3* " % ^ *= % V ;.- .^"\ T it b A T I S ON VENEREAL DISEASES BY A. VIDAL, (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 COLOKED PLATES. TRANSLATED, WITH ANNOTATIONS, GEORGE C. BLACKMAN, M.D., FELLOW OF THE EOTAL MEDICAL AND CHIRURGICAL SOCIETY OP LONDON; FORMERLY ONE OF PHYSICIANS TO THE EASTERN AND NORTHERN DISPENSARIES, NEW YORK. SECOND EDITION. NEW YORK: SAMUEL S. & "WILLIAM WOOD, 261 PEARL STREET. 1855. > >* 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. STEEEOTTPEDBT PRINTED BT THOMAS B. SMITH, E. N. GROSSMAN, 82 & 84 Beekman Street. 82 & 81 Beekman St 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 SypMlis" 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 ,JVew York Journal of Medicine and Surgery for iv EDITOR'S PREFACE. October, 1840. The value of these can be better appreciated in another part of this work. Through the politeness of Dr. Van Buren, the editor has recently had an opportunity of seeing (though too late to incorporate the details in his Notes) an instance of that exceedingly rare affection, tertiary syphilis in the infant. In this patient, there were nodes on the ulna and forehead, and enlargement of both testicles ! 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. fta&U of CflttUitts PAGE Preface 1 Introduction 13 Synonyms 13 Historical Sketch 14 Syphilitic Yirus 19 Observation 26 Experiment 32 Inoculation. , 33 Inoculation of Animals 36 Syphilization 40 Transmissibility of Secondary Accidents 49 PART I. PEIMITIYE VENEREAL *DISEASES 67 CHAPTER I. Blennorrhagia 68 , CHAPTER II. Blennorrhagia in the Male *72 Section I. — Blennorrhagia of the Urethra *72 Consequences of Blennorrhagia 88 Blennorrhoea 88 Uretrorrhagia 119 Urethral Pains. . . .«. 122 Perverted Sensations in the Urethra — Absence of Sensations 124 Blennorrhagic Orchitis 126 Blennorrhagic Prostatitis 139 Blennorrhagic Cystitis . . . ' 146 Blennorrhagic Nephritis 149 Blennorrhagic Ophthalmia 153 Blennorrhagic Arthritis 158 Section II. — Blennorrhagia Balano-preputial 163 V! TABLE OF CONTENTS. CHAPTER III. PAGE Blennorrhagia in the Female 172 CHAPTER IV. Blennorrhagia in both Sexes 188 Anal Blennorrhagia 189 Buccal Blennorrhagia 190 CHAPTER V. Chancre 190 Diseases which may be regarded as accidents of Chancre, Phimosis, and Para- phimosis 227 Phimosis 227 Paraphimosis 229 CHAPTER VI. Bubo 234 CHAPTER VII. Vegetations 255 CHAPTER VIII. Mucous Tubercles S>> ' 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 CONTESTS. yii PAGE Section VI. — Can a person have syphilis more than once ? 290 Section VII. —Therapeutics 292 I. Mercury 293 External employment 293 Internal use of Mercury 300 Mercurial Compounds 301 II. Other Mercurial Preparations 305 III. Accidents produced by Mercury 305 Salivation and Stomatitis , 305 Cholic and Diarrhoea, Mercurial Tremors 315 TV. Iodine 316 V. Iodide of Potassium.; , 317 Accidents attributed to Iodide of Potassium 322 VI. Iodide of Iron 324 VII. Gold, Silver, Platina 325 VIII. Double Salts * , 328 IX. Sudorific Woods 329 X. Compounds, partly mineral, partly vegetable 330 CHAPTER II. On Special Consecutive Venereal Affections 331 Section I. — Syphilitic Eruptions — Syphilides 331 I. General Characters 332 II. Varieties 336 Exanthematous Syphilitic Eruptions 337 Syphilitic Papular Eruption 338 Syphilitic Squamous Eruption 340 Syphilitic Vesicular Eruption 341 Syphilitic Bullae 344 Syphilitic Pustular Eruption 34*7 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 899 viii TABLE OF CONTENTS. PAQB 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 showed themselves profound observers. With this view, I have selected a plan sufficiently extensive to embrace the most important practical details, and yet which, without having too wide a scope, will, I trust, enable all to comprehend the substance of our knowledge on the speciality now termed syphilography. From the time that venereal diseases were first somewhat carefully studied, it has been admitted, that, shortly after the application of the virus, certain lesions are generally produced on the parts contaminated ; these are the primitive venereal accidents. Again, there are certain other morbid conditions, which are ordinarily observed subsequently to the above ; these are the consecutive venereal accidents. Under this by no means modern division, these affections may be advantageously studied. I have adopted it, believing it to be the most rational and best adapted to the purposes of instruction, and not as serving as the basis of any particu- lar system. Hunter recognized two varieties of the consecutive or constitutional dis- ease, and M. Ricord having availed himself of this subdivision, includes all the accidents under the heads of primary, secondary, and tertiary vene- x PREFACE. real disease. In this species of triad, of ancient date,* this writer fancied that he had discovered the basis of a true classification, on which he has engrafted not only a system, but a system the exact symmetry of which was well calculated to captivate an age inclined to absolute certainty, whilst its apparent simplicity has been greatly admired by certain minds, which it is unnecessary here to characterize. A distinguished writer has remarked, that system and hypothesis are synonymous terms-; now we know the result of subjecting the latter to a somewhat rigid criticism. Still this system seemed to withstand not only the force of reason, but of arguments based on clinical observation. It rested its claims upon exper- iment, the influence of which may be imagined during the period to which we have alluded. Its opponents were therefore compelled to descend to the same ground, and it was attacked with the same instrument, as it were, that had been employed in its establishment. Various were the experi- ments performed, and the proceedings adopted. Some of these proved, that chancre was not the only accident that admitted of inoculation, but that those termed consecutive might also be thus transmitted. Now as the system was based essentially upon the exclusive inoculability of chan- cre, these results struck at its very foundations. They likewise seriously compromised the classification dependent on it, as the only admitted dis- tinction between chancre and the other accidents was thus destroyed. Other experiments showed that chancre itself, or the most virulent syphi- litic poison, from some natural or accidental cause, was perfectly harmless when applied to certain individuals ; therefore, as the system boasted as its test for syphilis, the infallibility of chancrous inoculation, it found itself wanting in view of its practical application. Thus, the immutable laws, of experiment, proclaimed by M. Ricord, were annulled by experiment itself, and the promised certainty resulted in un- certainty.! It required but a slight knowledge of medical philosophy, and a little reflection upon the results of experiments, according as they are performed in the exclusively physical, or in the exclusively pathological order, to have anticipated what here occurred. Then came the cases prov- ing that the secondary might appear after the tertiary accidents, and vice versa. The order of the system being thus compromised, what remained ? In the body of this work may be found the proofs of what has been here asserted. However, I shall be brief upon these points, for the main ob- ject of this work is to collect the practical truths which are the results of observation, and those which have survived the downfall of systems. Still * Vid. "La methods curatoire de la maladie venerienne" of Thiery de Herry, and p. 259 of this "work, where I have exposed this triad in its author's ovn 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! PREFACE. xi I have thought it my duty to warn the young practitioner against disap- pointments and regrets, there being nothing, in my opinion, more danger- ous, either in study or in practice, than to invest mere forms with cer- tainty, and to pronounce that to be infallible which can be but probability or uncertainty. After the two principal divisions, — primitive and con- secutive venereal diseases, — 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 of this chapter is evident, for, in the opin- ions there examined, the interests of the family, of justice, and of society in general, are involved, and yet the majority of French works on these topics are very incomplete ? In the fourth part, we shall consider the prophylaxis of venereal diseases, including general and private prophy- laxis, and regulations of medical police. In the Introduction, after a few observations upon the synonyms, may be found an historical sketch of the venereal disease. I shall express an opinion on the nature of the syphilitic virus, and its principal effects. The causes of error in observation will be shown; experiment justly appre- ciated ; the process of inoculation explained, whilst syphilization will be judged. This introductory chapter will conclude with some general ob- servations on the transmissibility of secondary accidents. Since I have stated, in the commencement, that I propose to make a resume of the facts, opinions, and therapeutics, constituting syphilography, my great indebtedness to my predecessors will be obvious. All shall be quoted with acknowledgment. I will submit to the reader what expe- rience has taught me at the Zmircine, in the female wards; and what I have learned at the Hopital du Midi, during a service of more than ten years, since I became the successor of Cullerier, — -the honest man, the sage practitioner. Placed in a theatre so vast, I could not remain indifferent to questions by which science was agitated. I have ventured to discuss one of the most important, the transmissibility of the secondary disease. I think that, by experiment, I have decided it in favor of the contagionists. My experiments have been repeated in France and in Germany; all have pro- duced a brilliant discussion in the Academy of Medicine. MM. Vel- peau, Lagneau, Gribert, Grerdy, 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 Medecine, 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 engravingSj 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 trie 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 napoliiain, 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, at the venereal hospital, who, in a strife, was bitten on the thumb by his comrade, and who was thus, at the same time, inoculated with a chancre. HISTORY. I shall be brief in my sketch of the history of 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 aposihema in inguine propter ulcera virgce, proptera quod est decensus humorum ad ilia loca* Further, Lanfranc advises a method of prevention, which I will mention when I discuss the subject of prophylaxis. I will add, that even before the fifteenth century there existed, as for example in London, regulations of medical police for certain houses of prostitution. There can then be no doubt of the existence, in antiquity, of local non- virulent venereal diseases, and there is strong presump- tive evidence also, that there were those of a specific nature, which produced both local and constitutional symptoms. Thus, it is very probable, that more than one syphiloid affection might have been found in that confused mass of cutaneous diseases, and among those lepers so often noticed among the ancients, and which have not yet disappeared, as is maintained by the hygienists. What led to the use of mercury after the epidemic of the fifteenth century ? It was the success obtained in the earlier ages, when it was em- ployed for the cure of those diseases which were confounded with lepra, and among which were the syphilides. Is this not another * Pract. III., doctr. II., cap. IL IQ 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 sow 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 YIIL, 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 under my care an excessively feeble young man, of a scrofulous habit, whose body is covered with pustules, whilst his lower extremities are affected with rupia, deeply excavated ecthyma, with cracked black 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 f The pathognomonic signs of sy- philis become more distinct and easy of recognition, in proportion as we isolate them from the diseases with which they were com- plicated, and from the epidemic influences by which they were modified. Then indeed, we may collect the elements of syphilis, and establish a form of disease entitled to a scientific nomencla- ture. In alluding to the earliest period in the history of the vene- real disease, I have stated, that it could then boast neither of name, therapeutics, nor of books ; but from the commencement of the sixteenth century, it has received many names, has had a special therapeutics, and has given rise to innumerable volumes. 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 syphihtic virus, in substance, cannot be detected; in its simple unmixed state, it eludes all our efforts at observation ; here, micrography and chemistry have shown their impotence. This poison is manifested only by its effects, of which the most remark- able is its great facility of reproduction. Brought into certain re- lations with the living tissues, and in certain conditions, the virus develops a morbid action, the result of which is its reproduction, its multiplication. It is there a kind of germination, for the cause produces an effect which becomes of itself again the cause. Obser- vation has demonstrated the existence of a syphilitic virus, for the number is infinite who have contracted chancres by connection with those affected with chancres. But to remove the doubts of certain minds, a resort must be made to experiment. In fact, pus from a chancre, inserted on the point of a lancet beneath the epi- dermis, has given rise to the same form of ulceration, possessing the same property of reproduction. The syphilitic virus has ordinarily for its vehicle a thin, sero- sanious, mal-assimilated pus, in which organic detritus is more or less apparent. But pus the most laudable, muco-pus, may also be the means of conveying the virus, and it would seem to possess no influence in modifying its nature. The virus may exist not only in the morbid secretions, but it has not been proved that it may not change the normal secretions. It unites with the blood, and there undergoes certain modifications by which it becomes inti- mately blended with it. A particular kind of pus, that produced by gangrene, seems to neutralize the virus. Virulent pus may, like vaccine matter, for a long time be pre- served in tubes, or between two glass plates, without losing its properties ; of this Percy has furnished the proof. But to develop these properties of pus, it must be applied in a liquid state, or be so placed that it will be rendered such by the moisture of the part in which it is inserted. Even when greatly diluted, a solution of this pas 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 Menorrhagia produced by one kind of virus, and chancre by another ? To these, Hunter replied in the negative, and explained the different effects by the difference in the surfaces to which it is applied. If specific pus is brought into contact with secreting surfaces, Menorrhagia is the result (these surfaces are the lining membranes of the vagina and urethra) ; if the same pus is applied to the skin and the mucous membranes bordering upon it (as, for example, those of the glans, the prepuce, the vulva, and the lips), a chancre will follow. But as chancres have been observed in all the mucous membranes to which it has been applied, the theory of Hunter was necessarily abandoned. A double virus was then adopted as a substitute, and this doctrine was defended by Benjamin Bell and Hernandez. I shall notice this theory when I treat of blennorrhagia, but I feel bound here to show how it has been defended by Hernandez, in the face of arguments deemed most weighty, since they were derived from the results of experiments. An experimenter by the name of Andre inoculated himself with gonorrheal matter, which produced a chancre. To this fact Hernan- dez replies that it is of but little importance as it is an isolated one, and because it has been reported by an unknown surgeon. But Hunter likewise produced chancres in the same manner. The ob- jection now raised 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 mucopurulent 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 (posilivisme), 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. Kicord 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 Theses. 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. Rieord, 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. — Gr. 0. B, f I am satisfied, as must be those who have carefully examined the two patho- logical specimens on which M. Rieord ■ relies to establish his theory, that they were 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 connection between the indu- rated chancre and the scaly eruption. {Treatise, 2d Amer. Ed. p. 285.) Mr. Egan is disposed to adopt with but slight modifications the views of Mr. Carmichael, and with the latter regards the experiments made by M. Ricord as lending a support to the doctrine of a plurality of poisons {op. cit. pp. 49, 52 ; and Carmichael's Clin. Led. p. 52). M. Ricord, indeed, states that in his experiments — "always per- formed on the patients themselves 1 — 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-marked underated 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 avo 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 1S46-7 (vid. Lect. viii.), " we are in this respect no worse off with syphilis than with many other affections; out of fifty patients, the subjects of operation, wo 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 lias happened, otherwise than by saying it depended on the constitution." — G. C B. x (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 stor}^ is familiar, of the young girl, who, to disguise herself, put on the breeches of a man, and thus contracted syphilis. A mask, the clothes of a per- son infected, the seats of a privy, it is said, have each been the means of conveying the disease. The authenticity of these cases, however, is not beyond reproach, and even if it were, it would furnish an argument in favor of the communicability of the second- ary disease. The sexual organs of the female may serve, so to speak, as a depot, from which the virus may be extracted. A man having connection with this female may contract the disease, and yet the woman herself escape infection. This has long been known. Thus, we read in Astruc (torn. 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 exjDlana- 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, (yerole 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, {yerole 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. Kicord denies both the incubation and the non-consecutive syphilis, {yerole 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 lapeau 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. 23 INTRODUCTION. lie 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 svphilographers 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 giveri 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'^ 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 SypMlida. 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. Xow, 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 Mm. 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- SO 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. Richet, the family physician of a Parisian merchant, met M. Ricord in consultation. The case was that of a child, affected with syphilitic ulcerations in the ano-genital regions. Both parents and nurse being apparently perfectly sound, much perplexity was felt in deciding upon the origin of these ulcerations. The fact was mentioned, that ten clerks lodged in the same house, and perhaps one of these might be affected! Seizing upon this happy suggestion M. Ricord at once attributes the infection to the dandling of the child upon the naked hands of one of these clerks. M. Velpeau, in his communication to the Academy of Medicine, Sept. 21st, 1852, states that by accident he had learned from Dr. Richet, that this story of the posed clerk was a mere invention, having no other foundation than the circumstances above mentioned. In a letter subse- quently addressed to M. Velpeau, Dr. Richet observes: "Xo, 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. lOi), 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 narrowing influence of theory, exclaims: "Thus, to limit primary syphilis to chancres, an urethral chancre in certain cases of blen- norrhagia must be supposed, and chancres with flat primary tubercles, or 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 irrational manner, must be accused of error or credulity. In a word, we must cull, prune, strike off, polish, and reduce to a certain measure marked in advance, all the elements of science that they may fit the famous 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 the tact and skill required to discover the true origin of the disease in these perplexing cases ! For all the details connected with this case the reader may consult the collection of Reports and Discussions, entitled " Be la Syphilization,"