to the conduct during coition. Thus it is recommended that the act be not prolonged, that it be hastened, useless advices in many cases, for it is not al- ways easy to prolong, and still less, to accelerate the act. Ejacu- lation has also been advised, under the idea, that the sudden and rapid passage of the semen may carry off the contagious matter. Such advice, especially that respecting the rapidity of the act and the ejaculation of the semen, has been given by practitioners, and this too without the least idea of the difficulty, in the way of com- plying with such directions. The precautions after coition should be prompt and thorough. It has been advised that the person should void his urine. True, when the bladder contains urine, and it is possible to pass it, it is a good practice, for in passing through the canal, it may remove the infectious matter from the urethra. Those who have phimosis, may close the orifice with tAvo fingers, and fill the preputial cavity Avith urine, Avhich as it leaves the urethra washes the mucous lin- ing of the glans and its envelope. But what is of most importance, is the application of lotions, to Avhich in the case of a female should be added vaginal injections. These lotions should be made to reach every part of the mucous membrane; every fold should be inspected, nothing should be overlooked. Circumstances may 490 VIDAL ON VENEREAL DISEASES. occur in which it is difficult to carry out the measures here recom- mended ; thus the necessity of retreating after the act, a false pride, the fear of wounding the feelings of the person Avith whom they have had connection, too great confidence, or a state of intoxica- tion, may all cause them to be omitted. If one is so fortunate as to be able to put the above plan into execution, there is a strong probability that contagion will be prevented. The proof of what I have here asserted, is the immunity enjoyed by prostitutes, who have already paid the penalty of their neglect by syphilitic infec- tion. It does not always depend, as M. de Castelneau has always supposed, on a kind of syphilitic saturation; but is most frequently the result of the precautions which these women take both before and after coition, and the applications of which they make such frequent use. This is one of the reasons why we do not find these women returning to special hospitals. There is also another, and of that I speak in another place ; there are females who though registered, find the means of treating themselves, or of being treated in houses of prostitution. Acids mixed Avith water were long since recommended as ex- cellent lotions. Thus, Lanfranc, in 1290, advised that the penis should be washed with vinegar and water. The passage Avhich I quote from this author is remarkable not only in a hygienic but in an historical point of view, for it has been regarded as a proof of the ancient existence of syphilis. It is as follows : "Si quis vult membrum ab omni corruptions servare cum recedit d muliere quam habet suspectam de immundicitia, lavet illud cum aqua aceto mixtoz." After Lanfranc, Harrison de Gaddesden and Fallopius recom- mended the use of urine and of wine, which has lately been highly lauded by M. Eicord, especially the aromatic wine. Peyrile advises the use of ammoniac, while M. Malapert praises a solution of the bi-chloride of mercury. In England it is a common custom to wash the parts with water rendered slightly caustic with soap and a few grains of fixed alkali, (carbonate of potash.) Males inject a little of this solution into the urethra,, which I consider a bad practice, for the fining membrane of the urethra is easily irri- tated, and the injection may produce an urethritis, which, had it oeen omitted, might not have become developed. In Belgium, there is a decree of the burgomaster, requiring a flask of oil and a bottle of a solution of the sub-carbonate of potash to be placed in each chamber of a house of prostitution. M. Eicord has made experiments to ascertain the action of cer- tain substances on virulent pus. When he inoculated this pus mixed with an alkah or an acid somewhat concentrated, the results of the inoculation were negative. These substances decomposed the pus, not as some have supposed, in virtue of any specific prop- erties, but by their power of destroying matter or organic pro- ducts indiscriminately. Sulphuric, nitric, hydro-chloric, and acetic acids, and pure chlorides mixed with virulent pus have also pre- vented the success of its inoculation; whilst the same subject, on whom a pustule Aras produced by pure pus, that modified by one of the substances mentioned produced no effect, even though placed PRIVATE PROPHYLAXIS. 491 side by side with the first, and under the same conditions for suc- cess, with the exception of the neutralizing agent. The same re- sults followed the use of the alkaline caustics, such as potash, soda, volatile alkali, wine, alcohol, and concentrated decoctions of tannin. All are aware ofthe public experiments made by Luna-Calderon, at the venereal hospital in Paris, for the purpose of showing the prophylactic power of a substance which he had invented. .This physician scraped or cut his prepuce, Avhich Avound. he covered with virulent pus. If after this inoculation, his remedy was applied, no chancre followed; if not applied, the inoculation was followed by a chancre and sometimes by bubo. Luna-Calderon carried his secret with him to his grave.* M. Langlebert was more generous. He believed that he had invented a prophylactic, and immediately presented it to the public. It is composed as follows: IJ. Alcohol rectified to 40 degrees Cartier, or 95 Gay-Lussac, 3 x. Soft soap of potash with excess of base, 3 x. Dissolve and filter; then add : Essential oil of rectified citron, 3 v. M. Langlebert thus relates his experiments: " On Monday last, July 14th, I took pus from the surface of a phagedenic chancre, with an indurated base, and immediately in- oculated the left thigh of M. E.; then, steeping my lancet again in the same pus, I scraped the right thigh, so as to remove, to a slight extent, the epidermis and a part of the surface of the dermis. This being done, and wishing to place my proceeding under every pos- sible disadvantage, to satisfy myself I repeatedly dipped my lancet in the virulent pus, and deposited it all warm and living as it were, layer after layer, on the wound which I had made. I then waited five or six minutes, when I applied my prophylactic. The next day the pus inoculated on the left thigh had produced its customary effect: an inflamed pimple, already surmounted by a small vesicle, appeared at the punctured point; whilst the right thigh, where everything had been done to favor the action of the virus, there was nothing but a small scab covering the wound which had been made. " This experiment inspired me with so much confidence that I did not hesitate to repeat it publicly. On Friday last, July 18th, at one of my lectures, I scraped the left arm with a lancet dipped in the same pus, and the virulence of Avhich I had proved by inocu- lating a monkey, on Avhich a perfect chancre was developed. I immediately inoculated two of my students, MM. Albanel and Moreau, at their own request. At the expiration of six minutes I applied my prophylactic, and at the present time, July 21st, nothing has appeared with the exception of a small dry scab over the parts scraped."f * Vid. Demonstration pratique de la prophylaxie syphilitique, authentiquement con- stats, by Luna-Calderon. Paris 1815. ,,,.,... ,,. . , , M f Vid. Lettre adressie le 22 Juillet, 1851, & FAcademie de piedecine, par le docteur Jdinglebert. 492 VIDAL ON VENEREAL DISEASES. To form an estimate of the value of the prophylactic measures indicated, two principal circumstances are required: 1st. When the pus is deposited only on a sound surface; 2d. When there is a so- lution of continuity or a local manifestation, an effect of the virus. It is evident that, in the former case, the mechanical action may suffice; thus lotions with simple water may remove the matter and prevent contagion. Everything depends upon the speedy and thorough washing of the parts, in fine, on personal cleanliness. Alkaline or acid substances may be added to the Avater, as has been already mentioned; or instead of these we may use aromatic Avine; but I doubt their efficacy when used of feeble strength; they must possess great activity to enable them to decompose the pus and destroy the virus; they should resemble those which M. Eicord mixed with the pus which he was about to inoculate, or their effect will be reduced to a simply physical action. Water alone might then be equally efficacious. In the second case, that is, when there is a solution of continuity, and the virus has already produced some effect, simple washing is not sufficient. Then, the measures proposed by Luna-Calderon and M. Langlebert, offer the greatest pretensions. I doubt their being true and certain prophylactics, for even if certain substances can destroy the virulence of pus before it has been inoculated, and while it remains without the tissues, they may not possess this power when it is inserted beneath the skin, and has already en tered the system. Having finished his experiments on this sub ject, M. Eicord remarks: "But if these substances may be re garded as prophylactics by the effects they produce before inocula- tion, we should not forget that it was only Avhen the mixture had been made at the very moment of inoculation; for, when pus has been, as it were, implanted in our tissues, and the latter have be- come infected, unless the parts be destroyed by caustic, to a depth exceeding that of the tissues contaminated, a chancre Avill be de- veloped. After the rigorous results of inoculation," adds M. Ei- cord, "we cannot depend on the efficacy ofthe prophylactic meas- ures mentioned, except for the purpose of destroying virulent pus that has been deposited on a sound surface, or temporarily to destroy a virulent secretion in an individual who, without it, might have communicated disease. As to the means proposed by M. Langlebert, and his experi- ments already mentioned, they await the action of a committee appointed by the Academy of Medicine ; on which account I for- bear to prejudge them. But it will have been remarked that only six minutes passed between the inoculation and the application of the prophylactic. It is necessary, therefore, that it should be ap- plied at once after contagion, which may occur at the commence- ment of coition, and the latter be prolonged for more than six minutes. H the act is soon accomplished, and the prophylactic immediately applied, it may then act only physically, in removing the virulent matter. I should add, besides, that M. Eicord's cauterization is not cal- culated to inspire great confidence. In treating of chancre and its GENERAL PROPHYLAXIS.—MEDICAL POLICE. 493 treatment, in the first division of this work, I have shown how rapidly the virus may penetrate the system, and have mentioned the remarkable case of Professor Dumeril, who, stung by a viper, notwithstanding the immediate suction and cauterization of the wound by his son, suffered the general effects of the poison. Now, it is well known, that the inoculation of the syphilitic poison has always been compared to that of the viper, the justice of which comparison has been particularly acknowledged by M. Eicord. I believe, therefore, that this physician is not warranted in asserting that the cauterization of a wound inoculated with syphilitic pus will prevent the formation of a chancre ; and that he is far from the truth in stating that this cauterization will prevent constitu- tional infection, for he must have forgotten his observations on the rapidity of the penetration of the virus into' the system, his general- izations upon its effects, and especially the advice that he has given, to cauterize to a depth exceeding that of the parts contaminated, for in a moment the whole system is infected. We see, therefore, to what private prophylaxis is reduced; it amounts, strictly speaking, to nothing more than an observance of personal cleanliness. It should, likewise, not be forgotten that most of the other measures proposed come under the shield of inoc- ulation, which itself is worthy of but little confidence, especially since it has been clearly proved that the pus of chancre cannot always be inoculated, and that there are indiAtiduals who possess the power of resisting the action of the most virulent pus. I have nothing here to add in reference to the syphilitic vaccina- tion with chancrous pus, as proposed by M. Auzias, nor that re- commended by M. Diday, with the blood of an individual affected with tertiary symptoms, because I have already devoted sufficient space to this subject in my Introductory Remarlcs, and because I have shown, in the second part of this work, that a person, may have syphilis several times. We may have, then, experimental inoculation and physiological inoculation. In speaking of the possibility of being infected with syphilis by inoculation, of course my remarks are intended to apply only to that proposed by M. Auzias for that of M. Diday has been decided to be quite harm- less ; it can do harm only by inspiring the person vaccinated with false security. CHAPTER II. GENERAL PROPHYLAXIS.—MEDICAL POLICE. Tn all a^es the authorities have watched over prostitution; they have even gone so far as to regulate it. We find in ancient Greece that at Athens, inspectors were appointed, to examine into the customs and dresses ofthe females not, however, in a.hygienic point of view Borne, which regulated so categorically houses of 494 VIDAL ON VENEREAL DISEASEa prostitution, and which established a hierarchy among courtezaus, Borne, which attempted to repress the disorders produced by de- bauchery, did nothing in the way of instituting a medical police for prostitutes. In the middle ages we find new police regulations; they are now more severe, occasionally cruel, and nearly always inefficient; thus, the whip, the confiscation of goods, and even banishment, were in turn inflicted by Charlemagne, St. Louis, and the parlia- ments, not only on the prostitutes, but on the mistresses of the establishments in which they were received. It was at this period, especially during the reign of St. Louis, that the inutility and even dangers of these measures became again manifested. It was, therefore, deemed more expedient to regulate prostitution. Un- der these regulations we may include those of the London pohce, by which Avomen affected with a scalding were driven from houses of prostitution; regulations folloAved in Yenice, in 1302. At length those famous statutes of Queen Jane were passed at Avignon, statutes which have been so often praised, for women were no longer driven from their places of abode, but weekly visits were ordered, and a true medical police was established. Unfortunately these statutes are apocryphal, as shoAvn by the researches made at Avignon by Dr. P. Yvaren.* In 1449, Parliament began to moderate its severity; it no longer banished persons laboring under venereal disease, but made an exception in /avor of patients which were poo,r and had no home ; for them it provided an asylum. Finally, in 1536, infected persons were no longer looked upon as guilty, but as unfortunate sufferers. Parliament still relented even to such an extent as to show more humanity than the administrators of hospitals, the nat- ural guardians of the sick. Parliaments, indeed, struggled with these administrators for twenty-one years, trying to obtain the grant of a small hospital connected with the parish of St. Eustache, What decrees, what injunctions, what threats were necessary to procure shelter for a few suffering mortals! At that time vene- real patients Avere obliged to obtain fraudulent admission into the Hotel Dieu. Again were they banished. At last a special estab- lishment was opened for them in the rue de Lourcine, and to the magistracy were they indebted for this act. Still it was was not until 1684 that the treatment of these crea- tures was ventured upon in a corner of the Salpetriere, at that time a prison for prostitutes guilty of disorderly conduct. Those who were sick then received some attention, but what could they avail Avhen always preceded by the lash ? And yet we find un- fortunate females seeking an arrest Avith the hope of being sent to the Salpetriere, and of there obtaining rehef of their sufferings. The Salpetriere having become crowded, the Bicetre was opened to venereal patients. This soon became as crowded and unhealthy as the Salpetriere. The history of this period, in reference to * Vid. the notes of this physician, appended to his excellent translation into French, of the poem of Fracastor. GENERAL PROPHYLAXIS.—MEDICAL POLICE. 495 what was required to obtain admission, the number of patients in a ward, the hygiene of this ward, its mortality, is too horri- ble for my pen, and I forbear; yet all this happened after 1689, an epoch most fertile in philanthropic deeds and in charitable dis- courses ! Finally, in 1792, the Capucins were opened to the unfortunate subjects of syphilis; this asylum, at present the Hopital du Midi, which I have seen in a very bad condition, was regarded as a for- tunate abode, though the mortality was one in forty! True, at the Bicetre, it was one in ten! However, it is from this period that the real progress in the treament and hygiene of venereal patients begins to date. First of all, they must be sought and isolated, so as to withdraw from society these active agents of contagion. Hence the idea of subjecting prostitutes to a sanitary inspection. The serious application of this idea dates from the ordinance of 1657; but those women only were examined Avho, detained at the Salpetriere, had suspicious symptoms of the disease. It was necessary to extend this ordinance so as to include prostitutes at large. This project was formed by several lieutenants of the police in the eighteenth century, but they did not dare to put it into execution, lest it might compromise their authority in the eyes of the public, by appearing indeed to favor the vice, by af- fording prostitutes the dangerous privilege of a certain security. Finally, under the prefecture of Dubois, in 1800, this project as well as certain others temporarily required by the economists, and always regarded as chimerical, were actually carried into execu- tion. From this time, we have a true medical police, since their authority was not limited to the suppression of the vice, but in- cluded likewise sanitary considerations. Two practitioners, Cou- lon and Teytaut, were charged to visit periodically houses of pros- titution, the expense being borne by the prostitutes themselves, who paid a monthly tax of three francs. Even a consulting hall was established, Avhere females unable to obtain admission to the hospital, received advice and medicine gratuitously, thus permit- ting them to be treated among themselves. This establishment received the name of Dispensaire de Salubrite. There is at present, in every town in France, a dispensary, but the ancient tax imposed on the prostitutes having been abolished in 1818, the expense is borne by the municipality. Were I to assert that these dispensaries are perfect, I should state that which is absurd. At these institutions the visits are generally made. In Paris the prostitutes, living by themselves, are examined twice a month. In many of the toAvns they are visited weekly. It is necessary that this rule should never be violated, and that they should never be treated by themselves. When once it is known that a female is diseased she should be removed at once to a special hospital, and there re- main until entirely cured. I purposely underline these remarks A number of females, of every occupation, whom poverty or de bauchery induce to lead a life of prostitution, escape the police Here is one of the dangers of a medical police, and yet these are the Avomen who infect the greatest numer of young men! 496 VIDAL ON VENEREAL DISEASES. Girls in houses of prostitution are visited weekly, and whenever they change their residence. When one is found diseased she should be actually and immediately conducted to a special hospital, and not fraudulently to another hospital. They should never be treated in these houses under the promise that they Avill not have connection during their treatment. Experience has taught us what value to place on the promises of the mistresses of these es- tablishments. Every girl Avhose health there is reason to suspect during the interval between the visits, should at once be taken to a hospital and examined. The inefficacy of the medical police arises, I repeat, from the fact that certain girls are treated by themselves and in the houses of prostitution, where they still scatter the disease ; another reason is that the visits are not sufficiently frequent, for the mean period of incubation is four days; consequently, a woman who shall have received the germ of the disease on the evening or day before the visit, will appear to be sound and receive a certificate to that effect, and yet she will for seven entire days be capable of communicating the disease to those who have connection Avith her. At these visits the girls should be examined with the greatest care. We should not be satisfied Avith that of the external organs alone, but Avith that of the speculum Ave should explore the vagina and the neck of the uterus. The most convenient speculum for this purpose is the bi-valvular instrument. In some cases, it may permit a portion of the mucous membrane to portrude between the branches at the time of their separation, and may sometimes pinch this membrane when it is withdrawn. To obviate this in- convenience, it has been proposed to add two other valves, which are easily united and separated from it, thus facilitating its intro- duction. But a httle precaution and tact will render such addition unnecessary. The female should be placed upon a table in the same position as if to undergo lithotomy, or she may sit on an arm-chair, or lie on a bed ; the legs should be flexed upon the thighs, and the latter upon the pelvis. The speculum, well oiled, is held in the right hand; with the left the operator separates the labia majora and the right labia minora, an assistant separates at the same time those on the left side. If no assistant be at hand, the left middle finger should be applied over the fourchette, whilst with the other fingers the labia are separated; the extremity of the closed instrument is made to rest upon the middle finger in such a manner as not to press against the urethra and superior orifice of the vagina. Dur- ing the introduction of the instrument we should be careful to press upon the fourchette so as to efface a small cul-de-sac which exists behind it, for it may obstruct the operation, or give rise to pain if an attempt be made to force the passage of the instrument. The vulvar ring having been passed, the instrument is glided on from below upwards and from before backwards, and as it passes on toAvards the uterus, we examine the parts exposed. The vaginal walls applied against the instrument form a kind of rose with an opening at its centre, and at its circumferance the GENERAL PROPHYLAXIS.—MEDICAL POLICE. 497 natural folds of the canal. We know that we have reached the neck of the uterus by the absence of the folds and a change of color m the lining membrane, but more particularly by the ap- pearance ofthe os tincae. It is sometimes difficult to isolate it with the valves of the instrument, either on account of its deviation, or the particular position in which the female has been placed. The examination is concluded by slowly withdrawing the speculum, by which proceeding the whole extent of the vagina is again brought into view. This second inspection may sometimes expose lesions which escaped notice at the first examination. The subject of general prophylaxis cannot be completed with- out referring to the means of preventing the spread of contagion by the male. But if we have already discovered the difficulties attending the visits of inspection of the female, whom the laws, as it were, have placed at our disposal, what can we expect when we come to the male, to whom the right of visit does not extend. In the army the case is different; there, discipline and subordination, and interests easy to be appreciated, have rendered possible the detection of the malady, and the immediate application of the remedy. In the first place, the punishment indiscriminately in- flicted on soldiers with the venereal disease, on their discharge from a hospital or infirmary, has been abolished, and thus soldiers no longer conceal the existence of affections which they suppose to be venereal; they can now seek assistance from the surgeon without apprehension ; their cure is therefore more speedy, an ad- vantage both as regards their own health, and the propagation of the malady. The minister of war has recommended to the commanders in the army, and to the heads of the administration, to unite with the civil authorities in opposing, to every possible extent, the spread of a scourge so disastrous in its effects to the public as well as to the army. These recommendations have produced beneficial re- sults, but we could hope for still better, if the instructions were de- cided, simple and precise, so as to insure their execution. In Belgium, the medical inspector-general of prostitutes is di- rectly associated with the heads of the venereal hospitals, and after each admission the name and residence of the person who has com- municated the disease are taken. In a circular from the inspector- general of the army, bearing date of December 21, 1842, M. Ylem- inckz issued to all the heads of the military hospitals, the following regulation adopted in the garrison at Liege:. "Every person found diseased, is immediately interrogated by the officers and sub-officers of his company who have received an order from their chief; a corporal accompanies the patient with the commissary of police to the residence of the woman infected. This agent takes their depositions, arrests her, causes her to be examined, and sent to a dispensary; he furnishes the corporal with a duplicate of the soldier's testimony, the corporal takes him to the hospital, and the document is dehvered in custody to the surgeon. In the absence of this individual, the health officer of the establish- ment surrenders him at once to the person in command. No ve- 32 498 VIDAL ON VENEREAL DISEASES. nereal patient can be treated in the barracks. Soldiers are severely punished. if they fail to make known their attacks, as are those whoj by false statements, prevent the search for an infected prosti- tute, hut for those only. The inspector-generals maintain frequent ; communication with the physician in charge of the syphilitic wards for soldiers. "Such," says M. Yleminckz, "are the advantages of these regu- lations, that in 1845, out of a force of from twenty-five to thirty thousand men, in the Belgian army, there were but one hundred and fifty affected with venereal disease, (one patient out of one hundred and ninety soldiers.) There would not," he observes, "have been one hundred, if the sanitory police at Gand and at Namur had acted efficiently." M. Bertherand, who mentions with approbation these regulations, adds: " Now contrast this with what occurs in France! At the venereal hospital in Strasbourgh there are daily from one hundred to one hundred and fifty patients; ii we add to this an equal number of cases of urethritis, and the milder forms of chancre, treated in the regimental infirmaries, we find that eight thousand men in garrison furnish, first, as many venereal patients as are found in the whole Belgian force; second, the sextuple proportion of one syphilitic patient to thirty-three men. If we consult the table, at the commencement of this Avork, of cases treated in our hospital from 1836 to 1846, calling the price of one day one franc, we shall find that the mean cost, on the budget of war, of syphihs, at Strasbourg, is nearly forty thousand francs per annum. " Why, in our barracks, is not the head of department conjointly responsible, to a certain extent, for the prevention of disease ? The . severe punishment of the venereal soldier having been abolished, the deposition of the brigadier or corporal has lost all its odious character. Their repugnances once overcome, it well be easy to make men of standing, like the heads of department, understand that >t is as much for the morality and dignity of the corps to de- tect a soldier that Avould conceal the venereal disease, as one affect- ed with the itch, or any other contagious malady. " With false notions of hygiene, the soldier should no longer be shut out of public houses, known and examined, and be reduced to the resources of clandestine prostitution. Surely it is better to overlook visits to the former, and redouble our vigilance as regards these private women, in which all large towns abound. Females who are not subjected to examination, who have a thousand plans for escaping sanitary visits, are the most dangerous of all pros- titutes. " The measures proposed by the inspector-in-chief ofthe health of the army in Belgium, supposes perfect harmony and constant intercourse between the local authorities and the officers in com- mand, aided by the army surgeons. With us, the number of in- termediate agents impede the progress of matters, if they do not render it impossible by the obstacles they present, and the disgust which they inspire. The distribution of the corps, the frequent changes of the health officers, do not allow them to establish Avith GENERAL PROPHYLAXIS.—MEDICAL POLICE. 499 special physicians, the intercourse indispensable to success in pre- venting the spread of the venereal disease."* I here terminate my remarks on prophylaxis, stating that the idea of obtaining from each patient admitted into a hospital, and every practitioner consulted, the name and residence of the'parties who communicated the disease, and that of granting to every phy- sician authority immediately to arrest such person—ideas partly carried into execution in the Belgian army, Avould, if adopted in civil life, produce the most happy results. But I touch here upon a delicate question, which I propose hereafter to discuss in a man- ner commensurate with its importance. * Bertherand, Precis des maladies veneriennes. Strasbourgh, 1852. THE END. •w . , - t..vkd . t •' 1 ' "-V ^, i^ ' ^ IK v r f ft- . 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