- 
 
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 JMMM^'
 
 Southern Subscription Igencr.) 
 W. B. DALSTON. 
 
 Medical Books. 
 
 17 ft 19 E. Alabama St., 
 
 ATLANTA, GA. 
 
 II IN 81971 
 
 IRVINE. CALIFORNIA 92664
 
 THE 
 
 VENEBEAL DISEASES 
 
 INCLUDING 
 
 STRICTURE OF THE MALE URETHRA 
 
 BY 
 
 E. L. KEYES, A.M., M.D., 
 
 PBOFESSOB OP DEBMATOLOGY AND ADJUNCT PBOFESSOB OP SUBGEBY IN THE BELLEVTJE HOSPITAL 
 
 MEDICAL COLLEGE ; ONE OF THE SUBGEONS OF BELLEVUE HOSPITAL ; CONSULTING 
 
 SURGEON TO THE CHABITY HOSPITAL, ETC., ETC. 
 
 NEW YORK: 
 
 WILLIAM WOOD & COMPANY 
 
 27 GKEAT JONES STKEET 
 
 1880
 
 OOPYBIQHT, 1880, BY 
 
 WILLIAM WOOD & COMPANY. 
 
 Tuow's 
 
 PRINTING AND BOOKBINDING COMPANY, 
 
 201-213 East i2tA Street, 
 
 NEW YORK.
 
 PROFESSOR WILLIAM H. VAN BUREN, 
 
 IS GRATEFUL ACKNOWLEDGMENT OP 
 
 MUCH VALUABLE COUNSEL 
 
 AND 
 
 IN REMEMBRANCE OP MANY TEARS OP PROFESSIONAL ASSOCIATION, 
 
 THIS BOOK 
 
 Snscribeb 
 
 BY THE AUTHOR
 
 I/ 
 
 PREFACE. 
 
 THIS volume is designed by the publishers to be one of a series 
 addressed to the general medical practitioner. My aim has, therefore, 
 been to present the various venereal diseases as clearly as possible, 
 avoiding such unnecessary refinement npon theoretical and mooted 
 points as would be apt to lead to confusion or to error. 
 
 Practical- utility, as well as what I believe to be sound doctrine, has 
 been kept constantly in view, and no effort has been made to display a 
 long list of remedies. Such means as I have found most valuable are 
 recorded, together with suggestions from well-recognized authorities. 
 A physician cannot afford to have many remedies for a given disease 
 if he expects to use any of them well. 
 
 My views on many of the subjects included in this volume, are 
 already before the public, scattered through various books and essays. 
 In the main these views are unchanged. Such alterations as time and 
 a larger experience have effected are recorded herein. My ideas on the 
 treatment of syphilis are only modified in that the tonic dose of the 
 specific is made rather smaller, and the course rather longer than 
 formerly. 
 
 I have opposed the views of those gentlemen who are throwing con- . 
 fusion in the way of the general practitioner by trying to break down 
 the distinctions between the initial lesion of true syphilis, and chancroid; 
 and who teach that chancroid may be derived from the products of the 
 syphilitic early or late lesions. I have also taken issue with the experi- 
 menters who claim to prevent syphilis by excising the initial lesion, on 
 the ground that something more than induration in a sore is necessary 
 in order to prove it to be a syphilitic chancre. Without a reliable history 
 showing previous freedom from syphilis in such patients, added to con- 
 frontation, the records of excised chancres fail to be convincing, and 
 the moderate percentage of claimed success is, thus far, not proven. 
 It is to be hoped that some good will eventually come of these exper- 
 iments, but more accuracy of observation must be brought to the inves- 
 tigation than has been yet employed. 
 
 Finally, I have raised my voice, for what it may be worth, in protest 
 
 6 6"? 3
 
 VI PREFACE. 
 
 against the views of the new school in urethral pathology, which seems 
 to claim that every natural undulation in the tissues of the pendulous 
 urethra is a stricture fit for cutting, and that all the ills of the genito- 
 urinary passages may be accounted for by the existence of these undu- 
 lations, and, usually, made to disappear when the latter are cut. 
 
 To the honest labor and mechanical genius of the leader of this 
 school I tender my respect. The profession is indebted to him for 
 some capital instruments and for a broader understanding of the toler- 
 ance and of the possible capacity of the urethra than it has yet pos- 
 sessed. 
 
 The profession as a whole doubtless still underrates the normal 
 capacity of the male urethra, and after the present rage for cutting has 
 passed and the reaction has come, a calm equilibrium will finally es- 
 tablish itself, which, on the whole, will be to the advantage of those 
 patients who in time to come may suffer with urethral difficulties. 
 
 The theories of the new school are as ingeniously perfect as the 
 instruments which carry them out ; but, unfortunately, its claims seem 
 to leave out of view that the disease for which the patient seeks relief 
 is only a symptom, and that such symptom may be due to a variety of 
 causes. What will cure the symptom in one case will not necesarily do 
 so in another. And a serious criticism upon the methods of the new 
 school is that it does not generally, in its lists of published cases, give 
 any prominence to those cases which have been cut without relief of 
 the symptoms complained of. 
 
 In short, the pathology and the treatment of the new school are 
 narrow, and tend to encourage routine practice in the young, to the 
 detriment of a careful study of each case. 
 
 Thanks are due to Dr. G. H. Fox, of New York, for the admirable 
 photographs from nature after which many of the woodcuts illustrat- 
 ing venereal lesions have been made. Syphilitic lesions cannot be per- 
 fectly represented without the use of color, but I think that the exhibi- 
 tion of the topography of the different eruptions is in itself enough to 
 justify the use of woodcuts. 
 
 E. L. KEYES. 
 NEW YORK, Jan. 1, 1880. 
 
 No. 1 Park Avenue, 
 Corner of Thirty-fourth Street East.
 
 CONTENTS. 
 
 PART I. 
 CHAPTER I. 
 
 CHANCROID. THE NON-SYPHILITIC VENEREAL TTLCEB. 
 
 PAGE 
 
 Chancroid. Definition. General Description of Typical Clinical Chancroid. 
 The Nature of the Chancroidal Poison. Answers to the Objections made to 
 the Existence of any Special Chancroidal Virus, and Discussion of the Alleged 
 Cases of Chancroid purporting to have been produced by the Inoculation of 
 Pus not derived from a Chancroid. Is the Poison of Chancroid a Modified 
 Syphilitic Virus ? Unity and Duality in Syphilis. Twelve Propositions set- 
 ting forth Facts relative to the Question of Duality, and believed to be sus- 
 tained by Facts, Experimental and Clinical, now before the Profession. 1 
 
 CHAPTER II. 
 
 CHANCROID. DESCRIPTION OP ITS SPECIAL FEATURES AND OF THE VARI- 
 ATIONS TO WHICH THEY ARE LIABLE. 
 
 Pathological Histology of Chancroid ; Comparative Histology of Syphilitic Chancre 
 and of Chancroid. Transmission of Chancroid to Animals. Transmission of 
 True Syphilis to Animals. The Relative Frequency of Chancroid. The Meth- 
 ods of Chaucroidal Contagion, Direct and Mediate. The Inoculation of Chan- 
 croid. Auto-inoculation and Hetero-inoculation. Case illustrating the Diag- 
 nostic Value of Auto-inoculation. Inoculation in Generations. How to Prac- 
 tise Experimental Inoculation. The Incubation of Chancroid ; Variation in 
 Incubation. Course of Chancroid; Period of Increase; Stationary Period; 
 Period of Repair ; Variations in Course. Situation of Chancroid; Variation 
 in Situation. Number of Chancroids. Form of Chancroid; Variations in 
 Form. Follicular Chancroid. Subjective Symptoms of Chancroid. Condi- 
 tion of the Base. Duration of Chancroid ; Variations in Duration. Cica- 
 trix of Chancroid. . . .... 15 
 
 CHAPTER III. 
 
 CHANCROID. DIAGNOSIS, PROGNOSIS, AND TREATMENT. 
 
 Diagnosis. Diagnostic Table of Chancre, Chancroid, and Herpes. Ulcerated Non- 
 virulent Abrasions. Different Varieties of Pseudo-chancre and their Treat- 
 ment. Six Propositions of Importance bearing upon the Question of Auto-
 
 Vlll CONTENTS. 
 
 PIGS 
 
 inoculation for Purposes of Diagnosis. The Prognosis of Chancroid. The 
 Treatment of Chancroid. Prophylactic Treatment. Radical Treatment. 
 The Reason why Cauterization will not always arrest a Chancroid. How to 
 cauterize a Chancroid. Palliative Treatment of Chancroid. lodoform and 
 its Use, and other Topical Applications. Anal and Rectal Chancroids. Ure- 
 thral Chancroids. Sub-preputial Chancroids. Chancroid at the Margin of 
 the Prepuce. Chancroid of the Vulva and Vagina. Chancroid of the 
 Fingers. 24 
 
 CHAPTER IV. 
 
 CHANCKOID. THE COMPLICATIONS OF CHANCROID, AND THEIR TREATMENT. 
 
 Chancroid complicated by Inflammation. Inflammatory Phymosis and Paraphy- 
 mosis, with their Treatment. Phagedaena, Sloughing and Serpiginous, and 
 its Treatment. Chancroid complicated by Syphilis. The Lymphangitis of 
 Chancroid, Inflammatory and Virulent, and its Treatment. The Bubo of 
 Chancroid, Simple, Indolent, Spontaneous (Bubon d'Emblee). Treatment of 
 Simple Bubo. Treatment of Indolent Bubo. Virulent Bubo, or Subcuta- 
 neous Chancroid. Treatment of Virulent Bubo. . 37 
 
 PART II. 
 CHAPTER I. 
 
 SYPHILIS. 
 
 General Considerations upon Syphilis. Definition of Syphilis. Effects of Climate 
 upon the Disease. Present Mildness as compared with former Virulence. 
 Outline of the Course of Syphilis. General Pathology of Syphilis. General 
 Description of the Pathology of the various Lesions due to Syphilis, and the 
 Lack of any Specific Quality in the Elements constituting these various 
 Lesions 53 
 
 CHAPTER II. 
 
 SYPHILia 
 
 The Poison of Syphilis : is it a Vegetable Fungus ? The Production of Syph- 
 ilis in Different Animals. The Alleged Antagonism between Syphilis and 
 Cancer. Secretions which contain the Poison of Syphilis. Peculiar Viru- 
 lence of the Secretion of Mucous Patches. Vaccinal Syphilis. Pathological 
 Secretions. Physiological Secretions. Infection by Milk ; by Semen. Trans- 
 mission of Syphilis by Inheritance through the Mother alone ; through the 
 Father alone. Date at which a Healthy Pregnant Woman must get Syphilis 
 in order to Poison her Child. Choc en-retour. Transmission by Inheritance 
 to the Third Generation. 61 
 
 CHAPTER III. 
 
 SYPHILIS. 
 
 Methods of Contagion in Acquired Syphilis, Direct and Mediate. The Duration 
 of Syphilis and the Question of Marriage. Cauterisatio Provocatoria. The
 
 CONTENTS. IX 
 
 PACK 
 
 Prognosis of Syphilis, and the Influence of Constitution and of Intercurrent 
 Physiological and Pathological Conditions upon its Course and Duration. 
 Second Attack of True Syphilis occurring in Individuals who have already 
 once had Syphilis. . 75 
 
 CHAPTER IV. 
 
 SYPHILIS. 
 
 The Incubation of Syphilis. Description of Syphilitic Chancre : the Raw Ero- 
 sion, the Superficial Ulcer, the Herpetiform Chancre, the Mixed Chancre, 
 Chancre of the General Integument, Chancre of the Lip, of the Nipple, of 
 the Urethra. Syphilis without Chancre. Typical Course of Chancre. Spe- 
 cific Induration. Complications of Chancre by Phagedaena. Treatment of 
 Chancre by Excision and other Means. The Lymphangitis of Chancre. 
 The Bubo of Syphilis, and its Treatment 85 
 
 CHAPTER V. 
 
 SYPHILIS. 
 
 A Table giving a Comprehensive View of the Features, Course, Symptoms, etc. , 
 of Chancroid, as compared with Similar Conditions, when met with in con- 
 nection with Syphilitic Chancre. The Stages of Syphilis : Primary, Secon- 
 dary, Tertiary. Malignant Syphilis. The Second Incubation. Syphilitic 
 Fever. Symptoms attending the Beginning of General Syphilis. . . .97 
 
 CHAPTER VI. 
 
 THE GENERAL TREATMENT OP SYPHILIS. 
 
 Syphilis a self limiting Malady. It gets well tinder all Treatments sometimes, 
 but yields the best Results to small Doses of Mercury continued for a long 
 Time. Syphilization and Tartarization. The Hot Springs of Arkansas. 
 Preventive Treatment of Syphilis. Excision of Syphilitic Chancre. The 
 Hygienic Treatment of Syphilis. The Hygiene of the Mouth. Hygiene of 
 the Anus and of the Genitals. Hygienic Medication. Kumyss. Specific 
 Treatment of Syphilis. General Consideration of the Value of Mercury and 
 the Different Kinds of Mercurial Treatment. Salivation. Time at which 
 the General Treatment of Syphilis should be commenced. Detail of the 
 Tonic Treatment of Syphilis by Mercury. The Time at which a Tonic Course 
 of the Mercurial Specific may be stopped. 104 
 
 CHAPTER VII. 
 
 THE GENERAL TREATMENT OF SYPHILIS CONTINUED. 
 
 Mercurial Fumigation. Simple Method of taking a Bath at Home. The Inunc- 
 tion of Mercury. Other Methods of giving Mercury. The Treatment of Sali- 
 vation. The Local Treatment of Syphilitic Lesions of the Integument; of 
 Mucous Membranes. The Iodides and the Preparations of Iodine. The 
 Evil Effects of the Iodides. The Dose of the Iodides. The Mixed Treat- 
 ment. When to cease giving the Iodides. Zittman'a Decoction. . . . 122
 
 X CONTENTS. 
 
 CHAPTER VIII. 
 
 SYPHILIS OF THE SKIN. 
 
 PAGE 
 
 Special Characters of the Syphilidea : Polymorphism, Color, Form, Absence of 
 Subjective Symptoms. Characters of Scabs, Ulcers, Cicatrices in Syphilis. 
 The Syphilides: Erythematous, Papular, Pustular, Ecthymatous, Pigmen- 
 tary, Vesicular, Squamous (Circinate, Palmar and Plantar), Tubercular (Gen- 
 eral, in Groups). Tertiary Syphilides. Rupia. Tertiary Pustular Syphilide. 
 Ecthyma. Pustular Syphilide in Groups. Tertiary Syphilitic Ulceration. 
 Gumma of the Skin 142 
 
 CHAPTER IX. 
 
 SYPHILIS OP MUCOUS MEMBRANES. 
 
 Erythematous, Ulcerative, Mucous, and Scaly Patches, and Gummatous Ulcers of 
 
 the Mucous Membranes of the Mouth, Nose, and Fauces. . . . . 165 
 
 CHAPTER X. 
 
 SYPHILIS OF LYMPHATIC GLANDS, OF HAIRY PARTS, OF THE FINGERS AND TOES, 
 OF MUSCLES, TENDONS, APONEUROSES, BURS^E, JOINTS, BONES, AND CARTILAGE. 
 
 Epitrochlear and Post-cervical Indolent Glandular Engorgement. Syphilitic Alo- 
 pecia. Syphilitic Onychia and Paronychia. Dactylitis. Syphilitic Myostitis, 
 Congestive, Diffuse, Gummatous. Syphilis of Tendons, Sheaths of Tendons, 
 and Aponeuroses. Syphilis of the Bursae. Syphilis of Ligaments and Joints. 
 Syphilis of Bones. Osteocopic Pains. Nodes, Dry Caries, Gummy Tumor 
 of Bone. Mercury as a Cause of Bone Disease. Syphilis of Cartilage. . . 171 
 
 CHAPTER XL 
 
 SYPHILIS OF THE RESPIRATORY SYSTEM. THE DIGESTITE TRACT, ABDOMINAL 
 GLANDULAR ORGANS, AND THE VASCULAR SYSTEM. 
 
 Syphilis of the Nose. Syphilis of the Larynx; non -Ulcerative Ulcerative. 
 Syphilis of the Trachea, Bronchi, and Lungs. Syphilis of the Digestive 
 Tract. Gumma of the Tongue. Syphilis of the (Esophagus. Syphilis of the 
 Stomach and Intestines. Syphilitic Stricture of the Rectum. Syphilis of the 
 Peritoneum. Syphilis of the Pancreas. Syphilis of the Liver. Diffuse and 
 Circumscribed Hepatitis. Gumma of the Liver; Amyloid Degeneration. 
 Syphilis of the Spleen. Syphilis of theThymus, of the Supra-renal Capsules, 
 and the Abdominal Glands. Syphilis of the Heart. Syphilis of the Arteries, 
 Veins, and Capillaries. 190 
 
 CHAPTER XII. 
 
 SYPHILIS OF THE NERVOUS SYSTEM. 
 
 General Pathology of Nervous Syphilis. Syphilis of the Brain, Pachymeningitis, 
 Gummata of the Meninges, Encephalitis, White Softening, Gummata of the 
 Brain. Syphilis of the Cerebral Arteries. General Symptoms of Brain Syphi- 
 lis, Prognosis, Treatment. The Special Affections produced by Syphilitic Le- 
 sions of the Brain. Syphilitic Hemiplegia, Epilepsy, Generalized Paralysis,
 
 CONTENTS. XI 
 
 PAGE 
 
 Catalepsy, Chorea, Aphasia, Insanity. Brain Syphilis simulating Sunstroke 
 often followed by Desire to Sleep. Syphilis of the Cord. Syphilitic Para- 
 plegia. Syphilitic Locomotor Ataxia. Syphilis of Special Nerves, of Nerves 
 of Special Sense, and Nerves of Motion. Syphilis of the Sympathetic. . . 205 
 
 CHAPTER XIII. 
 
 SYPHILIS OF THE GENITOURINARY SYSTEM IN BOTH SEXES. 
 
 Syphilis of the Kidney. Syphilitic Albuminuria. Syphilis of the Penis. Syphi- 
 lis of the Testicle ; Epididymitis, Orchitis (Diffuse, Gummatous). Diagnostic 
 Table of Syphilitic, Tubercular, Cancerous, and Sarcomatous Enlargement of 
 the Testicle. Treatment of Syphilis of the Testicle. Impotence due to 
 Syphilis. Syphilis of the Genital System in the Female. Functional De- 
 rangements of Menstruation due to Syphilis. The Effect of Syphilis upon 
 Pregnancy. Cause of Abortion in Syphilis. Syphilis of the Mammary 
 Gland, Diffuse, Parenchymatous, Gummatous 219 
 
 CHAPTER XIV. 
 
 SYPHILIS OF THE EYE AND EAR. 
 
 Syphilis of the Eyelids and Conjunctiva. Syphilis of the Cornea, the Iris (Plastic 
 and Gummatous Iritis). Syphilis of the Vitreous, of the Ciliary Body, of the 
 Choroid, of the Retina (Atrophy of the Retina, Retinitis Pigmentosa). 
 Syphilitic Optic Neuritis. Syphilis of the Ear. Syphilis of the Outer Ear 
 and Auditory Canal. Plastic Myringitis. Syphilis of the Auditory Nerve.' 
 Syphilis of the Middle Ear. Ear Affections found in Inherited Syphilis. 
 Catarrhal Inflammation of the Middle Ear, Deaf -mutism. .... 235 
 
 CHAPTER XV. 
 
 INHERITED SYPHILIS. 
 
 Syphilis does not change in Type during Transmission by Inheritance. The Syphi- 
 litic Foetus. Bone Syphilis in Inherited Disease. Inherited Syphilis in the 
 Infant. Date of Appearance of Symptoms in Inherited Disease. Pemphigus 
 of Inherited Syphilis. The Syphilitic Countenance. Syphilitic and Mercu- 
 rial Teeth. Interstitial Keratitis. General Treatment of Inherited Syphilis. 237 
 
 PART III. 
 
 GONORRHOEA AND ITS COMPLICATIONS. 
 CHAPTER I. 
 
 GONOREHCEA IN THE MALE. 
 
 Definition. True Gonorrhoea is not acquired by Contact of the Urethra with Pua 
 not in itself Gonorrhoeal. Cases illustrating that Urethral Pus does not al- 
 ways produce Gonorrhoea in the Female, nor Vaginal Pus in the Female 
 always Gonorrhoea in the Male. The Causes of Urethral Inflammation. 
 Symptoms of Urethritis in an Unhealthy Urethra not due to the Contact of a
 
 Xll CONTENTS. 
 
 PAGE 
 
 Virulent Pus. Symptoms of Inflammation in a healthy Urethra, due to Con- 
 tact of Gonorrhceal Pus or other Irritating Substance, under Circumstances 
 capable of generating Urethritis. Chordee. Lymphangitis of the Prepuce. 
 Spasmodic Stricture. Breaking the Chordee. Gleet. .... 249 
 
 CHAPTER II. 
 
 TREATMENT OF URETHRAL INFLAMMATION IN THE MALE. 
 
 The Relation of the Physician to his Patient during the Treatment of Urethritis. 
 The Abortive Treatment of Gonorrhoea. Hygienic Treatment ; Medical Treat- 
 ment by Alkaline Diuretics, by Sandal- Wood Oil, by Copaiba (Copaibal Ery- 
 thema), by Cubebs, by Turpentine, by Iron, by Tincture of Cantharides. 
 The Internal Treatment of Gleet. The Use of Injections in Urethritis. 
 How to Inject the Urethra. Dressings for the Penis during Urethritis. 
 Treatment of Chordee. Treatment of Painful Urination. Treatment of Re- 
 tention of Urine in Gonorrhoea. Treatment of Venereal Warts. Treatment 
 of Inflammatory Phimosis. Paraphimosis and its Treatment. . . . 258 
 
 CHAPTER III. 
 
 COMPLICATIONS OF GONORRIKEA IN THE MALE. 
 
 Inflammation of the Follicles of the Urethra. Follicular and Peri-Urethral Ab- 
 scesses. Cowperitis. Inflammation of the Lacuna Magna. Death due to 
 Gonorrhoea. Gonorrhoeal Cystitis. Gonorrhoeal Epididymitis. Sterility fol- 
 lowing Gonorrhoeal Epididymitis. Treatment of Gonorrhoeal Epididymitis, 
 Prophylactic and Curative. The Tobacco Poultice. Strapping the Testicle. 
 Chronic Epididymitis. 275 
 
 CHAPTER IV. 
 
 STRICTURE OF LARGE CALIBRE. 
 
 Stricture of the Male Urethra. Spasmodic Stricture. Examples of this Form of 
 Stricture. Stricture of Large Calibre : Symptoms, Diagnosis, Treatment. 
 Resiliary Strictures of Large Calibre. Internal Urethrotomy in the Pendulous 
 Urethra, the Limit of the Cut, the Result, and the After-treatment. . . 290 
 
 CHAPTER V. 
 
 STRICTURE OF SMALL CALIBRE. 
 
 Symptoms of Tight Organic Stricture; Diagnosis. Expedients for Threading fine 
 Strictures. Treatment of Stricture of Small Calibre. Continuous Dilata- 
 tion. Internal Urethrotomy of the Deep Urethra. Divulsioii. Perineal 
 Section; with a Guide; without a Guide. Urethral Fever and its Treat- 
 ment.
 
 CONTENTS. Xlll 
 
 CHAPTER VI. 
 
 GONORRHO3A IN THE FEMALE. 
 
 PAGB 
 
 Symptoms, Complications, Treatment. Local Treatment. How to wash the Va- 
 gina. Medicated Vaginal Injections. Chronic Urethritis and its Treatment. 
 Chronic Cervicitis. Sterility in Women following Gonorrhoea. . . . 328 
 
 CHAPTER VII. 
 
 COMPLICATIONS OF GONOBBHO3A COMMON TO BOTH SEXES. 
 
 Gonorrhoeal Eheumatism. Time of Occurrence, Cause, Parts most often In- 
 volved. Chronic Hydrarthrosis. The Poly-articular Form. Neuralgia. 
 Bursitis. Nodes. Treatment. Gonorrhoea! Rheumatic Iritis, Conjuncti- 
 vitis, Aquo-capsulitis. Contagious Purulent Ophthalmia : its Symptoms, 
 Course, and Treatment 334
 
 INDEX TO ILLUSTRATIONS. 
 
 PAGE 
 
 FIGURE 1. Tin fumigating table and lamp 123 
 
 " 2. Papular syphilide in the white, 147 
 
 " 3. " " " negro, 149 
 
 " 4. Condylomatous venereal vegetations, 150 
 
 " 5. Superficial ecthyma, 152 
 
 " 6. Pigmentary syphilide, 153 
 
 " 7. Squamous " 155 
 
 " 8. Palmar " 156 
 
 " 9. Plantar " 156 
 
 " 10. General tubercular syphilide, 157 
 
 " 11. Grouped " " 158 
 
 " 12. Rupia, 160 
 
 " 13. Deep ecthyma, 161 
 
 " 14. Ulcerative syphilide, 162 
 
 "15. " " 162 
 
 " 16. Cicatrixof " 163 
 
 " 17. Dactylitis (toe), 176 
 
 " 18. " (finger), 177 
 
 " 19. " result of, 178 
 
 " 20. Syphilitic bursitis, 181 
 
 "21. " " 181 
 
 " 22. Syphilitic countenance, 243 
 
 " 23. Syphilitic teeth, 244 
 
 " 24. Mercurial " 245 
 
 "25. " " 245 
 
 " 26. Urethral syringe, 266 
 
 " 27. Cupped sound 268 
 
 " 38. Cold " . 269 
 
 " 29. Penis suspensory, 270 
 
 " 30. Bulbous bougie, 299 
 
 " 31. TJrethrameter Otis, 300 
 
 " 32. Conical steel sounds, 302 
 
 " 33. Urethrotome Otis, 306 
 
 " 34. Urethral tampon Bates, 309 
 
 " 35. Conical soft bougies, 313 
 
 " 36. Tips of whalebone bougies, ........ 813 
 
 " 37. TJrethrotome Maisonneuve, . . 316 
 
 " 38. Americanized Thompson's divulsor, 317 
 
 " 39. Olivary conical bougie, 318 
 
 " 40. Lithotomy tampon Guyon, 319 
 
 " 41. Catheter guide Gouley, . 319
 
 THE VENEREAL DISEASES, 
 
 PARTI. 
 
 CHAPTER I. 
 
 CHANCROID. 
 
 THE NON-SYPHILITIC VENEREAL ULCEB. 
 
 Chancroid. Definition. General Description of Typical Clinical Chancroid. The 
 Nature of the Chancroidal Poison. Answers to the Objections made to the Ex- 
 istence of any Special Chancroidal Virus, and Discussion of the Alleged Cases of 
 Chancroid purporting to have been produced by the Inoculation of Pus not de- 
 rived from a Chancroid. Is the Poison of Chancroid a Modified Syphilitic Virus ? 
 Unity and Duality in Syphilis. Twelve Propositions setting forth Facts rela- 
 tive to the Question of Duality, and believed to be sustained by Facts, Experi- 
 mental and Clinical, now before the Profession, 
 
 Definition. Chancroid is a virulent ulcer. It is local and never the 
 starting-point of syphilis. It is always due to contact of the surface in- 
 volved with pus derived from a similar ulcer, and its own secretions are 
 freely auto-inoculable. 
 
 These characters are cardinal and uniform. Clinically, a chancroid 
 does not exist which does not fulfil each of these conditions. A number 
 of objective features, which will be detailed later, stamp chancroid with 
 an especial clinical individuality in typical cases, but each of these latter 
 special features is subject to variation : the incubation ; the softness of 
 the base; the appearance of the edges and of the surface; the quality of 
 the secretion, and the subjective symptoms also, in a given case, all may 
 differ from those found in the typical chancroid, without disconcerting 
 the clinical observer. If, however, a chancroid could be due to anything 
 excepting the inoculation of chancroidal pus if its own pus could fail to 
 take, when inoculated for the first time, upon the clinical bearer of the 
 sore if chancroid derived from a chancroid could once be shown to be 
 the starting-point of true syphilis then the labors of Bassereau, Clerc, 
 Fournier, and a host of others have been in vain, and the profession is 
 plunged again into that obscurity regarding venereal disease which ob- 
 tained in the days of Hunter, and only yielded in the present century 
 to the campaign inaugurated against it by Ricord. 
 1
 
 THE VENEKEAL DISEASES. 
 
 The question of one or two poisons in syphilis will be discussed later. 
 Non-syphilitic chancroid first claims a detailed description. 
 
 GENERAL DESCRIPTION OF A TYPICAL CHANCROID AS IT IS CUSTOMARY TO 
 ENCOUNTER IT CLINICALLY. 
 
 A typical chancroid, unirritated and uncomplicated, is a rounded ulcer. 
 In a furrow it is oval, large or small, single or multiple, simple or com- 
 posed of several ulcers which have run together; its general physical 
 characters are as constant as are those of any classical cutaneous lesion 
 as constant, for instance, as are the physical characters of vaccinia. A 
 faint pink areola surrounds a chancroid. Its edges are abrupt, sharply 
 cut at right angles to the surface (not sloping away), very often slightly 
 undermined, because the superficial integument resists the advance of 
 the spreading ulcer a little longer than the less dense underlying struc- 
 tures. The bottom of the ulcer is either pallid, with pink granulations, 
 bathed in thick pus, or, more often, pultaceous, yellow, looking like dirty 
 cream; and this surface, composed of sloughy structures, permeated with 
 pus, is adherent, and blood flows on any attempt at its removal. The 
 structures all around and those underlying this ulcer are perfectly nor- 
 mal, soft, and flexible. The base of the ulcer can be easily lifted up from 
 the tissues beneath, and when rolled between the thumb and finger pre- 
 sents no rigidity. 
 
 Such an ulcer does not cause pain. Its bearer may be unconscious of 
 its existence, excepting that he sees it. The pus is creamy and freely 
 secreted from the ulcerated surface, and contains the broken-down de- 
 tritus of the anatomical elements which have been involved in the pro- 
 gressive march of the destructive ulcer. 
 
 Such is the simple clinical chancroid as seen in a typical case. Many 
 complications, however, may attend it and subject its appearance to cor- 
 responding variation. The more it differs from the type, the less possi- 
 ble is it for the surgeon to be positive in his diagnosis of its character. 
 Nothing is more capable of correct diagnosis by mere inspection than 
 typical chancroid; complicated chancroid may confound the astuteness of 
 the closest differential diagnostician. 
 
 It is therefore of the first importance, in commencing the study of 
 venereal disease, to comprehend what a chancroid is and to what varia- 
 tions it is liable, especially in these modern days when every ulcer pro- 
 duced by inoculation finds some sturdy advocate ready to proclaim it a 
 chancroid. 
 
 An attempt to trace the history of chancroid has given occasion for 
 the display of much erudition. No author has been more painstaking in 
 this direction than Bassereau, 1 who brings out evidence from the writings 
 of ancient Greek, Latin and Arabian surgeons, which establishes the pre- 
 sumption that contagious venereal ulcers have existed from all time; and 
 that some at least of these ulcers were chancroidal, it is hardly reasona- 
 ble to doubt. Such discussions, however, have no place in a text-book 
 dealing only with the practical aspect of the question. 
 
 The nature of the poison of chancroid is unknown. Different ob- 
 servers (Donne, Didier, Salisbury) have described varying parasites as 
 
 1 Traite des affections de la peau symptomatiques de la syphilis. Paris, 1852, p 
 217 et seq.
 
 CHANCROID. 3 
 
 the essential cause of chancroid; but no convincing demonstration has 
 been given to the profession of the truth of any theory, and the world is 
 to-day as ignorant of the nature of the essential poison of chancroid as 
 it is of the nature of the poison of syphilis or of scarlet fever. There is 
 a growing tendency in the profession, particularly noticeable of late 
 years, to disclaim the existence of any poisonous quality in chancroidal 
 pus. Such well-known authors as Hutchinson of London, Baumler of 
 Freiburg, and Bumstead of New York, have held this view. The latter, 
 in a very able article read in Philadelphia, 1876, before the International 
 Medical Congress, claims that the inoculation of the products of simple 
 inflammation may produce a chancroid upon persons who are syphilitic or 
 much debilitated. 
 
 But why an ulcer, let it resemble a chancroid perfectly why such an 
 ulcer produced upon a person in a pyogenic condition by the inoculation 
 of indifferent inflammatory pus, should be called a chancroid, even although 
 the pus be repeatedly auto-inoculable in generations, it is difficult to un- 
 derstand. Surely a pustule of acne is not a chancroid. If it were a 
 chancroid it would spread peripherally and behave like that classic ulcer. 
 The auto-inoculability in generations, of pus derived from a pustule of 
 acne, confirms the well-known conclusions of Von Roosbroeck, that all 
 pus is more or less irritating, more or less contagious. Many individuals 
 in poor health notoriously "fester" when they are scratched, without re- 
 quiring the inoculation of any substance to produce a suppurating sore. 
 The violence done to the skin shows up the quality of the latter, and it is 
 the pus-forming tendency which develops the ulcer upon a patient whose 
 integument may be subjected to violence of a mechanical or of a chemi- 
 cal sort, and not necessarily any poison introduced from without. 
 
 If chancroid could be produced de novo by the inoculation of ordinary 
 pus upon syphilitic and cachectic persons, the number of chancroids clin- 
 ically observed upon respectable people, syphilitic and cachectic, would 
 be vastly greater than it is. Balanitis (from tight prepuce), suppura- 
 ting herpes progenitalis, gonorrhoea, and suppurative leucorrhcea in the 
 female, are very common in such patients, but chancroid is exceedingly 
 rare among respectable people, and does not occur (so far as the writer 
 knows) clinically, excepting under circumstances which allow an opportu- 
 nity for contagion, direct or indirect, with the secretion of a similar ulcer. 
 
 The experiments of Pick, Koebner, Kaposi, Kraus, Reder, Lee, Bid- 
 enkap, Morgan, Wigglesworth, Von Roosbroeck and others, demonstrate 
 that all sorts of irritating secretions may produce ulcers and auto-inocu- 
 lable ulcers; but no one has shown that the minute prick of a pin dipped 
 in such pus will produce an ulcer yielding a chancroidal bubo the virulent, 
 not the simple suppurating bubo. No one has produced a typical chan- 
 croidal ulcer by inoculating from a half-glass of water in which one drop 
 of simple inflammatory pus had been placed as did Puche with a drop 
 of chancroidal pus. And Boeck, the sturdy advocate of syphilization, 
 would certainly not have gone to the trouble of collecting chancroidal 
 pus in the hospitals of Christiania to send into the surrounding country 
 for the purpose of syphilization, if ordinary pus would have done as well. 
 Boeck himself stated that chancroidal pus would yield positive results to 
 inoculation even when diluted with eleven hundred parts of ordinary 
 pus. 
 
 Some years since, at the Charity Hospital, I endeavored to produce 
 cutaneous ulcers by inoculation of indifferent patients with indifferent 
 pus, but the experiments were not long continued, for, although some
 
 4 THE VENEREAL DISEASES. 
 
 pustules were obtained, nothing resembling the rapidly spreading destruc- 
 tive chancroid appeared. 
 
 Tarnowsky, an excellent and competent observer, declares ' as deduc- 
 tions from a number of experiments, that the sores produced upon syphi- 
 litic persons by Bidenkap, Reder, and Koebner, are distinguishable by their 
 form, course, absence of bubo, and results, from true chancroid, and are 
 only the characteristic effects of the irritation of the skin in syphilitics. 
 He believes that any irritant, if strong enough, will produce like results. 
 He states that inoculation from these sores upon healthy subjects may 
 produce syphilis, but not chancroid. 
 
 Zarewicz " of Krakau inoculated syphilitic products upon syphilitics. 
 Pus was taken from the lesions so produced (without admixture of blood) 
 and inoculated upon healthy persons, always with negative results, while 
 the same pus yielded positive results when inoculated upon syphilitic 
 persons. This proves that the lesion was not a chancroid and was not 
 syphilis, but simply that irritating pus could be positively inoculated upon 
 syphilitic persons, while the same inoculations were negative upon healthy 
 persons. 
 
 On the other hand, a claim has been made by Bidenkap and Gjor 
 (quoted by Bumstead), that five patients, not themselves syphilitic, 
 inoculated themselves from sores produced by inoculation of the pro- 
 ducts of an irritated syphilitic chancre upon syphilitic patients, and that 
 while the inoculated ulcers took (like chancroids) upon these healthy 
 persons, only one of them became syphilitic, and in that case syphilis was 
 doubtful. 
 
 Only one of these cases is important, and that one at first sight seems 
 convincing. It is described by Bidenkap, and originally appeared in the 
 Wiener Med. Wchnschrft. of 1865 (No. 34). 
 
 A young woman, free from syphilis (in the hospital on account of ure- 
 thral and vaginal suppuration), inoculated herself with a needle through 
 curiosity, from ulcers which Bidenkap had produced upon a syphilic pa- 
 tient by first taking pus from an irritated syphilitic chancre and reinocula- 
 ting i* through many generations. An ulcer lasting two months and pro- 
 ducing another by spontaneous inoculation was the result upon the young 
 woman but no syphilis. Eighteen months later she acquired syphilis in 
 the usual way. 
 
 The facts in this case may be explained as follows: whatever syphilitic 
 poison taken from the chancre was inoculated upon the syphilitic patient 
 from whom the young woman got her pus, died out, since syphilitic virus 
 does not propagate itself by auto-inoculation. Acrid pus, auto-inoculable 
 in generations, only was left behind, and this the young woman used, not 
 getting any blood, and therefore avoiding contamination of the pus she 
 used with any of the true poison of syphilis. Had the true poison of 
 syphilis been inoculated she must have had chancre, which she did not 
 have; not having chancre, did she have chancroid? There is nothing in 
 the case to show that the syphilis of the patient furnishing the pus was 
 active at the time the pus was taken by the young woman, and there is 
 nothing to show that other irritating pus, such as that found in simple 
 ecthyma, or in scabies, might not have also taken upon the young woman, 
 if properly inoculated, and have produced an indolent ulcer, itself auto- 
 
 : Vrfcljahresschrift. f. Derm. u. Syph. I. and II. 1877. 
 
 s Prom a review by Ettinger : Jahresbericht ueber die Liestungen und Fortschritte 
 in der Gesmtn. Med. II. , ii. . 1878, p. 529.
 
 CHANCROID. 
 
 inoculable. She had a suppurating urethritis and vaginitis, and her posi- 
 tion in the pyogenic scale was probably high. 
 
 There is no law which compels all the pathological secretions upon a 
 person who is syphilitic to carry with them any portion of the true syphi- 
 litic virus by necessity. 
 
 On the contrary, if not admixed with blood, such secretions are not 
 poisonous in a syphilitic way. It is notorious that a chancroid upon a 
 syphilitic patient may clinically even reproduce either chancroid alone or 
 mixed chancre followed by syphilis. In the latter case doubtless some 
 blood gets inoculated with the chancroidal pus. This case, therefore, de- 
 monstrates nothing. 
 
 Conflicting evidence of this sort demands great consideration and care 
 before deductions can be drawn from it. Extensive experimentations 
 from syphilitics to non-syphilitics is not justifiable, and voluntary experi- 
 ments made by patients who declare themselves free from syphilis must 
 be received with great caution. 
 
 Clinically, however, there is certainly no question that chancroid is 
 derived (for practical purposes) always from contact of the part involved 
 with the secretions of a chancroid. Inflammatory products are not known 
 clinically to produce chancroids upon healthy people, and it is begging 
 the question to claim that they do so, simply because an ulcer may be 
 produced upon a syphilitic or upon an unhealthy person by inoculating 
 him with indifferent pus. 
 
 It is well known that the pus of impetigo is not contagious clinically 
 upon being ordinarily handled; yet who is unfamiliar with the fact that 
 an impetiginous child (or adult) is apt to have a prompt outcrop of pus- 
 tules upon any part overlying another part which is secreting pus, and to 
 get pustules readily upon spots where such pus has been deposited by 
 the nails ? Yet certainly these facts do not militate against the non-con- 
 tagious clinical quality (for others) of the pus of impetigo. 
 
 The inoculable quality of true chancroidal pus is a free, frank, 
 virulent, rapid inoculability. Such pus takes at once, upon the per- 
 son bearing the sore, in an unmistakable manner. The healthiest by- 
 stander may be made the subject of successful experiment an experi- 
 ment always successful unless the capacity of the skin to produce pus 
 has been overcome by prolonged inoculations, as in syphilization. The 
 incautious surgeon with a fissure on his finger learns the virulent inocu- 
 lability of chancroidal pus to his sorrow, and he afterward handles a sus- 
 pected case with the utmost circumspection, while he thrusts the same 
 cracked finger into the cavity of an abscess full of pus without taking the 
 least precaution or experiencing any evil result. For the successful he- 
 tero- or auto-inoculation of the clinical chancroid, no syphilis of the sub- 
 ject inoculated is necessary to secure a take, and no cachexia. 
 
 Is there then no difference between the pus of chancroid and that of 
 ordinary ulcerative inflammation ? Assuredly there is. And what is 
 this difference? Certainly we do not know what it is, but we know that 
 it is a virulent quality, and we call it a virus, a poison, not distinguish- 
 able in the pus by any microscopical or chemical quality yet described, 
 not due to any parasite yet discovered, but none the less a virus than the 
 virus of the rattlesnake a virus also imponderable and intangible by any 
 of the tests known to science. By its fruits it is known, by its effects its 
 qualities are disclosed. 
 
 Is the poison of chancroid a modified syphilitic poison? 
 There is not one fact to prove it. It behaves differently in all respects.
 
 6 THE VENEREAL DISEASES. 
 
 A true chancroid certainly cannot produce syphilis, and if syphilis can 
 produce something resembling chancroid, even yet identity is not estab- 
 lished unless the compliment can be returned, and this has never been 
 proved to be the case. Lindmann's 2,700 inoculations upon himself did 
 not exhaust his power of still producing successful chancroids upon his 
 own person. This does not resemble anything known of syphilis. Long 
 before reaching this number, believing himself protected by his inocula- 
 tions (on account of the doctrines of syphilization), he inoculated himself 
 once with matter taken from the tonsils of a friend who had syphilis. 
 This inoculation also took, and after forty-five days a syphilitic eruption 
 appeared. The doctor then resumed his chancroidal inoculations, but 
 with less faith than before in the protective value of syphilization. 
 
 Warnery of Lausanne, and Danielssen's case, are also classical examples 
 of the lack of similarity between chancroid and syphilis. The former, 
 after frequently inoculating himself with chancroid and getting only local 
 ulcers, finally used the secretion from a syphilitic chancre once, and gen- 
 eral syphilis ensued. Danielssen produced chancroids upon a patient 
 two hundred and eighty-seven times, until the pus-forming capacity of 
 the skin had been temporarily exhausted and chancroidal pus failed any 
 longer to yield positive results. Then the discharge from a syphilitic 
 chancre was used, and syphilis resulted. Meantime the suppurative ca- 
 pacity of the skin had returned on account of the rest allowed to it, and a 
 new inoculation of chancroids was instituted. These took, and the patient, 
 whose original disease was Norwegian leprosy, was again "syphilized" 
 to his own satisfaction, doubtless, certainly to that of Danielssen. The 
 case originally was reported in the Deutsche Klinik for 1858, p. 322. It 
 has since been quoted everywhere, and has done much to shake the faith 
 of the advocates of syphilization in the value of that proceeding as a 
 prophylactic. 
 
 These few cases place it beyond question that the poison of true 
 syphilis is not contained in chancroidal pus. None of the cases would 
 have existed excepting for the pleasing fiction of Auzias Turenne, which 
 he termed syphilization, and which at one time had many adherents in 
 the profession in different parts of Europe. Syphilization the repeated 
 inoculation of chancroidal pus upon an individual until the skin failed 
 any longer to respond to the irritation, and chancroids could no longer be 
 produced upon inoculating chancroidal pus this syphilization was pro- 
 posed as a means to be generally adopted for the purpose of furbishing 
 immunity to the poison of true syphilis. How little immunity was fur- 
 nished is shown by the cases described above. 
 
 Two points then seem to be clear: (1) chancroid pus is more freely 
 inoculable than pus derived from any other source; it will take in a char- 
 acteristic manner upon a healthy person as well as upon one who is syph- 
 ilitic or cachectic ; and (2) the poison of true syphilis is not contained in 
 chancroidal pus. 
 
 If now these two points have been demonstrated, what is it that con- 
 stitutes the virulence of chancroid and makes its pus more irritating than 
 pus derived from other sources ? There is but one reasonable reply to 
 this question, namely: there is a poison, a virus in chancroidal pus, pecu- 
 liar to itself, not capable of being generated de novo, not syphilitic in 
 nature, but sui generis, an entity in itself. We do not know what this 
 poison is, but by its effects its existence may be claimed. The advocates 
 of the simple inflammatory nature of the ulcer have failed to furnish con- 
 vincing demonstration of their claims even scientifically, while clinically
 
 CHANCROID. 7 
 
 no confrontation and no single sporadic case has been reported (so far as 
 the writer knows) showing that a typical clinical chancroid has originated 
 de novo. 
 
 The poison of chancroid not being the poison of true syphilis, is it a 
 modification of that poison ? 
 
 This position is very stoutly maintained by a respectable minority in 
 the profession, the notion being that the syphilitic poison, when nearly 
 exhausted in virulence, may produce a chancroid, or that secretions of or- 
 dinary ulcers upon syphilitic subjects become capable of auto- inoculation, 
 and that the hetero-inoculation of such secretions produces chancroids. 
 This reduces chancroid to the condition of a bastard ; but even if this 
 state of affairs could be absolutely proved, it would be unwise clinically 
 to admit of any relationship between chancroid and syphilis. A theoret- 
 ical relationship, while seemingly facilitating diagnosis and leading to 
 that grateful sense of accurate knowledge so agreeable to the searcher 
 after truth, is certain to add still further to the existing confusion in diag- 
 nosis and hopelessly to confound all intelligence in therapeutics. 
 
 The conservative position now held by the majority of writers upon 
 syphilis is undoubtedly the safest one. It is this: syphilis is a blood dis- 
 ease, and chancre is its first symptom. Chancroid is a local ulcer and is 
 not associated with any poisoning of the blood or productive of it. A 
 conviction of the truth of these statements is the only safe guide to ther- 
 apeutics. It spares the physician much confusion and many a patient 
 years of unnecessary anxiety. 
 
 Practically, the doctrine is productive of much comfort, leaving very 
 little room for annoyance to either physician or patient, and this annoy- 
 ance only that of differential diagnosis of the primary lesion in difficult 
 cases. This latter difficulty is always removed by observation during a 
 few weeks, the loss of which is not material should the malady in the end 
 prove to be syphilis. 
 
 Unity and duality in syphilis. The foregoing consideration of 
 the nature of the chancroidal virus leads so directly to the question of 
 unity or duality in syphilis that a few words upon this subject will be 
 more appropriate in this context than in its more natural position under 
 the head of syphilis. The detail of the battles that have been fought over 
 this question, with the array of cases on either side, is a wearisome matter. 
 A full consideration of the long series of articles written upon it would 
 take more space than this volume can afford, and would be flat and unpro- 
 fitable to the general reader. An excellent array of the cases and argu- 
 ments is presented by Baumler in Ziemssen's Cyclopedia. 
 
 A resume of the points which seem to be established at the present 
 date is all that is appropriate here. 
 
 When syphilis first began to be written about, after the outbreak at the 
 end of the fifteenth century, when it went under the name (generally) of 
 the French disease, it was uniformly recognized as a new malady. It was 
 not confounded with other venereal maladies known at that date, but was 
 uniformly described as a morbus novus, inauditus, incognitus, etc. The 
 writers who described it gave vent to their surprise in their words, and 
 were unanimous in that expression. As Bassereau puts it: "There was 
 one point upon which there was not the least difference of opinion be- 
 tween them; upon which the oldest, the youngest, the wisest and the most 
 ignorant were of unanimous accord, namely : that none of them had ever 
 observed anything analogous or similar to the French disease before the 
 arrival of Charles VIII. in Italy."
 
 8 THE VENEREAL DISEASES. 
 
 Soon, however, writers began to compare the new disease with other 
 venereal maladies, and finally, in 1551, Musa Brassavole united all the 
 diseases together and included them in the history of syphilis. 
 
 From that time, the end of the sixteenth until the present century, 
 the doctrine of syphilis was almost uniformly that of unity. Gonorrhoea, 
 all sorts of vegetations and all varieties of local ulcers, were, along with 
 the expressions of true syphilis, considered to be evidences of the action 
 of some internal blood-poison, some humor. In England, the powerful 
 brain of Hunter unfortunately fell into the wrong track in its interpreta- 
 tion of facts. Hunter had inoculated himself from an urethral discharge 
 and got syphilitic chancre at the spot inoculated. His own case was 
 published to the world; no one had thought of such a thing as an urethral 
 chancre, and the identity of gonorrhoea and syphilis seemed to be estab- 
 lished. Thousands of simple cases of gonorrhoea were salivated on ac- 
 count of this error, strengthened and sustained as it was by Hunter's 
 unfortunate experience. 
 
 Ricord, in Paris, in translating Hunter's writings and making his own 
 clinical observations, soon decided that gonorrhoea and syphilis were very 
 different maladies, and he first clearly demonstrated the difference be- 
 tween them. This, indeed, is his greatest achievement. 
 
 Ricord also, by a close study of the primary lesion, detected differences 
 in their physical characters, and noticed that some sores on the penis ac- 
 quired in sexual contact were followed by evidences of general syphilis, 
 while others were not. He did not clearly at first make out a difference in 
 the originating cause of these ulcers, although he intimated it. He stated 
 that all chancres were not alike: that some of them took on induration, 
 while others did not; that those which became indurated were followed 
 by general symptoms and called for general treatment, while those which 
 remained soft were injured by mercury, did not call for anything except 
 local treatment, and did not poison the blood. 
 
 In a thesis by Prieur, 1 Paris, 1851, even in his Lettres sur la syphilis, 
 1850, Ricord put out the first ideas of dualism in the syphilitic doctrine, 
 intimating in the latter treatise, in regard to syphilization, that perhaps 
 the induration in some chancres and its absence in others was due to a 
 difference in cause, and, in the thesis, stating that in his experience the 
 transmission of non-indurated chancre to healthy subjects always pro- 
 duced its like, while indurated chancre always recognized a similar lesion 
 as its point of origin. 
 
 In 1852, Leon Bassereau, by a review of laborious confrontations, es- 
 tablished the individuality of chancroid, and made it evident to the world 
 that venereal ulcers belonged to two distinct families, the one non-indu- 
 rated and local, the other indurated and followed by syphilis. 
 
 This is the doctrine of dualism. Clerc, following Bassereau, strength- 
 ened it. Ricord approved it formally in 1858, and gave it widespread 
 circulation by the weight of the influence his high authority in venereal 
 disease allowed him to exercise. Ricord had dissented from this view at 
 first, but upon his adoption of it the adherents to the doctrine of unity of 
 the syphilitic poison, i. e., similarity of cause in the production both of 
 the indurated and the non-indurated sore, received a blow from which 
 they have never recovered. 
 
 Long years before this time inoculations had been practised both 
 auto- and hetero-inoculation. Hunter had established experimentally that 
 
 1 Quelques questions sur la syphilis.
 
 CHANCROID. 9 
 
 indurated chancre was not inoculable upon its bearer or upon another 
 person already syphilitic, and syphilization had been practised since its 
 discovery by Auzias Turenne in 1844, the pus being taken from non-indu- 
 rated sores. Yet, in spite of a general knowledge of these facts, they 
 were not correctly appreciated until the labors of Bassereau translated 
 them and demonstrated dualism to the world. 
 
 Matters went smoothly enough for a time. The term dualism, how- 
 ever, was an unfortunate one. Its advocates did not mean precisely that 
 there were two poisons in syphilis. On the contrary, they were unicists 
 and believed that there was one and only one syphilis, and another distinct 
 virulent disease, known under different names, but best recognized in this 
 country by Clerc's denomination chancroid. 
 
 The dualists became over-confident in the strength of their new posi- 
 tion and began to make very bold assertions, allowing but little or no 
 chance for exceptions. 
 
 The Hunterian chancre was spoken of a great deal, but it has turned 
 out that this is one of the rather rare initial lesions of syphilis, the indu- 
 rated erosion being more uniformly the point of entrance of the disease. 
 Soft chancre and hard chancre came to indicate necessarily in the minds 
 of many (as they still unfortunately do), the one a local non-syphilitic 
 ulcer, the other always the point of entrance of syphilis. A final misfor- 
 tune was the adoption of the tenet that a soft sore could be always auto- 
 inoculated and a hard sore never, implying that anything which could be 
 auto-inoculated was a chancroid. Then, that syphilis could only be due 
 to infection by a hard chancre, etc., until the advocates of so-called dual- 
 ism had so weakened their position by positive statements that their ene- 
 mies threatened the integrity of the entire structure by picking flaws in 
 every portion of the too confident argument. 
 
 It turns out now that competent observers are ready to testify on all 
 sides that they see syphilis succeeding local ulcers which are not indurated. 
 Cases are bountifully adduced to show that all sorts of purulent secretions 
 are more or less inoculable, according to the quality of the secretion and 
 the nature of the individual. Other cases show that, after repeated inocu- 
 lation, chancroidal pus at last fails to take. Syphilitic chancres may be 
 auto-inoculated, and such pus reinoculated may finally produce an auto- 
 inoculable pus which does not necessarily contain the syphilitic poison. 
 Many of the later lesions of syphilis are auto-inoculable. The auto-inocu- 
 lation of syphilitic chancre may produce an abortive pustule, or a papule, 
 or nothing. Syphilis may be acquired twice by the same individual. 
 Finally, a chancre may be first soft, later hard, and be followed by syphilis; 
 and again, a chancroid may be exceedingly hard and yet not at all followed 
 by syphilis. 
 
 Cases have been adduced in support of all these facts, and still others 
 to show that syphilitic chancre may follow inoculation of blood, or of 
 secretions of secondary lesions, while phagedsena and suppurating bubo 
 are shown to be not at all the prerogatives of chancroid. 
 
 In face of all these facts what justification can the doctrine of two 
 poisons find the doctrine, call it unity or duality which claims that 
 chancroid is one disease due always and only to inoculation of chancroidal 
 pus, and syphilis another disease due always and only to contamination 
 with the syphilitic virus, directly by the individual, or indirectly by in- 
 heritance ? 
 
 In order to explain away these exceptional cases in so far as they 
 threaten the above doctrine, without detailing all the cases, it will be ex-
 
 10 THE VENEREAL DISEASES. 
 
 pedient to note the deviations from the rules formerly considered absolute, 
 and to accompany each by its explanation. Cases need to be referred to 
 by name only. They are most of them well known, and have been so gen- 
 erally quoted and requoted in the different books written upon syphilitic 
 subjects that the student can easily find them. This bird's-eye view will 
 give a more comprehensive general understanding of the condition of the 
 subject at the present day than any other which could be crowded into 
 the space at hand. The following twelve propositions rest upon such 
 positive proof that they can hardly fail to be accepted. 
 
 1. Chancroid upon a non-syphilitic patient is easy to com- 
 municate to any one, but in no such case among millions ob- 
 served has the inoculation been followed by syphilis. This bul- 
 wark of dualism has received no blow. It is as firm to-day as it was in 
 the time of Bassereau's investigations. 
 
 2. A non-indurated ulcer may be the starting-point of syph- 
 ilis. Every surgeon of large experience sees this. It has been espe- 
 cially noticed in the female that the syphilitic chancre often remains 
 soft, and the occurrence upon the male of a soft syphilitic chancre is not 
 so infrequent as to be phenomenal. But, induration is only one feature 
 of syphilitic chancre a very common one undoubtedly, nearly constant; 
 but the primary syphilitic lesion may exist without it. Scarlet fever 
 without the rash is none the less scarlet fever. The so-called black 
 measles (without a single pustule) is now known to be suppressed malig- 
 nant small-pox in many cases, and it is none the less small-pox because 
 the characteristic pustule is absent. If the other features of the chancre 
 accord with the type, and syphilis follows, and the chancre has originated 
 from contact with syphilitic poison, assuredly it is not a chancroid simply 
 because it is soft. It requires more than one symptom to make a disease. 
 A phagedenic syphilitic chancre is customarily non-indurated. 
 
 3. A chancroid may be indurated and not be followed by 
 syphilis. A hard chancroid is much more common clinically than a 
 soft syphilitic chancre. The induration of chancroid, however, is inflam- 
 matory and not specific, and it is generally as easy to distinguish this in- 
 flammatory hardness from the induration of syphilis as it is to tell moon- 
 light from sunlight. There are cases, however, in which it is impossible 
 to make a diagnosis, if the induration alone is relied upon. 1 In such 
 cases the prudent surgeon reserves his judgment until other signs have 
 come to make a diagnosis for him. There are other symptoms of chan- 
 croid far more distinctive than the lack of hardness. A hard ulcer is by 
 no means simply on that account a syphilitic sore. 
 
 4. Hunterian chancre so-called has come with many to sig- 
 nify syphilitic chancre. The truth is, that Hunterian chancre is 
 only one of the varieties of initial lesion. Other forms of the pri- 
 mary lesion are just as characteristic and just as syphilitic as Hunterian 
 chancre, and one of the lesions is much more common, namely, the in- 
 durated erosion not an ulcer at all. 
 
 5. A chancroid is not indefinitely auto-inoculabie. The capa- 
 bility of the skin to furnish ulcers upon local irritation of the proper sort 
 has its limit. The early investigators were too positive in their state- 
 
 1 Such cases have been on several occasions brought before the New York Dermato- 
 logical Society, a society reasonably expert in such matters, and have given rise to 
 hot discussion, and sometimes to nearly an equal division of opinion among the mem- 
 bers of that body, as to their probable syphilitic or non-syphilitic character.
 
 CHANCROID. 11 
 
 ments ?bout chancroidal pus. Truly it is very virulent. A patient in high 
 fever 1 will take it; cancer, leprosy, syphilis, a previous chancroid, none 
 of these prevent a take if chancroidal pus is properly inoculated. The 
 syphilizers of Norway, however, following Auzias Turenne, have clearly 
 demonstrated that the skin may be worn out in its capacity of responding 
 to the repeated inoculation of chancroidal (or other pus). The same 
 thing has been found to happen when the integument is kept long sup- 
 purating by other irritants as by tartar emetic. After a period of rest 
 the skin will again respond upon inoculation, and the patient may be again 
 repeatedly inoculated until again the inoculation will no longer take. 
 
 These facts would seem strange did we not have analogies in common 
 life. People who handle bees at first become poisoned when stung, and 
 the wounded parts swell and inflame considerably. After a time, how- 
 ever, the stinging fails to produce any more local disturbance, and the 
 sharp feeling, at the moment of being stung, is the only discomfort ex- 
 perienced. After a long interval, during which no bees are handled, the 
 sting again produces inflammatory trouble.* In some individuals the 
 same remarks apply to the bite of the mosquito. 
 
 Inability of the skin to produce pus upon inoculation does not, as the 
 syphilizers have hoped, prevent it from absorbing the poison of true 
 syphilis at once, as shown by Lindmann upon himself, and in Danielssen's 
 case. The value of these cases to dualism is hard to over-estimate. 
 
 6. Pus, not ehancroidal and not syphilitic, may be inocu- 
 lated in generations, as it is called, may produce a series of auto-in- 
 oculable ulcers upon the same individual, the pus of the last ulcer being 
 used to start the next one (Pick, Lee, Wigglesworth, Kraus, Reder, L. 
 Vidal, Kaposi, Bidenkap, and others.) 
 
 Here again the enemies of dualism take advantage of the assertions 
 of over-confident men, and endeavor to break down a very practical doc- 
 trine by a successful attack upon one of the outposts. But, although 
 chancroid is an auto-inoculable ulcer, an auto-inoculable ulcer is by no 
 means necessarily a chancroid. Impetigo and eczema produce suppura- 
 tion by auto-inoculation of overlying integument sometimes and are 
 not on this account chancroids. All sorts of pus have been successfully 
 used for this purpose, with the effect of demonstrating that some pus 
 takes much more easily than other pus. 
 
 A great difference also is found in individuals : some take easily, 
 some with difficulty, some not at all. Syphilitic persons and cachectic 
 persons form the best subjects for inoculation. It is well known that 
 some persons fester easily upon local injury, others with difficulty. A 
 patient with cachectic ecthyma may be scratched with a clean pin and 
 the spot v/iay suppurate. It is well known that where the skin of such 
 patients is subjected to injury, pus is very apt to be formed. The more 
 or less irritating and contagious quality of all pus is getting to be a doc- 
 trine quite generally recognized by those who study inflammation. 
 
 After the inoculation of indifferent pus an ulcer has not been shown 
 to be produced yielding a virulent bubo or giving pus so freely hetero-in- 
 oculable as chancroidal pus. The latter will take as brilliantly, when ap- 
 plied for the first time, upon the healthiest tiller of the soil, as upon the 
 most cachectic inmate of a hospital. 
 
 1 Keyes (Van Buren and Keyes) : Genito-urinary Diseases, with Syphilis. New- 
 York, 1874, p. 478, note. 
 
 2 These facts were communicated to me by a gentleman who raises bees.
 
 12 THE VENEREAL DISEASES. 
 
 7. A syphilitic chancre may be auto-inoculated, producing 
 an abortive pustule, an auto-inoculable ulcer, or, after a time, a 
 papule. (Bidenkap, Boeck, and many others.) 
 
 Generally, the old rule holds good, and the auto-inoculation of syphi- 
 litic chancre is negative in its result, This rule, however, has many ex- 
 ceptions. The syphilizers and Henry Lee have abundantly proved that 
 almost any syphilitic chancre may be rendered freely auto-inoculable by 
 rubbing it with savin ointment, or putting tartar emetic on it, or running 
 a seton through its base in short, by rendering its suppuration abundant 
 and creamy. Here it is evidently the pus which is the irritating agent, 
 and not the secretion of the chancre. The syphilitic chancre of pure 
 type does not suppurate at all, and the inoculation of its serous discharge 
 does not produce an auto-inoculable ulcer. It may give rise to an abor- 
 tive pustule, as may any local traumatism in some patients; but in the 
 vast majority of trials failure will be absolute. 
 
 There is nothing strange, again, in the fact that such chancres worried 
 into suppuration become auto-inoculable, since the pus of scabies, the pus 
 of ecthyma, have the same effect, not only upon syphilitics, but upon some 
 non-syphilitics. And finally, the occasional production of a hard non- 
 suppurating papule by auto-inoculation from a syphilitic chancre is not 
 very strange. If the inoculation be practised very early, before the body 
 is saturated with syphilitic poison, another chancre is the result. Just as 
 multiple primary inoculation to any extent upon a healthy person will 
 produce as many chancres as may be desired. The same fact is noted 
 clinically in cases of multiple syphilitic chancre. 
 
 Later on the papule, or the papular or pustular eruption produced by 
 auto-inoculation of syphilitic chancre, is simply a local lesion, a local ex- 
 pression of syphilis called out upon the skin by a traumatism. It is well 
 known that a blister upon a patient with latent syphilis may call out an 
 eruption. Vaccination may do the same thing. I have frequently seen 
 local prolonged pressure in a syphilitic case produce a local papule (e. (/., 
 from the shoe about the ankle). I have seen the wearing of an indiffer- 
 ent plaster upon the skin call out papules. A wound will sometimes do it. 
 The irritation of tobacco notoriously produces mouth-lesions in syphilitic 
 cases, as does the irritation of a broken tooth. Lack of cleanliness about 
 the anus and the genitals is a fertile cause of condylomata and mucous 
 patches. If then all sorts of irritants acting locally, mechanical and chem- 
 ical, upon syphilitics, can produce lesions, why may not the scratch of a 
 lancet, or the inoculation of the poison of syphilis, as contained in the dis- 
 charge of the primary lesion, do as well. 
 
 8. A syphilitic chancre, by hetero-inoculation upon a healthy 
 subject, may produce nothing 1 , or an abortive pustule not fol- 
 lowed by syphilis. Possibly it may produce an ulcer itself auto-inocula- 
 ble, which gets well and is succeeded by an indurated ulcer after incubation 
 followed by syphilis. This occurred in Danielssen's case. The explanation is 
 simple. The patient was in a pus-forming condition. Any pus would have 
 done as well as the pus from the irritated chancre used. An auto-inocu- 
 lable ulcer resulted at once, and got well. Then followed true syphilitic 
 chancre and its appropriate sequence, syphilis. 
 
 The cases adduced to support the first part of this eighth proposition 
 are meagre in number (seven) and scant in detail. Five of them are by 
 the anonymous physician of the Palatinate. Of these, three produced pus- 
 tules and inflamed; one sloughed; two produced, the one tubercles (ulcera- 
 ting)* tne other ulcers after thirty-six and forty-two days' incubation.
 
 CHANCROID. 13 
 
 These cases are difficult to explain. In the first three the hypothesis 
 of possible error as to the nature of the source of the poison might be 
 entertained, or previous syphilis in the inoculated person, or some possi- 
 ble incapacity on the part of the one inoculated to receive the poison. 
 In the last two the long incubation and the local developments make 
 it probable that they both acquired true syphilis by inoculation, and that 
 general symptoms of the ordinary kind did not follow. This we observe 
 sometimes clinically, especially in the case of women who get syphilis 
 from their husbands. No eruption and no obvious symptoms follow the 
 infection during the early period, while subsequent developments confirm 
 the existence of syphilis. Both of the last two cases here referred to 
 were women (the tenth and thirteenth cases of the anonymous Palatinate). 
 
 The two other cases of syphilitic inoculation not followed by syphilis 
 were those of Boeck and von Rinecker. The former was the case of a 
 woman. Large superficial pustules, auto-inoculable in three generations, 
 followed, and no general symptoms. This looks like the result of the in- 
 oculation of an irritated syphilitic chancre, where the pus alone took and 
 the syphilitic poison did not. The chancroidal pus would have been auto- 
 inoculable in more than three generations, and the possibility of inocula- 
 ting true syphilis negatively has no stronger theoretical objection than 
 the negative inoculation of vaccine virus and the latter is well known to 
 occur very often. 
 
 Von Rinecker's case was that of a boy of twelve, who was inoculated 
 from a primary lesion. The incubation was twenty-seven days, the re- 
 sult a tubercle without general symptoms afterward, and the conclusion 
 (for it was a take) is either that the boy had inherited syphilis, or was one 
 of the anomalous cases already referred to, and undoubtedly occasionally 
 encountered clinically, where no general symptoms followed the primary 
 lesion within the customary period. 
 
 These cases are important ones, and it may seem like begging the 
 question to try to theorize them away. But, even granting them all to be 
 what their authors claim, they are only exceptions among so many. Ex- 
 ceptions prove rules because observers are not omniscient, and certain con- 
 ditions which seem to be fulfilled must sometimes fail in spite of all our 
 efforts to detect the whole truth. The grouping of a certain series of 
 phenomena following certain causes constitutes a rule in the eyes of all 
 men, and no rule is more plentifully upheld by examples than that one 
 which states that the inoculation of the secretion of a syphilitic chancre 
 upon a healthy person produces, if anything, syphilis. 
 
 Between forty and fifty cases are on record in which syphilitic secre- 
 tions have been experimentally inoculated upon healthy persons. Among 
 these, seven are exceptions, the rest follow the rule. Confrontations cer- 
 tainly number thousands, and syphilis, when traced up, is always found 
 to be derived from syphilis in another. It does not arise de novo. 
 
 Vaccine virus is well known to be contagious, yet no one is astonished 
 when its inoculation sometimes proves abortive. In the epidemics of vac- 
 cinal syphilis, only a certain proportion of the children vaccinated get 
 syphilis. Even chancroidal virus (much more irritating and virulent than 
 the syphilitic poison) occasionally fails to take, probably because inocula- 
 tion is not properly performed, possibly on account of an idiosyncrasy of 
 the patient. Hiibbenet, 1 of Kiew, reports two cases where he uniformly 
 failed to get a positive result from the inoculation of chancroidal pus. 
 
 Die Beobachtung und das Experiment in der Syphilis. Leipsic, 1858, p. 11.
 
 14 THE VENEREAL DISEASES. 
 
 I have now a patient under treatment who acquired his disease from 
 a woman with whom a personal friend consorted a few moments later and 
 received no harm therefrom, and instances of this sort are by no means 
 uncommon. 
 
 The blood of syphilis is known to produce a syphilitic chancre by in- 
 oculation, and this proposition is not at all invalidated, because seventeen 
 out of the twenty-three reported cases of inoculation of syphilitic blood 
 gave negative results. The poison was doubtless more dilute in these 
 cases, or the inoculation improperly performed. 
 
 If the inoculation of syphilitic virus upon an uninfected person may 
 prove abortive and the inoculation of indifferent purulent secretions upon 
 some people may give rise to ulcers, auto-inoculable in generations then 
 these exceptional cases lose all their value, in so far as they controvert 
 the doctrine of two poisons: one, sui generis, for chancroid; the other, 
 specific, for syphilis. 
 
 9. Secretions derived from auto-inoculable ulcers, which lat- 
 ter have been originated from pus first taken from an irritated 
 syphilitic chancre, may by hetero-inoculation produce an auto- 
 inoculable ulcer, not followed by syphilis. This assertion rests 
 upon Bidenkap's case, which has already been discussed and a possible 
 solution offered (p. 4). 
 
 10. The pus from many of the later lesions of syphilis is auto- 
 inoculable, producing auto-inoculable ulcers (upon the syphilitic 
 patient) just as other indifferent, non-poisonous pus -will produce 
 a similar result, more or less marked in degree, according to the 
 quality of the pus (Pick, Melchior Robert, Koebner, Boeck, Bidenkap, 
 Clerc, Fournier, Lee, and others). What has already been said in this 
 chapter covers this point; no further explanation is necessary. 
 
 11. Vaginal secretions, taken from syphilitic women having 
 no ulceration of the genitals and auto-inoculated, produce auto- 
 inoculable ulcers upon these women resembling chancroids 
 (Morgan, of Dublin). The same reasoning in explanation applies here as 
 that alluded to under head 10. 
 
 12. A mixed chancre (Rollet) exists possessing the physical 
 qualities found in ulcers produced by both of the poisons. It 
 will be described later. It exists clinically. It has been produced ex- 
 perimentally. (Melchior Robert, Lindwurm, Basset, Laroyenne.) 
 
 Discussions upon the existence of one or two poisons for the different 
 sores will doubtless never cease. They are of value to the cause of sci- 
 ence, but unfortunate if their conclusions lead to the practice of treating 
 all venereal sores alike. 
 
 One may readily accept without damage the doctrine that there is only 
 one poison that poison syphilis, while chancroid is only a common ulcer 
 auto-inoculable, but not in any sense poisonous. This conclusion cannot 
 lead to practical harm. The doctrine which intimates that there is but 
 one poison syphilis, and that that poison produces sometimes chancroid, 
 sometimes syphilitic chancre, must be pernicious in its results, and lead 
 to years of needless dosing in the case of patients who require only local 
 treatment.
 
 CHAPTER II. 
 
 CHANCROID. 
 
 DESCRIPTION OF ITS SPECIAL FEATURES AND OF THE VARIATIONS TO WHICH 
 
 THEY ARE LIABLE. 
 
 Pathological Histology of Chancroid; Comparative Histology of Syphilitic Chancre and of 
 Chancroid. Transmission of Chancroid to Animals. Transmission of True Syphi- 
 lis to Animals. The Relative Frequency of Chancroid. The Methods of Chancroid- 
 al Contagion, Direct and Mediate. The Inoculation of Chancroid. Auto-inocula- 
 tion and Hetero-inoculation. Case illustrating the Diagnostic Value of Auto-inocu- 
 lation. Inoculation in Generations. How to Practise Experimental Inoculation. 
 The Incubation of Chancroid ; Variation in Incubation. Course of Chancroid ; 
 Period of Increase ; Stationary Period; Period of Repair ; Variations in Course. 
 Situation of Chancroid; Variation in Situation. Number of Chancroids. Form 
 of Chancroid ; Variations in Form. Follicular Chancroid. Subjective Symptoms 
 of Chancroid. Condition of the Base. Duration of Chancroid; Variations in 
 Duration. Cicatrix of Chancroid. 
 
 Pathological histology of chancroid. The minute structure of 
 chancroid, as revealed by the microscope, presents nothing special. That 
 quality which constitutes the virulence of chancroid does not become evi- 
 dent by being magnified, nor does it impress any property upon the elements 
 composing the ulcer peculiar to itself. Many efforts have been made to 
 establish points of comparative diagnosis, by the aid of the microscope, be- 
 tween chancroid and chancre, but without any success that can be practi- 
 cally utilized. Biesiadecki found v?ry little difference. The tissues of 
 the cutis and the lower cells of the epidermis are swollen in both instances, 
 the adventitia of the blood-vessels is said to be more dense in syphilitic 
 chancre and the walls of the capillaries thickened (Biesiadecki), the lumen 
 of the thick-walled vessels becomes diminished. The tissues in and around 
 the ulcer in both cases are filled with nucleated cells crowded together in the 
 meshes formed by separation of the bundles of connective tissue. These 
 cells soon render the line between the cutis vera and the mucous layer of 
 the epidermis indistinct, and the epithelial layer becomes thinner. Follow- 
 ing this, ulceration may ensue. 
 
 Verson believed the induration in syphilitic chancre to be due to new 
 formation of connective tissue; but the tissue is not peculiar in any 
 way. Buhl found the blood-vessels enlarged and their coats infiltrated 
 in chancroid as well as in chancre. Auspitz and Unna 1 (the latest in the 
 field) attempt to make clear the characters distinguishing syphilitic chan- 
 cre from chancroid; but they do not succeed in doing more than the un- 
 aided eye had done before, and certainly point out nothing pathognomo- 
 
 1 Die Anatomic der syphilitiechen initial-sclerose. Separat abdruck aus der Viertel- 
 jahresschrift f. Derm u. Syph. Wien, 1877, pp. 161.
 
 16 THE VENEREAL DISEASES. 
 
 nic nothing which could be relied upon to help the clinical inquirer, even 
 if he cut out the initial lesion to study it up in a case of doubt. 
 
 They confirm the thickening of the adventitia of the vessels noted by 
 Biesiadecki (and frequently found elsewhere by other observers). They 
 speak of the cellular infiltration and of the hypertrophy of fibrillary con- 
 nective issue. This fibrillary material Unna 1 says is pure collagen. He 
 thinks this gives its hardness to syphilitic chancre, that it is most marked 
 in the adventitia of the individual vessels. He believes that the starting- 
 point of the disease is in the vasa vasorum, endothelial changes coming 
 later. Where there are no vasa vasorum the adventitia is the point of 
 origin of the process. The lymph-spaces disappear in the fibrous felting 
 of the skin, while round-celled infiltration is general. Frequently there is 
 absence of true ulceration and very often there is actual preservation of 
 the epidermis over the lesion, which sometimes even increases in thick- 
 ness and grows downward, sending off lateral shoots. 
 
 In all this description there is surely nothing which may not be imi- 
 tated by other processes not syphilitic. Nothing specific has been found, 
 and most of these facts were presumed before the microscope was brought 
 to bear upon these special lesions, for true chancroid is an ulcer, true syph- 
 ilitic chancre often is not. 
 
 Transmission to animals. In 1844, Auzias Turenne succeeded in 
 producing a number of positive takes upon different animals by inoculat- 
 ing them with chancroidal pus. Robert de Weltz, six years later, took pus 
 from chancroids which he had produced by inoculation upon a cat and 
 a monkey, and inoculated his own arm four times, with success. Turenne 
 inoculated chancroidal pus in generations upon animals, and found that 
 ulcers soon failed to be produced. The peculiar virulence of chancroid, 
 it appears, does not long continue upon the soil furnished by the tis- 
 sues of the lower animals a rather peculiar fact, when it is remem- 
 bered with what ease profuse suppuration is set up in some of them (the 
 rabbit). Turenne, on account of his discovery that the virulence of 
 chancroid died out by repeated auto-inoculation, and believing that chan- 
 croid was syphilitic for he was a unicist established the doctrine of syph- 
 ilization, an attempt to cure syphilis by repeated and exhaustive inocula- 
 tion of chancroid a doctrine which with some modifications exists even 
 at the present day, in spite of the death of its sturdy advocate, Boeck. 
 Turenne was consistent in his practice with his theory. He made no 
 public confession of what he was doing, but he undoubtedly syphilized 
 his own body, which at his death is reported to have been covered with 
 scars. 
 
 In the light of modern inoculations it may be contended that the auto- 
 inoculable sores produced upon animals were not chancroids, but ulcers 
 not poisonous, auto-inoculable in generations, like the ulcers produced 
 upon a cachectic person by the inoculation of acne-pus; and the fact that 
 Weltz produced ulcers upon himself by re-inoculating this pus from the 
 animal back to himself would not in the least oppose such a conclusion. 
 Two recorded circumstances, however, carry conviction that the poison of 
 chancroid is transmissible to animals, develops there, and may be carried 
 back again and successfully inoculated in man. The two cases are those 
 of Ricordi and Diday : the former produced a chancroidal bubo (a virulent, 
 not a simple bubo), in a rabbit, while Diday, in 1851, by inoculating his 
 
 1 Vierteljahresschrift f. Derm. u. Syph. 1878, p. 543.
 
 CHANCROID. 17 
 
 own penis with pus derived from an ulcer which he had originated by 
 inoculating chancroidal pus upon the ear of a rabbit, produced a chancroid 
 upon himself. His chancroid soon became phagedenic, and was attended 
 by suppurating (not virulent, however) bubo. 
 
 Up to the present time a distinguishing mark between the poisons, 
 claimed by the advocates of two poisons, has been that chancroid could 
 be transmitted to animals, while syphilis could not. Numerous attempts 
 at inoculating syphilis had been made, but they invariably failed to de- 
 monstrate that any animal could acquire syphilis. Depaul's syphilitic 
 monkey and the cachectic syphilitic cat of Vernois have not been regard- 
 ed as more than effects of a vivid imagination. It may be, however, that 
 the judgment of the profession on this point also must be modified if the 
 recent discovery made by an eminent scientist is confirmed by future in- 
 vestigation. 
 
 At a meeting of naturalists ' at Cassel, in 1878, Klebs announced the 
 discovery of a parasite, the cause of syphilis. The microscope showed 
 him certain slowly moving little rods in freshly extirpated Hunterian 
 chancres. From these by cultivation he produced a plant composed of 
 stationary rods terminating in spiral prolongations of jointed rods. By 
 inoculating these cultivated helikomonads, as he calls the plants, upon 
 an ape, he produced symptoms resembling syphilis. By inserting under 
 the skin of another ape a piece of a syphilitic chancre, he claims to have 
 produced symptoms upon the integument, in the mouth, the bones of the 
 skull, meninges of the brain, etc. tissue-changes identical with those pro- 
 duced by syphilis in man, while from the blood of this ape he cultivated 
 a plant resembling that inoculated upon the first ape. 
 
 These new discoveries will doubtless be at once tested. Should they 
 prove accurate, another distinction between chancroid and syphilitic chan- 
 cre, formerly relied upon by the dualists, will have disappeared. 
 
 The relative frequency of chancroid. The poison of chancroid is 
 more virulent than that of syphilitic chancre; it takes more easily, as proved 
 by the number of negative results attending inoculation of syphilitic 
 blood upon healthy persons, and the free auto- and hetero-inoculability 
 of chancroid. Chancroid may recur indefinitely in the same individual. 
 Hence, it is to be expected that chancroid will be found more frequently 
 than chancre, and all statistics drawn from hospital experience prove this 
 to be the case. Puche's statistics of ten thousand from the Midi Hospital 
 credit nearly a clear eighty per cent, of the cases to chancroid, and the 
 statistics of the Plymouth Naval Hospital give seventy per cent. The 
 practitioner among respectable people, however, is astonished at the 
 small number of chancroids he encounters. Herpetic troubles are cer- 
 tainly more common than anything else taking the world at large; and 
 Fournier, out of three hundred and thirty-four cases in his own private 
 practice, only encountered eighty-two chancroids. The statistics of Four- 
 nier, quoted by Lancereau (2d ed., p. 82), and doubtless covering hospital 
 cases, credits chancroid with a little over sixty-six per cent, of the whole 
 number reported. 
 
 The conclusion is, as Fournier pointed out, that the greater care and 
 neatness exercised in the higher classes protects them in a measure from 
 chancroid, but offers no gurantee against infection by the seemingly less 
 formidable primary lesion of true syphilis. The conclusion becomes 
 especially obvious on considering the fact that mucous patches, which 
 
 1 Allg. Wien. med. Zeitung, Oct. 15, 1878, p. 418.
 
 18 THE VENEREAL DISEASES. 
 
 may lie concealed high up in the vagina, and last for months at a time, 
 are as capable of communicating syphilis as is the true syphilitic chancre. 
 
 The manner of contagion. The chancroidal virus is not volatile. 
 Chancroid is only possible by contact of chancroidal pus with a surface 
 deprived of epithelium. Cullerier's famous experiments show this. Two 
 women were found with no lesion of the vagina in either case. The vagi- 
 nal secretions were auto-inoculated without effect. Chancroidal pus was 
 placed in the vagina, where it remained thirty-five minutes in one case, 
 nearly an hour in the other. Then the contents of the vagina in each case 
 were successfully auto-inoculated. In both the vagina was washed with 
 an astringent solution, and in neither did any vaginal ulcer follow. 
 
 The surgeon knows well that, so long as there are no cracks in his fin- 
 gers, he may handle chancroidal pus with impunity. 
 
 There is one exception to this rule, namely, where chancroidal pus is 
 placed upon healthy epithelium, remains there undisturbed, erodes the 
 epithelium by virtue of its acridity, and thus prepares a way for the ab- 
 sorption of the virus. In this way chancroids of long incubation are ex-. 
 plained; and in a similar way the follicular chancroid, in which a few 
 leucocytes bearing chancroidal virus are believed to be rubbed into the 
 mouth of a healthy follicle, and thence gradually to erode a way by which 
 contagion becomes possible through the thin wall of the follicle under- 
 neath the surface of the superficial epidermis. The period of incubation 
 in this case is also generally long. 
 
 The methods of contagion are two, direct and mediate. 
 
 Direct contagion. In direct contagion the source supplying the pus 
 and the part inoculated come into direct contact. This is the usual way. 
 In sexual intercourse, when a chancroid upon an individual inoculates a 
 portion of overlying contiguous integument, when a fissure on the physi- 
 cian's finger becomes contaminated while practising the vaginal touch 
 these are all instances of direct contagion. 
 
 Mediate contagion. This means that there is an intermediate car- 
 rier of the pus which receives it from its source and deposits it where it 
 finally takes root. The vagina may be the medium of contagion receiving 
 the pus from one man to give it up to another immediately without itself 
 becoming contaminated. Cullerier's cases prove the possibility of this 
 but it must be very rare. The prepuce may play a similar intermediate 
 part. The lancet of the surgeon gives rise to mediate contagion in cases 
 of inoculation. 
 
 Inoculation of chancroid. The pus of chancroid remains virulent 
 until the ulcer is healed, but decreases in virulence toward the end. A 
 single corpuscle is believed to be capable of producing a chancroid by in- 
 oculation. Frozen and corked up in bottles, the pus retains its virulence 
 for a long time (Boeck). Boiling heat, acids, alkalies, corrosive subli- 
 mate, alcohol, decomposition all destroy the virulence of the pus. Boeck 
 believes that dried pus is inert; Sperino taught the contrary. Inocula- 
 tion is spoken of under two heads auto- and hetero-inoculation. 
 
 Auto-inoculation is the inoculation of the patient with the secretion 
 of the chancroid he himself bears. This is generally effected purposely as 
 a test by the surgeon. It may take place by contact of adjacent surfaces. 
 In such a case it is called spontaneous auto-inoculation. Auto-inocula- 
 tion as a diagnostic test is not so commonly employed now as formerly. 
 As a test it is thought to be deceptive, since so many other kinds of pus 
 produce ulcers upon some persons. These latter ulcers are not chancroids, 
 but they secrete pus and are apt to deceive. Chancroid, moreover, is so
 
 CHANCROID. 19 
 
 well understood now to be harmless and unproductive of syphilis, that in 
 cases of doubt it may be observed for a time, or treated at once, as the sur- 
 geon chooses, without calling for any internal medication or disturbing the 
 patient's peace of mind in the future, should no symptoms follow. 
 
 Yet auto-inoculation is still an excellent resource in many cases, the 
 frank take of the true ulcer being very characteristic and always easy to 
 obtain upon a fresh subject a fact which cannot be affirmed to the same 
 extent about any other kind of pus. In the following case, on one occa- 
 sion it proved of great value. 
 
 In midsummer, a thin apothecary came to me with an oval ulcerated 
 fissure at the edge of a somewhat tight prepuce. This prepuce he pulled 
 back twenty times a day in order to inspect the ulcer better. His wife 
 was away. He was greatly frightened, and in such a state of depression 
 that he could neither eat nor sleep. The fissure was several weeks old, 
 suppurating only moderately. It did not look very virulent, and I as- 
 sured the man that his fears and his manipulations were keeping the ulcer 
 in existence, and that it would get well if let alone. Weeks passed, how- 
 ever, and it did not get well under simple medication. It did not spread 
 and there was no bubo. I sent him for an opinion to a number of sur- 
 geons of eminence, and all agreed that the ulcer was a simple one, kept up 
 by the weakness and anaemia of the patient, and the position of the sore. 
 
 Finally the patient's wife was about to return and he was convinced 
 of the simple nature of his sore, which had now lasted many weeks un- 
 changed. I inoculated him twice on the forearm, mainly as an experi- 
 ment. In three days the inoculated points became two brilliant typical 
 chancroids. 
 
 The wife was detained away by a telegraphic excuse, and a single 
 cauterization with fuming nitric acid cured all three ulcers promptly, the 
 character of the ulcer on the prepuce changing immediately on the fall 
 of the slough. 
 
 Inoculation in generations is repeated inoculation of pus from one 
 source, taking the supply for each fresh sore from the one last produced, 
 until the pus no longer takes on the same individual. Fresh pus derived 
 from a new parent source may now start a new process of inoculation in 
 generations upon the same patient, and then again fresh pus, until at 
 last the skin will no longer take, and abortive pustules at best, or noth- 
 ing results, from any fresh inoculations. This much syphilizers have 
 proved, and the process they have adopted is the one just described. 
 
 After a patient has been " syphilized," as it is called, and has a rest, 
 he may be syphilized again, since the skin recovers from its immunity. 
 
 Thus it appears there is a limit to auto-inoculation, but no one knows 
 how long one would continue susceptible to inoculation were only one 
 chancroid created at a time. Lindmann certainly reached twenty-seven 
 hundred, and was still succeeding when last reported; and practically (cer- 
 tainly for clinical purposes), it may be affirmed that there is no limit to 
 to the susceptibility of an ordinary individual to chancroidal virus. He 
 may take as often as he is exposed. 
 
 The method of inoculation of syphilizers is perhaps the best. A mi- 
 nute portion of pus is taken on the point of a lancet, and held at right 
 angles to the skin at the point selected for inoculation. The tip of the 
 lancet is made to penetrate just below the epidermis, rotated, withdrawn, 
 and its point is wiped off upon the minute wound. Extensive scarifica- 
 tions are to be avoided, since they produce large, irregular sores, and not 
 the round typical chancroid.
 
 20 THE VENEREAL DISEASES. 
 
 The point most suitable for auto-inoculation for diagnostic purposes 
 is the breast below the nipple. Here the skin resists a take. A true 
 chancroid will undoubtedly always take here, but the resulting sore is 
 not apt to be troublesome, and phagedaena is almost unheard of in this 
 region. The head and face are peculiarly bad soil for a take, and would 
 be proper sites for auto-inoculation, except for the fact that severe chan- 
 croids do sometimes occur in these regions, and the resulting scar is dis- 
 figuring. Chancroids have been repeatedly produced on the face by auto- 
 inoculation, and the ancient notion that all venereal ulcers on the face 
 are necessarily syphilitic is not accurate. The upper and outer part of 
 the thigh is also a good site for auto-inoculation for diagnostic purposes. 
 It is out of the way of the absorbents, and not likely to inflame exces- 
 sively, or to become complicated in this region. Over the insertion of 
 the deltoid in the arm is another good site. 
 
 Hetero-inoculation is the inoculation of pus from one patient to 
 another, as practised by syphilizers. Chancroid, as found clinically, is also 
 the result of hetero-inoculation. 
 
 Incubation of chancroid signifies the time which elapses between 
 contact with the poison and the appearance of the ulcer. If we had mi- 
 croscopic eyes, we should recognize, probably, that changes in the tissues 
 commence immediately upon contact of the virus with a denuded surface. 
 As it is, by the end of twenty-four hours, the inoculated point is distinctly 
 red, during the second or third day a pustule forms, and generally by the 
 third day, if the pustule be broken, a fully formed minute chancroid, pos- 
 sessed of all the characters of the typical ulcer, is found, with its abrupt 
 margin, suppurating floor, soft base, pink areola, etc. Boeck says that the 
 pus is contagious, taken from the pustule on the third day. Clinically the 
 same holds good, and the incubation of chancroid is placed at two or three 
 days, very rarely longer. When first found by the patient, it is generally 
 already an ulcer or an exulcerated fissure. Sometimes it is a pustule. 
 
 Variation in incubation. Clinically, incubation may reach a week, 
 possibly ten days. This occurs in cases of follicular chancroid, or when 
 the pus has been deposited upon unbroken epithelium and has to erode 
 its way through before a take can be effected. Sometimes the ulcer is 
 not found by an unobservant patient until many days have elapsed, because 
 it has caused no pain, and has not attracted attention. Such a patient, 
 on finding a large ulcer by accident, will think it impossible that such a 
 sore could have escaped his attention had it existed the day before, and 
 he will declare that it has just appeared, and resent the suggestion that 
 he has overlooked it. 
 
 Course of chancroid. Uncomplicated chancroid tends to run 
 through three definite periods: the period of increase, the stationary pe- 
 riod, the period of repair. 
 
 .Period of increase. This lasts one or two weeks, occasionally a lit- 
 tle longer. The ulcer increases in size, preserving absolutely its charac- 
 teristic features. It generally stops when it reaches about one-fourth of 
 an inch in diameter, but may rapidly spread to the diameter of an inch or 
 more. 
 
 Stationary period. During about two weeks, sometimes longer if 
 unmolested, the ulcer tends to remain absolutely stationary, not undergo- 
 ing any change that can be appreciated. In persons not very susceptible 
 to the poison, very often toward the end of a course of syphilization the 
 stationary period does not exist, but repair sets in after the ulcer has 
 reached a certain size.
 
 CHANCROID. 21 
 
 Period of repair. This comes on gradually. The floor of the ulcer 
 grows more pink and even, "the edges become sloping, and cicatrization 
 advances slowly from the circumference toward the centre. 
 
 Variations in course. Many of the deviations in the typical fea- 
 tures of chancroid lead to variations in its course. They will be consid- 
 ered under the heads of relapse, inflammation, phagedasna, gangrene. 
 
 Situation of chancroid. Chancroid is commonly found in the fur- 
 row behind the corona glandis on the penis of the male, and posteriorly in 
 the fourchette of the vagina of the female. A natural pocket exists at 
 these points, the epithelium is soft there, and abrasions not uncommon, 
 especially along the side of the frenum in the male. In this situation 
 chancroid frequently ulcerates its way beneath the frenum, and some- 
 times perforates the urethra. The pus naturally gravitates to the four- 
 chette in the female. 
 
 Variation in situation. No portion of the body is exempt from in- 
 oculation by chancroid. The head and face, once considered exempt, has 
 been proved not to be so by numerous syphilizers. R. W. Taylor has 
 shown that, clinically, chancroid upon the head may be of exceptional se- 
 verity, and three very interesting cases of phagedenic chancroid of the 
 face are reported by Profeta, of which the first is especially striking. 
 A serpiginous chancroid, lasting two years, had occasioned extensive 
 ravages upon the face. The patient had inoculated his own hand 
 while handling the sore, and Profeta inoculated himself from the ulcer 
 with positive result. Hygiene, with local stimulants, cured the ulcer 
 promptly. 
 
 Chancroids are common anywhere upon or within the prepuce in the 
 male, the ostium vaginas in the female. At the orifice of the urethra they 
 are encountered in both sexes, and they are apt to be sluggish in their 
 course in these situations. Chancroid deep in the urethra of the male is 
 very rare. They are also rare deep in the vagina, but have been observed 
 upon the neck of the uterus, and (Delmas and Combal) within the uterus. 
 The anus and rectum are the seat of chancroid either communicated a 
 preposterd venere, or, in the female, due to spontaneous auto-inoculation, 
 the chancroidal pus trickling down over the anus from the vaginal four- 
 chette as the patient lies upon her back. The fingers of the surgeon and 
 of the patient with chancroid are apt to become poisoned accidentally. 
 
 Number of chancroids. Clinically, chancroid is multiple among 
 hospital and dispensary patients, often solitary in the better classes, who 
 are more scrupulously clean. If multiple abrasions have been simultane- 
 ously poisoned during sexual intercourse, the resulting ulcers will natu- 
 rally be multiple from the first. Often, however, but one sore comes out 
 at first, and this by spontaneous auto-inoculation produces many similar 
 sores in the immediate neighborhood. Around the anus, and at the mar- 
 gin of the prepuce, chancroid is nearly always multiple. When chancroid 
 is multiple from the first, the numerous ulcers are apt to be small. Single 
 chancroid is generally larger. Sperino found in practising syphilization 
 that, the greater the number of points of simultaneous inoculation, the 
 smaller was the relative size of the resulting ulcers. He utilized this dis- 
 covery in lessening the size of the scars of his patients, whom he syphi- 
 lized. 
 
 Form of chancroid. The typical chancroid has been described 
 (p. 2). It is round, or may be unsymmetrically irregular on account of 
 the situation, or the shape of the abrasion or fissure inoculated, or on 
 account of the running together of several chancroids of different sizes,
 
 22 THE VENEREAL DISEASES. 
 
 in which case its border is described by segments of uneven circles. Mul- 
 tiple chancroid of the anus is stellate. 
 
 Variations in form. Instead of being an open ulcer, chancroid 
 sometimes remains scabbed over. The thick pus dries up on the surface, 
 but continues to be formed beneath the scab, from the sides of which it 
 oozes under pressure. It advances by the formation of new rings of pus 
 under the epidermis around the old scab, and generally has a livid areola 
 outside of all. It resembles rupia, is by no means common, and is called 
 ecthymatous chancroid. Lift off the crust in such a case, and the charac- 
 teristic ulcer will be revealed. 
 
 Follieular chancroid. In this form of chancroid, infection takes 
 place through the mouth of a healthy follicle, into which a few pus-cells 
 have been rubbed. It is a clinical chancroid, and cannot be produced ar- 
 tificially. Inoculation takes place beneath the plane of the surface epi- 
 dermis, and if the latter happens to be tough, it retains its integrity for 
 a considerable period after the tissues beneath it have been melted down 
 into pus. 
 
 Therefore, when seen it is a large acuminated pustule, often covered 
 by a peculiarly dense epidermis. The lesion varies in size, and is full of 
 thick pus. Suppuration tends to spreads peripherally beneath the epi- 
 dermis until the latter has broken. By cutting away the thickened epi- 
 dermis the typical chancroid is disclosed. The incubation of follicular 
 chancroid is long, as already stated. The lesion is uncommon. I have 
 seen three cases all on the genitals. Two of them were sent for inspec- 
 tion from the Bellevue Dispensary, by Dr. E. A. Banks, of New York. 
 The largest was nearly a half-inch in diameter at the base, and elevated 
 quite a third of an inch above the surface of the integument. 
 
 Subjective symptoms of chancroids. There are none in a typi- 
 cal case. An uninflamed, uncomplicated chancroid is not painful. It 
 itches or prickles somewhat at times, but nothing more. If, however, 
 from its position it is subjected to irritation (anus, end of penis), or from 
 local applications or other cause it becomes at all inflamed, then it be- 
 comes painful, more or less so according to the individual and the 
 amount of inflammation. Practically, chancroid rarely exists clinically 
 free from irritation, and it is generally, therefore, found to be painful, 
 sometimes acutely so. A rapidly spreading chancroid is painful, as is 
 also a chancroid when attacked by gangrene or phagedsena. 
 
 Condition of the base. The base of an unirritated chancroid is soft. 
 If inflamed from irritation, it becomes hard, indurated, and feels as a small 
 boil in the skin sometimes does. This induration sometimes cannot be 
 distinguished with certainty from the induration of syphilitic chancre. 
 Generally, however, the difference is striking. The induration of chancroid 
 is manifestly an inflammatory affair. The integument is discolored for a 
 certain distance around the edge of the ulcer, with a distinct inflamma- 
 tory blush. The tissues give to the fingers the sensation of being matted 
 together, glued to each other and to the surrounding parts. The edge 
 of the induration is not sharply defined, but fades away insensibly into 
 the surrounding tissues. The hard mass is adherent to such portions of 
 integument as override it, and often closely attached to the parts be- 
 neath. Pressure upon the induration causes pain. 
 
 How different is all this from the typical induration of a syphilitic 
 chancre that tense, elastic, insensitive, non-adherent, sharply defined un- 
 derlying induration so familiar to the fingers once accustomed to it, and 
 yet so difficult to be certain about in all cases in which it is imperfectly
 
 CHANCROID. 23 
 
 developed. The induration of syphilitic chancre often precedes the ulcer, 
 or occurs simultaneously with it. That of chancroid always follows the 
 ulcer. 
 
 Duration of chancroid. A typical ordinary chancroid untreated lasts 
 in most individuals from four to eight weeks, according to its size. If 
 very small, it gets well perhaps sooner. The larger it gets the longer 
 time does it require for cicatrization. Abortive pustules and imperfect 
 " takes " get well in a few days. Toward the end of a series of auto- 
 inoculations in syphilization, when the virulent quality of the pus is dy- 
 ing out, the ulcers grow smaller and get well sooner. 
 
 Variations in duration. Irritated and inflamed chancroids are slow 
 in getting well. To this class belong all chancroids about natural orifices 
 or where motion is apt to disturb them, such as chancroids of the anus, 
 of the meatus urinarius, of the orifice of the prepuce, upon the back of a 
 knuckle. Extensive chancroids of the vagina and rectum in the female, 
 and of the rectum in the male, sometimes last indefinitely. They cease in 
 the end to be true chancroids, and their pus ceases to be auto- or hetero- 
 inoculable. Their bases become indurated, they remain in part cicatrized 
 (chancroidal structure of the rectum), in part ulcerated, and frequently 
 pass for tertiary syphilitic ulcerations. Bois de Loury and Costilhes ! 
 have described some forms of these ulcers. Differential diagnosis between 
 them and syphilitic similar lesions and some forms of epithelial cancer is 
 sometimes very difficult. Internal treatment does not affect them. Lo- 
 cal stimulating treatment sometimes cures them. Bridge, of New York, 
 cured a bad case in the rectum, on one occasion, by lumbar-colotomy. In 
 the vagina excision is the best treatment. These ulcers are rarely en- 
 countered except in the wards of a large hospital. Charity Hospital of 
 this city always has a number of them in its wards. They are customarily 
 found upon the persons of old prostitutes. 
 
 The duration of chancroid is greatly influenced by phagedaena. Four- 
 nier has reported a case lasting fourteen years. 
 
 An uncomplicated chancroid occasionally relapses, often without ob- 
 vious cause. This is by no means common, but it has been noted, and it 
 is possible for a chancroid which has almost cicatrized to break down again 
 into ulceration and spread possibly to the same extent as before, or even 
 farther. 
 
 Cicatrix of chancroid. An ordinary uncomplicated chancroid may 
 fail to destroy the papillary layer of the integument, and in such case no 
 scar is left. Generally the scar is quite visible, especially when occurring 
 upon the outer integument, and, of course, once formed it is permanent. 
 It is generally thin and smooth, never pigmented. 
 
 1 Des ulcerations chroniques, ou chancres chroniques des parties genitales de la 
 femme. Paris, 1845.
 
 CHAPTER III. 
 CHANCROID. 
 
 DIAGNOSIS, PROGNOSIS, AND TREATMENT. 
 
 Diagnosis. Diagnostic Table of Chancre, Chancroid, and Herpes. Ulcerated Non-viru- 
 lent Abrasions. Different Varieties of Pseudo-chancre and their Treatment. Six 
 Propositions of Importance bearing upon the Question of Auto-inoculation for Pur- 
 poses of Diagnosis. The Prognosis of Chancroid. The Treatment of Chancroid. 
 Prophylactic Treatment. Radical Treatment. The Reason why Cauterization 
 will not always arrest a Chancroid. How to cauterize a Chancroid. Palliative 
 Treatment of Chancroid. lodoform and its Use, and other Topical Applications. 
 Anal and Rectal Chancroids. Urethral Chancroids. Sub-preputial Chancroids. 
 Chancroid at the Margin of the Prepuce. Chancroid of the Vulva and Vagina. 
 Chancroid of the Fingers. 
 
 FOR clinical purposes the differential diagnosis of chancroid is with 
 syphilitic chancre, and with that alone. The doubt may arise as to whether 
 a given lesion be a chancroid, or a solitary herpetic ulcer, or an ulcerated 
 abrasion; and, although scientifically these points are interesting and im- 
 portant, they are not paramount. 
 
 It is only possible to make a differential diagnosis clear within short 
 limits of space by arranging the typical features of the lesions under com- 
 parison in the form of a table. 
 
 Although syphilitic chancre is to be described later on, yet it is expe- 
 dient to place a short diagnostic table here, on account of the context. 
 This table only deals with the important broad typical characters of the 
 two sores. For closer details of the minor features of syphilitic chancre 
 in differential diagnosis, the reader is referred to the more extensive table 
 later on. 
 
 A diagnostic table, to be accurate, must be minute in detail; but this 
 minuteness destroys its value for clinical purposes to the student, who 
 wants the broadest possible distinctions, clearly made and strongly con- 
 trasted. It is therefore expedient to give two diagnostic tables, the first 
 broad, clear, short, referring to the typical ulcer, and not considering ex- 
 ceptions or complications; the second, more in detail, for fear that the first 
 might lead into error. But few points, and those cardinal, will be made 
 in the first table, that it may be a sort of primer of diagnosis for virulent 
 venereal disease. It seems best to include herpes in the first table. The 
 second table will be given after a description of syphilitic chancre. 
 
 A diagnostic table cannot cover all the ground, and it is not intended 
 to do so. It is in the main accurate for typical cases only, and its func- 
 tion is to serve somewhat as does a diagrammatic chart. A table of this 
 sort is sometimes of very great value, but it cannot be depended upon io 
 exceptional cases.
 
 CHANCROID. 
 
 25 
 
 Diagnostic Table of the Distinctive Features upon the Genitals of Pure 
 
 Typical Cases of 
 
 SYPHILITIC CHANCRE. 
 
 CHANCROID. 
 
 HERPES PROGENITALIS. 
 
 1. History. Sexual con- 
 tact with a syphilitic chan- 
 cre or mucous patch, the pa- 
 tient himself being virgin of 
 syphilis. 
 
 2. Situation. Anywhere. 
 
 3. Incubation. About 
 three weeks. 
 
 4. Origin. Papule. 
 
 5. Type. Bloody excori- 
 ation. 
 
 6. Number. Unique. 
 
 7. Physiognomy. Round, 
 raw papule, or livid excoria- 
 tion, or funnel-shaped ulcer. 
 If an ulcer, the edyes are 
 adherent, the floor is pulta- 
 ceous, the suppuration is 
 scanty. 
 
 8. Auto-inoculation fails. 
 
 9. Course. Slow through- 
 out. 
 
 10. Pain. Absent. 
 
 11. Induration. Present. 
 
 Sexual contact with a 
 chancroid ; syphilis has noth- 
 ing to do with either party. 
 
 Most common in the fossa 
 alongside of the frenum. 
 About three days. 
 
 Pustule. 
 
 Suppurating deep ulcer. 
 
 Multiple. 
 
 Round ulcer, with sharply 
 cut, abrupt edges, often un- 
 dermined, uneven pultace- 
 ous floor, suppurating abun- 
 dantly. 
 
 Succeeds. 
 
 Rapid, but gets well slow- 
 ly. 
 Present. 
 
 Absent. 
 
 Of ten spontaneous; some- 
 times follows unaccustomed 
 sexual intercourse. Syphilis 
 may be ignored in searching 
 for a cause. 
 
 Usually subpreputial. 
 
 If due to intercourse, 
 twenty-four hours to a few 
 days. 
 
 Several clusters o vesi- 
 cles. * 
 
 Irregular, superficial ul- 
 cer. 
 
 Multiple. 
 
 Superficial ulcer, with 
 thin borders plainly (at first) 
 composed of a number of 
 small ulcers which have run 
 together. 
 
 Fails. 
 
 Rapid, and gets well 
 promptly. 
 
 Sharp, tingling sensation 
 at first. 
 
 Absent. 
 
 These features are very clearly different in the different lesions. It 
 takes more than one symptom to make a disease, and very few symptoms 
 are absolutely constant in any disease. A typical chancroid ought to ac- 
 cord very closely to the description given above. When it is much com- 
 plicated it may be quite wide of the mark. In such case its peculiarities 
 may be found detailed in the more thorough diagnostic table, following 
 the description of syphilitic chancre, at p. 97. In all cases of doubt, in 
 every instance where the few broad distinctions clearly pointed out in 
 this table fail to make the diagnosis certain, there is no safety in any 
 course but delay. Delay will always make the diagnosis more certainly 
 than any table. One mistake in the wrong direction, one condemnation 
 of a healthy person to the years of distress of mind which he is sure to 
 suffer if he supposes himself to be syphilitic and all the more in some 
 cases if no symptoms of the disease appear later to confirm his doubts 
 one such error more than counterbalances any possible good that might 
 arrive in any number of cases by a few weeks' gain in the time of diag- 
 nosis between chancroid and syphilis. 
 
 Besides syphilitic chancre, there are other lesions liable to be mistaken 
 for chancroid, but none of them commonly give any trouble to the close 
 observer. 
 
 An abrasion acquired during sexual intercourse, and ulcerating subse- 
 quently, is sometimes suggestive of chancroid. Such an abrasion occurs
 
 26 THE VENEREAL DISEASES. 
 
 at the moment of contact, and, unless small, is usually shortly afterward 
 recognized perhaps by a drop of blood. 
 
 The edges of such an abrasion are generally jagged, and the base of 
 the ulcer but little depressed, and discharging a thin sero-pus. But yet 
 such an abrasion by neglect in debilitated persons, by lack of cleanliness, 
 by inappropriate treatment (partial cauterizations with nitrate of silver), 
 may acquire in time a physiognomy so nearly resembling that of chancroid 
 that a diagnosis is almost impossible. Under these circumstances there 
 remain the alternatives of auto-inoculation over the insertion of the del- 
 toid, under the nipple or on the outer and upper part of the thigh; of 
 delay, with the use of cleanliness, soothing and mildly stimulating local 
 dressings, and tonics internally; or, finally, if the patient's state of mind 
 calls for it, and the person from whom he acquired his sore cannot be 
 found for inspection, no harm can come by adopting the conclusion that 
 the suspicious ulcer may be a source of poison to others, and treating it 
 as if it were a chancroid, by thorough destructive cauterization. 
 
 Should a patient present himself on the morning after suspicious in- 
 tercourse with an abrasion still fresh upon him, what is to be done ? It 
 is manifestly an abrasion, and the patient has been exposed to any poison 
 that may have been present in his partner. Several hours have passed, 
 absorption has been accomplished; what is to be done ? Very little ex- 
 cept to make a reserved prognosis. Hill's case, Diday's experience, the 
 results of the excisions of syphilitic chancres by Auspitz and Kolliker (p. 
 93), make it improper to promise any immunity from infection if true 
 syphilis be dreaded; and if chancroid be feared, it is not of enough impor- 
 tance to justify a painful cauterization until the lesion has developed. 
 Cleanliness, a little lead-water and a few days' time is all that a recent 
 abrasion calls for. The same treatment also applies to herpes, but it is of 
 advantage to make the lotion somewhat more stimulating than lead-water 
 for herpetic cases. Thus, a simple treatment for a week or ten days be- 
 comes an important aid to diagnosis, capable of saving the patient subse- 
 quent distress and shielding the physician from blame. 
 
 The diagnosis between chancroid and an ulcerated syphilitic lesion 
 situated under the prepuce sometimes gives trouble. An ulcerated mucous 
 patch rarely exists unaccompanied by other lesions, through aid of which 
 its nature may be defined. The pseudo-chancre, however, gives trouble. 
 It is rare as a lesion clinically, and different ulcers have been described 
 as pseudo-chancres by different observers. Founder's pseudo-chancre of 
 syphilitics a secondary induration with ulceration often occurring at the 
 seat of the primary lesion is not likely to give any diagnostic trouble. 
 
 A spontaneous pustule may occur under the prepuce of a syphilitic 
 patient without any suspicious contact, and ulcerating may resemble 
 chancroid closely. This is a pseudo-chancre. An ulcerated gumma is 
 quite apt to appear under the corona glandis, near the pocket of the fre- 
 num, late in syphilis. This ulcer resembles a chancroid, and is quite likely 
 to eat into the urethra if not arrested by treatment. I have seen several 
 instances of both of these sores, particularly the latter, mistaken for chan- 
 croid. The first resembles chancroid greatly; the latter not so closely, 
 because its underlying base and border are quite hard, and its history 
 shows that it started as an induration under the mucous membrane. 
 
 Finally, a pseudo-chancre may occur after suspicious intercourse, due 
 to contagion with any pus, such as pus from an irritated syphilitic chan- 
 cre, an ulcerated mucous patch, from vaginal discharges; and any of these 
 kinds of pus may produce (as is well known), upon the body of a patient
 
 CHANCROID. 27 
 
 already syphilitic, a suppurating sore much resembling, perhaps exactly 
 like, a chancroid but not a chancroid, as has been shown in Chapter II. 
 Such a lesion is a pseudo-chancre. 
 
 Only two other lesions, so far as I am aware, have ever been called 
 pseudo-chancre. These are the mixed chancre of Rollet (to be described 
 later), and the result of inoculation of a true chancroid upon a syphilitic 
 (Tarnowsky), from which latter a simple chancroid may be acquired by 
 another through contagion, or, if the blood of the patient be admixed 
 with the secretion inoculated, true syphilitic chancre as well. The name 
 of pseudo-chancre ought not to be applied to these two lesions, since it 
 leads to confusion, for the first is a compound ulcer possessed of both 
 poisons, the last a simple chancroid upon a syphilitic patient. 
 
 The other three pseudo-chancres, however (1) the spontaneous, not 
 specific, non-indurated, sub-preputial ulcer of syphilitics, (2) the result of 
 hetero-inoculation upon syphilitics in intercourse with syphilitic or indif- 
 ferent pus, and (3) the ulcerated perforating gumma of the genitals all 
 of these pseudo-chancres are fertile sources of error in their diagnosis 
 with chancroid. 
 
 They all occur upon patients already syphilitic; the pus of the first 
 two may be auto-inoculable in generations in each of them, especially 
 the first and the last, there may be no other sign of syphilis present upon 
 the individual. Often a diagnosis can only be made by a close study of 
 the history of the patient, and prolonged attentive inspection of the le- 
 sion. The first two sometimes have the appearances of both chancre and 
 chancroid, but the resemblance to chancroid is the more striking. The 
 perforating gumma is often mistaken for chancroid, occasionally for lupus. 
 A pseudo-chancre rarely looks like a true syphilitic chancre (Fournier's 
 pseudo-chancre of course excepted), but it has certainly been sometimes 
 described as such, and the patient, on its account, has been credited with 
 two attacks of true syphilitics (p. 83.) 
 
 Hence, the practitioner may find himself in face of a pseudo-chancre, 
 one of the three mentioned, and be unable to say whether it is a chan- 
 croid, or not. In such a case what is he to do ? Perhaps the safest rule 
 is this: cauterize thoroughly any pseudo-chancre which is auto-inoculable, 
 and in case of any reasonable suspicion that the ulcer is a gumma, give 
 iodide of potassium. The patient already has syphilis, and he is in no dan- 
 ger of harm from a little more anti-syphilitic treatment. The first two of 
 the three ulcers under consideration will get well by local treatment alone, 
 or by no treatment. They rarely, if ever, become phagedenic. The last 
 ulcer, the perforating gumma, is another matter. This ulcer also gets 
 well in the long run, spontaneously, but meantime it has destroyed tissue, 
 perhaps eaten into the urethra, or made a ragged excavation in the head 
 of the penis. Sympathetic suppurating bubo is rarely, if ever, found 
 with pseudo-chancre, and least of all with this ulcerated gumma. The 
 main hope of diagnosis is in studying the history of the sore and being 
 familiar with its course and appearance. I have published elsewhere the 
 record of a case * in which a tertiary destructive ulcer of the frenum had 
 been cauterized by a gentleman in high authority, as chancroid, and 
 where the malady, failing to get well, had finally been pronounced lupus, 
 and extirpation with the knife gravely decided upon. The man recovered 
 promptly under anti-syphilitic treatment. 
 
 Cauterization does not cure these cases, although they may improve 
 
 1 Case XLVIII. : Van Buren and Keyea. Op. cit., 1st ed., p. 537.
 
 28 THE VENEREAL DISEASES. 
 
 temporarily under the burning. More tissue is destroyed by the local 
 treatment than can be spared, and valuable time lost which might have 
 been employed in intelligent general treatment. 
 
 In only one form of the pseudo-chancre, then, can a mistake in diag- 
 nosis lead to any serious misfortune, namely, in the perforating gummy 
 ulcer of the penis. A knowledge of this fact is the best safeguard 
 against committing a serious error. The lesion, ulcerated gumma of the 
 penis, is described in full on p. 164. 
 
 Certain chancroids are hidden from view. The urethral chancroid 
 almost invariably involves the meatus, but possibly might be out of sight. 
 A sub-preputial chancroid in case of phymosis, an anal chancroid resem- 
 bling fissure these and possibly other varieties cannot be diagnosticated 
 in the usual way. In such case, when the suspicion of chancroid arises, 
 the test of auto-inoculation is invaluable. If auto-inoculation produces 
 a characteristic chancroid (especially if the patient be not syphilitic or 
 cachectic) it may be positively predicated that the source of the inoculated 
 pus was chancroid. 
 
 In auto-inoculation practised for purposes of diagnosis, six facts should 
 be remembered : 
 
 (1). A gangrenous phagedenic chancroid loses its poisonous quality, 
 just as decomposed chancroidal pus is no longer virulent, and auto-inocu- 
 lation fails. 
 
 (2). Auto-inoculation of almost any pus, upon a patient already syphi- 
 litic, may take and produce an ulcer resembling chancroid. 
 
 It must be remembered that the source of such pus is not necessarily 
 a chancroid. 
 
 (3). An ulcer may be a mixed chancre, in which case its auto-inocula- 
 tion will take as a true chancroid; but the patient has syphilis none the 
 less. 
 
 (4). Auto-inoculation of an irritated true syphilitic chancre may some- 
 times take as an ulcer resembling chancroid, and non-irritated true syph- 
 ilitic chancre by auto-inoculation very exceptionally takes as a papule. 
 
 (5). A serpiginous phagedenic ulcer is auto-inoculable, but its auto- 
 inoculation may produce a chancroid, which, in its turn, becomes phage- 
 denic, since phagedaena is a property of the patient and not of the chan- 
 croidal virus he secretes. Hetero-inoculation of a phagedenic chancroid 
 is no more apt to produce a phagedenic sore than is the hetero-inocula- 
 tion of any other chancroidal pus. The deduction is, if auto-inoculation 
 of a phagedenic sore be attempted, the site chosen for the puncture should 
 be the breast under the nipple, since phagedaena rarely occurs here, and 
 the ulcer should be at once destroyed as soon as it can be pronounced a 
 take. 
 
 (6). In all cases of auto-inoculation destroy the little ulcer produced at 
 the test-point as soon as it has served its purpose. 
 
 PROGNOSIS OF CHANCROID. 
 
 Uncomplicated chancroid gets well in a few weeks, and never leads to 
 a result more serious than a triQing local scar. Chancroid of the most 
 malignant type, attended by the most serious complications, never produces 
 syphilis. 
 
 This one fact, that chancroid is not a blood disease and never produces 
 syphilis, reduces all the damage it can do its bearer to such mischief as
 
 CHANCROID. 29 
 
 any ulcer of similar extent and severity might equally well accomplish. 
 In rare instances this damage is considerable. A severe and protracted 
 chancroid of the rectum leads to stricture of that gut with all its distress- 
 ing results; the mouth of the urethra may be nearly sealed up by the con- 
 tracting cicatrix of a chancroid. 
 
 The minor possible results of deformity by eating into the urethra, 
 and of phymosis by cicatricial contraction, must be remembered. 
 
 Erysipelas may attack a simple chancroid as well as any other lesion. 
 The more extensive and complicated sores naturally lead to serious local 
 consequences. 
 
 Phagedaena may stretch itself over large portions of the surface of the 
 body, and last for years. 
 
 Sloughing phagedoena may destroy great segments of the penis, or so 
 eat away its outer investment, that the resulting scar leaves the organ 
 practically useless. A slough has been known to open a large vessel, and 
 serious haemorrhage as a complication thus becomes possible. 
 
 These extreme results are indeed possible, but they are so rare that 
 they may be disregarded in giving an ordinary prognosis. 
 
 TREATMENT OF CHANCROID. 
 
 Preventive treatment. A number of substances have been used 
 experimentally to abort chancroids produced by auto-inoculation. Of 
 late years but little has been done in this direction, and the text-book on 
 syphilis written by Rollet ' contains about all that is known on the subject. 
 Preventive treatment is rarely, if ever, called for by the patient. In fact, 
 the incubation period is so short that a patient has already a typical mi- 
 nute chancroid when he first discovers it, and when he seeks his physician 
 the chancroid is perfectly formed and beyond the reach of prophylactic 
 measures. The only preventive treatment to be recommended to a pa- 
 tient is that he avoid all sources of contagion; and the best preventive 
 treatment of the spread of ulcers upon a patient by spontaneous auto-inoc- 
 ulation, is destruction of the poison at the source of contagion on his own 
 person, by caustic, or the most absolute cleanliness, if total destruction 
 be impossible. The abortive treatment can only be called for when the 
 surgeon has contaminated a fissure on one of his own fingers in manipu- 
 lating a patient with a poisonous discharge. Rollet states that all the 
 strong mineral acids, some of the vegetable acids, the alkaline caustics, 
 and certain salts, such as chromate of potash, sulphate of iron, diluted 
 with water until they are too weak to attack the healthy epidermis, will 
 cause a point of artificial inoculation to abort, if kept in contact with the 
 surface for several hours and applied within a short period of the inocula- 
 tion three to six hours, occasionally as late as twelve to twenty-four 
 hours. Rollet and Rodet think best of a concentrated solution of citric 
 acid. 
 
 These means are very simple and easy of application. It is difficult to 
 believe that absorption is so slow that anything could avail twenty-four 
 or even six hours after inoculation. If this be true, it constitutes a dif- 
 ference between chancroid and syphilis greater than any yet advanced; 
 for the rapidity of absorption of the virus of the latter, and inability of 
 local treatment to abort it after it has once been applied, are well known. 
 
 1 TraitS des maladies veneriennes.
 
 30 THE VENEREAL DISEASES. 
 
 Rollet's suggestions, then, may be tried ; but practically, the surgeon 
 can do better. If he fears inoculation at a fissure in his finger, he immedi- 
 ately plunges his finger into any water at hand (preferably containing 
 carbolic acid), rinses it rapidly, dries it promptly upon a clean towel, and 
 immediately places the suspected spot in his mouth and sucks it. The. 
 unabraded epithelium of the mouth is a bar to contagion should any virus 
 survive the washing, and the comparative immunity of the face to chan- 
 croid is another safeguard from double contagion. After sucking for a 
 moment and expectorating the saliva, the fissure should be touched with a 
 ten per cent, solution of carbolic acid, which is slightly caustic, a strong 
 solution of nitrate of silver, or even with chromic acid, and, if the precau- 
 tions have been followed carefully, contagion will not occur at the acci- 
 dentally inoculated point. 
 
 Radical treatment. Chancroid owes its prolonged existence to the 
 virulence of its pus. Destroy that virulence and the poisonous quality 
 at once disappears, the ulcer becomes a simple traumatism, and the pro- 
 cess of repair begins. Nature herself demonstrates this method of cure. 
 Sometimes a chancroid inflames a sub-preputial chancroid, for example. 
 The tissues become tumid and congested around it, its circulation becomes 
 strangulated, its surface sloughs. As soon as the slough has formed the 
 pus ceases to be auto-inoculable (if the subject be reasonably healthy), and 
 repair goes on at once with the throwing off of the dead tissues. Any 
 means, therefore, which will kill all the living tissues constituting the base 
 of the ulcer and at the same time neutralize all the free poison upon the 
 surface, will radically cure a chancroid. 
 
 There are but two exceptions to this rule: (1). Unless a chancroid 
 is very young, it is apt to return if cut out or cauterized. I have cut away 
 a chancroid with half an inch of prepuce lying between it and the healthy 
 parts, and yet that portion of the wound where the lymphatics were most 
 abundant the neighborhood of the frenum became chancroidal. The 
 most scrupulous attention to cleanliness was paid in this operation. (2). 
 Some old chancroids certainly do not get well after the most extensive cau- 
 terization. This is notoriously true of serpiginous phagedenic sores. 
 Each cauterization brightens them and they do better for a time, but the 
 chancroidal features return to the ulcer and repair fails to follow the clear- 
 ing away of the slough. 
 
 This is never the case with a young chancroid. Such an ulcer, cau- 
 terized thoroughly, ceases absolutely to exist as a chancroid. 
 
 The explanation to this is not, I think, so difficult as it seems at first 
 glance. It is the poison, which must be destroyed to cure a chancroid by 
 cauterization. This poison resides in the pus-corpuscle upon the surface 
 of the sore, and is certainly also present in the base of the sore. In the 
 young ulcer it is confined to these two localities, and a cauterization which 
 includes the infiltrated tissues underlying the ulcer certainly destroys the 
 virulence of the sore. 
 
 In an old chancroid, however, and especially in a creeping, phagedenic 
 chancroid, the poison has infiltrated the tissues for a certain distance be- 
 yond the base of the ulcer, and cauterization does not destroy all the poi- 
 son. It is eliminated from these tissues in course of nature by the white 
 corpuscles, the wandering cells, which become possessed of it and wash it 
 out at the ulcerated surface. If the ulcerated surface is destroyed, it be- 
 comes reinfected by poison brought from beneath; and for the same rea- 
 son the wound of circumcision frequently becomes poisoned, when the 
 prepuce is the seat of chancroid, in spite of such precautions as burning
 
 CHANCROID. 31 
 
 the chancroid previously to the ablation of the foreskin, and perfect clean- 
 liness during and after the operation, 
 
 Why it is that the poison in ordinary cases dies out after a few weeks, 
 and is all eliminated with the pus, while in other cases of advancing pha- 
 gedasna it seems able to perpetuate itself almost indefinitely, it is impos- 
 sible to say, since we do not understand the nature of the poison. The 
 probability is that the difference is solely a question of the soil in which 
 the chancroidal poison finds itself, for phagedaena is a quality of the indi- 
 vidual, and does not imply the inoculation of any special variety of chan- 
 croidal pus. 
 
 With the understanding, then, that in many old cases the chancroidal 
 poison is widespread, and cannot be all reached by any means capable of 
 totally destroying the ulcer, it is yet a uniform opinion among authorities 
 that total destruction of the ulcer is the only certain cure of chancroid 
 and this is true without exception in all cases where the chancroid is 
 young. At exactly what age chancroid ceases to be curable by the de- 
 struction of its surface, and a reasonable amount of tissue beyond, cannot 
 be stated. Cauterization never does harm, and the rule is to cauterize a 
 chancroid thoroughly as soon as its diagnosis is established, and to destroy 
 all points of diagnostic auto-inoculation very promptly. This gives the 
 best chance of speedy and permanent cure. 
 
 Potential caustics are most manageable as destructive agents, and 
 therefore better than other means of destruction. Any surgeon may use 
 his favorite caustic, acid or alkaline, but it must be a strong one. Acetic 
 acid or carbolic acid will not do, and nitric and sulphuric acids fill all the 
 requirements of any case. The chloride of zinc and other pastes pain 
 more than the acids, and their application requires much more skill and 
 care than the latter, that they may be applied thickly enough to destroy 
 all the tissue required, and not left on so long as to destroy too much. 
 The nitric and sulphuric acids meet the wants of all cases the first to be 
 used as a liquid, the second as a paste (carbo-sulphuric). 
 
 To prepare a chancroid for cauterization, all pus should be removed 
 from it by holding pellets of absorbent cotton upon it, and the surround- 
 ing surface should be wiped as dry as possible. Upon the ulcer so pre- 
 pared, a drop of pure carbolic acid is first placed, a little blotting or other 
 bibulous paper being ready in the surgeon's hand to absorb any excess of 
 acid that may escape out of the cup in the skin formed by the chancroid. 
 The carbolic acid causes much less pain than pure nitric acid, and it be- 
 numbs the sensibility of the ulcer so that the application of nitric acid 
 afterward is far less painful than it would otherwise have been, and none 
 the less effective. 
 
 The drop of carbolic acid is absorbed out of the chancroid with bibu- 
 lous paper, and the white, dry cup representing the chancroid is now 
 ready for the final cauterization. 
 
 A glass rod, drawn to a point, is now dipped into fuming nitric acid, 
 and enough acid placed upon the chancroid to fill its depression even 
 with the surface. The bibulous paper is again used, if any excess of acid 
 trickles over. This application is but slightly painful. The surrounding 
 tissues are now held tense, and the little drop is watched. If the edges 
 of the ulcer are undermined, the point of the glass rod should be moved 
 around under the border beneath the surface of the drop of acid, so that 
 all the recesses of the sore may be equally acted upon. 
 
 As the acid cauterizes the base of the ulcer, an areola of white color 
 is seen to grow gradually around the sore under the epithelium. When
 
 32 THE VENEREAL DISEASES. 
 
 this areola gets to be as broad as a sheet of blotting-paper is thick, the 
 cauterization is perfect. If it does not become so broad after watching it 
 for two or three minutes, the drop of acid should be soaked out of the ulcer 
 and a new one put in and so on until the areola of white dead cauterized 
 tissue reaches the required thickness. Then the sore is dried perfectly, 
 covered with scraped lint or absorbent cotton, and left to itself. It is 
 rarely necessary to alkalinize the surface; but this may be promptly done, 
 if thought necessary, with a drop of liquor potassae. 
 
 The white piece of tissue killed by the acid turns brown, then black. 
 If its position is such that it may be exposed to the air, it is best to let it 
 dry up and heal by scabbing, as it will sometimes do. Most chancroids, 
 however, are sub-preputial. The little eschar begins shortly to slough off, 
 a line of healthy suppuration forms around and beneath it. Absorbent 
 cotton or moistened lint answer perfectly well as dressings to absorb the 
 pus, or, if stimulation be needed, a good dressing, and one perfectly 
 cleanly, is either of the following: 
 
 $. Spts. rect 3 iss. iij. 
 
 Aquae q. s. ad i. 
 
 M. 
 Or- 
 
 ^ . Chloral hydrat gr. i. iij. 
 
 Aquae 3 i. 
 
 M. 
 
 In many cases a little vaseline or balsam of Peru, upon a piece of pre- 
 pared lint, gives most satisfaction. 
 
 A small chancroid thoroughly burned ought to be well in ten days, 
 more extensive sores require more time. 
 
 In case it is decided to cauterize a chancroid with an irregular base, 
 overhanging edges, or pockets, where perhaps from the position of the 
 sore the liquid acid cannot be evenly applied to the whole surface, the 
 carbo-sulphuric paste meets the requirements of the case. This paste 
 originated with Ricord, and is formed by mixing vegetable-charcoal dust 
 with pure sulphuric acid until a black paste is formed. This is kept tightly 
 corked in a bottle. It is applied with a flat piece of wood and pressed 
 down into all the inequalities of the sore. The ulcer is filled up even 
 with the surface, and the paste bound on and left to do its work of de- 
 struction. There is no danger that it will eat too deeply into the tissues. 
 It chars the tissues before it, and the cauterizing action cannot penetrate 
 beyond a safe depth. 
 
 But two cautions are to be given relative to the cauterization of un- 
 complicated chancroid in the usual positions. 
 
 (1). Never touch a chancroid with caustic unless each and every 
 abrasion in the neighborhood, and all suppurating spots, can be totally and 
 simultaneously destroyed. For if any chancroidal pus remains unneu- 
 tralized it is ready to poison the healthy ulcer left by the separation of 
 the slough, and to reconvert it into a chancroid. Thus, chancroid at the 
 margin of the prepuce cannot be cauterized if sub-preputial chancroid 
 also exists and is spared. 
 
 (2). In case of numerous sub-preputial chancroids, if the foreskin be 
 naturally tight the reaction following cauterization may inflame the pre- 
 puce sufficiently to cause phymosis and conceal the cauterized spots from 
 view. A fear of this occurrence need not deter the surg-eon from a free
 
 CHANCROID. 
 
 use of the cautery. The cavity of the prepuce can be kept syringed out, 
 and if the cauterization has been effective the chancroids will certainly 
 get well, even within an inflamed prepuce. 
 
 PALLIATIVE TREATMENT OF CHANCROID. 
 
 When all the chancroids cannot be reached, when the surfaces in- 
 volved are quite extensive, the chancroids already a number of weeks old 
 and not phagedenic, and in cases of certain regional chancroids, urethral, 
 anal, rectal, at the margin of, or beneath a tight prepuce, cauterization 
 is not generally applicable, and palliative treatment must be employed. 
 
 When all the chancroids cannot be reached, or are so large and old 
 that cauterization is not justifiable, cleanliness is the first requisite of 
 treatment. Frequent washings with warm water lightly carbolized (half 
 of one per cent.), are to be recommended. The surfaces should be 
 washed with a syringe, or by trickling warm water upon them, and dried 
 by touching them with bibulous paper. Unquestionably the most effi- 
 cient local application for these chancroids is iodoform, and its applica- 
 tion pure, in powder or mixed into a paste with glycerine and scented 
 with essential oils, is rarely painful. But respectable people will not use 
 iodoform. Its peculiarly penetrating and tenacious odor is unmistak- 
 able. Those who have once smelled it upon any one else fear disclosure 
 from the very fact of using it, and most of those who are unfamiliar with 
 it at first, soon get to abhor it. In spite of all this it remains the most 
 efficient local application for chancroids too old to burn, and by a careful 
 person can be often so used as to escape all the disadvantage attaching 
 to it. 
 
 Nothing will disguise the odor of iodoform. Oil of peppermint is per- 
 haps the best of the aromatic oils for the purpose. Many other sweet- 
 smelling oils have been used. These are combined with powdered iodo- 
 form in ointment with various greasy excipients, or the powder is rubbed 
 into a paste with glycerine and then scented. The misfortune is that the 
 odoriferous principle is more volatile than the iodoform, and, aided by 
 the heat of the body, soon leaves the odor of the iodoform supreme. Ap- 
 plications of iodoform, dissolved in ether or chloroform, have been re- 
 commended. Their application is painful, the solvent evaporates, and 
 the odor exhales as strongly from the fine dust left precipitated over 
 the surface of the ulcer, as if it had been at first deposited there in its 
 natural state. 
 
 Still, iodoform is too good a substance to be given up. Those who do 
 not object to the odor can use it freely as a powder, or rubbed into a 
 paste with glycerine. Others may use it undetected if their chancroids 
 are sub-preputial and the prepuce reasonably long. The sores must be 
 washed and dried. A little fine iodoform dust is then taken upon a 
 narrow piece of card and scattered over the ulcerated surfaces. The pre- 
 puce must now be carefully pulled forward and a piece of absorbent 
 cotton placed in its orifice. No portion of the iodoform must be allowed 
 contact with the clothes or the fingers of the patient. He must be care- 
 ful, upon urinating, to pull out the cotton gently, retract the prepuce only 
 enough to disclose the meatus, and put in a fresh piece of cotton immedi- 
 ately. He must change his dressing frequently, at home, and use great 
 care in his washings, not to let the water which has run over the sores 
 touch any part of his person or of his clothing. By using such pre- 
 3
 
 34 THE VENEREAL DISEASES. 
 
 cautions, the most fastidious patient may employ this valuable remedy 
 without betraying himself. 
 
 The effect of iodoform upon chancroids is very striking. It fresh- 
 ens up the surface wonderfully, and greatly shortens the duration of the 
 sores. When it cannot be used, the choice of a local dressing lies between 
 many soothing and gently stimulating applications. If the sores are sub- 
 preputial, and the prepuce loose, it is well always to pull back the fore- 
 skin, and, whatever dressing is employed, to interpose a film of moistened 
 prepared lint, or dry bibulous paper, or absorbent cotton, in such position 
 that it will lie between the sores and the healthy tissues, when the fore- 
 skin has been replaced. 
 
 When the discharge is not profuse, dry absorbent dressings alone may 
 be used, or, in addition, the ulcers may be sprinkled with powdered oxide 
 of zinc, or starch with a little calomel (gr. x. to 3 i.)> or bismuth and ly co- 
 podium in equal parts. The addition of a little camphor keeps the secre- 
 tions sweet. The dressings must be changed often, and the sores fre- 
 quently washed and dried. These remarks, be it understood, apply to 
 chancroids which may not be burned, and where idoform is objectionable 
 for any reason. 
 
 When the discharge of pus is considerable, rather stimulating, moist 
 dressings are preferable, and lint slightly moistened with the fluid selected 
 should be kept constantly applied to the surface of the ulcer. Any of 
 the following lotions will serve : 
 
 3 . Zinci sulph gr. i. iij. 
 
 Aquae i. 
 
 M. 
 Or 
 
 $. Potass, permanganatis gr. i. iij. 
 
 Aquae i. 
 
 M. 
 Or 
 
 $. Acid carbolic gr. ij. iij. 
 
 Aquae i. 
 
 M. 
 Or 
 
 $. Ferri et potass, tart gr. v. xx. 
 
 Aquae f i. 
 
 M. 
 Or 
 
 IJ Vini aromatic 3 i. iij- 
 
 Aquae q. s. ad f i. 
 
 M. 
 
 With sucb applications and patience, all uncomplicated chancroids 
 get well within a reasonable period. In using No. 2, 4 or 5 of the above, 
 care must be taken by the patient not to soil his linen ; the others leave 
 no stain. 
 
 Internal medication is of no value in ordinary cases of chancroid. If 
 the patient be manifestly debilitated, he should receive tonics and good 
 food, and all functional derangements demand appropriate attention, but 
 there is no internal specific for chancroid. Rest of body is sometimes 
 desirable. 
 
 If the ulcers prove very sluggish, and need spurring on, it is useful to
 
 CHANCROID. 35 
 
 make an occasional application, directly to the ulcerated surfaces, of bro- 
 mine 3 ij- to the L, or of pure carbolic acid, or of a saturated solution 
 in water of permanganate of potash. A thorough going over with nitrate 
 of silver will sometimes freshen the ulcers up ; but time is the most effi- 
 cient element in effecting a cure in all ulcers too old for rapid cure by 
 thorough cauterization, or where destructive measures have been inap- 
 plicable from the first. 
 
 Anal and rectal chancroids are always obstinate and difficult to 
 manage. The daily stretching of the parts by the faeces, and the diffi- 
 culty of maintaining perfect cleanliness, are the main obstacles to cure. 
 
 Cauterization is inappropriate for ulcers in this region. Frequent 
 washings with warm water containing chlorinated soda, and confinement to 
 bed, with lavish use of iodoform powder upon all the ulcerated surfaces, 
 is unquestionably the best treatment for recent chancroids in these regions. 
 Constipation must be prevented. When the chancroid has lasted for years, 
 and produced stricture of the rectum, extirpation with the knife, linear rec- 
 totomy, or lumbar-colotomy, may be required to effect a cure. (Bridge's 
 case.) 
 
 Chancroids at the margin of the meatus urinarius may be cauterized 
 unless they run too far down into the urethra. In such case iodoform 
 plugs (a roll of lint covered with cerate and sprinkled with iodoform) will 
 hasten cure. If the patient objects to this, he must wait long for nature 
 to help him, for chancroids in this locality are very sluggish. Urethral 
 chancroids are best let alone. They are very rare, and their ultimate 
 effect is stricture of the urethra. 
 
 Sub-preputial chancroid implies a chancroid concealed by a pre- 
 puce, either congenitally tight, so that it cannot be retracted, or in a 
 state of temporary phymosis from inflammation. The latter condition 
 will be discussed under the head of Complications (p. 37). 
 
 When a chancroid is inside of a congenitally contracted foreskin, its 
 presence can sometimes only be surmised. Generally a lump, tender on 
 pressure, may be detected at one spot, however, or there may be several 
 of them; and the auto-inoculability of the pus, and possible existence of 
 chancroids at the margin of the prepuce, help to make the diagnosis. 
 
 In treating such chancroids, if the prepuce be not inflamed and in 
 danger of strangulation, it is not necessary to use the knife. No exten- 
 sive destruction of the parts within the prepuce is apt to occur unaccom- 
 panied by such external evidences of destructive inflammation as will 
 naturally call for heroic interference. 
 
 Cleanliness is, if possible, more necessary in treating these chancroids 
 than any others. A syringe with a long, flattened nozzle l should be 
 used, its point inserted well down to the sulcus behind the corona, and 
 into the pockets on either side of the frenum. Warm injections of the 
 one-half of one per cent, solution of carbolic acid should be made fre- 
 quently enough to keep the pus from accumulating. Ricord praises the 
 occasional injection of a gr. v. xv. solution of nitrate of silver. Iodoform 
 shaken up with balsam of Peru may be injected into the depths of the 
 preputial cavity with a syringe. Generally, these chancroids are slow, 
 and cleanliness, with time, the only real elements in the cure. 
 
 Chancroids of the margin of the prepuce, there being no ulcers 
 within, if they can be thoroughly exposed, should be cauterized. 
 
 Chancroids undermining the frenum call for a division of the frenum, 
 
 1 Such a syringe has been devised by Dr. R. W. Taylor, of New York.
 
 36 THE VENEREAL DISEASES. 
 
 to hasten their cure and avert the possibility of bleeding, should the fre- 
 num get accidentally ruptured or eaten through by ulceration. This is 
 best accomplished by tying a stout silken ligature around it, and cutting 
 the ligature short. The ligature cuts its own way through very promptly, 
 and then the open chancroid may be treated more satisfactorily. 
 
 Chancroids of the vulva and vagina call for especial care. Cau- 
 terization, if applied, must be done with great accuracy and thoroughness, 
 with the parts fully exposed. The speculum must always be used, and 
 the whole of the interior of the vagina inspected for other ulcers, or cau- 
 terization of the chancroid of the fourchette, or elsewhere, is apt to be 
 ineffective. Young chancroids anywhere about the female genitals (ex- 
 cept at the orifice of the urethra) may be successfully cauterized ; old 
 ones are best treated with cleanliness, disinfectant injections, rest, and 
 iodoform. lodoform may be easily so managed upon a female as not to 
 be offensive in odor. Follicular chancroids on the labia majora, at the 
 roots of the hairs, are not very unusual in woman. They look like boils 
 at first. They should never be poulticed, but opened very early, and 
 cauterized thoroughly. 
 
 The external genitals in the female sometimes become greatly hyper- 
 trophied from the prolonged presence of chancroids at the ostium vaginae. 
 Treatment of the hypertrophy is useless until the chancroids are cured, 
 after which it usually slowly subsides spontaneously. Traces of it may 
 remain almost indefinitely. 
 
 Chancroid of the fingers. When the surgeon or accoucheur gets a 
 chancroid upon the finger, it should be thoroughly cauterized, and then 
 splinted, and kept covered up from dust and exposure to air. A chan- 
 croid on a knuckle is sometimes as hard to cure as a chancroid of the 
 anus or at the meatus urinarius, the reason being that the incessant in- 
 jury done by motion of the part keeps the ulcer alive. An ordinary 
 abrasion will sometimes ulcerate, and last for weeks upon a knuckle. I 
 have known one such abrasion to be diagnosticated as a syphilitic chancre, 
 and the patient kept miserable for years, fearing syphilitic eruptions 
 which never came. A splint putting the knuckle at rest is all the special 
 treatment that is required in these cases.
 
 CHAPTER IV. 
 
 CHANCROID. 
 
 THE COMPLICATIONS OF CHANCROID, AND THEIR TREATMENT. 
 
 Chancroid complicated by Inflammation.' Inflammatory Phymosis and Paraphymo- 
 sis, with their Treatment. Phagedsena, Sloughing and Serpiginous, and its 
 Treatment. Chancroid complicated by Syphilis. The Lymphangitis of Chan- 
 croid, Inflammatory and Virulent, and its Treatment. The Bubo of Chancroid, 
 Simple, Indolent, Spontaneous (Bubon d'Emblee). Treatment of Simple Bubo. 
 Treatment of Indolent Bubo. Virulent Bubo, or Subcutaneous Chancroid. 
 Treatment of Virulent Bubo. 
 
 CHANCROID may be complicated by inflammation, phagechena, syphilis, 
 lymphangitis, and bubo. 
 
 Chancroid, complicated by inflammation. An ulcer doubtless 
 cannot exist without some inflammation, but a typical chancroid is at- 
 tended by so little of this process that, practically, inflammation does not 
 exist; certainly there is no pain, heat, redness, swelling, or interference 
 with function worthy of being taken into account. Most chancroids, 
 however, as encountered clinically, are inflamed in a measure, and possess 
 all the five qualities of inflammation to a greater or less extent. This 
 amount of inflammation does not constitute a complication. 
 
 When a chancroid inflames from mechanical or chemical irritation, or 
 from the habits of the patient (drinking, debility), its base hardens, its 
 discharge grows thinner and sanious, pain is complained of, and generally 
 the course of the sore is prolonged, the surrounding tissues becoming 
 cedematous and indurated, and the ulcer finally pale, flabby, unhealthy, 
 going on to a slow cicatrization. Simple (non-virulent) bubo is very much 
 more apt to occur with an inflamed chancroid than with a typical ulcer. 
 
 When inflammation complicates sub-preputial chancroid, the tissues 
 of the prepuce become much distended with serum, and sometimes very 
 hard and rigid from stiffening of the connective tissue by inflammatory 
 exudation. A superficial lymphangitis is the cause of these phenomena; 
 the larger lymphatic vessels may escape entirely. This lymphangitis is 
 not an erysipelas, although it greatly resembles it. It is not an uncom- 
 mon complication of chancroid, while true erysipelas is a rare one. 
 
 Inflammatory phymosis or paraphymosis, under these circumstances, 
 often ensue. If the chancroid occupies the inner surface of the prepuc'e, 
 it is in danger of strangulation among the inflamed tissues, and may fall 
 into total gangrene, a large portion of the prepuce, with the chancroid, 
 sloughing away, and allowing the glans penis to protrude through the 
 opening, making a sort of double-headed penis. The remains of the pre- 
 puce in such cases long continue thickened and indurated, and require to 
 be trimmed away finally, when cicatrization is complete. 
 
 This result of inflammation is not a serious one, since the sloughing
 
 38 THE VENEREAL DISEASES. 
 
 process kills the chancroid outright and repair commences with the sepa- 
 ration of the slough, just as it does after effective cauterization. 
 
 A more disastrous result of inflammatory phymosis is the possibility 
 of many new points of auto-inoculation within the cavity of the prepuce, 
 the retained poisonous pus excoriating the surface of the glans penis and 
 perhaps inoculating the meatus. Portions of the new chancroids may 
 then slough, and considerable loss of the glans penis ensue, with stricture 
 of the meatus from cicatrization. The liability of causing bubo by allow- 
 ing an inflamed prepuce over a chancroid to remain long unrelieved is to 
 be borne in mind, and the possibility of extensive denudation of the penis 
 by the backward burrowing of the retained chancroidal pus has been clin- 
 ically proved (Vidal). 
 
 Inflammatory paraphymosis may complicate a chancroid when 
 the prepuce is short. The swelling encircling the penis may become so 
 great that the circulation of that portion of the penis lying in front of the 
 constriction is menaced. 
 
 The treatment of inflammatory complications of chancroid is obvi- 
 ous. Rest must be insisted upon, the penis elevated and covered with 
 moist, cooling, evaporating lotions, or with astringent solutions. Among 
 the former, one of the best is: 
 
 ]J. Glycerine 
 
 Spts. rect ..................................... 3 i. ij. 
 
 Liquor, plumbi sub-acetat. dil ........... q. s. ad | i. 
 
 M. 
 
 It is to be kept constantly applied cold upon a thin cloth on the outside 
 of the penis. 
 
 Solutions of tannin act exceedingly well as astringents in some con- 
 ditions of cedema of the penis. The main objection to it is that it stains 
 white fabrics. From gr. x. xx. in ^ i. of water is strong enough. It 
 must be constantly applied fresh, and the penis kept well elevated. 
 
 These applications are palliative. The treatment of the chancroid, 
 meantime, goes on by sub-preputial injections, idoform applications, or 
 whatever it may be. If the sub-preputial discharge of pus gains in quan- 
 tity, if the inflammation fails to yield and gangrene is to be feared, then 
 but one course is left, namely: to slit open the cavity of the prepuce^ 
 cut away the redundant tissue, circumcising the patient, and dress un- 
 sparingly with iodoform. Cauterization in these cases will not prevent 
 the wound from becoming inoculated, and only prolongs the duration of 
 the sore. 
 
 In cases of paraphymosis the line of stricture of the prepuce must be 
 divided with the knife as soon as the circulation of the penis in front of 
 it is threatened. If the circulation continues perfect it is better in most 
 cases not to attempt to reduce the paraphymosis, since the latter insures 
 the advantage of leaving the ulcers exposed to view. A patient with para- 
 phymosis is generally confined to bed, and the odor of iodoform ceases to 
 be an objection to its use. 
 
 Chancroid complicated by phagedaena. This is the most formid- 
 able of all the local complications of chancroid. Phagedeena occurs in 
 two forms: (1), sloughing phagedaena; (2), serpiginous phagedaena. The 
 
 disposing general causes of phagedaena are not fully known. It some- 
 times attacks a florid, healthy-looking youth, and often spares a cadaver- 
 ous consumptive, or a patient debilitated by excesses of all sorts. It is a
 
 CHANCROID. 39 
 
 rare complication. Phagedaena is not confined to chancroids. Any ulcer 
 syphilitic, scrofulous, or simple may be attacked by it. Phagedaena is a 
 peculiar quality of the individual. The pus from a phagedenic ulcer will 
 not produce phagedaena by hetero-inoculation. This has been abundantly 
 proved by Fournier's confrontations, Sperino's syphilization, the inocula- 
 tions of Salneuve, Rollet, and others. Conversely, it is known that a sim- 
 ple chancroid produced upon a patient with phagedaena is liable also to 
 become phagedenic, showing clearly that the phagedenic quality is a per- 
 sonal one. 
 
 Among the presumed predisposing causes of phagedaena have been 
 grouped all depressing dietetic, hygienic, diathetic and pathological con- 
 ditions old age, misery, alcoholism, scrofula, malaria, digestive troubles 
 but not one of these can be proved efficient even in a majority of cases. 
 As local causes, lack of cleanliness and mercurial ointment (Ricord) have 
 been accredited with a fair share of the blame in the production of pha- 
 gedaena, but probably without good ground for the accusation. It is prob- 
 able that phagedaena is a personal idiosyncrasy, perhaps allied to the 
 scrofulous diathesis (but independent of it), not existing continuously in 
 a given patient, and aggravated by those causes which have generally been 
 considered capable of generating it. No other explanation than this cov- 
 ers the cases of bright-eyed, rosy-cheeked, fat, hearty boys, with good 
 appetites, strong physical powers, and in the healthy performance of their 
 functions with phagedasna. I have encountered several cases of this sort. 
 On the other hand, who has not met with broken-down patients with 
 syphilis, consumption, cancer, malaria, fever, cachexia, old age, dyspep- 
 sia, whose chancroids belong to the simplest possible type and run their 
 course mildly in a reasonable time. 
 
 Sloughing phagedaena. When a chancroid is attacked by sloughing 
 phagedaena the tissues beneath it swell up and become livid for a distance 
 around. The pus gets scanty and sanious. The ulcer grows larger and 
 dryer; a slough, gray, brown, black, promptly forms upon it; the part be- 
 comes excessively painful; the slough separates promptly, or slowly, ac- 
 cording to its thickness; and then comes a lull in the process. 
 
 After a rest of longer or shorter duration a new attack of pain an- 
 nounces the commencing formation of a new slough, and the process re- 
 peats itself. Large excavations in the tissues are thus caused, for slough- 
 ing phagedaana spares nothing. It does not dissect out the vessels or ar- 
 rest itself at a barrier formed by a new tissue. Fortunately, it generally re- 
 mains superficial and advances on one side while it gets well on the other. 
 This is not always the case. It may sweep away the penis in the male, 
 destroy the labia and perineum in the female, make the most extensive 
 ravages before its fury is appeased. It has been compared to hospital 
 gangrene, which it much resembles. It may even endanger life by excit- 
 ing peritonitis when ulcerating deeply over the abdomen, or giving rise to 
 profuse haemorrhage by cutting through a blood-vessel. It may wear 
 out the sufferer by pain, fever, exhausting diarrhoaa, and debilitating 
 sweats. 
 
 The poisonous chancroidal quality of these ulcers remains as tested 
 by inoculation, yet the poisoned surface seems to grow tolerant of the 
 virus after a time, and one side of the great ulcer will be cicatrizing, 
 while a fresh slough is forming on its opposite border. 
 
 Serpiginous (creeping) phagedaena. This form of phagedaena is 
 milder in all respects than the sloughing variety, but, in revenge, it is more 
 chronic. The former exhausts itself, yields to treatment, or kills the pa-
 
 40 THE VENEREAL DISEASES. 
 
 tient within a reasonable period, while creeping phagedana seems to have 
 little or no reaction upon the general health, is not attended by much 
 pain or any fever, and yet continues sometimes almost indefinitely. The 
 longest duration for a phagedenic chancroid yet recorded is fourteen 
 years. This case is reported by Fournier, the phagedaena commenced in 
 a virulent bubo at the groin, and was still open at the knee when reported 
 by Fournier several years ago. Its duration was not due to bad treat- 
 ment, for Ricord had had the patient under his care for several years. 
 
 The nature of the creeping phagedsena is not known any more than 
 that of sloughing phagedaena. All that can be said is, that it is not trans- 
 mitted by hetero-inoculation, and generally occurs upon the debilitated. 
 The lower orders of society furnish most of the cases for hospitals. Among 
 the upper classes it is seldom seen, except in its mildest form, which con- 
 sists simply in an unusual spread in the area of the ulcer, some deviation 
 from the rounded shape, and a certain prolongation of the duration of the 
 sore. 
 
 Serpiginous phagedfena commences as a swelling at the borders of the 
 chancroid, which become more red than usual. Some headache may be 
 complained of, and a burning sensation at the advancing edge of the 
 ulcer. The connective tissue falls into molecular gangrene more readily 
 than the fibrous felting of the cutis vera, and, as a consequence, the bor- 
 ders of the ulcer become largely undermined. The remaining bridges 
 and their flaps of livid skin, perforated here and there where the ulcera- 
 tive action has eaten through to the surface, make pockets and sinuses 
 around the ulcer, some of which extend to long distances. In this manner 
 all the integument of the penis may be dissected up, large pouches run 
 down the thigh and around the crest of the ilium, or (more rarely) up over 
 the abdomen. 
 
 As one side of the ulcer advances the other generally heals, and thus 
 the ulcer creeps for months, perhaps for years, over the surface. The base 
 of the sore retains its chancroidal character. It is uneven, gray, covered 
 with adherent, pultaceous secretions, and occasional prominent, flabby 
 granulations bleeding at the slightest touch. The discharge is watery, 
 bloody, usually free, occasionally scanty, but still auto-inoculable. 
 
 Periods of rest of greater or less length occur during the progress of 
 phagedsena, when the ulcer remains stationary, or even, perhaps, seems 
 to be healing all around; arid then, without apparent cause, the phage- 
 denic action will commence again at one border, while cicatrization goes 
 slowly on undisturbed at the other. 
 
 Phagedaena once seen cannot afterward be confounded with anything 
 else. Its attacks are not limited to chancroid, but are also seen in the 
 serpiginous ulcerative scrofulide or syphilide. In any case of doubt, diag- 
 nosis must rest upon the history of the origin of the process (in a chan- 
 croid or virulent bubo), and upon the auto-inoculability of the pus. 
 
 The bubo attending phagedenic chancroid may be a simple one, or may 
 be virulent, and itself take on phagedenic action. Phagedaena seldom, if 
 ever, attacks simple inflammatory bubo. 
 
 Serpiginous phagedaena never gets beneath the deep fascia ; a change 
 of tissue will often stop it, and it will dissect out nerves and vessels, leaving 
 them exposed in the wound; it is generally arrested at mucous membranes. 
 Unless commencing in the vagina, it rarely enters it, and does not enter 
 e rectum from without. In both of these localities, especially the va- 
 gina, it may thrive and last for years ; but in these cases it has originated 
 in a chancroid, upon the mucous surface, and has not commenced outside,
 
 CHANCROID. 41 
 
 as phagectaena in a bubo, for instance, and worked its way from the in- 
 tegument into the vagina. 
 
 Treatment of phagedaena. All possible improvement in the hygie- 
 nic surroundings of a patient, a generous and varied diet, and internal 
 tonic measures, are of value in treating phagedsena. Cod-liver oil, if it 
 can be digested, quinine in large doses, especially in the depressing fever 
 of sloughing phagedsena, and iron, are excellent remedies. Custom has 
 sanctioned the preference of Ricord's tartrate of iron and potash, in ten 
 to twenty grain doses in solution, as a tonic in phagedaena. Ricord 
 thought it was nearly a specific, and some cases certainly do well upon it. 
 
 The internal treatment of phagedaena by opium will sometimes suc- 
 ceed, especially in old cases of serpiginous sore, where there is more pain 
 than usual. Some surgeons place much reliance upon opium in all condi- 
 tions of chronic ulcer. Rodet reports cases of serpiginous chancroids, 
 which got well under opium, after other means had failed. The solid 
 opium (or an extract) is given in small and repeated doses, gradually in- 
 creased as the patient acquires tolerance, and pushed to the point of keep- 
 ing him slightly narcotized all the time. If good effect is to follow, it 
 commences within a week or ten days. The objections to the treatment 
 are the constipation it occasions, to be met by the use of appropriate lax- 
 atives given with the opium, and the possible danger of establishing the 
 opium-habit. 
 
 The local treatment is more important than general measures. It 
 must be remembered that a chancroid never commences phagedenic. It 
 exists as a chancroid for a varying time, and then takes on phagedsena. 
 A chancroid by auto-inoculation upon a person with phagedasna acts in 
 this way, and the advantage of early and thorough destruction of all chan- 
 croids becomes on this account very evident. 
 
 Both forms of phagedtena require the same local treatment. They 
 should be managed like cases of hospital gangrene. Total destruction of 
 all the tissues involved, and extending widely beyond the immediate area 
 of disease, is certainly the best treatment. This cauterization must be a 
 severe one. It will not destroy more tissue than the ulcer left to itself 
 would have eaten away, and an imperfect cauterization will do more harm 
 than good. 
 
 Ether should always be administered in these cases. The ulcer must 
 first be ready for cauterization. All overhanging bridges and flaps of un- 
 dermined livid integument must be cut away. It is best to do this with 
 scissors, and to sear the bleeding edges at once with a thermo-cautery 
 (such as Paquelin's). When all sinuses have been laid open, and the 
 whole ulcer is flat and exposed and the bleeding arrested, then the sur- 
 face should be washed with a solution of carbolic acid, and dried with 
 bibulous paper. Next, it should be touched all over with pure carbolic 
 acid. This whitens the surface, but leaves it soft, and it may be dried, 
 and left quite clean and white, ready for the final cauterization. 
 
 Nitric acid cannot be depended upon in burning these extensive ulcers. 
 A certain depth beneath the ulcer must be destroyed in all directions, in 
 order that the cauterization may prove effective. As the floor of the ulcer is 
 uneven, a liquid caustic cannot be applied uniformly over the whole sur- 
 face ; it will spare the elevations, and spend its force upon the depressions. 
 There is no reason why, if accurately applied, nitric acid should not serve 
 as well here as any caustic ; but the difficulty is mechanical, and other 
 caustics are better. 
 
 The choice of caustic lies between actual cautery and a caustic paste,
 
 42 THE VENEREAL DISEASES. 
 
 Hot irons do not cauterize well, because they give up their heat very 
 promptly, and, therefore, cauterize unevenly. The electro-cautery is bet- 
 ter, or the naphtha cautery of Paquelin, because the cautery point can 
 be kept uniformly hot throughout the entire sitting, no matter how pro- 
 longed the latter may be. By the use of these means, employed with 
 the utmost deliberation and care, if the entire base and the surrounding 
 integument for one-fourth of an inch can be absolutely charred by the 
 cautery, nothing more can be asked, and a cure of the phagedaena may be 
 confidently expected. 
 
 Unfortunately, but few phagedenic sores are sufficiently small, or so sit- 
 uated as to be certainly totally destroyed in this manner without endanger- 
 ing surrounding parts. In such case, if the ulcer is suitable for cauteriza- 
 tion at all, a caustic paste should be employed. Either the chloride of zinc, 
 or the carbo-sulphuric paste may be used preferably the former, freshly 
 prepared, by mixing equal parts of chloride of zinc and dried flour, with a 
 few drops of alcohol, into a paste. This is to be packed and crowded into 
 all the uneven crevices and irregularities of the surface already prepared, 
 as directed above, and thoroughly dried out. The packing is done with 
 a small wooden spatula, and the excavation of the ulcer filled in even with 
 the surface of the surrounding integument at the edges, but not laid on, 
 thicker at any one spot than one-eighth of an inch, since this thickness is 
 ample. The packing is now accurately covered with a piece of prepared 
 lint cut to fit, the surrounding epidermis is greased with vaseline freely, 
 then the whole surface is generously dusted with powdered starch or lyco- 
 podium, covered with a thick layer of absorbent cotton, the whole retained 
 by a snug roller-bandage. 
 
 Morphine may be required to control pain. The bandages should be 
 removed in from twelve to twenty-four hours, the surface washed, and 
 dried with absorbent cotton, and finally dressed with a mildly carbolized 
 water dressing, or any other simple application. 
 
 Bromine has been suggested for these ulcers, and a saturated solution 
 of permanganate of potash, but neither of these means have been generally 
 enough employed to justify a conclusion as to their exact value. The 
 methods above detailed are certainly efficient where cauterization is justi- 
 fiable. 
 
 There are many cases of bad phagedaena in which cauterization should 
 not be attempted. In any case, when the whole surface cannot be laid 
 bare and included in one cauterization, other means must be used. This 
 exception covers many cases of vaginal and rectal phagedasna cases in 
 which such extensive layers of integument have been dissected up, that 
 it becomes unsurgical to remove them, e. ff., when the integument of the 
 penis is very much undermined, cases in which long sinuses exist involv- 
 ing too extensive destruction of tissue. Finally, cauterization is not ap- 
 plicable when there is danger that the caustic may do harm by eating in 
 too deeply; on this account, extensive and deep phagedaena over the 
 femoral vessels, which would stay the hand of the operator through fear 
 >f going too deeply, is not a proper case for caustic. Finally, if thorough 
 snzation has once failed, it is better to try other means before resort- 
 ing to it again, and under these circumstances the occasional application 
 
 the lighter caustics, carbolic acid, bromine, saturated solution of per- 
 manganate of potash, have a place, and doubtless will freshen up the sur- 
 face and help to cure in many cases where thorough cauterization cannot 
 be applied, or has failed. 
 
 n here cauterization is not applicable, pure powdered iodoform is.
 
 CHANCROID. 43 
 
 incomparably the best local application. The ulcer should be covered 
 with iodoform dust, which is to be renewed as often as the discharges 
 wash it away. This, with disinfecting washes of weak carbolic acid or 
 weak chlorinated soda-water, is an excellent resource, and often acts like 
 a charm. Ricord's old favorite as a local application, gr. xx. xl. solu- 
 tion of tartrate of iron and potash, must not be forgotten. 
 
 An attack of ordinary erysipelas passing over a phagedenic chancroid 
 sometimes cures it entirely. 
 
 The method of treating phagedenic, syphilitic, and other unhealthy 
 sores, by intermitted or continuous submersion in water, has been revived 
 of late, and brought into prominence through the publication, by Mr. 
 Arthur Cooper, 1 of some exceptionally good results obtained by its use in 
 the Lock Hospital, upon patients under the care of Mr. Alfred Cooper 
 and of Mr. Milner. 
 
 This treatment is not at all new. The names of Hebra in Germany, 
 Hutchinson in England, and Hemard in France, are well known in con- 
 nection with it; but the supposed difficulty in carrying out the process, 
 a lack of widespread conviction in its superior value, and the fact that 
 text-books do not commonly advise this form of treatment, have kept it 
 out of general use, and prevented it from being tested on a large scale. 
 It is time that this apathy, regarding what promises to be an excellent 
 method, should come to an end. The reliable results which have been 
 published certainly render the method worthy of trial in all severe cases 
 of phagedaena, whether attacking chancroid, chancroidal bubo, or a syphi- 
 litic sore. 
 
 The method of submersion employed by Mr. Cooper is simple and 
 easy to carry out, while its effectiveness can hardly be doubted after read- 
 ing the report of the cases in which it was used. Briefly, the method is 
 as follows: 
 
 The patient is made to sit in a hip-bath, or other convenient bath, so 
 that the site of the ulcer may be entirely submerged for from eight to 
 ten hours a day. The water is kept as nearly as possible at a uniform 
 temperature of 98 F. A blanket over the shoulders, and another (or a 
 rubber air-cushion) between the buttocks and back and the cold tub, 
 complete the apparatus. Here the patient quietly remains all day. In 
 the evening finely powdered iodoform or other suitable dressing is put 
 upon the sore, and the patient goes to bed. 
 
 On the following morning the patient enters his bath without disturb- 
 ing the dressing of his local ulcer. The water of the bath thoroughly 
 soaks these dressings and removes them without pain. 
 
 A purge before the course of baths, and a continuance of tonics, and 
 any appropriate internal medication during their use, is recommended. 
 
 Cooper's paper reports thirty-one cases. Of these, twenty-two were 
 sloughing or phagedenic ulcers of the penis, which had been in existence 
 from a few days to several weeks before treatment was commenced. The 
 remaining sores were phagedenic, tertiary syphilitic, and gangrenous 
 lesions, involving the genitals or their neighborhood. In none of the 
 cases was the bath used longer than twelve days; in most of them the 
 ulcer is reported to have become healthy in from two to six days. Some 
 excellent cases are detailed, showing the rapidly favorable influence of 
 the submersion. 
 
 Three cases of the "slowly spreading non-inflammatory form of phage- 
 
 1 London Lancet, May 24, 1879, p. 731.
 
 44 THE VENEREAL DISEASES. 
 
 <l;i'na " are reported by Mr. Cooper as having relapsed after a discontinu- 
 ance of the baths. The writer believes that this was due to too short a 
 continuance of the submersion treatment. 
 
 Only three failures were reported: one refused to continue the bath 
 after nine days; number two was too fat to sit comfortably in the bath; 
 in number three, the bath aggravated the pain of an extensive tertiary 
 ulcer; usually pain is relieved by the bath. 
 
 If the sore is sub-preputial, circumcision should be performed. It is 
 stated that the wound " scarcely ever takes on the diseased action." The 
 bath should be continued at least a day after the wound looks quite 
 healthy, and continuous submersion, as recommended by Hutchinson, 
 tried when intermittent treatment fails. 
 
 Chancroid complicated by syphilis. Chancroid is not said to be 
 complicated by syphilis when a patient with syphilis gets chancroid. The 
 term is applied only to the mixed chancre, where both poisons exist at one 
 and the same time in the local sore. This ulcer will be described at p. 
 87. The previous existence of syphilis in a patient does not at all 
 modify the appearance or course of chancroid. 
 
 THE LYMPHANGITIS OP CHANCBOID. 
 
 About two-thirds of all chancroids remain purely local; the other third 
 is attended by bubo, which latter may be inflammatory and resolve, or 
 suppurate, or be virulent. What proportion of chancroids is attended by 
 lymphangitis is not known, but it certainly is less than one-third. The 
 lymphatic trunks rarely become implicated without simultaneous bubo, 
 while bubo frequently occurs when there is no lymphangitis. 
 
 Lymphangitis attending chancroid is of two varieties: inflammatory 
 and virulent. 
 
 Inflammatory lymphangitis. In this affection, one or more of the 
 lymphatic trunks upon the back or sides of the penis becomes thickened, 
 mainly by inflammation of the connective tissue surrounding the vessel. 
 A hard cord is felt under the skin, with perhaps several knotty swellings 
 along its course, usually sensitive to pressure, sometimes adherent to the 
 skin, varying in size from a goose-quill to a broad band, according to the 
 extent of the surrounding inflammation, sometimes marked upon the sur- 
 face by a red line. This hard cord may extend from the chancroid a cer- 
 tain distance, or may be traced to the root of the penis. Sometimes it is 
 found only toward the root of the penis, being absent in front. If the 
 superficial lymphatics are also involved, the skin may become oedematous, 
 erysipelatous, hot, and tender. If the hard cords are sufficiently tender, 
 erection puts them upon the stretch and causes pain. If the inflammatory 
 symptoms run high, there is a corresponding amount of general reaction 
 in the way of fever, etc. 
 
 The terminations of inflammatory lymphangitis are by resolution and 
 suppuration. The pus of the latter is always simple, non-virulent, and is 
 due to excess of inflammatory action. The little abscess generally heals 
 promptly, and the lymphangitis always gets well. 
 
 Virulent lymphangitis is very rare. It possesses all the foregoing 
 mptoms in a high degree, and goes on promptly and necessarily to sup- 
 puration at one or more of the knotty points along the inflamed cord. 
 
 e pus discharged is auto-inoculable, and yields chancroid. The ab-
 
 CHANCROID. 45 
 
 scesses at the suppurating points do not heal, but become chancroids, and 
 require to be treated as chancroids. 
 
 Treatment. Mild cases require no special care. If pain and surface 
 redness run high, a cool, evaporating lotion (p. 38) is appropriate, the 
 patient remaining in bed with the penis elevated, and not hanging down 
 between the thighs. Poultices are objectionable, since they soften the 
 epidermis, and tend to increase the size of the resulting chancroid, should 
 suppuration ensue and prove virulent. Abscesses should be opened 
 promptly, and dressed dry with absorbent cotton, frequently changed. 
 They get well shortly if the suppuration be innocent; if virulent, they are 
 chancroids, and must be treated as such. 
 
 THE BUBO OF CHANCROID. 
 
 The term bubo is no longer confined to inguinal swellings, but is ap- 
 plied indifferently to the enlargement of any lymphatic gland in the body 
 when the immediate cause is a recent venereal ulcer, chancroidal or syphi- 
 litic. 
 
 All authors and statisticians agree that bubo occurs with chancroid, 
 not oftener than once in three cases. It is more common in men than in 
 women, and the strumous and lymphatic are especially prone to it. The 
 inflammation is confined to the ganglia of the superficial chain, the deep 
 glands always escape, the glands nearest the ulcer are most often involved. 
 There are two varieties of bubo: the simple, and the virulent. No statis- 
 tics show their relative frequency; but it is probable that, if only those 
 buboes which actually suppurate are considered, the number of virulent 
 buboes will be found fully as great as that of the simple suppurating 
 variety. 
 
 Bubo usually occurs in the groin corresponding to the side of the penis 
 involved by the chancroid ; but it may be in the other groin, when it is 
 called a crossed bubo; or double bubo may occur with a single sore. Only 
 one group of glands is involved in suppuration. 
 
 Bubo is sometimes peri-glandular, the gland itself escaping. When a 
 chancroid inflames, simple bubo is a little more apt to occur than with the 
 typical uninflamed sore. 
 
 Simple bubo. This is the so-called sympathetic bubo. It is due to 
 the presence of irritation along the line of the lymphatic radicals belong- 
 ing to the gland involved. Simple bubo may occur spontaneously from a 
 strain, or without known exciting cause, in a lymphatic person. It is 
 found sometimes complicating gonorrhoea, or attending ulcerated herpes. 
 It may even occur in connection with an irritated syphilitic chancre. Any 
 sore of any character may give, rise to it in a subject who is predisposed, 
 especially if he be run down physically at the time; but chancroid is the 
 most common cause. 
 
 Simple bubo generally occurs early, if at all, commencing within a week 
 or two after the chancroid is fairly under way; yet, it may occur when 
 the ulcer has nearly run its course. The immediate determining causes 
 are often fatigue, excess, mechanical injury to the gland ; but chancroid 
 alone may cause it without the assistance of any of these additional prov- 
 ocations. 
 
 Generally, only one gland is affected, or one gland so much more promi- 
 nently than the others that the latter may be disregarded. Exception' 
 ally, several glands suppurate.
 
 46 THE VENEREAL DISEASES. 
 
 The symptoms of simple inflammation of a lymphatic gland are at first 
 a sense of stiffness in the groin and a slight swelling of a single gland. 
 The gland rolls under the skin, is sensitive to pressure, and the seat of 
 pain upon standing, walking, and particularly upon going upstairs. As 
 the gland increases in size, the pain proportionately increases. The skin 
 finally adheres and becomes reddened. Then it becomes redematous, and 
 a central soft spot appears, indicating suppuration. Occasionally the 
 peri-glandular tissue suppurates, the gland itself undergoing resolution. 
 Left to itself, the abscess opens, discharges for a varying period, accord- 
 ing to the general condition of the patient and the amount of rest he 
 allows the sore. Much exercise always interferes with rapid repair, on 
 account of the position of the ulcer. Occasionally the pus burrows in 
 various directions beneath the skin. 
 
 This is the typical inflammatory bubo. Its course may be arrested 
 spontaneously, or by treatment at any period, even after suppuration has 
 been established. Simple pus in a bubo may be absorbed. The amount 
 of fever or general systemic disturbance is considerable in some cases, ab- 
 sent in others. Suppuration may be announced by chill. Finally, simple 
 bubo may be complicated by gangrene or by erysipelas, but, apparently, 
 not by phagedaena. 
 
 Indolent bubo is a sub-variety of simple bubo. Patients with this 
 form of bubo are generally lymphatic or strumous in constitution. The 
 bubo is often double, a number of lymphatic glands being involved on 
 each side. These glands grow rather slowly, and become matted together 
 by inflammatory changes in the surrounding atmosphere of connective 
 tissue. The compound tumor may reach the size of an egg or a small 
 orange, be attended by but little pain, and perhaps no appreciable systemic 
 disturbance. The adherent integument over the lump is thin, livid, some- 
 times shining, usually of a dead hue, sometimes smooth, sometimes cedema- 
 tous and lying in welts over the glands along the folds of the groin. The 
 pressure of the tumors may so interfere with the return circulation from 
 the penis and scrotum that the latter become enormously cedematous in a 
 passive way. Generally the penis and scrotum are not altered. 
 
 This livid, chronic enlargement in the groin may continue for weeks, 
 possibly for months unchanged, occasioning very little annoyance. Some- 
 times, on the other hand, it is attended by considerable pain. The chan- 
 croid may have healed up long before any change has occurred in the 
 buboes sometimes even before they have reached their full development. 
 
 The course of indolent bubo is variable. Sometimes it undergoes 
 gradual resolution without any breakage of the skin, occasionally after 
 small foci of suppuration beneath the skin have given evidence of their 
 existence by fluctuation. Generally, peri-glandular suppuration occurs, 
 and one or more small perforations of the. thinned and livid integument 
 occur, allowing exit to a small amount of sanious watery fluid containing 
 a few pus-corpuscles. Discharge from these openings continues, but the 
 glands do not break down. The pus burrows in different directions slowly 
 under the skin, and at the bottom of long sinuses other little livid ab- 
 scesses may form and open spontaneously, leaving rigid fistulae to dis- 
 ;harge interminably. The openings in the" skin may enlarge, and a gland 
 covered with pale, unhealthy granulations protrude. 
 
 This condition of things may last for months, even years. The pus of 
 
 ich a bubo is never auto-inoculable if the patient be even reasonably 
 
 The indolent bubo may occur independently of chancroid in all 
 
 espects, and follow the above detailed course accurately. There is an
 
 CHANCROID. 47 
 
 indolent bubo of syphilis similar, in many respects, to the one just de- 
 scribed, excepting that it does not often suppurate. Treatment of indolent 
 bubo, p. 49.) 
 
 The spontaneous bubo or bubo without a sore, is a simple bubo 
 arising from a strain, fatigue, struma, cachexia, local injury. It has 
 nothing to do with syphilis, and no connection with chancroid, and does 
 not imply either of the latter diseases any more than does a suppurating 
 gland in the neck. Much was formerly written of this bubon d'JEmblee, 
 especially as a supposed evidence of the existence of syphilis without a 
 sore. 
 
 Less will be heard of it in the future. Its claims to recognition as a 
 venereal malady have been entirely overthrown, and its accidental posi- 
 tion in the groin alone gives it interest and respectability, more than at- 
 taches to the same identical lesion when it occurs spontaneously in the 
 axilla. 
 
 A form of spontaneous bubo has been described furnishing auto-inoc- 
 ulable pus, and not accompanying a chancroid. Such a bubo must exist 
 upon a cachectic or syphilitic person, whose skin may be induced to ul- 
 cerate by the application of non-virulent pus or a chancroid must have 
 existed, as a cause, and have cicatrized, or have been overlooked. It may 
 have been in the rectum and not have been sought after at all. In any 
 case the bubon d'Emblee of the present day is not considered to be either 
 chancroidal or syphilitic. It is a spontaneous, simple, inflammatory bubo. 
 
 Treatment of simple bubo. Simple bubo may often be aborted. 
 The moment a trifling stiffness in the groin begins to be felt, and a single 
 gland is found, by pressure, to be the sensitive spot, the greatest amount 
 -of rest possible should be insisted upon. Rest in bed is most desirable, 
 but patients will rarely consent to it. In any case the patient should 
 keep off his feet as much as possible. The diet should be moderated in 
 conformity to the rest enjoined, not for any so-called antiphlogistic rea- 
 son. Stimulants should be avoided. A laxative may be required. The 
 chancroid should be cauterized at once, if it is a sore suitable for that 
 treatment. In this way its poisonous quality is best allayed, and the 
 bubo perhaps saved from becoming virulent. 
 
 If the patient is full-blooded, a dose of bitter water or of salts, 1 every 
 morning, will probably serve as well as leeches the objection to the lat- 
 ter being that their bites sometimes fail to heal, and all become inoculated 
 should the bubo prove virulent. The same objection must be urged 
 -against all the strong counter-irritants and vesicants used to abort bubo. 
 They are not of service unless they take off the cuticle. If they do this, 
 and the bubo, proving virulent, suppurates promptly, the resulting chan- 
 croid is much larger than it need be. The risk of this is not counter-bal- 
 anced by any material gain likely to be derived from the treatment. Only 
 simple buboes can be aborted by these means, which are not uniformly 
 successful; and simpler means, not at all dangerous, will often answer as 
 well. 
 
 Iodine does not seem to me to possess any value in aborting simple 
 bubo, and all ointments which have to be rubbed in with the fingers lead 
 to as much harm by mechanical irritation as they do good by virtue of the 
 medicament they contain. I am confident that I have seen great good 
 
 1 Keeping the patient nauseated with tartar emetic for twenty-four hours has not 
 proved valuable in my hands, nor the expedient of gr. -, X - sulphide of calcium, hourly, 
 -although I have as yet had but little experience with the latter remedy.
 
 48 THE VENEREAL DISEASES. 
 
 follow the application of the following lotion to the skin over the gland,, 
 several times a day, with a camel's hair brush : 
 
 . Tr. aconiti rad., 
 
 Tr. belladonna;, aa 
 M. 
 
 If the skin be tender, so as to experience any irritation from this ap- 
 plication, the lotion may be diluted with water. It is not desirable to 
 irritate the skin. Cold applications I have not found to be trustworthy, 
 and heat is not desirable at the very first, 
 
 Should the bubo fail to abort and go on to suppuration, it is not 
 necessary in all cases to open it. The popular idea that it is harmful to 
 put back (z. c., prevent suppuration in) a bubo is entirely without foun- 
 dation in fact. If the bubo has slowly and deliberately advanced, it 
 cannot be virulent, and the pus it contains may be absorbed in some in- 
 stances. The proper treatment in most cases is rest and slight pressure 
 constantly applied to the gland, with the use of iodine locally, which, 
 under these circumstances, is of value. The pure tincture of iodine 
 should not be used ; it hardens and dries up the skin, and causes irrita- 
 tion. Further absorption of iodine is also impossible after the first few 
 applications, which make out of the epidermis a barrier against absorp- 
 tion as absolute as the shoe does for the foot. The compound tincture 
 diluted with an equal quantity of water, and kept applied sufficiently 
 often to keep up a slight yellow color of the surface, is all that is neces- 
 sary. 
 
 If the little abscess makes the skin tense, and its history proves it not 
 to be virulent, it may be evacuated by aspiration, with a fine aspiration- 
 needle introduced through the healthy skin near the point of suppura- 
 tion, and thrust obliquely into the cavity of the abscess. 
 
 By these means, with good food, cod-liver oil, and tonics, a bubo 
 which has suppurated may sometimes be discussed without leaving a 
 scar. The reddened skin grows pale, the tense shining surface flattens 
 and scales off, the watery parts of the pus are absorbed into the circula- 
 tion, then the solid parts undergo fatty metamorphosis, become disinte- 
 grated, and are slowly taken up by the circulation and disposed of. 
 
 When an abscess of a gland forms rather promptly in spite of efforts 
 to arrest it, when the collection of pus is large, when the patient desires 
 to save time by encouraging suppuration, a poultice of equal parts of 
 ground flaxseed and elm bark, put on hot and frequently changed, is the 
 best local application. As soon as the skin has adhered all around, and 
 a central soft spot of fluctuation can be detected, it is proper to open the 
 abscess. No harm is done if it is opened too soon, and great mischief 
 may result if the opening is too long delayed, and the bubo should finally 
 prove virulent. In case of doubt whether pus has formed or not, a large 
 needle (2 Dieulafoi) upon a subcutaneous injection syringe, acting as an 
 exploring needle, will solve the doubt. In all cases where any shade of 
 ioubt exists that the bubo may possibly be virulent, no time should be 
 lost, and an opening is to be made on the first evidence of suppuration. 
 
 To open a bubo a few precautions must be observed. After re- 
 
 moving the poultice, washing and drying the parts, all the hairs likely to 
 
 terfere with the dressing should be cut short. A curved, sharp-pointed 
 
 stoury is passed into the cavity of the abscess at its highest or lowest 
 
 part. Once in the cavity, the point is made promptly to follow the long
 
 CHANCKOID. 49 
 
 axis of the cavity wherever that may lead, and is brought out through 
 the skin at this point. Then, by a sliding motion, the bistoury incises 
 the skin between the points of entrance and exit, and the greatest possi- 
 ble length of incision which the length of the cavity of the abscess will 
 allow, is thus attained. There is no possible advantage in a small in- 
 cision. The object is to obtain a free exit for the pus, which may be 
 virulent. Haemorrhage is not to be feared from a simple incision of the 
 skin; it will certainly heal as soon as the cavity of the abscess fills. 
 The trouble with incisions generally is that they are too short, and have 
 to be kept open by a variety of means, after a while, in order to allow 
 the cavity of the abscess time to fill up. The long axis of the cavity of 
 the abscess is the best guide for the direction of the incision, starting, of 
 course, at the most dependent part of the cavity of the abscess, or at its 
 highest point. The direction of the cut is generally along the fold of the 
 groin; but this is a matter of no importance, except in people who are 
 very fat and these are less likely to have suppurating buboes than 
 others. 
 
 If exposure of the cut edge of the skin to the air for a few moments 
 does not arrest haemorrhage, the oozing surfaces may be touched with 
 the liquid subsulphate of iron, and any spirting point tied. The excess 
 of pus and blood that wells through the cut is washed away, the epider- 
 mis of the cut edges greased with vaseline, and a dry dressing of absor- 
 bent cotton at once applied. This is to be changed repeatedly at first. 
 No exploration of the abscess is desirable, no pressure upon it allowable, 
 until after it has digested for a day or two, and disclosed its character. 
 No poultice should be used after the incision. 
 
 If the diagnosis of simple bubo has been correct, the cavity fills 
 promptly, and, by the aid of a little balsam or indifferent stimulating 
 lotion, closes in a reasonable period. If the bubo has been virulent the 
 open cavity of the abscess is a chancroid, and requires treatment as such. 
 
 Treatment of indolent bubo. Indolent bubo cannot be put back 
 by aconite, or belladonna, or iodine, at the start. From the beginning 
 to the end the best local treatment for indolent bubo is pressure. This 
 cannot be satisfactorily obtained except by confining the patient more or 
 less. A good method of applying pressure is to put the patient upon 
 his back, make a nest of one or two thicknesses of woollen batting over 
 the lump in the groin, and upon this place a canvas bag partly filled 
 with very fine bird-shot, regulating the pressure by the tolerance of the 
 patient. Two or three pounds is generally all that can be comfortably 
 borne, although the patient may bravely start out with a heavier weight. 
 Pressure by the pad of a truss (Ricord) is only applicable, if at all, to 
 discuss an indolent bubo, not to abort it. 
 
 Another excellent method of effecting pressure is to moisten one or 
 two fine sponges, and dry them under heavy pressure, so that when 
 dried they are thin and flat. One or more of these is now bound by a 
 spica bandage tightly over the indolent gland, and when the parts have 
 become accustomed to the pressure, the bandage and sponges are moist- 
 ened with hot water. The swelling of the sponges causes a great 
 amount of soft equable pressure. Every twenty-four hours the sponges 
 and bandages are to be renewed. 
 
 If the patient cannot attend properly to pressure, and have it thor- 
 oughly carried out, other expedients may be resorted to. Here the tinc- 
 ture of iodine may be used with advantage, but more by virtue of its 
 counter-irritating properties than for any special property of the iodine. 
 4
 
 50 THE VENEREAL DISEASES. 
 
 The surface should be kept black, cracked, and sore, new iodine being 
 applied when the epidermis scales off. Blisters of cantharidal collodion, 
 applied one after another, are also of value, as is punctate cauterization 
 applied with Paquelin's thermo-cautery. The platinum point is first 
 brought to a white heat, kept at that point of temperature, and rapidly 
 touched upon the skin over the tumor, at twenty to fifty different spots, 
 according to the size of the lump. The application is not very painful, 
 and a good effect in a resolvent way is often produced upon the indolent 
 glands during the formation and separation of the minute sloughs. 1 
 
 Should suppuration come on, it does not call for any modification in the 
 treatment. The suppuration is generally peri-glandular, and its entire 
 absorption may sometimes be brought about by pressure. Should the 
 abscess open spontaneously, or be opened by the surgeon to discharge its 
 bloody -look ing serum, the treatment by pressure may be continued unin- 
 terruptedly. 
 
 If the knife be used, and time be valuable to the patient, the best 
 and most satisfactory treatment of indolent bubo, after peri-glandular 
 suppuration has occurred, is in many cases, undoubtedly, extirpation of 
 the offending glands. Ether should be given, all pockets and sinuses 
 laid freely open, and all the diseased glands scraped out with the finger 
 or sharp spoon; or, if they are very large and adherent below, transfixed 
 with a double ligature through the pedunculated portion, which is to be 
 securely tied before the gland is cut away. All the enlarged glands being 
 removed, and haemorrhage arrested by tying bleeding points, or apply- 
 ing subsulphate of iron or the Paquelin cautery, the gaping cavity is 
 stuffed full of oakum soaked in balsam of Peru. Any stimulating dress- 
 ing may be applied later. This treatment is generally more satisfactory 
 than the extensive use of caustic pastes sometimes employed in these 
 cases. 
 
 The appropriate internal remedies for indolent bubo are tonics, gener- 
 ous diet, with wine and cod-liver oil. 
 
 Virulent bubo. The virulent bubo is a subcutaneous chancroid. It 
 is known sometimes as the bubo of absorption. Some of the true chan- 
 croidal virus, whatever it may be, has ascended the lymphatic channels 
 and lodged in a gland. Here it breeds, promptly calls ulcerative action 
 into play to effect its own elimination, and immediately begins to work 
 its way to the surface, where an ulcer finally appears as a chancroid. 
 Therefore suppuration is inevitable. 
 
 A virulent bubo may arise from a simple, from an inflamed, or from a 
 phagedenic chancroid. There is no certain date of its appearance. It 
 may commence very late. In Puche's " well-known case it came on three 
 years after the appearance of a phagedenic serpiginous chancroid. Occa- 
 sionally it declares itself just as the simple chancroid from which it arises 
 is getting well. It is usually mono-glandular. Sometimes double bubo 
 exists with a single chancroid on one side a simple bubo, on the other 
 virulent. 
 
 ' Ina recent German journal, anewmethodof treatingthese indolent glands is spoken 
 
 t>y Jacubowitz. He injects into them a watery solution of the iodine of potassium, 
 
 t to thirty. He injected in one case, at one sitting, into one gland as large as a 
 
 '? K l S *' XV< f the iodide in 1 i- of water, injecting small quantities into different 
 
 the gland. He repeated this injection during two days, four times with suc- 
 
 * he claims. Multiple acupuncture has also been well spoken of. I have not 
 
 yet tned either of these methods. 
 
 * Lemons sur le chancre : Bicord (Foumier). 2d ed., 1860, p. 46.
 
 CHANCROID. 51 
 
 k, 
 
 There is no positive diagnostic feature which distinguishes virulent 
 from simple suppurating bubo at first; but the course of the virulent bubo 
 is more active, more violent. Peri-adenitis with suppuration is quite apt 
 to occur about a virulent bubo. The pus formed outside the gland in 
 such a case is not virulent until poisoned by contact of the pus within 
 the gland. Ricord's beautiful demonstration of this is well known. The 
 case is one in which a peri-glandular abscess was opened, and its pus in- 
 oculated with negative effect. At the same time a gland lying at the 
 bottom of the abscess was punctured, and a drop of pus taken from its 
 centre was auto-inoculated with positive result. What more brilliant 
 demonstration can be required of the difference in acridity of simple pus 
 and the poisonous pus of chancroid. 
 
 The first features of virulent bubo, then, are precisely those of simple 
 suppurating adenitis accentuated. As soon as virulent bubo is opened to 
 the air, its true chancroidal characters begin to appear. The cut edge of 
 the skin becomes at once inoculated, and the whole cut border ulcerates. 
 The opening, whether made by nature or the knife, grows larger by be- 
 ing eaten away by the slowly advancing ulceration. The borders of the 
 ulcer get hard, livid, undermined, while the integument surrounding the 
 edges of the sore assumes a dusky purple hue, perhaps perforates in a 
 new spot, or sloughs away in pieces. The bottom of the abscess, now an 
 ulcer, becomes irregular, worm-eaten, covered with a pultaceous, adherent 
 deposit, discharging plentifully an ill-conditioned pus, inoculable upon 
 the bearer. 
 
 This ulcer, with its ragged, abrupt, ulcerated, and undermined edges, its 
 uneven, pultaceous floor, and auto-inoculable discharge, is a true chancroid, 
 subject to all the complications to which chancroid is liable. The pus 
 may burrow along the groin, down the thigh, or upon the abdomen, lead- 
 ing to obstinate sinuses which much prolong the duration of the sore. 
 
 Phagedaena, either in the sloughing or in the serpiginous form, may 
 attack a chancroidal bubo. The latter is more common, and is usually 
 the orign of those extensive chancroids which last for so many years. 
 One such of fourteen years' duration is on record. The course of serpi- 
 ginous chancroid in the groin is usually upward over the abdomen, where 
 it generally stops after having occasioned considerable destruction of 
 tissue. 
 
 The tissues sought out for destruction by serpiginous phagedaena are 
 the connective and cutaneous layers down to the deep fascia. It is a 
 very common thing in a large hospital to see a poor fellow, who has been 
 on his back for weeks or months, with a raw spot in the groin and over 
 the abdomen, as large as the hand, from the floor of which several large, 
 raw-looking, unhealthy glands project. The glands have been spared by 
 the phagedenic action, which has swept away everything else down to 
 the deep fascia. 
 
 If the phagedaena does not exhaust itself upon the abdomen, it gener- 
 ally turns downward after a time and takes possession of the thigh. The 
 thorax, although not absolutely proof against phagedaena (as, indeed, even 
 the face is not), yet is very rarely attacked by it. For this reason, the 
 chest-wall below the nipple is the position generally selected for diagnos- 
 tic auto-inoculation of phagedenic sores. 
 
 A phagedenic bubo may have originated from a non-phagedenic chan- 
 croid, just as a phagedenic chancroid of the penis may have a simple bubo 
 or no bubo at all. Other points relative to phagedaena may be found upon 
 p. 38 et seq.
 
 52 THE VENEREAL DISEASES. 
 
 Treatment of virulent bubo. When it is suspected, from the ra- 
 pidity of impending suppuration, that a given bubo is virulent, it is wiser 
 not to poultice it at all. No external applications, no internal medication 
 is of any value. Suppuration need not be encouraged it is certain to 
 come promptly enough. Above all things, no leeches or blisters should be 
 applied to break the skin and furnish new foci for inoculation after the 
 bubo has begun to discharge. As soon as even a few drops of pus have 
 collected the knife should be used, and the suppurating cavity laid freely 
 open. The peri-glandular suppuration being nearer the surface and in less 
 dense tissue, can sometimes be opened without cutting into the gland at 
 all. When this can be done, it is very desirable. The gland surely will 
 open later; but the point of importance is the size of the cavity outside 
 of the gland, which must eventually become one vast chancroid. The 
 sooner this outside cavity is opened to the air the smaller it will be, and 
 the longer it can remain open without becoming poisoned with the dis- 
 charges from the virulent gland the greater is the chance that its walls 
 will consolidate and extensive burrowing be prevented. Therefore, it is 
 wise to open any bubo, which has rapidly advanced to suppuration, at the 
 earliest possible moment after pus has formed, to cut through the integ- 
 ument from without inward, if there is very little matter and not a con- 
 siderable cavity full of pus, and to endeavor to determine whether the 
 suppuration may not be exclusively peri-glandular. Should it prove so, 
 the gland might be taken out at once unopened, and there is a possibility 
 that the abscess might remain simple, instead of becoming chancroidal. 
 If both collections are opened together, however, or, what is more custom- 
 ary, if the outer abscess has already become contaminated by the gland- 
 ular abscess, before either of them have been opened, then the abscess is 
 already a chancroid before it is opened, and the passage of a knife through 
 it does not alter its character. 
 
 The line of treatment, now, is that suitable for a large chancroid. 
 Cauterization is not desirable, cleanliness is of the first importance, iodo- 
 form the best remedy. Any pouching of the borders indicating a ten- 
 dency to burrow should be counteracted by prompt incision to the bottom 
 of the pouch. The cut edges will become ulcerated and the chancroid 
 enlarged, but this is preferable to the formation of a sinus. A little ab- 
 sorbent cotton should lie constantly upon the ulcer to suck up the dis- 
 charges as they form. The general detail of management is the same as 
 that for ordinary chancroid, p. 41. 
 
 Should a virulent bubo commence to grow phagedenic while under ob- 
 servation, no time is to be lost. The most thorough cauterization possi- 
 ble is all that can be done; and if this is undertaken promptly, and effi- 
 ciently carried out, the new enemy may often be destroyed along with the 
 old one. The general and local management of phagedaena have been 
 given on p, 41 et seq.
 
 PART II. 
 
 CHAPTER I. 
 
 SYPHILIS. 
 
 General Considerations upon Syphilis. Definition of Syphilis. Effects of Climate upon 
 the Disease. Present Mildness as compared with former Virulence. Outline of 
 the Course of Syphilis. General Pathology of Syphilis. General Description of 
 the Pathology of the various Lesions due to Syphilis, and the Lack of any Specific 
 Quality in the Elements constituting these various Lesions. 
 
 Definition. Syphilis is a specific disease, acquired only by inheritance 
 or by direct contact of a surface capable of absorption with the poisoned 
 secretions of a person already diseased. It is characterized by periods of 
 eruption of varying severity, and periods of repose of varying duration. 
 The earlier symptoms are superficial, the latest involve the viscera. No 
 organ in the body is exempt from paying tribute to the disease; the con- 
 nective tissue suffers most. Treatment may shorten and modify the dis- 
 ease; time alone can wear it out. A perfect recovery is possible. 
 
 GENERAL CONSIDERATIONS. 
 
 The foregoing definition simply touches upon the outskirts of syphilis. 
 Nothing can define it short of a detailed description. It is a disease of 
 magnificent exceptions, full of absorbing interest. It resembles everything, 
 and yet retains that special type of personal individuality which enables 
 the careful student to ferret out its peculiarities amidst a labyrinth of 
 symptoms due to other causes, and triumphantly to institute a treatment 
 which is almost certain to lead to a happy result. The origin of syphilis 
 is involved in impenetrable darkness. It has been the subject of learned 
 essays, and volumes have been written to prove all manner of things con- 
 cerning it. Captain Dabry affirms that it was well known among the Chi- 
 nese two thousand years before Christ, and many believe that it has ex- 
 isted in all countries ever since, under a variety of unpronounceable names; 
 that it was known to physicians of ancient days, and during the middle 
 ages, although its nature was not then fully recognized. Another equally 
 stalwart corps of controversialists aver as hotly in other learned essays, 
 equally founded upon fact, that the disease was brought from America 
 upon the ships of Columbus, and from this origin spread like a plague 
 promptly through all Europe. 
 
 In a text-book proposing to deal with practical questions, much dis-
 
 54 THE VENEREAL DISEASES. 
 
 cussion upon this point is as unprofitable as it must be stale, for there are 
 no new facts to adduce, only new combinations of them to be made, and 
 no adequate advantage attaches to a successful accomplishment of the 
 
 task. 
 
 It is well, however, to know that syphilis was not recognized as a mor- 
 bid unity until the end of the fifteenth century, at and after the period of 
 the siege of Naples (1494-5) by Charles VIII. That then, and for a con- 
 siderable time thereafter, the disease behaved with unwonted virulence, 
 attacking all classes of society, and killing a large number of its victims. 
 From that time to the present day, syphilis has been a subject of peculiar 
 interest to all classes of medical men. It enters the domain of every branch 
 of pathology. A close acquaintance with it is claimed by the physician, 
 the surgeon, the specialist, in nearly all branches. Miles of pages have 
 been written about it, and yet all is not known. Every year adds to our 
 exact knowledge, and brings new symptoms and new growths of morbid 
 phenomena into the fold of syphilis, which were not there before. Nearly 
 all the important questions in syphilis are still in dispute among high 
 authorities : Is the poison single or double capable of producing only 
 one, or of yielding two diseases ? Is it peculiar to man, or may animals 
 also be affected? What secretions will transmit the disease, and what 
 secretions are innocuous ? Is it curable, or not ? What treatment is best ? 
 All these, and many more important questions, are not finally settled to 
 the satisfaction of the profession at large. The question of syphilis of the 
 nervous system has been probably nearly solved of late years, and the 
 lesions of inherited syphilis are in a fair way to be clearly comprehended; 
 but the whole question of hereditary transmission from the father is in- 
 volved in unspeakable doubt, the facts on both sides being nearly equally 
 strong. 
 
 To the quack, syphilis is a glorious harvest; to the unprofessional mind, 
 a mysterious horror of nastiness ; to the medical student, a simple sequence 
 of chancre, secondaries, and tertiaries, easily cured the first and second 
 by mercury, the last by "potash," as he puts it; and to the earnest stu- 
 dent, a mine of increasing interest, always yielding new treasures to hon- 
 est toil, full of pleasant surprises, comforting by the sense of power a 
 knowledge of its truths conveys, and going far to create in the physician 
 respect for the art he practises and a certain amount of belief in the spe- 
 cific action of drugs. 
 
 Syphilis is encountered everywhere in the palace of the mighty, in the 
 hovel of the slave. It infects the infant before its first breath, and attends 
 the gray hairs of age tottering to the tomb. The point of entrance of the 
 poison may not be found, need not be sought generally, and no amount 
 of respectability can be a guarantee that any given individual may not 
 have encountered one of the protean forms of approach -which this mon- 
 ster is capable of assuming. 
 
 Whatever and wherever was the first origin of syphilis matters little; 
 now it is everywhere, and probably spreading. All countries on the globe 
 possess it. Iceland and Africa are said to suffer least ; but, whatever im- 
 munity the African may enjoy at home, he loses by transplantation, for 
 all the worst forms of syphilis are seen in the negro in this country. 
 
 In certain parts of the world syphilis is said to be exceptionally mild, 
 
 s m Portugal. H. Lee quotes Ferguson as ascribing this to the fact that 
 
 the population are saturated with syphilis, and owe their immunity to the 
 
 they are for the most part derived from syphilitic parents. Lee 
 
 relieves also that the lower classes in other countries are in a measure pro-
 
 SYPHILIS. 55 
 
 tected from severe syphilis in the same way, and that the children of 
 syphilitic parents who themselves have inherited no disease, have yet de- 
 rived from their parents a measurable protection from severe attacks of 
 syphilis. In certain countries, on the other hand, syphilis is said to be 
 exceptionally malignant South Sea Islands, Mexico. The acquisition 
 of syphilis by one race of people from another is believed to produce a 
 severe type of disease. Syphilis acquired by Europeans from the Chinese, 
 or by residents ot' the United States from Central or South Americans, is 
 said to be unusually bad in its results. It is well known that sailors habit- 
 ually have the disease severely, and they acquire it, doubtless, often in 
 foreign ports. Hirsch ' has shown that no necessarily good or bad influ- 
 ence upon the evolution of syphilis attaches to climate alone. In a gen- 
 eral way an equable climate is less unfavorable than an uneven one. A 
 person not acclimated is believed to be more apt to suffer severely in any 
 climate than a native, if he gets his poison from a native ; while, on the 
 other hand, it has been frequently noticed that where the disease is im- 
 ported into a country previously exempt, the inhabitants fall beneath the 
 new malady as under a plague. 
 
 A natural deduction from the foregoing facts is, that finally syphilis 
 will become uniformly acclimated all over the world ; that it will diminish 
 in severity as it increases in extent, and perhaps, at last, may exhaust its 
 virulence entirely. Certain it is that the syphilis of the present day is 
 not the syphilis we read of in the past. It can be recognized as the same 
 disease ; all the features are there, but much of the sting has gone out 
 of it. Occasional cases of malignant syphilis and bad types of disease 
 still appear to remind us of what the poison can do, and the damaging 
 blight which the inherited taint often inflicts upon its innocent victim 
 attests the continued virulence of the malady. In a majority of cases, 
 however, in reasonably healthy persons, the type of the disease, as encoun- 
 tered at the present day, is mild ; it can be controlled to a great extent 
 by treatment ; thousands of individuals pass through it, unharmed in tis- 
 sue, in feature, in function, to reach a green old age and die of natural 
 causes, leaving behind them healthy offspring, who know not the sins of 
 their fathers. 
 
 OUTLINE OF THE COURSE OF SYPHILIS. 
 
 After contact of the poison with a surface capable of absorption, 
 nothing unusual happens for several weeks; this is the period of incuba- 
 tion, in which the disease, already acquired, is supposed to hatch or ripen. 
 A period of incubation is quite common in contagious diseases, especially 
 in those which involve the blood. When poison is brought into contact 
 with the tissues, if its effect is to be local there is no incubation; witness 
 the poison of the bee, of the mosquito, of chancroid. If its effect is to be 
 general, it lies dormant while increasing in the blood, until finally it has 
 accumulated enough force to break out and produce symptoms; and these 
 symptoms may be general from the first, as in measles, scarlet fever, small- 
 pox; or a lesion may first reappear at the point of entrance of the poison 
 hydrophobia, syphilis. 
 
 The lesion which first appears at the inoculated point is called a chan- 
 cre, whether it appears upon the genitals, the fingers, the face, or else- 
 
 1 Handbuch der histor. geograph. Pathologic. Erlangen, 1860.
 
 56 
 
 where whether it is a dry papule, a moist tubercle, or an excavated ulcer. 
 This lesion is generally attended by a peculiar hardness of the tissues im- 
 mediately underlying it, known as a specific induration. Within two 
 weeks the neighboring lymphatic glands generally become slightly en- 
 larged and verv hard, in an almost painless manner, many glands being 
 usually involved at the same time. None of these glands suppurate as a 
 
 rule. 
 
 Generally, in about a month after the glands enlarge, after the second 
 period of incubation, an eruption appears scattered more or less uniformly 
 over the whole body. These eruptions, for there are a number of them 
 which may appear pustular, papular, erythematous, squamous, differing 
 in intensity in different individuals these eruptions are all characterized 
 by certain'general peculiarities, to be detailed later, which stamp them 
 with an individuality found by experience to belong to no other group 
 of eruptions. Their color is peculiar, their grouping, their course, the 
 absence of pain or itching, and other features, generally make it easy to 
 distinguish these eruptions from others composed of the same elementary 
 lesions, but due to a different cause. 
 
 Just before the outbreak of the first of the early eruptions, some pa- 
 tients (perhaps one-third) suffer from a mild amount of fever, the temper- 
 ature, generally moderate, in exceptional cases mounting quite high. 
 Also, coincidently with the first general eruption, or before it, there is a 
 tendency to a slight general indolent engorgement of certain lymphatic 
 glands, notably the post-cervical chain and the epi-trochlear glands. 
 Rheumatoid pains are often complained of worse at night. Sometimes 
 there is headache, a general fall of hair is often noticed (alopecia), and 
 acute iritis may be an attendant symptom. 
 
 Also, with the first eruptions, or just before them, erythematous 
 patches, erosions, ulcers, and peculiar lesions called mucous patches, are 
 quite certain to make their appearance within the mouth and upon the 
 throat of the patient. Such erosions, patches, and ulcers crop out from 
 time to time throughout the entire course of syphilis, often continuing to 
 appear for many months after all other evidences of the disease, local and 
 general, have passed away. 
 
 Several outbreaks upon the skin may follow each other during the 
 first year. In such case the eruptions are generally slower in their course, 
 each succeeding one a little slower than its predecessor, a little deeper- 
 seated in the integument and less generalized in distribution, more group- 
 ed into patches. 
 
 The bodily health sometimes fails considerably during the first year, 
 but it sometimes remains seemingly undisturbed, more especially in those 
 cases in which the stomach retains its tone and the appetite continues 
 fair. 
 
 At the end of a year or more of such outbreaks, there is a natural lull 
 
 in the course of the disease. There may be an entire absence of symptoms 
 
 for many months. In very exceptional cases the lull remains permanent, 
 
 d the patient seems to be and to remain well from that time on. Usu- 
 
 lly, however, after a period of quiescence more or less long, new out- 
 
 reaks appear upon the skin, in groups of pustules, scales, or papules, and 
 
 new, whitened, excoriated patches and ragged ulcers come out upon the 
 
 i and in the mouth. Periosteal pains in all the superficial bones are 
 
 apt to make themselves felt, chiefly at night, and a certain amount 
 
 of failure m general health is customary. 
 
 state of things prolongs itself for a period varying from a few
 
 SYPHILIS. 57 
 
 months to two years or more, and terminates by leaving the patient sound 
 and well, or by merging into the next, the tertiary stage. The stage just 
 described is sometimes known as intermediary; the eruptions occurring 
 in it often leave slight permanent scars. 
 
 In a typical case, after an interval, or, perhaps, without any halt, the 
 disease puts forth its last group of symptoms. These symptoms are ex- 
 ceedingly variable in intensity and extent. All the superficial, as well as 
 the deep textures of the body, as well as all of the internal organs, may be 
 involved in these lesions. The lesions of this stage, wherever they occur, 
 are characterized by connective-tissue hyperplasia, or by gummatous de- 
 posits, and in either case, by thickening of the walls of arteries within the 
 pathological areas. In the skin, patches of tubercles and serpiginous ul- 
 cers appear : ecthyma and rupia, gummata of the subcutaneous tissues. 
 Nearly all the lesions of this stage leave deep scars. The throat may be 
 attacked by rapidly destructive gummy ulceration, the bones of the nose 
 may die and come away. Ulcers may develop upon the mucous membrane 
 of the stomach and intestine, and cut off nutrition. The liver, the lungs, 
 the kidneys, the heart, all have their chance at suffering from tertiary dis- 
 ease, as indeed do all the internal organs and tissues. The brain comes 
 in largely for a share of notice when the phenomena of tertiary syphilis 
 are mentioned. Nearly all known chronic diseases giving symptoms 
 through the brain, or through the nerves, may be simulated by the symp- 
 toms of tertiary syphilitic disease of the brain and nerves. Chorea, epi- 
 lepsy, paraplegia, hemiplegia, nearly all forms of paralysis, aphasia, de- 
 mentia, insanity, mania, and many other maladies often owe their origin 
 to tertiary syphilis, and are perfectly curable by a well-directed course of 
 anti-syphilitic medication. 
 
 The bones, and joints, and tendons, and bursas, and muscles, must not 
 be forgotten. They all offer tribute to tertiary syphilitic disease, and 1 
 furnish appropriate symptoms, as do indeed all the structures of the 
 body. 
 
 After yielding symptoms in the tertiary stage, more or less severe 
 in type, syphilis in course of nature declines, and leaves its victim spon- 
 taneously. But, before this period has arrived, such vital organs may 
 have become involved in permanent changes in their structure, due to syphi- 
 lis, that health is no longer possible, and sometimes life itself cannot be sus- 
 tained. Death, as a direct result of syphilis, is uncommon in the adult, 
 but may be produced by the occurrence of structural changes in the vital 
 organs, or by the cachexia of tertiary syphilis. Cachexia is one of the 
 marked phenomena of this stage, and sometimes seems to be independent 
 of obvious organic changes in the tissues. 
 
 This glimpse of the natural history of syphilis is far from perfect. 
 The glory of syphilis is its irregularity. No two cases exactly resemble 
 each other, and yet the family likeness is quite strong in all. Whole 
 groups of customary symptoms may be omitted during the evolution of 
 the disease. Symptoms may be strangely out of place. Tertiary gum- 
 mata occasionally appear a few months after chancre, and symptoms of 
 brain syphilis in the same period, while, on the other hand, erythematous 
 and scaly spots upon the palms, the soles, and in the mouth, may crop 
 out long after even the tertiary period seems to have come to a natural 
 end. 
 
 Constant vigilance on the part of the diagnostician is called for in the 
 investigation of many of the desperate phenomena of varioys chronic dis- 
 eases, to decide if there be anything in them suggestive of syphilis. Such
 
 58 THE VENEREAL DISEASES. 
 
 a cause is often found when least expected, and the reward amply repays 
 a careful search, for no serious case is so desperate but that the prognosis 
 is bettered, if new light can be thrown upon it by ascribing it to syphilis 
 as a cause. A well-directed treatment in such a case will sometimes ren- 
 der favorable a prognosis which, without it, must have been fatal. 
 
 THE GENERAL PATHOLOGY OF SYPHILIS. 
 
 The changes wrought by syphilis upon the organs and tissues of the 
 body are very limited in number and very uniform in type, but the symp- 
 toms to which they give rise are as varied as are the functions of the or- 
 gans and tissues involved. When the poison is first absorbed, no one 
 knows what becomes of it. It is probably increasing in quantity during 
 the period of incubation, and working its way through the lymphatics 
 into the system. Some authorities believe that it only grows locally dur- 
 ing the first period of incubation. The blood quickly begins to feel the 
 influence of the poison, and, as first clearly shown by Ricord and Grassi, 
 to experience a diminution in the bulk of its red globular contents, while 
 the amount of albumen and of white cells become increased. The latter 
 change, as Virchow has shown, is doubtless due to the fact that a num- 
 ber of the lymphatic glands are in a state of irritation due to the poison. 
 
 Aside from these changes which have in them nothing peculiar to 
 syphilis, since they are apt to be found as well in any other debilitating 
 disease the pathological individuality of syphilis always shows itself in 
 all stages of the disease^ through the medium of congestion, of new con- 
 nective-tissue formation, or of new cellular growth, and the three are usu- 
 ally more or less combined. They are found in the chancre (page 15), 
 they all exist in the syphilitic bubo. There is an afflux of blood to the 
 part, the bundles of connective-tissue fibres are thickened and condensed, 
 and a large number of new cells are present. These cells resemble leuco- 
 cytes, the white corpuscles of the blood. According to Cohnheim, they 
 are nothing else but out-wandered cells, which formerly were white 
 blood-corpuscles; yet the great pathologist Virchow cannot distinguish 
 between these white cells found in the syphilitic chancre and the cells 
 found in a fresh gummy tumor. Who then shall decide that there is 
 anything specific microscopically in the character of syphilitic tissue ? It 
 is in the structure and arrangement, not in the elements of syphilitic new- 
 growths, that the microscopist seeks to make a distinction between them 
 and other morbid neoplasms. 
 
 The roseola of syphilis is largely congestive, and due to vaso-motor 
 paresis in the terminal capillaries upon certain areas of skin. In the 
 papule, there is cellular infiltration as well. In the pustule and vesicle, 
 the exudation of pus and serum beneath the epidermis has no character 
 imprinted upon it, by its syphilitic origin, which the microscope can de- 
 tect, and so on through the various lesions of the skin. The later cuta- 
 neous manifestations are, as a rule, gummatous. The tubercles, the ulcers, 
 the gummata of the skin, are all essentially different varieties of gumma- 
 tous infiltration. They all undergo, in the evolution of the lesion, the 
 natural retrograde, fatty -granular metamorphosis which is the natural 
 termination of pure gummatous products. 
 
 Within the body there are three pathological types of change due to 
 syphilis: connective tissue hyperplasia, gummatous"deposit, arterial thick-
 
 SYPHILIS. 59 
 
 en ing, and two secondary changes often following prolonged syphilitic 
 disturbance atheroma and amyloid degeneration. 
 
 The connective-tissue hyperplasia plays perhaps the most important 
 part of all. The elements of all the organs in the body are separated 
 and held together, suspended, as it were, in an atmosphere of connective 
 tissue. Even the brain has its fine connective-tissue parenchyma, and 
 the substance of the bone is none the less a variety of connective tissue 
 because it happens to be solidified with earthy salts. 
 
 One of the commonest expressions of visceral syphilis is that the con- 
 nective-tissue parenchyma of a given organ undergoes hyperplasia. Its 
 elements increase in number, soft round cells and spindle-cells appear, 
 while all the meshes of the tissue become more succulent from conges- 
 tion. This state of things, however, does not last long. The hypertro- 
 phic process comes to a stop, the blood recedes from the congested ves- 
 sels, the succulent new tissue forms into fibres and contracts; cirrhosis is 
 the result. Fibrous bands, with all the retractile quality of cicatricial 
 tissue, now replace the former delicate connective-tissue atmosphere of the 
 organ involved. The result is inevitable. The delicate, essential compo- 
 nent elements of the gland or the organ which has been the seat of this 
 change become squeezed, and partly strangulated by the unwonted pres- 
 sure exerted upon them from all sides, and the function of the organ 
 becomes thereby necessarily impaired. 
 
 But there is nothing specific in this form of connective-tissue hyper- 
 plasia. Other forms of cirrhotic change closely resemble it in all micro- 
 scopic details. 
 
 The gummy tumor (syphiloma of Wagner) is a specific product. It is 
 not due to any other malady or to any morbid process other than syphilis; 
 but there is nothing distinctive about the cells of a gumma. They are 
 nucleated cells, as seen in a young gumma, looking more or less like white 
 blood-cells. They lie very closely crowded together in among the ele- 
 ments of the other tissues, which they push aside. A few spindle-cells 
 are generally found among the succulent round cells, showing the tendency 
 of the tissue to organize into connective tissue. 
 
 Such collections of cells may develop in a connective-tissue stroma 
 anywhere: in or under the skin, under the periosteum, in the Haversian 
 canals, in the brain, the tongue, the throat, the lungs, the liver, the 
 spleen, the kidneys, the testicle; in any place where connective tissue and 
 blood-vessels are found in short, almost anywhere in the body. Gum- 
 mata commence to form usually around small blood-vessels or in the ad- 
 ventitia of large ones, and are found of minute size scattered along the 
 fibrous septa of an organ in connection with more or less general connec- 
 tive-tissue hyperplasia, or as a single large nodule of independent forma- 
 tion, seemingly a solitary lesion amid surrounding health. 
 
 The connective tissue around a large gumma becomes condensed and 
 thickened into a sort of fibrous envelope for the newly formed mass. Af- 
 ter a time the gumma reaches the size which it is to attain, and then de- 
 generative changes commence in it. According to Rindfleisch, this is a 
 mucous metamorphosis of the cells of the gumma, commencing centrally 
 in the mass. The cells now disintegrate and become caseous. Sometimes 
 they are wholly absorbed, the spot remaining as a hard cicatrix. This 
 cicatrix represents mainly the outside connective-tissue thickening which 
 surrounded the gumma, puckered in and occupying a depressed area 
 corresponding to the position and proportionate to the size of the origi- 
 nal lesion. Fatty granular degeneration and caseous transformation in
 
 6Q THE VENEREAL DISEASES. 
 
 large gummata surrounded by a considerable cyst-wall of condensed con- 
 nective tissue yield a fluid a sirupy or a cheesy mass, according to cir- 
 cumstances. This mass may persist for a time, and often to the unaided 
 eye much resembles pus, especially when seen in subcutaneous gummata. 
 These collections may persist for a long time in internal organs, not ne- 
 cessarily doing much damage. The danger from a gumma is usually di- 
 rectly in proportion to the importance of its place of development. A 
 small gumma compressing a large vessel will naturally cause more phys- 
 ical disturbance than a larger gumma more safely situated. One of the 
 common (the most common) conditions in which to find an old gumma is 
 a tough, dirty white, or yellowish cicatrix containing the atrophied re- 
 mains of the tissue originally invaded by the gummatous infiltration, and 
 more or less of the unabsorbed caseous remains of the gummatous cells 
 themselves. 
 
 Gummata situated near the surface generally tend to act like abscesses, 
 to soften centrally and then ulcerate their way to the surface, discharge 
 and eliminate themselves in the form of gummy ulcers, and, unless they 
 become serpiginous, slowly to cicatrize. 
 
 The gummatous material is not then in itself specific, but its peculiar 
 quality is evident to any one studying its course. Similar material to 
 that constituting gumma is found in syphilitic chancre and in some of 
 the secondary lesions; yet it acts in a different way, being absorbed with- 
 out material destruction of tissue, and often without leaving any scar in 
 the first instance, although not necessarily without scar in the second. 
 This difference has been explained by the hypothesis that the actual 
 syphilitic virus comes into contact with the tissues directly at the point of 
 chancre, and in the secondary stage through the medium of the poisonous 
 blood; that these tissues behave in one way under these circumstances, 
 but in a totally different way when they undergo a specific reaction from 
 some incidental cause, having themselves been previously modified by 
 contact with a poison which has now ceased to exist; for it is well known 
 that the blood in tertiary syphilis is not poisonous directly, or, at least, 
 cannot be directly hetero-inoculated with a positive result. This explana- 
 tion is pure theory, and only explains what is undoubtedly a fact by 
 stating it in other terms. 
 
 Another pathological change produced by syphilis is a modification in 
 the walls of the blood-vessels. Biesiadecki found the vessels thickened 
 in the primary lesion, but it has been since discovered that this thicken- 
 ing is a constant accompaniment of all inflammatory, especially chronic 
 inflammatory changes. Huebner, in his studies of brain syphilis, claims 
 that a large share of the important pathological changes which occur in 
 that organ are due primarily to changes in the walls of the arteries of the 
 brain, commencing as an endo-arteritis, and culminating in a thickening 
 of the wall of the vessel and an obliteration of its calibre. The syphilitic 
 endo-arterial changes occurring in the different large arteries of the body, 
 unquestionably in undergoing retrogressive metamorphosis, lead directly 
 to atheroma and a weakening of the arterial wall, and this again becomes 
 a direct cause of aneurism. 
 
 The amyloid changes so often found after death in liver, spleen, and 
 
 idneys, in subjects who have long suffered from syphilitic cachexia, do 
 
 t differ from the amyloid changes due to other causes such as pro- 
 
 onged suppuration. It is only syphilitic in that it is quite frequently 
 
 encountered in connection with that disease.
 
 CHAPTER II. 
 
 SYPHILIS. 
 
 The Poison of Syphilis : is it a Vegetable Fungus ? The Production of Syphilis in 
 Different Animals. The Alleged Antagonism between Syphilis and Cancer. 
 Secretions which contain the Poison of Syphilis. Peculiar Virulence of the Secre- 
 tion of Mucous Patches. Vaccinal Syphilis. Pathological Secretions. Physiolo- 
 gical Secretions. Infection by Milk ; by Semen. Transmission of Syphilis by In- 
 heritance through the Mother alone ; through the Father alone. Date at which a 
 Healthy Pregnant Woman must get Syphilis in order to Poison her Child. Choc 
 en-retour. Transmission by Inheritance to the Third Generation. 
 
 The poison of syphilis. That syphilis is essentially a poison has 
 always been conceded; but two points regarding it have given rise to 
 much dispute, namely: exactly what the poison is, and exactly where it 
 resides. Both of these points are still the subject of earnest investiga- 
 tion, and much serious and honest difference of opinon exists about them 
 among intelligent men. 
 
 Humoral pathologists had no difficulty with poisons in the blood. An 
 assumed condition of irregularity in the fluids of the body was a humor, 
 and any amount of theory could be manufactured to fit the facts as they 
 appeared. Pathology of the present day is more exact, and demands 
 tangible evidence and proof of what a virus is, or else it confesses its 
 ignorance, and simply retains the term virus because that is a familiar 
 one, and because there is none better at hand. An assumption of a poi- 
 sonous quality in that which is the essence of syphilis serves practically 
 to assist in accounting for the phenomena of the disease, yet pathology 
 does not claim to know at all what the poison of syphilis is. The poison 
 of chancroid most virulent in its local effects, the poison of phagedsena, of 
 measles, of scarlet fever, of rabies, of erysipelas, of septicaemia, and many 
 others, none of these are known except by their effects. The snake-poi- 
 son, which may easily be collected and examined, does not disclose to the 
 microscopist, or to the chemist, in just what its poison consists. We 
 must, therefore, be satisfied for the present where we are, and wait until 
 science has advanced a step farther, and has been able to separate the 
 syphilitic poison from the fluids which contain it, while we still acknowl- 
 edge that a poison does exist, because the phenomena of the disease are 
 best accounted for upon that hypothesis. As to what the poison is, it is 
 wiser to confess ignorance. 
 
 The advance which modern investigation is making toward a discov- 
 ery of the exact cause of septic disease tends to locate these poisons in 
 living germs. Intimations have recently appeared in print that a granu- 
 lar substance has been discovered in snake-poison, in which presumably 
 resides the septic principle. The minute, rounded, microscopic bodies 
 strongly refracting the light, which sink to the bottom after a time in a 
 tube containing pure vaccine lymph, have been shown by the investiga-
 
 62 THE VENEREAL DISEASES. 
 
 tions of Chauveau and Burden Sanderson to be actually the contagious 
 element of the lymph. The contagious quality has been shown not to 
 reside in the liquid portions of the fluid. The strong advocates in mod- 
 ern days of the bacterial origin of diphtheria, erysipelas, anthrax, inflam- 
 matory changes in the tissues, show the drift of scientific thought; and 
 although, unfortunately, the difference between the bacteria producing 
 diphtheria and those supposed to produce other diseases has not been 
 made out, yet it is to be hoped that closer investigation may eventually 
 discover in them distinguishing traits. 
 
 The same efforts to discover a living germ as the poison of syphilis 
 have been, and are still, being made in the profession. Salisbury and 
 Hallier both discovered a fungus which they believed to be the cause of 
 syphilis; but other observers have failed to accept their conclusions, and 
 the latter have gradually disappeared from view. More recently Lostor- 
 fer found some little shining corpuscles in the blood of syphilitic patients, 
 which seemed to behave in a peculiar manner, and immediately he an- 
 nounced that the poison of syphilis had at last been discovered. Compe- 
 tent observers promptly investigated the claims of the discoverer, and a 
 few months were sufficient to demonstrate to the satisfaction of every 
 one that the supposed syphilitic corpuscles were found in normal blood, 
 probably owing their existence to the white cells of the blood. Thus 
 faded another pleasant delusion. 
 
 Now another claimant is in the field for the honor of discovering the 
 germ which bears the poison of syphilis. Klebs, a well-known and thor- 
 oughly capable observer, cultivates a spore which he finds in syphilitic 
 blood (apparently a moving bacterium), produces a plant, inoculates it 
 upon an ape, produces consecutive ulcers recalling the ulcers of syphilis 
 clinically and histologically, shows them to Professor Pick, who recog- 
 nizes their resemblance to syphilitic ulcers, kills the animal, and finds 
 between the dura mater and the skull a material much resembling gumma, 
 and a quantity of organic germs analogous to the forms which had been 
 inoculated upon the animal. Klebs l placed a portion of a freshly extir- 
 pated syphilitic chancre under the skin of another ape, December 29, 
 1877. The wound healed without suppuration, the glands swelled 
 slightly. In six weeks the animal had fever, and shortly afterward a crop 
 of papules came out upon the neck, head, and face. The papules were 
 flat, two or three millimetres in diameter, and of brownish red color. 
 These lesions scaled off, but did not ulcerate, and the papules, together 
 with the fever, disappeared, leaving no trace. Nothing new appeared 
 externally, but in five months after the inoculation the strength of the 
 animal failed, and it died. Under the site occupied by the papules 
 during life, although no deeper-seated disease had then been detected at 
 these points, the skull showed evidences of periostitis and of caries sicca 
 exactly such changes as are found in man due to syphilis. A focus of 
 interstitial fibrous thickening containing spindle-cells was found in the 
 lung, the pleura being extensively thickened over it in a radiate manner. 
 Certain new formations of cells resembling young syphilomata were 
 found in the kidneys. Finally, some blood taken from* this ape yielded 
 plants looking very much like the fungus which had been inoculated 
 upon the first ape. The parasite, Klebs says, consists at first of movable, 
 then of stationary rods, from which latter grow spiral masses of linked 
 
 1 Both cases are reported from the proceedings of a meeting of naturalists at 
 Cassel, in the Allg. Wiener med. Zeitung, October 15, 1878, p. 418.
 
 SYPHILIS. 63 
 
 rods. Klebs calls the plants helikomonads, does not attempt to classify 
 them botanically, and considers them to be the cause of syphilis. A 
 number of observers are doubtless now at work testing the conclusions 
 of Klebs. It is certain that their accuracy will be questioned, and more 
 than probable th,at the whole theory of their causal relation to syphilis 
 will be overthrown. 
 
 E. Cutter, of Boston, in a lecture on the morphology of the blood, 
 delivered before the American Medical Association, January 7, 1878, 
 speaks of having found threads of mycelium and bacteria of a coppery 
 color in syphilitic blood, and the white blood-cells full of spores, which 
 escape by a rupture of the wall of the cell. Dr. Heitzmann, at a recent 
 meeting of the New York Pathological Society, stated that he believed 
 he had discovered the syphilitic poison as it exists in the blood. He de- 
 clined to make it known until further study had convinced him of the 
 accuracy of his facts. Thus it will be seen that investigation is active, 
 but the problem is not yet solved. 
 
 Other animals, besides the apes of Klebs, have been successfully in- 
 oculated with pieces of chancre, or its secretion: guinea-pigs (Legros, 
 Bradley), monkeys (Depaul), cats (Vernois, Bradley), and ulcers and 
 gummata produced, leading to marasmus and death; but the profession 
 has been slow in accepting the evidence as demonstrating syphilis in 
 these cases. They will be mentioned farther on. 
 
 Thus far, then, no positive proof has been adduced to show what the 
 poison of syphilis really is; many more experiments must be made before 
 the question can be set at rest. 
 
 It has been intimated strongly by Diday and Rollet, that an antago- 
 nism existed between the poison of syphilis and the cancerous diathesis. 
 Inoculations of syphilitic secretions capable of conveying the disease 
 were made by Rollet, by Diday, and by Rodet, with negative result, upon 
 cancerous patients. But this antagonism is certainly only apparent. I 
 have seen many cases in which syphilis and cancer existed clinically in 
 the same patient; and Hutchinson, of London, at the forty-sixth meeting 
 of the British Medical Association, went so far as to record his belief 
 that, while the syphilitic dyscrasia was not a cause of cancer, yet the 
 prolonged local irritation of a syphilitic sore might induce a cancerous 
 action in the part involved. This assertion, doubtless, refers only to 
 epithelioma. 
 
 The secretions -which contain the poison of syphilis. The uni- 
 ty or duality of the syphilitic poison has been already discussed (p. 7). 
 It remains to consider another important question, namely, in what secre- 
 tions does the poison exist in such a state that it may be transmitted by 
 contact. 
 
 The thin serous secretion of a syphilitic chancre contains the poison 
 probably in as concentrated a state as it can be furnished by the economy. 
 The contagiousness of chancre and its clinical hetero-inoculability in kind 
 upon a virgin subject have never been doubted, since the initial lesion of 
 syphilis has been recognized as the starting-point of the disease. Con- 
 frontations and direct experimental hetero-inoculations have proved this. 
 
 The authority of Hunter, in England, and the proclamation of Ricord, 
 in Paris, made as late as 1851, that the poison of syphilis was transmissi- 
 ble only through the secretions of the primary syphilitic sore, and that 
 none of the later lesions contained the poison in their secretion, controlled 
 the opinion of the general profession for a long time after the assertion 
 had been clinically and experimentally demonstrated to be an error.
 
 64 THE VENEREAL DISEASES. 
 
 The experiments of Wallace, of Dublin, in 1835, amply demonstrated 
 that inoculation of the secretion taken from ulcerated mucous tubercles, 
 and from the early pustular syphilides, would produce syphilis in a healthy 
 subject. Waller, of Prague, followed in 1851, and since then a great 
 number of other investigators have been added to the list, including the 
 familiar names of Gibert, LindwQrm, Barensprung, and Hebra, while the 
 clinical experience of every physician who sees much syphilis constantly 
 brings to light cases where the source of contagion has been, not chancre, 
 but the mucous patch. 
 
 The contagious properties of secretions from mucous patches, and sec- 
 ondary ulcerated surfaces upon mucous membranes, have become of late 
 years 'so obvious, clinically, that it is questionable whether this lesion does 
 not divide the honors of propagating syphilis equally with chancre, or pos- 
 sibly even surpass its rival. Fournier has called attention to this fact, 
 and Biiumler has emphasized it. Mucous patches and mucous tubercles, 
 ulcers of the mucous surfaces all these lesions secrete freely and are in a 
 position frequently to be brought into contact with surfaces capable of 
 absorption. The long duration of these lesions makes them especially 
 dangerous. They last for months at a time, and relapse frequently while 
 the syphilitic chancre, for the most part, occurs upon a patient but once 
 in a lifetime, and is of comparatively short duration. Abrasions may be 
 inoculated during sexual contact as well from a mucous patch as from a 
 chancre. 
 
 Nearly all the examples of the primary lesion of syphilis encountered 
 upon the mouth or on the face, the primary lesion of a suckling child de- 
 rived from a syphilitic nurse, of a healthy nurse from an infant with in- 
 herited disease, the cases of syphilis acquired from using spoons, pipes, 
 glass-blowers' tubes, those communicated by the surgeon through the in- 
 strumentality of the Eustachian catheter, the digital chancre of the accou- 
 cheur in all of these, quite certainly in most instances, the vehicle of the 
 poison has been the secretion of a mucous patch. 
 
 Perhaps the best recorded clinical evidence of the inoculability of mu- 
 cous patches and ulcers is that furnished recently by the report of Maury 
 and Dulles, 1 of Philadelphia. James Kelly, it appears, gained his support 
 by walking through the country and tattooing, for a small sum, all those 
 whom he could induce to submit to his mutilation. Along his track it 
 was found that fifteen individuals had acquired chancre at the tattooed 
 points, with subsequent syphilis, out of twenty -two tattooed. Kelly was 
 in the habit of putting his needles into his mouth and mixing his colors 
 with saliva. On examination, Dr. Maury found that his mouth was full 
 of secondary syphilitic lesions. 
 
 Hetero-inoculations of syphilitic blood, and of pieces of solid tissue, 
 which of course contain blood, have been made experimentally by a num- 
 ber of physicians (Waller, the Anonymous Surgeon of the Palatinate, 
 Pellizzari, Gibert). Some of the inoculations took; others yielded only 
 negative results, showing that the intensity of the poison in blood is not 
 particularly great. Pellizzari made five inoculations, of which only one 
 took. Among the last three, which are the most celebrated, one subject 
 of experiment was inoculated with warm blood, with positive result; the 
 other two, Drs. Rossi and Passigli, were inoculated in the same way, at 
 the same time, but the blood had become cold and was coagulated. The 
 result in these two inoculations was negative. 
 
 1 Am. Journ. of Med. Sciences, January, 1877, p. 44.
 
 SYPHILIS. 65 
 
 Clinically, cases are encountered where blood seems to be the vehicle 
 of contagion where, for instance, a man acquires chancre, and confronta- 
 tion fails to detect any physical lesion in the female, although perhaps 
 here Morgan's theory of the contagiousness of vaginal mucus in syphilitic 
 women may explain the infection. 
 
 The secretions from pathological lesions, not themselves syphilitic, 
 although occurring upon the bodies of syphilitic persons, do not contain 
 the virus of syphilis, unless admixed with blood. Gonorrhoea upon a 
 syphilitic patient reproduces gonorrhoea by inoculation, and not syphilis; 
 and the same is true of chancroid. 
 
 Vidal believes that urethritis upon a syphilitic person may produce 
 syphilis by inoculation. Hill, Marsten, and Hammond incline to the same 
 opinion. Tarnowsky, 1 in endeavoring to decide this point, made eighteen 
 inoculations with blennorrhagic secretions from syphilitic upon healthy 
 patients, and got one positive result. This result goes to prove that such 
 discharges do not contain the syphilitic poison, for in one case in eighteen 
 there surely might have been an admixture of blood with the inoculated 
 secretion. In further explanation of the exceptional case may be advanced 
 the well-known fact that urethritis may come on in a syphilitic person, 
 due solely to the development of suppurating mucous tubercles within his 
 urethra, and these tubercles may yield a discharge which resembles that of 
 ordinary mild urethritis (blennorrhagia) in all respects. Such discharges 
 will get well under anti-syphilitic treatment, as I have had personal occa- 
 sion to observe, and such discharges certainly must contain the syphilitic 
 virus as well as do the discharges of mucous patches situated elsewhere. 
 If the discharges of urethritis are hetero-inoculable, producing syphilis, 
 many wives would get the disease who now escape, and certainly more 
 than one out of the eighteen cases of Tarnowsky ought to have yielded 
 a positive result. Without concluding, then, that such discharges cannot 
 be contagious, it is best to consider that more proof is required before 
 accepting the fact as demonstrated. 
 
 Duplay's negative inoculation with pus from a pustule of acne pro- 
 duced upon a syphilitic patient, by iodide of potassium, is in point here. 
 
 Vaccinal syphilis perhaps yields the most convincing evidence that 
 heterologous diseases upon a syphilitic person do not contain the poison 
 in their secretions. It is well known in all epidemics of vaccinal syphilis, 
 and there have been many, that all the children vaccinated from the vesicle 
 upon the arm of a syphilitic child do not become poisoned, and, as a rule, 
 that those first vaccinated escape (receiving the serum only), while the 
 last comers get also some of the blood, and they develop both vaccinia 
 and chancre at the inoculated spot. It has been demonstrated beyond 
 question that pure, clean vaccine lymph, taken from a syphilitic person, 
 is safe, and not poisoned with syphilitic virus, so long as admixture with 
 blood has been avoided. The vaccine scab from a syphilitic person doubt- 
 less could not be used without great danger of inoculating syphilis, since 
 the scab always contains a portion of the true skin of the patient from 
 whom it comes. The epidemics of vaccinal syphilis should teach the phy- 
 sician never to use lymph taken from a child known or presumed to be 
 syphilitic, for no amount of care can absolutely guarantee the absence of 
 a trace of blood from the vaccine virus he has gathered. 
 
 Even at the present day epidemics of vaccinal syphilis are reported, 
 and they are likely to continue. So late as Feb. 2, 1878, there appeared 
 
 1 Vortrage iiber venerische Krankheiten. Berlin, 1872. 
 5
 
 6(5 THE VENEREAL DISEASES. 
 
 in the Italian Medical Gazette of Lombardy the history of twenty-six 
 children vaccinated from one syphilitic vaccinifer, among whom fourteen 
 acquired syphilis. In New York the question of the transmission of 
 syphilis bythe public vaccinators has several times been before the Health 
 Board, and the possibility of such an accident is constantly coming up in 
 the minds of fathers of children in private life. 
 
 Such experience as that published by Jonkoffsky, 1 where fifty-seven 
 children (foundlings) were vaccinated with lymph taken from eleven chil- 
 dren with inherited syphilis, without the transmission of syphilis in any 
 case, can be set off by HutchinsonV admirable report, in which ten out 
 of twelve vaccinated got syphilis, the vaccinifer being a seemingly healthy 
 child, who afterward was discovered to have inherited disease, although 
 the mother seemed healthy at the time as healthy as did the child. 
 
 Vaccinal syphilis frequently kills its victims, and there is no possible 
 excuse for it in the present day. Pure vaccine virus can be obtained on 
 quill and ivory points, taken directly from the calf, in most large cities in 
 civilized countries, capable of transportation for a short distance; while 
 vaccine lymph, in glass tubes, may be safely sent over the world and re- 
 tain its powers, as may also the scabs from the calf. 
 
 It must be remembered that vaccination may call out latent syphilis, 
 and produce an eruption upon a patient already syphilitic, just as a blister 
 or other traumatism may do. 
 
 The secretions from tertiary lesions of syphilis, serpiginous ul- 
 cers, lesions of bone, etc., do not seem to retain any inoculable quality, so 
 far as the transmission of syphilis is concerned. Diday's sixteen negative 
 inoculations of blood, derived from patients with tertiary syphilis, seem to 
 prove this, as well as the fact that a patient with tertiary lesions still upon 
 him may occasionally acquire chancre anew, and run through a second 
 mild course of true syphilis (p. 83). The one exceptional case quoted by 
 Bumstead, of the Ohio surgeon who acquired syphilis by inocxilating his 
 finger while operating upon syphilitic disease of the bones of the skull, 
 cannot overthrow the rule without more cases to confirm it, for there are 
 so many accidental ways in which a surgeon, with an abrasion on his fin- 
 ger, may acquire syphilis in the exercise of his profession, that the great 
 wonder is how any person escapes who handles the disease at all custom- 
 arily. 
 
 Therefore, with tertiary syphilitic secretions, as with non-syphilitic 
 pathological secretions upon syphilitic persons, it is well to reserve judg- 
 ment for a time. They may possibly be capable of carrying the poison 
 of syphilis without admixture of blood; but it has not yet been proven 
 that they do so. 
 
 Of the physiological secretions it may be quite confidently affirmed 
 that none of them are able to communicate syphilis by inoculation. Mor- 
 gan's vaginal mucus seems to be an exception to this rule, but it is more 
 than probable that none of the prostitutes in the Lock Hospital had a 
 vagina so nearly healthy as to secrete only mucus ; the discharge in every 
 case must have been muco-pus, as, indeed, it was generally claimed to 
 have been. The experiments, moreover, related more to the auto-inocu- 
 lability of these secretions than to their poisonous, syphilitic character. 
 
 The tears, the urine, the saliva, the perspiration, the milk, the semen, 
 have all been repeatedly inoculated without success. Very recently a dis- 
 
 1 St. Petersbnrger med. Zeitachrift, 1872. I. p. 73. 
 
 1 London Lancet, April 7, 1873, quoting Med. Chir. Trans. Vol. LIV., 1871.
 
 SYPHILIS. 67 
 
 cussion has been raised upon the last two physiological secretions, regard- 
 ing their power of transmitting syphilis. 
 
 Infection by milk. Voss ' reports a case where the injection of a 
 Pravaz syringeful of milk from a syphilitic woman, under the skin of a 
 healthy person, produced syphilis ; but his conclusions are arrived at with- 
 out just grounds. The report states that an abscess first occurred at the 
 seat of the injection ; then, after an incubation of forty days, a few pap- 
 ules (the alleged chancres) appeared around the seat of the abscess, and 
 in five days (and this is the weak point, for no general eruption due to a 
 chancre was ever known to appear within five days of the primary lesion) 
 a general maculo-papular syphilide came out. 
 
 A single case can never constitute a rule in syphilis, for it is almost 
 an impossibility to be certain to have eliminated all other sources of con- 
 ceivable contagion, excepting the one under consideration. 
 
 Milk from syphilitic patients has already been several times injected 
 under the skin, with negative result (Padova and Profeta). 
 
 Another case, published as one of transmission of the disease by 
 syphilitic milk, deserves notice here. Cerasi a has reported that a child 
 was given to an apparently healthy woman to nurse ; that the child had 
 no chancre at the mouth, and that the nipple remained unbroken ; but 
 that, in three months, the child became syphilitic, quickly developed gen- 
 eral symptoms, and died in a convulsion. The autopsy revealed gum- 
 mata in the brain and lungs, and an indurated liver. It now turned out 
 that the nurse had had chancre two months before assuming charge of the 
 child. 
 
 It seems paltry even to discuss such a case, for the child dies promptly 
 with the lesions of inherited disease; the nurse has no symptoms except 
 headache, rheumatic pains, and some pallor of complexion, while no rea- 
 sons are given for supposing the father and mother of the child to be 
 healthy. 
 
 None of these cases, therefore, can count against the investigations of 
 other competent observers, and milk must still be considered incapable in 
 itself of transmitting syphilis, either by inoculation or by ingestion, and 
 must remain so until incontrovertible proof is adduced to the contrary. 
 
 The apparent infections by milk recorded by a number of observers 
 are more than set off, as the matter now stands, by carefully observed 
 cases, where children have suckled syphilitic nurses and remained sound, 
 while inoculations of milk directly proves its lack of noxious quality. If 
 the nursing syphilitic woman has a mucous patch, and the child a fissure 
 on the lip, then the whole premises are changed, and chancre on the lip 
 of the child is the natural result. 
 
 Zeissl believes that children do become infected by nursing syphilitic 
 women, whose nipples and lips, in consequence of a mercurial course, show 
 no signs of syphilis ; but he does not state positively in what manner he 
 believes the transmission of syphilis to occur in these cases. 
 
 The infectious quality of semen is a matter of very serious dis- 
 pute, both as to its direct contagious properties and its capacity by im- 
 pregnation to infect the offspring, the mother remaining healthy. 
 
 On the first point the recent experiments of Mireur 3 bear directly. 
 
 1 Petersb. med. Wochenschrift, No. 23, 1876. 
 
 2 Gaz. di Roma, July, 1877, and Jahresbericht f. gesammten Med. , Bd. IL, Abt. 
 II., 1878. p. 520. 
 
 3 Annales de derm, et de syph. No. 6, Tome VIIL, 1877.
 
 68 THE VENEREAL DISEASES. 
 
 With true French indifference to the means by which he arrived at his 
 material for experiment, he inoculated four healthy individuals with semen 
 obtained from a man of twenty-six years, in fresh secondary syphilis, who 
 had not received any treatment. The subjects of experiment were long 
 and carefully observed in each c'ase, with negative result. 
 
 Such positive proof of the lack of contagious quality in the semen 
 more than counterbalances the claim of Von Barensprung, that semen may 
 directly infect a woman, if she conceives at the time ; or of Porter and 
 Parker, that she may be poisoned through the semen alone, without con- 
 ception, and without the receipt of any primary lesion on her part. The 
 small size and ephemeral character often of the primary lesion in the fe- 
 male renders it necessary to accept the last part of this assertion with 
 much reserve ; and the evidence at best is only negative, for a little blood 
 may very easily escape from an abrasion in the male, and carry the poi- 
 son along with the semen. On the other hand, the mass of clinical evi- 
 dence is enormous, going to show that men in full syphilis, but without 
 local lesion, may have intercourse with impunity, and may even impreg- 
 nate healthy women, and not transmit syphilis to them at all, or even to 
 the offspring. That the semen, however, can transmit syphilis by inheri- 
 tance seems to be pretty conclusively proved, as will be related farther on, 
 but it certainly does not always do so. 
 
 TRANSMISSION OF SYPHILIS BY INHERITANCE. 
 
 In connection with the study of the virus of syphilis, and of the fluids 
 which contain it and may transmit it, the question of transmission by in- 
 heritance naturally comes to mind, and calls for consideration in this its 
 appropriate place. The question is a knotty one and one, as yet, far 
 from being solved to the satisfaction of the professional world. 
 
 In the sixteenth century, after syphilis became generally known, its 
 transmission by inheritance was accepted. Afterward it was doubted. 
 Hunter doubted that syphilis could be inherited. Ricord thought inheri- 
 tance was rather the exception than the rule. During all this time there 
 was a general belief prevalent in the profession that syphilis could descend 
 to offspring, especially if the father were diseased ; and finally, Vassal, 
 and later, Cullerier, took the other view, and were the starting-point of 
 that opinion which to-day embraces a very large and respectable follow- 
 ing, namely: that the father's disease, or health, is a matter of no impor- 
 tance, so far as syphilis in the child is concerned, and that inherited 
 syphilis cannot occur, except as a result of constitutional syphilis in the 
 mother. 
 
 ^ When both parents are diseased, the child is quite certain to be syphi- 
 litic, unless the poisonous quality of the malady in both parents, and espe- 
 cially in the mother, be pretty nearly exhausted. Cases have been re- 
 corded where the child appeared sound, in spite of disease in both parents ; 
 and all records dealing with this question refer to cases in which, the 
 mother being diseased and producing a number of children, some of 
 these suffer but little, if at all, 1 while others, born later, are manifestly 
 syphilitic. This suggests the thought that during the lulls of disease, 
 when the natural tissues of the mother seem to be healthy, perhaps the 
 ovum may be free from the germ of the disease. It is certain that a 
 
 1 Mireur, p. 91.
 
 SYPHILIS. 69 
 
 syphilitic woman under treatment may produce a child in all respects 
 healthy, and then, giving up medicine under the idea that she is well, 
 mav give birth later to a child about whose syphilis there can be no doubt. 
 One of Thurman's cases, quoted by Mireur, 1 is in point here. Both parents 
 were syphilitic, both had apparently recovered under treatment, and nei- 
 ther of them showed any trace of syphilitic symptoms afterward, while 
 they continued under Thurman's observation. Seven children were born 
 to these parents successively, became covered with syphilitic eruptions, 
 and died. In the eighth pregnancy, the mother was submitted to mer- 
 cury. A healthy child was born, which remained well and grew up. In 
 the ninth pregnancy, the treatment was continued, and the child was born 
 healthy. In the tenth pregnancy, supposing herself well, treatment was 
 neglected. The child appeared well at birth, but a syphilitic eruption 
 came out later, and it died in six months. The mother finally became 
 pregnant for the eleventh time. She again received mercury, and her 
 child was born, and continued healthy. 
 
 That there are some unexpected peculiarities about the transmission 
 of syphilis by inheritance, is certain. The theory that in certain cases 
 the mother, by continuing to carry infected children, becomes by this 
 means herself constantly more and more diseased, cannot be supported, 
 because the examples proving it are altogether too exceptional to be rea- 
 soned from. It may seem to account for the fact that the older children 
 are sometimes more diseased than the earlier ones born to the same syph- 
 ilitic parents (as a matter of fact, this is exceptionally rare) ; but the 
 rule remains that, in the vast majority of instances, syphilis exhausts it- 
 self by lapse of time in the mother, and her children become less and less 
 diseased, and finally healthy. 
 
 When the woman alone is syphilitic, the child is quite certain to 
 inherit the disease. The ovule itself is a part of the poisoned mother, and 
 its development into an unhealthy child is a matter almost of necessity. 
 Exceptions to this rule have been alluded to above, where the mother has 
 syphilis, then produces a healthy child, then a syphilitic one. Most of 
 these cases (Zeissl has several of them) can be explained away. Those 
 which cannot, must either be accepted as a mystery yet unsolved, or as- 
 cribed to the fact that, during a lull in the disease, the impregnated ovule 
 was and remained healthy throughout. Adam Owre, of Christiania, in a 
 number of communications which have appeared of late years, contends 
 hotly for, and adduces numbers of cases in support of Cullerier's proposi- 
 tion, that syphilis in the child is inherited from the mother alone. His last 
 report covers forty -two syphilitic fathers having eighty-nine children. All 
 the fathers were syphilitic, all the children were well, all the mothers 
 remained healthy, all the cases were observed in private life. 
 
 Sturgis, of New York, has stoutly upheld this proposition; and J. W. 
 Thompson says, in the Richmond and Louisville Medical Journal for Feb- 
 ruary, 1876, that he has a list of seventy-two persons (adults and children) 
 who themselves are sound and their mothers well, while he " positively " 
 knows that all their fathers had syphilis. Mireur, in his pamphlet on the 
 inheritance of syphilis, also takes this view. Two of Mireur's cases claim 
 rehearsal here, for they demonstrate beyond the possible shadow of a doubt 
 that a syphilitic father may produce a healthy child if the mother remains 
 sound. One of the cases (p. 26) is this. C. has chancre and syphilis. 
 In one year he marries. In ten months a healthy child is born, who con- 
 
 1 Sur 1'heredite de la syphilis. Paris, 1867.
 
 70 THE VENEREAL DISEASES. 
 
 tinues well up to two years of age. Then the child acquires a chancre 
 upon the lip from kissing its father, who has at the time an indolent ero- 
 gion upon one of his lips, and in due time a roseola and mucous patches 
 at the anus appear upon the child. In another case equally instructive, a 
 syphilitic man impregnates his healthy wife and his syphilitic mistress at 
 about the same time; both children come to term. The one born of the 
 healthy wife has no disease; the illegitimate child, who is said to be the 
 image of its father and whose mother is also syphilitic, is diseased. 
 
 When the father alone is syphilitic, the child unquestionably 
 often escapes if the mother remains well. I have the most positive evi- 
 dence of this in the cases of seven young men with twelve children : 
 each father had syphilis, was treated by me throughout the disease, got 
 married and had children under my observation, all in the city of New 
 York. All the children and all the mothers are well. All the young men 
 married before their symptom had entirely disappeared, all of them have 
 had some slight but positive symptom of syphilis since marriage. Some 
 of the children are under constant observation. All of them are occasion- 
 ally seen. None of them have ever shown a sign of syphilis. A great 
 number of other corroborative cases are constantly turning up under my 
 observation, and there can be no reasonable doubt of the fact that a heal- 
 thy woman, by a syphilitic man, may have a healthy child. 
 
 But that a healthy woman by a syphilitic man must have a healthy 
 child, is altogether another question, and certainly is not a fact, if there 
 is any value in evidence. Frankel, 1 in examining placentae, found fourteen 
 which he believed to be syphilitic, in women who seemed healthy. The 
 value of this observation, however, is more apparent than real, because 
 many pathologists deny that the so-called syphilitic placenta is due to 
 syphilis at all, of necessity. 
 
 Hutchinson and von Rosen are inclined to ascribe more power to the 
 father than to the mother, in transmitting syphilis by inheritance. R. 
 W. Taylor, 8 of New York (two cases), and J. N. Hyde,' of Chicago (three 
 cases), Van Harlingen, 4 of Philadelphia (one case), have published very 
 strong cases to show that the father alone, if syphilitic, can produce a 
 diseased child, the mother remaining sound. Caspary, * Keyfel ' (43 
 healthy mothers, 44 syphilitic children, the fathers being syphilitic), Di- 
 day 7 (26 cases), and many others, have recently come forward to sustain 
 the proposition that the father alone, without disease in the mother, may 
 transmit syphilis to the offspring. 
 
 The strongest of all the public documents sustaining this side of the 
 question is the recent monograph by Kassowitz, 8 wherein the whole sub- 
 ject is submitted to an exhaustive study going to show, without leaving 
 room for much doubt, that inherited- syphilis in the child may descend from 
 the father alone. 
 
 I have encountered, in what I believe to be a reasonably large expe- 
 rience, but one case sustaining this view, and that one was imperfectly 
 observed. The case was that of a child dying shortly after birth with 
 
 1 Archiv f. Gynaekologie, 1873, Vol. V., p. 45. 
 1 Archives of Clinical Surgery, September, 1876. 
 * Archives of Dermatology, April, 1878, p. 103. 
 'Ibid., April, 1877, p. 211. 
 
 6 Vierteljahresschrift f. Derm u.Syph., 4th Heft, 1875. 
 8 Separat Abdrnck aus dem iirbzl. Intelligenzbl. , No. 21, 1876. 
 ' Annales de dermatologie et de syphiligraphie, T. 8, No. 3, p. 161. 
 Die Vererbung der Syphilis : Braumiiller. Wien, 1876.
 
 SYPHILIS. 1 
 
 pemphigus and cachexia, where the autopsy showed syphilitic lesions in the 
 lungs, liver, and other organs. The mother was apparently, and always 
 had been, healthy, and so did the father appear to be; but the latter 
 confessed, after a sharp examination, that he had had syphilis eight years 
 before. The mother was not kept under observation long enough to give 
 this case full value. The mother was a patient of Dr. C. C. Lee, of New 
 York, who asked me to see the case with him. 
 
 It seems fair to accept as proved, therefore, that a syphilitic father 
 may procreate a syphilitic child, and that, if the mother at the time of 
 conception is healthy, she may remain so, or seem to remain so, indefi- 
 nitely, the child being born syphilitic. 
 
 This statement leaves two very weak points unsatisfied by explanation. 
 The points, both negative, are these: in no case, so far as I remember, 
 has it been shown that a healthy mother, who had produced a syphilitic 
 child diseased from its father, afterward became herself poisoned by ex- 
 perimental or accidental inoculation. The other point is this: Colles's law, 
 so called, states that a child with inherited disease may poison a healthy 
 stranger whom it suckles, by inoculating the breast; but that the same 
 child cannot poison its mother. How this rule can possibly stand, unless 
 the mother is already diseased, it is hard to conceive. And yet no au- 
 thentic instance has been recorded in which, among the great number of 
 cases observed, any exception to Colles's law has been noted. Brizio 
 Cochi in 1858, and Miiller in 1861, are quoted by Kassowitz as having 
 reported exceptions to this law; but Kassowitz adds that the cases were 
 not described with great accuracy or distinctness, and therefore, scienti- 
 fically, they are of no value. Caspary l attempted the only possible posi- 
 tive solution to this question. He found a seemingly healthy woman with 
 a syphilitic husband and a syphilitic child. He inoculated the woman 
 with the secretion of syphilis without effect, thus seeming to prove that 
 although apparently healthy, she already had syphilis. 
 
 I myself have one case bearing on this point. A woman has had un- 
 der my observation three children, all syphilitic. Her husband was and re- 
 mains syphilitic. The first child was a few months old when I first saw it. 
 It was sent to me for treatment, with the statement that it had been born 
 healthy, had been poisoned by its wet-nurse, and in time had poisoned its 
 father. The child and the father were manifestly syphilitic. The mother 
 thought she was sound, and would have passed for being well, except for 
 a very thorough examination, which detected an occasional suspicious- 
 looking macule upon the skin, and some small but beautifully character- 
 istic mucous patches upon the throat and inside the mouth. All three 
 were treated. The baby died. The mother lost her symptoms at once, 
 and considered herself so well that she refused treatment; the father's 
 symptoms continued and were severe. 
 
 After a time the wife again became pregnant in another city. A child 
 was born apparently healthy. The mother was a picture of perfect health, 
 and considered herself well. The father was still under treatment. The 
 baby was pronounced healthy by the doctor in attendance, and given to a 
 wet nurse. The nurse soon got a sore on the nipple, then a sore was 
 found on the baby's mouth, and both nurse and child commenced to give 
 evidences of syphilitic poison by eruptions. On this account the nurse 
 was accused of having poisoned the child with syphilis, and was discharged. 
 The child's mouth was treated, another nurse was sought, accepted the 
 
 1 Vrtljhschrift f. Derm. u. Syph., 4th Heft, 1875.
 
 72 THE VENEREAL DISEASES. 
 
 place, and after a few weeks the family again came to New York. The 
 mother seemed to be in the perfection of health, and no trace of syphilis 
 existed upon her. The child, now about eight months old, looked like an 
 old man ; the head was small, the fontanelle nearly closed, the body 
 wasted, the voice hoarse, while a large fungating ulcer occupied the corner 
 of the mouth. The father had white patches on the tongue and squa- 
 mous, serpiginous spots on the scrotum. 
 
 The new nurse was pale, had one raw, hard, beefy-looking ulcer on 
 the nipple and breast about one inch long and half an inch wide. She 
 was feverish, sore throat was commencing, with pains in the bones at 
 night. 
 
 Nurse and baby were put under treatment. The former continued to 
 have a few mild symptoms of syphilis while under observation (six 
 months). The child's symptoms disappeared under treatment. 
 
 Finally, the mother became pregnant again. She seemed to be per- 
 fectly well, but I urged her to take treatment continuously through the 
 term of utero-gestation. This she failed to do efficiently, because she en- 
 joyed, seemingly, the absolute perfection of health and looked perfectly 
 well. At the end of the eighth month, without cause, the child's move- 
 ments in the womb ceased. At term, in February, 1879, she was delivered 
 of a dead child, the macerated condition of the latter showing that it had 
 been dead some time. In August, 1879, I saw the mother ; she had 
 taken no treatment, but showed no sign of syphilis. 
 
 This case is very instructive. Had I not seen the mother before the 
 death of her first child, I should have felt certain that she had no syphilis, 
 for, from that date until this writing, now a period of more than three 
 years, she has not shown the least symptom of syphilis, except by the 
 fact that she has produced two syphilitic children. 
 
 In summary of the foregoing statements, it seems just to conclude: 
 
 1. When both parents are syphilitic, the child is almost necessarily dis- 
 eased. Exceptions are probable under treatment of the mother, or when 
 lapse of time has exhausted the disease in the mother; exceptions are 
 possible during lulls in the disease, or under circumstances with which 
 science is at present unfamiliar. 
 
 2. When the mother is diseased and the father healthy, the child is 
 syphilitic, excepting under the same circumstances as obtain when both 
 parents are diseased. 
 
 3. When the father is diseased and the mother healthy, the child is 
 healthy, as a rule. Sometimes the child is diseased under these circum- 
 stances, while the mother seems to be and continues to remain well in all 
 respects, as testified to by a number of perfectly competent observers. 
 
 In connection with this question of the transmission of syphilis by in- 
 heritance, three other points must be considered, namely: the date at 
 which a woman, carrying a child, may become syphilitic without poison- 
 ing the child; the " choc en-retour" of Ricord; and the transmission of 
 syphilis to the third generation. 
 
 Date at which a pregnant woman may become syphilitic 
 without poisoning her child. Unless the mother, who has been 
 healthy and carries a healthy child, gets a chancre before the seventh 
 month of pregnancy, it is believed that her child will escape (Ricord, 
 Boeck, Barensprung, Frankel, and others). 
 
 If the mother gets her chancre at the moment of conception, or soon 
 after, she is apt to miscarry. If she gets it later, the child goes to term, 
 but is born thoroughly poisoned, with poor chance of surviving. The
 
 SYPHILIS. 73 
 
 common agreement is that, if the chancre does not appear before the 
 seventh month, the child is safe. This is not always the case, however, as 
 proved by Chabalier's l case, in which chancre did not occur until the 
 ninth month, due to intercourse at the end of the seventh month, with 
 thirty-eight days' incubation. In this case the child had syphilis, of which 
 it died. 
 
 Choc en-retour is a fanciful expression, meaning that a healthy wo- 
 man conceives by a syphilitic man, that the-ovum becomes diseased through 
 impregnation with diseased semen and in its turn poisons the mother, the 
 latter never having any chancre, but becoming directly contaminated by 
 contact of her fluids with the infected fluids of the fostus. 
 
 The possibility of choc en-retour reopens the whole question of the 
 inheritance of syphilis from the father alone, already discussed above. 
 The possibility of this method is seriously doubted by many, steadfastly 
 believed in by others. It will stand or fall upon a final and definite solu- 
 tion of the question of inheritance from the father alone. If the father 
 can transmit syphilis to his offspring by some quality his malady has im- 
 printed upon his spermatozoa and there is no reason to believe that this 
 is absolutely impossible then it is very probable that choc en-retour ex- 
 ists, and that the prolonged presence of the child in utero necessarily 
 poisons the mother, without chancre, giving her perhaps a modified form 
 of the disease not enough poison to betray itself by the usual symptoms 
 of syphilis, but enough to protect her from acquiring the disease after- 
 ward in a natural way, or by inoculation (Caspary), and preventing her 
 child from giving her chancre of the breast, thus justifying Colles's law. 
 
 An occasional able essay upholding the possibility of choc en-retour 
 appears. Diday a recently published such a paper, stating than an ovum, 
 or an embryo, or a foetus, poisoned by the father, might produce disease 
 in the mother at any time before birth. 
 
 The transmission of syphilis to the third generation has gener- 
 ally been doubted. A common belief is, that after syphilis has been once 
 transmitted by inheritance it degenerates into something like scrofula, 
 which in its turn may be transmitted, although the syphilis may not. The 
 truth seems to be, that the activity of the syphilitic poison is freshened up 
 by transmission to a growing child. Infection of a healthy nurse by a dis- 
 eased child is very common. Von Rinecker inoculated a healthy physician 
 with pus taken from a pustule of acne upon a child forty-nine days old, 
 whose syphilis was inherited. 3 Everything goes to show that the poison in 
 a baby is exceedingly active, although that in the parents may have almost 
 died out before the child is born. The reason syphilis is not generally 
 transmitted to the third generation is, that if the quantity of poison in 
 the child is great and the quality intense, the baby does not survive. 
 If it is less powerful, the child overcomes it, throws it off, or, at least gets 
 so far along in the tertiary stage before it has reached the age at which it 
 can marry and have a child, that transmission to the third generation is 
 very seldom encountered. I have a case now under observation in which 
 I expect finally to prove transmission to the third generation; but the 
 facts are not yet ripe for mature conclusions, and I withhold them. Hutch- 
 inson * believes he has seen one instance of transmission in the third gen- 
 
 1 Journ. de med. de Lyon, May, 1864. 
 
 8 Annales de dermatologie et de syphiligraphie. T. 8, No. 3, p. 161. 
 
 3 Verhandlungen der phys. med. Gesellschft. in Wiirzburg. Vol. III., 1852, p. 391. 
 
 4 Reynolds's System of Medicine. I., p. 100.
 
 74 THE VENEREAL DISEASES. 
 
 eration. Simon, in the debate on syphilis before the London Pathological 
 Society in 1876, thought he had seen a case. Lewin ' reports a case, and 
 Atkinson, of Baltimore, another. 9 
 
 Enough evidence from different quarters, therefore, seems to have 
 been collected to decide that syphilis may be transmitted to the third 
 generation. 
 
 1 Wien. med. Presse. No. 1, 1876. 
 
 * Archives of Dermatology, Jan., 1877, p. 106.
 
 CHAPTER III. 
 
 SYPHILIS. 
 
 Methods of Contagion in Acquired Syphilis, Direct and Mediate. The Duration of 
 Syphilis and the Question of Marriage. CauterisatioProvocatoria. The Prognosis 
 of Syphilis, and the Influence of Constitution and of Intercurrent Physiological 
 and Pathological Conditions upon its Course and Duration. Second Attack of 
 True Syphilis occurring in Individuals who have already once had Syphilis. 
 
 THE methods by which syphilis may be acquired are many. They 
 have been foreshadowed in the last chapter during the consideration of 
 the transmission of syphilis by inheritance, and of the fluids which con- 
 tain the poison. On the methods of acquiring syphilis by inheritance, 
 nothing more will be said; the present section deals with syphilis acquired 
 by contagion. 
 
 Syphilis may be acquired by contact of a surface capable of absorption 
 upon any part of the body with the poison of syphilis as contained in any 
 of the fluids capable of holding it (Chapter II.), whether those fluids are at 
 the time upon the body of the person yielding the poison, or upon some 
 indifferent object. This opens the subject of direct and mediate conta- 
 gion. _ 
 
 Direct contagion. Syphilis acquired by sexual intercourse in the 
 usual way is an instance of direct contagion. The surface capable of ab- 
 sorption upon the healthy person is brought into direct contact (usually) 
 with the source of the poison. But there are many methods of direct 
 contagion other than that by sexual intercourse; as illustrating these 
 methods may be instanced: the chancre of the lip, acquired by kissing, a 
 mucous patch being the source of the poison; the digital chancre of the 
 surgeon, acquired while manipulating poisoned parts; or of the accoucheur, 
 acquired while practising the vaginal touch ; the chancre on the nipple of 
 the healthy nurse, taken from the mucous patch in the mouth of the syph- 
 ilitic child, and vice versa. Such examples might be multiplied indefi- 
 nitely. 
 
 Mediate contagion. Puche's often-quoted case is an excellent 
 instance of mediate contagion, the healthy prepuce acting as the medium: 
 A married man with a long prepuce has intercourse with a former mis- 
 tress. He returns home unwashed, and repeats the sexual act with his 
 wife, leaving in her vagina some syphilitic secretion which he had ob- 
 tained from the mistress, and carried in the folds of his prepuce. The 
 man escapes infection, but his wife acquires chancre. Spoons and forks, 
 cups and tobacco-pipes, tattooing-needles (p. G4), are well-known media 
 of contagion, receiving saliva which contains the secretions from mu- 
 cous patches in the mouth, and depositing it upon a fissure int he lip 
 of another person. All hetero-inoculations, for purposes of experiment 
 or otherwise, are instances of mediate contagion. In the industry of
 
 76 THE VENEREAL DISEASES. 
 
 glass-blowing, the passage of the tube from mouth to mouth has been 
 known to effect a widespread distribution of the poison. There are 
 some grounds for believing that a new cigar may retain in an active 
 state, at its twisted end, some of the syphilitic poison derived from the 
 mouth of the man who originally rolled it wetting the twisted end, as 
 is often done, with saliva. Vaccination as a means of mediate contagion 
 has already been noticed. Surgical instruments have sometimes been 
 the medium of contagion. Hardy states 1 that, in 1876, a specialist in 
 ear disease, in Paris, is believed to have inoculated thirty or forty persons 
 with the Eustachian catheter. He (Hardy) had treated five of these. 
 Wet cups have carried the disease, the transplantation of teeth has done 
 the same, and the practice of the religious rite of circumcision. 
 
 A knowledge of the variety of methods 'by which syphilis may be 
 conveyed is of great value to the patient, who is ordinarily ignorant of 
 it. It is well to instruct him in this, as well as to give him directions 
 about the local and general treatment of his disease, so that, while curing 
 himself, he may know how to preserve those by whom he is surrounded 
 from infection. 
 
 The duration of syphilis, and the question of marriage. 
 Zeissl is reported to have once made the statement that, if a man has 
 syphilis once, he has it for ever, and that his ghost after death will still be 
 syphilitic. Fournier has reported a case where a gummy tumor on the 
 thigh appeared fifty-five years after chancre. In face of this strong as- 
 sertion and this authentic case, each emanating from a gentleman occu- 
 pying an authoritative position in the profession, who shall say that syph- 
 ilis ever gets well, and not stand condemned by his own words ? 
 
 And yet syphilis undoubtedly does get well. It is notorious that a 
 patient while syphilitic cannot take the disease. Thousands of inocula- 
 tions have been made upon such patients, by hosts of experimenters 
 especially by Boeck and the syphilizers the matter inoculated being de- 
 rived either from syphilitic secondary lesions or from syphilitic chancres. 
 The result has been invariably one of two: either the inoculation has 
 proved negative, or one of these two lesions has followed: (1) an abortive 
 pustule or papule sometimes going on to ulceration, or (2) an ulcer yield- 
 ing auto-inoculable pus, and considered by some to be a chancroid. In no 
 instance, and at no stage of syphilis, has experimental inoculation of 
 syphilitic virus upon an infected person been attended by the develop- 
 ment of a fresh attack of syphilis, with its characteristic consecutive 
 phenomena. Protection against future attacks is secured by a single 
 infection; and yet there are a number of cases on record, resting on evi- 
 dence which silences criticism, proving that true syphilis may be acquired 
 twice by the same individual, and may in one lifetime run through its 
 different stages twice (p. 83). It follows that the first syphilis must be 
 well, or the second could not have been acquired. 
 
 The only flaw in this argument is that furnished by the facts that: (1) 
 tertiary lesions are no longer contagious, and do not involve a persistence 
 of the original poison as such, or at least not in its original state; and 
 (2) occasionally patients still suffering tertiary lesions upon their persons 
 bear healthy children. Therefore such persons, although still syphilitic, 
 dp not possess the active poison of syphilis, and therefore may take the 
 disease again. Consequently it must be granted that there is no guaran- 
 tee that the impress received by the organism upon the acquisition of 
 
 1 Gaz. des hop., Sept 10, 1878, p. 833.
 
 SYPHILIS. 77 
 
 syphilis is ever totally eradicated, and that if the poison, as a poison, 
 becomes exhausted by time, yet the possibility of after-outbreaks if not 
 virulent, at least due to syphilis cannot be positively denied by any 
 honest observer. 
 
 This statement at first sight seems to present a gloomy outlook for the 
 patient, and to cast despair into the hopes of the physician in all his ther- 
 apeutic efforts. But, practically, this is not the case. The treatment of 
 syphilis is one of the few glories of medicine. It offers one of the very 
 rare examples of the specific action of drugs. A close knowledge of its 
 intricate workings and its myriad symptoms gives the physician a breadth 
 of power over chronic disease, which he can acquire in no other way. 
 When least expected, syphilis crops out as a cause of symptoms, which 
 may have long baffled explanation, in a person whose character and sur- 
 roundings place him above reproach. The multiple means of mediate con- 
 tagion place syphilis within, not only the possibility, but almost the prob- 
 ability, of all mankind. The sanctity of virgin purity does not shield its 
 possessor, the gray hairs of the sage do not protect him, the holy atmo- 
 sphere of religion is no barrier, which syphilis by the aid of mediate con- 
 tagion may not easily break down. 
 
 And yet, notwithstanding the widespread prevalence of the disease, 
 it is usually a kindly enemy, and does not trouble its victims much at the 
 present day, in the atmosphere of New York at least. Were it not for 
 its treachery, it might be laughed at, but it is eminently respectable in its 
 strength, and it sometimes exercises its power with a virulence which is 
 appalling. It pervades the whole body, and may spring out when least 
 expected, and its possessor has little safety, except in that comfort which 
 a prolonged thorough treatment affords. No disease equal to syphilis, in 
 obstinacy and virulence, yields a like ready response to treatment ; and 
 no condition, however seemingly hopeless, need excite despair, if only 
 syphilis can be made out as a cause. 
 
 Practically, in the vast majority of instances, syphilis is a very mild 
 disease. It gets well, to all intents, under a variety of treatments, or un- 
 der no treatment at all very often; and the main advantage possessed by 
 one treatment over another is the power which it may give of imme- 
 diately controlling symptoms which directly threaten life, limb, or func- 
 tions, and the guarantee afforded by experience in its use against relapse, 
 or serious disease late in life. 
 
 It is a less serious matter to have syphilis than that one's father should 
 have died of consumption or of cancer. Bad malaria, or dyspepsia, or 
 rheumatism, or eczema, or psoriasis, or a number of other maladies, are 
 infinitely worse than ordinary syphilis, far harder to manage, and much 
 more likely to relapse. The danger and the severity of common syphilis 
 is much oyerrated by the profession, as well as by the public. Bad syphi- 
 lis is undoubtedly a horrible disease ; but there is very little bad syphilis in 
 the community, compared with the total number diseased. 
 
 Therefore, allowing that bad cases may continue to relapse almost in- 
 definitely, and that some late lesion, due to syphilis, may occasionally ap- 
 pear after any treatment upon a patient once affected, even possibly up 
 to the hour of his death, yet the common duration of the disease is only 
 about two and a half to three years, and many cases do not have symp- 
 toms longer than during a few months. After the first year, or year and 
 a half, there is generally but little trouble; and when the disease has fairly 
 died away, the patient is as well as ever, and may go on to a ripe old age 
 without ever again hearing of his enemy, having healthy children, and
 
 78 THE VENEBEAL DISEASES. 
 
 passing through the changes incident to advancing life exactly like any 
 
 one else. 
 
 The question of marriage links itself naturally to the question of 
 the duration of syphilis. When may a syphilitic man marry ? A man's 
 life is not necessarily blighted by syphilis; and although the first impulse. 
 of a young man, upon acquiring the disease, is to forswear matrimony, 
 yet he changes his mind after a time, and very justly so, when he finds 
 that syphilis is not the horrible plague he had supposed it to be. The 
 man who marries during the activity of syphilis commits a sin, the pen- 
 alty of which is paid by his wife, his children, and society. In that pen- 
 alty he shares, but he has no right to throw any of his burdens upon an- 
 other, especially if he considers that other an object worthy of any regard. 
 After the virulence of the disease has become exhausted, then a man may 
 marry, and should marry, as discharging a duty due to society. 
 
 The time at which marriage becomes justifiable cannot be stated with 
 absolute accuracy. In a general way it may be safely said that a man 
 should not marry until at least three good years lie between him and his 
 chancre, and at least one year has elapsed since the disappearance of the 
 last symptom which can be ascribed to syphilis. Also, it is wise for a 
 man not to marry until he has passed through a prolonged, mild mercu- 
 rial course, and kept himself under observation for a number of months 
 after all treatment has been suspended. 
 
 For a woman the time should be longer. She retains the power of 
 producing diseased offspring much longer than the male; and, although 
 syphilis in the female is commonly less intense than in the male, it is on 
 that account none the less obstinate and protracted. It is hard to fix upon 
 a proper date at which marriage may be allowed in the syphilitic female, 
 but it is safe to say that at least five years from chancre, and a prolonged 
 immunity from symptoms without treatment, should be insisted upon; that 
 a previous prolonged mercurial course shall be an essential to obtaining 
 the physician's consent to assume a share in the responsibility of marriage, 
 and that in case of pregnancy the patient should submit herself to the 
 mild action of mercury during the entire period of utero-gestation. With 
 these precautions it will be reasonably safe for a syphilitic female to marry. 
 
 Cauterisatio provocatoria. An attempt has recently been made 
 by Tarnowsky ' to find a test of the existence of syphilis, to apply to pa- 
 tients in whom the disease may be latent. He thinks that he has suc- 
 ceeded; but it will take many years to decide whether some of the patients, 
 upon whom cauterisatio provocatoria produced only a negative result, may 
 not yet develop symptoms due to syphilis. 
 
 The cauterisatio provocatoria is an application of the well-known prin- 
 ciple that latent syphilis may be called into activity by the application of 
 an external irritant. A blister, a vaccination, a traumatism, will some- 
 times call out symptoms of syphilis upon a patient apparently well, but 
 really in a condition of latent syphilis. 
 
 ^ At one time it was believed that a course of sulphur-bathing would 
 bring out any remains of syphilis under which a patient might be suffer- 
 ing, and that if such a course left the skin sound a cure might be confi- 
 dently affirmed. This, like all other previous tests, has proved fallacious. 
 
 Ricord's carbo-sulphuric paste was employed by Tarnowsky upon two 
 hundred and fifty patients suffering from chronic maladies of the skin 
 
 > J Y^ ] ' a ];' 88chrift - f ' Derm - * Sypk, rx -5 Jahresbrcht. f. Gesmmt. Mei, II. Bd., 
 Abt. ll., Io7o, p. 525.
 
 SYPHILIS. 79 
 
 and internal organs. The result of its action is summed up in a number 
 of conclusions, some of which are in substance as follows: 
 
 (1). A positive result proves that syphilis exists; a negative result does 
 not prove the contrary. 
 
 (2). A positive result is the following: a dark red border, not disap- 
 pearing on pressure, comes on after all inflammatory action produced by 
 the cauterization has disappeared. This band is from three to five mm. 
 broad. It has a sharp border, is indurated, grows slowly, and acquires a 
 brown tint. After twenty to thirty days it gradually subsides. 
 
 At the same time, with the appearance of this border, a sharp-edged 
 induration forms beneath the cauterized area. This increases for fifteen 
 to twenty days, and then gradually disappears. If any one of the above 
 detailed features is absent, the cauterization cannot be said to have pro- 
 duced a positive result. 
 
 Finally, around the cauterized area, after the cauterized tissue has 
 separated, round or serpiginous ulcers, papules, ecthymatous pustules, or 
 tubercles appear, which go far to make more certain the positive result of 
 cauterisatio provocatoria. 
 
 (3). If the inflammatory results of the cauterization have not disappeared 
 by the tenth to the fifteenth day, the first set of phenomena mentioned 
 above cannot be observed, and the cauterization loses its diagnostic 
 value. Prolonged inflammation is most apt to be observed in non-syphili- 
 tic, weakened, cachectic persons. A separation of the slough in the first 
 five or ten days interferes with an accurate observation of the result of 
 the cauterization, as does also the appearance about the focus of irrita- 
 tion of eczema, erysipelas, etc. 
 
 (4). The younger and the healthier the individual, and the less irritable 
 his skin, the more accurate are the results which may be derived from a 
 cauterisatio provocatoria. 
 
 (5, 6, 7). The nearer the date of chancre to the time of cauterization, the 
 more likely is this test to give a positive result, and to call out symptoms 
 of syphilis locally. 
 
 I have as yet no experience with this test. It can do no harm to try 
 it, but it will be unwise to rely upon the results attained by it until its 
 accuracy shall have been tested by a sufficient lapse of time, and at the 
 hands of other observers. A reliable test of the termination of syphilis 
 is very desirable. Koebner ' has tried it. He says that Tarnowsky's 
 effort is the revival of a similar attempt already undertaken by Meggen- 
 hofen. Koebner tried the cauterisatio provocatoria upon ten syphilitic 
 individuals early and late in the disease. In two of the former the test 
 was applied before any mercury had been given, but the result was nega- 
 tive. Indeed, Koebner failed to get any positive resxilt, although four of 
 his patients had had relapses of their syphilis at the date of his writing. 
 Other investigators will doubtless soon be heard from. Still more recently 
 Kaposi has tried this test. He denies its value. 
 
 The prognosis of syphilis, and the influence of constitution 
 and of intercurrent physiological and pathological conditions 
 upon its course and duration. A solution of this question explains 
 many of the apparent peculiarities of syphilis. If it were necessary to 
 decide which single quality of syphilis was more certain to belong to the 
 disease in all cases than any other, the quality of treachery would proba- 
 bly be selected. Uncertainty as to what the disease may eventually do 
 
 1 Vierteljahreaschrift f. Derm. u. Syph. H. IV., 1878, p. 589.
 
 80 THE VENEREAL DISEASES. 
 
 interferes seriously with accuracy of prognosis. I think I have demon- 
 strated this in another place, 1 adducing cases to show that no amount of 
 mildness in the appearance of the chancre, or the course or symptoms of 
 early syphilis, is any guarantee that the future course of the disease will 
 be equally light, no matter which of the treatments ordinarily in use is 
 employed against the malady. The seven cases in the essay referred to 
 are examples of the mildest forms of syphilis, treated in all known ways 
 except by the prolonged mild use of mercury and by syphilization. I was 
 unable to find a case where the mild, continuous treatment had been used, 
 which commenced very mildly and yet terminated very severely ; and 
 syphilization is not practised in this country. FournierV record of forty- 
 seven cases of cerebral syphilis lends further weight to the opinion that 
 mildness of the early course of syphilis does not necessarily mean mildness 
 throughout. Of Fournier's forty-seven cases, in only two did the syphili- 
 tic symptoms commence severely; one was moderately severe, thirty were 
 ordinary cases, and fourteen were actually benign. The old notion, there- 
 fore, that a light beginning in syphilis can be counted upon to indicate a 
 type of disease in itself necessarily mild, is not accurate. And yet, what 
 else is there to judge from ? Certainly, a severe phagedenic chancre is 
 quite apt to portend a bad attack of syphilis. Diday's idea that the 
 length of incubation of the chancre, and a long period of delay in the ap- 
 pearance of the secondary symptoms, portended a mild case of disease, is 
 of some value, but certainly not absolutely trustworthy. As'far as the 
 first symptoms show anything, however, they do in a measure declare the 
 character of the subsequent symptoms, but they do not guarantee it; the 
 element of treachery steps in, and no honest prognosis can be a very posi- 
 tive one. 
 
 In a general way, then, with room for exceptions and leaving out for 
 the present the question of personal constitutional peculiarities, it may 
 be affirmed that a long incubation to the chancre, mildness in the primary 
 lesion, a long secondary incubation, mildness in the earliest eruption 
 (roseola) such qualities in the early symptoms indicate a mild type of 
 disease. Such a syphilis may run itself out in a few months, unaided 
 even by any treatment, and may possibly never be heard from again. It 
 often does appear in one form or another later in life, but commonly then 
 shows the same light type as that in which it started. 
 
 On the other hand, a short incubation to the chancre, severity in its 
 symptoms, or the duration of the latter, especially if the chancre be at- 
 tacked by phagedaena, intensity in the local character of the first out- 
 breaks (pustular instead of erythematous), and resistance of the latter to 
 treatment particularly that form of disease in which symptoms usually 
 occurring in the tertiary stage come on early in the course of the malady 
 (malignant syphilis) all of these features in the beginning of syphilis 
 indicate severity in the type of the disease, and the prognosis must be 
 modified accordingly. 
 
 Something more must be said in relation to both these classes of 
 cases those commencing mildly, and those commencing severely. It 
 often happens that cases mild in the quality of their symptoms are severe 
 in regard to duration. Cases in which light scaly eruptions occur, and 
 dry patches, with persistently relapsing mouth and throat lesions these 
 
 'Keyes: Treatment of Syphilis, etc. Trans. International Med. Congress, Phila- 
 delphia, 1877, p. 726. 
 
 1 La syphilis cerebrale, etc. L'ficole de nv'd., Aug. 30, 1875.
 
 SYPHILIS. 81 
 
 often occasion great annoyance to the physician. No very severe symp- 
 toms occur at any time; but the persistent tendency of mild lesions to 
 reappear annoys the sufferer greatly, by keeping his malady before his 
 mind, and tests his patience to the utmost. In compensation it may be 
 confidently asserted that many cases, seemingly very severe in the early 
 stages, pertinaciously resisting treatment, running to ulceration, and 
 bringing despair to the patient such cases often expend their violence 
 in the early part of the attack, and so exhaust the virulence of the dis- 
 ease in one or two years, that the patient never hears from it again, 
 and passes through long years of after-life perfectly sound, bearing only 
 the scars to indicate the ravages occasioned by his former enemy. This 
 fact is undoubted, and a knowledge of it is often very comforting to the 
 patient. 
 
 The influence of constitution upon the course and the type of 
 syphilis is very obvious. Two persons infected from the same source do 
 not have exactly the same type of disease. Both acquire identically the 
 same poison, but the symptoms are quite certain to run a different course. 
 This result can only be due to a difference in the constitution of the pa- 
 tient; and yet, the capriciousness of syphilis shows itself in this as in 
 all other matters, and it is not safe to be too positive in basing a prog- 
 nosis upon either the appearance of robust health or very obvious consti- 
 tutional defects. 
 
 In a general way, it is true that a healthy person in good hygienic 
 surroundings, living a regular life, is best able to stand an attack of 
 syphilis, and ought to escape lightly; while a sickly person, in bad sur- 
 roundings, should, by right, be overwhelmed by the disease. This is in 
 a measure true, but exceptions are too common to make the fact of much 
 value. A vigorous youth in the flower of health may wilt under the 
 blight of syphilis, while a puny consumptive or a white-blooded dyspep- 
 tic suffers very little more while the disease is upon him than before he 
 acquired it. It is this picturesque quality of syphilis which lends it such 
 absorbing interest: the unknown element controls the issue, and a prog- 
 nosis, to be honest, must always be guarded. 
 
 Despite all these exceptions, constitution does, on the whole, modify 
 the course and intensity of the symptoms of syphilis. The rheumatic 
 and the scrofulous tendencies are most obvious in their effects upon the 
 symptoms of the disease. In the individual of so-called gouty habit, the 
 evolution of the disease is slow, the type of eruptions dry and scaly, 
 chronic, relapsing, often quite superficial. Many purely gouty eruptions, 
 especially on the legs, resemble syphilitic eruptions so closely, that noth- 
 ing short of the history of the patient and the result of treatment can 
 positively establish a distinction between them. Pains and joint trou- 
 bles, iritis, and bone disease, arterial complications leading to brain 
 symptoms, are more to be expected in this class of patients than in any 
 other; but perhaps the tenacity of life which these patients enjoy com- 
 pensates in a measure for their greater tendency to certain forms of 
 disease. 
 
 The condition of patients with phthisical tendencies is nearly always 
 aggravated by an intercurrence of syphilis. 
 
 Scrofulous patients are quite certain to have syphilis badly. Not 
 phthisical patients alone for any one may have fibrous phthisis, whether 
 he is scrofulous or not; but patients- who are intensely lymphatic, who 
 run readily into suppuration, ulceration, and pus-formation, who get 
 white swelling of the knee, and hip-joint disease, and caries of the spine 
 6
 
 82 THE VENEREAL DISEASES. 
 
 from injuries, the effect of which would be readily thrown off by another. 
 Patients of this class have moist vesicular and pustular lesions early in 
 the disease, for the most part, and are prone to run early into ulcerative 
 
 lesions. 
 
 Certain lymphatic glands are sometimes involved and remain indolently 
 enlarged, or suppurate and communicate with the surface, remaining long 
 open "as ulcers in some of these cases. The character of the scrofulide is 
 imprinted upon the syphilide, and the compound lesion goes through a 
 slow evolution, and recovering, yields a compound scar bearing the char- 
 acters of both lesions. Inveterate ulcers and destructive bone disease are 
 apt to attend syphilis in patients of this class, and added to this is some- 
 times an intolerance of mercury, which interferes with treatment and com- 
 plicates the situation. 
 
 Not only is syphilis influenced by other diatheses, but in return it in- 
 fluences other conditions. Many chronic maladies of the skin, as well as 
 of the internal organs and tissues, when occurring upon a syphilitic patient, 
 do better if to the treatment suitable to the disease is added a certain mild 
 amount of anti-syphilitic medication. Syphilis influences the healing of 
 fractures. I have had a case, and have personal knowledge of another, 
 both in the thigh, where the fracture would not solidify until the patient 
 had been put under the influence of large doses of the iodide of potassium, 
 although in neither case at the time was the patient suffering from any 
 obvious symptom of syphilis. H. L. Petit ' has an analogous case quoted 
 from Dron; and Zeissl, another quoted from Swediaur; Barnes, another 
 in the London Lancet, for 1873. II., No. 18. 
 
 Sometimes ordinary wounds upon a syphilitic person fail to do well, 
 and if irritated, assume the character of syphilitic ulcers (Petit, 2 Sturgis 3 ) ; 
 but this is exceptional rather than the rule. 
 
 As for the prognosis of syphilis relative to the question of transmission 
 by inheritance, it may be confidently asserted that the malady wears itself 
 gradually out, and that finally, in most instances, the patient becomes en- 
 tirely capable of bringing healthy children into the world. 
 
 Prostrating and excessive work, irregular habits, excess of any kind, 
 dissipation, bad hygiene, poor food, insufficient clothing, over-treatment 
 (by excess of drugs), under-treatment (of too short duration), no treat- 
 ment, bad treatment all tend to aggravate the general prognosis. 
 
 Sex influences prognosis greatly. Women are more apt to become 
 anaemic than men, and to grow greatly debilitated. Their symptoms are 
 not nearly so characteristic of the disease as a rule, but the duration of 
 syphilis with them, and the periods of latency, are seemingly longer. 
 Pregnancy aggravates syphilitic symptoms temporarily. The power of 
 transmission by inheritance is certainly longer retained by the female than 
 by the male. The light character of the active symptoms of syphilis in 
 the female makes it much easier for the physician to fail to detect the 
 disease when present, and for the patient to ignore it when its activity 
 has passed. It is dangerous, therefore, in a suspicious case, to decide that 
 there is no syphilis in a female, simply because she denies its existence 
 and bears no marks of its passage. 
 
 The age of a patient certainly influences prognosis. The activity of 
 the disease is very great in babyhood, and young children very frequently 
 
 1 De la syphilis dans sea rapports avec le traumatisme. Brochure. Paris, 1875. 
 
 * Ibid. 
 
 3 Relation of Syphilis to the Public Health. Pamphlet. New York, 1877.
 
 SYPHILIS. 83 
 
 die of syphilis, inherited or acquired. Old people, on the other hand, have 
 less vitality and power of resisting disease, and syphilis acquired in ad- 
 vanced life is therefore often severe, but rarely directly fatal. Certain 
 German authorities have denied this, and declare that syphilis acquired 
 late in life is ordinarily a mild disease. I have not usually found it so. 
 
 Boeck, of Christiania, in his Researches on Syphilis, concludes that the 
 average duration of life in syphilitics is less than in persons not so af- 
 fected, and believes also that syphilis when acquired late in life is a less 
 serious matter than it proves at a younger age. He thinks that syphilis 
 acquired by infants is not often grave, and that the most malignant forms 
 occur upon persons between the ages of twenty and thirty. In these con- 
 clusions, excepting possibly the first, Boeck is at variance with many other 
 observers. 
 
 The truth is that syphilis is, in most cases, a very manageable disease, 
 and prognosis is more influenced by the intelligence exercised in treating 
 it than it is by all other circumstances combined; but there are occasional 
 exceptions to this rule, as there are to all others relating to syphilis. 
 
 Reinfectio syphilitiea. Second attacks of true syphilis unques- 
 tionably do occur. This is not more strange than second attacks of other 
 maladies, one course of which generally protects a patient for life, such 
 as small-pox, scarlet fever, measles, vaccinia, etc. Zeissl, 1 in 1858, first 
 called general attention to the fact that true syphilis may be acquired 
 and run through its course twice, and since that time a host of other ob- 
 servers have brought forward cases to swell the list. Koebner 2 collated 
 forty cases, Gascoyen 3 eleven, Caspary * three, and numbers of other ob- 
 servers one, two, and three cases. Diday 5 says that he personally saw 
 twenty cases and he collected five others. He believes that generally the 
 course of the second malady is very mild, although two among his twenty 
 ran a severe course in the second attack. In both of these cases the inter- 
 val between the two infections was nearly twenty years. In some of 
 Diday's cases, when the second chancre appeared the patient still was suf- 
 fering from tertiary symptoms remaining over from the last attack. 
 
 An attentive reading of most of these cases of so-called second infec- 
 tion makes it clear that there is no second attack at all, but that that 
 form of pseudo-chancre exists (already described, p. 26) which is not 
 at all uncommon, is really a small, solitary, ulcerated gumma of the penis, 
 and is very frequently observed late in syphilis, even upon patients who 
 do not practise sexual intercourse at all. Thus, in fourteen out of Diday's 
 twenty-five cases, he states that there was an ulcer with characteristic in- 
 duration, but that the inguinal glands did not become indurated, and no 
 further sign of syphilis followed. Surely a mild syphilis this certainly 
 no fresh attack at all. 
 
 Several of Koebner's cases and of Gascoyen's also, are open to the 
 same criticism as Diday's cases, so that second attacks of true syphilis are 
 not so common after all. But second attacks certainly do occur. Hutch- 
 inson's case, observed in a physician, cannot be questioned ; and many 
 others equally convincing exist, where for a second time a patient has had 
 an indurated chancre after a long period of incubation, followed by gan- 
 
 1 Lehrbuch der Syphilis, 2d ed., p. 58, 1872. 
 ! Berliner klin. Wochenschrift, 46, 1872, p. 549. 
 3 Med. Times and Gaz., Dec. 5, 1874. 
 
 * Deutsche med. Woch., and Vierteljahresschrift f. Derm. u. Syph., 1, 1876. 
 
 * Archives gen. de med., July and August. 1863.
 
 84 THE VENEREAL DISEASES. 
 
 glionic engorgement, secondary eruptions, and lesions upon the mucous 
 membranes passing through a course characteristic of syphilis. While, 
 then, it must be granted that second attacks of true syphilis do really 
 occur, although very exceptionally, it is fair to conclude that many of the 
 reported cases of second attack are instances of one of the forms of 
 pseudo-chancre, and not second attacks of syphilis at all. 
 
 The only reported case with which I am familiar, in which a person 
 with inherited syphilis acquired syphilis again, is one reported by Hutch- 
 inson in his article on syphilis, in Keynolds's System of Medicine.
 
 CHAPTER IV. 
 
 SYPHILIS. 
 
 The Incubation of Syphilis. Description of Syphilitic Chancre : the Haw Erosion, 
 the Superficial Ulcer, the Herpetiform Chancre, the Mixed Chancre, Chancre of 
 the General Integument, Chancre of the Lip, of the Nipple, of the Urethra. 
 Syphilis without Chancre. Typical Course of Chancre. Specific Induration, 
 Complications of Chancre by Phagedaena. Treatment of Chancre by Excision 
 and other Means. The Lymphangitis of Chancre. The Bubo of Syphilis, and 
 its Treatment. 
 
 The incubation of syphilis is that period of rest which always oc- 
 curs between the absorption of the virus and the appearance of the chan- 
 cre at the spot where absorption took place. Its average duration is 
 twenty-one days, and it has been known to occupy nearly all the inter- 
 mediate points between ten days (case of Lindmann) and fifty-six days 
 (von Sigmund), one special case having been reported by Fournier where 
 the incubation seems to have lasted for seventy-five days. Fournier 
 quotes another from Guerin of seventy-one days. 
 
 This period of rest between the time of exposure and the time at 
 which the disease shows itself is one of the peculiarities of maladies due 
 to the absorption of a poison (small-pox, hydrophobia, scarlet fever) in 
 which the blood becomes involved. It seems to require a certain time, 
 after the poison has gained access to the absorbent lymphatics and veins, 
 before it can ripen sufficiently to occasion even a local outbreak of dis- 
 ease. This local outbreak in syphilis always occurs at the point of en- 
 trance of the poison, and the disease continues, apparently, confined to 
 this point for a period of so-called second incubation, after which its 
 symptoms become generalized. How different is this course from that 
 immediate local poisoning of the tissues found in chancroid! 
 
 The large number (nearly fifty) of well-recorded authentic cases of 
 experimental inoculation of secretions capable of producing syphilis upon 
 patients who were capable of taking the disease, has solved this question, 
 and made the incubation period one of the most fixed of all the facts of 
 syphilis. Confrontations have done as much to establish the period, and 
 accurate clinical observation by skilled and reliable observers has finally 
 confirmed the fact beyond dispute. 
 
 Why the time of incubation varies so much is not known. The short- 
 est authentic case on record is that of Lindemann. He had been inocu- 
 lating himself with chancroidal pus, and finally took some pus from an 
 ulcer upon the tonsil of a syphilitic friend. The period of incubation of 
 his chancre is put down as ten days; but the second incubation is placed 
 at three months. This long second incubation makes it perfectly reason- 
 able to explain away the exceptionally short first incubation in his case. 
 Lindemann was, doubtless, capable of free and rapid secretion of pus.
 
 86 THE VENEREAL DISEASES. 
 
 That his skin did not become easily " syphilized," and incapable of pro. 
 ducing pus upon inoculation with chancroidal secretions, is shown by his 
 2,700 successful inoculations upon himself of the pus of chancroid, as 
 recorded by Fournier. Six to eight weeks is a very fair period of second- 
 ary incubation longer than the average. Why may it not have been, 
 then, that Lindemann, being in a pyogenic state, produced an ulcer upon 
 his skin by inoculating pus from the tonsillar ulcer of his friend ? And, 
 supposing this similar to his previous self-inoculated chancroids, he sim- 
 ply records it as a take. The true syphilitic character of the sore may 
 not have appeared until some days later a feature which would have 
 lengthened his primary incubation and shortened the secondary incuba- 
 tion, making both conform more nearly to the type. 
 
 Be this as it may, ten days may be well allowed as the shortest period 
 of incubation. Clinically, cases have been reported near this date. I 
 have seen a case where I believe the incubation to have been eleven 
 (nearly twelve) days; although, in the great majority of instances, it has 
 been the full three weeks, or more. The incubation in cases of experi- 
 mental inoculation has very rarely gone over the month, and, in the 
 greatest number, has lasted between three and four weeks. 
 
 During this period of rest, as a rule, absolutely nothing happens of 
 which the patient is conscious. Sometimes an abrasion has occurred 
 during sexual intercourse. This gets well in a few days, or it may ulcer- 
 ate slightly; but, finally, everything clears up, and just as the patient 
 (if his fears have been aroused) has begun to consider himself fairly safe, 
 at the spot where poisoning occurred the primary lesion shows itself, 
 and goes on to full development. Clinically, without confrontation, it is 
 often difficult to establish the exact limits of the incubation period, on 
 account of the promiscuous and repeated intercourse which the patient 
 has indulged in. 
 
 Syphilitic chancre. The initial lesion of syphilis is a chancre, 
 which appears after a period of incubation upon the spot at which the 
 poison was first absorbed. It occurs clinically, under a variety of forms 
 which resemble each other very little. There is, indeed, nearly as great a 
 variety in the local expression of primary syphilis as is known to be the 
 case in secondary syphilis. The simplest method of giving a comprehensive 
 view of these different primary lesions will be to describe in short detail a 
 typical case of each variety, afterward treating the subject as a whole, 
 and discussing the different variations from the true type, which may be 
 encountered, and the occasional complications. Chancres, as encountered 
 clinically upon the male and female genitals, are: (1) the raw erosion, 
 more or less indurated ; (2) the superficial ulcer, more or less indurated ; 
 (3) the deep, funnel-shaped ulcer, always indurated; (4) the herpetiform 
 chancre, running into one of the above varieties; (5) the mixed chancre. 
 The syphilitic chancres of the lip, of the nipple, of the general integument, 
 also have their type-forms, and chancres of the urethra, anus, and rectum 
 must be considered. 
 
 The raw erosion. This is the most common form of syphilitic chan- 
 cre. Most estimates place its occurrence as high as sixty to seventy-five 
 per cent, of all forms. It is found in both sexes on the integument, as 
 well as upon a mucous or semi-mucous surface, of variable size from that 
 of a small split-pea to a large beefy patch as big as a copper penny. The 
 surface may be in any shade of red. Occasionally it is of a light subdued 
 pink. Generally the color approaches purple, passing through all shades 
 of lividity. Sometimes in a large patch extravasated blood makes it more
 
 SYPHILIS. 87 
 
 dark, or even pigmentation in an old patch heightens the effect. There 
 ma.y be a central adherent false membrane (Clerc), but usually the surface 
 is literally raw; not discharging pus, not ulcerated, but yielding a trifling 
 discharge of bloody serum. 
 
 In shape this erosion is oval, or irregularly rounded; perhaps it may 
 run along a natural fissure. Several may occasionally coexist upon one 
 patient, appearing simultaneously. Induration of these erosions is com- 
 mon, less marked as a rule in the female, sometimes partial, sometimes 
 beneath the whole surface, often parchment-like and imperceptible unless 
 the whole integument at the seat of the erosion be lifted up, and the 
 lesion gently pinched, laterally between the thumb and finger. Sometimes, 
 on the other hand, the induration is very prominent and bulges up above 
 the surface like a solid tubercle, with a flat, raw top. 
 
 The superficial ulcer. This form of primary lesion is very common, 
 and is much like the last in most of its features. In fact, many chancres 
 are first, erosions, then ulcerate superficially, and perhaps later return to 
 the eroded state. The only difference between the chancre and the ero- 
 sion is that this form is ulcerated. The ulcer is slight, its borders are 
 adherent and sloping. Its underlying induration may be parchment-like, 
 is more apt to be of split-pea variety, or there may be an elevated tuber- 
 cle with a dome-like, ulcerated cap. Finally, the induration may be 
 slightly excavated downward, and then the ulcerated surface is corre- 
 spondingly depressed. The floor of these ulcers is grayish, the discharge 
 scanty, thin, sero-purulent perhaps bloody. 
 
 The Hunterian chancre, formerly looked upon ^,s a type, is almost 
 rare enough to be an exception. It is simply a very pronounced chancre 
 of the variety last described, where the induration is considerable and the 
 excavation proportionately great. This chancre is a large mass of woody 
 induration, of rounded form, in the centre of which is an oval or rounded 
 ulcer extending deeply into the induration, funnel-shaped, with a pulta- 
 ceous floor, adherent sloping edges, and yielding a thin, moderate, puri- 
 form discharge. 
 
 The herpetiform chancre, so-called, is very exceptionally rare. In 
 the few examples I have seen of it the period of incubation could rfot be 
 satisfactorily determined. A single cluster of vesicles appeared upon the 
 inner surface of the prepuce behind the corona. These looked and be- 
 haved at first precisely like similar attacks of herpes from which the pa- 
 tient had previously suffered, but the ultimate course was very different. 
 The little ulcers of the cluster spread and ran together; induration ap- 
 peared under the base of the ulcer, which became quite large; the ingui- 
 nal glands tardily took on induration; and an attack of true syphilis fol- 
 lowed in due course. I have been unable to overcome the conviction, im- 
 pressed upon me by observing these cases, that herpetiform chancre is 
 simply accidental herpes, upon the site of which, and before its ulcers 
 have healed, syphilitic chancre comes out. 
 
 The mixed chancre of Rollet is a combination of the two sores, 
 the chancroid and the syphilitic chancre. Each sore runs its course, and 
 the compound lesion possesses the characters of both. The mixed chan- 
 cre has been produced experimentally. The two cases of Lindwurm arid 
 Melchior Robert quoted by Rollet, show the characters of the mixed 
 sore. Lindwurm inoculated one of a number of chancroids upon a female 
 patient with the poison of syphilis. All the chancroids went on as usual, 
 got nearly well, and the patient left the hospital. Later she returned. 
 The one inoculated chancroid had broken out afresh, and had become
 
 88 THE VENEREAL DISEASES. 
 
 hard. It remained an ulcer long after the others got well, and was at- 
 tended by an outbreak of general syphilis. 
 
 Robert inoculated a medical student with the secretion of a mixed 
 sore. Auto-inoculable soft chancroid followed. When the first ulcer 
 had nearly healed, it reulcerated, became hard at the base, and general 
 syphilis followed. 
 
 A mixed chancre, then, may result from the inoculation of either sore 
 upon the other, and its characters will be correspondingly modified ac- 
 cording to the period of development of either sore; either one may be 
 nearly well before the other gets fairly under way. If the compound 
 poison is inoculated, the chancroid would naturally be well along in its 
 course before it assumed any syphilitic features. 
 
 Inoculation of the secretion upon a healthy subject clinically may 
 produce chancroid alone, or mixed sore, or, it is said [but this must be 
 quite exceptional], chancre alone; just as vaccination from a syphilitic 
 child may produce in the healthy one either vaccinia alone, or both vac- 
 cinia and chancre, or chancre alone. Clinically the mixed chancre is very 
 rare. 
 
 Chancre of the general integument occurs as a flattened papule 
 or elevated tubercle, or excoriated patch, or a moist, flat tubercle, or an 
 indurated ulcer. All of these forms have been seen and studied in con- 
 nection with experimental auto- and hetero-inoculations, and they may be 
 encountered clinically. The lesions resemble the same varieties upon the 
 penis. The excoriations are often in part or totally scabbed over; there 
 may be nothing more than an insignificant, dry, scaling papule upon the 
 skin to mark the point of entrance of syphilis. The flat, moist tubercle 
 resembles exactly the condyloma the flat, mucous tubercle of the skin. 
 I have seen a number of them at a time upon the skin, as the initial 
 lesion of syphilis some dry, some moist, some scaling, all livid, raised, 
 flat, and none of them markedly indurated. Finally, a superficial or a 
 deep excavated ulcer may mark the starting-point of syphilis upon the 
 skin, and in such case the induration of the ulcer is apt to be quite exten- 
 sive. 
 
 Chancre of the lip is generally a globular mass of induration as 
 large as a marble, with an excoriated or exulcerated surface. I have seen 
 two lesions of this sort, both upon young girls, both acquired innocently 
 from a lover's kiss. The only other case I have seen was on the lip of an 
 old Frenchman. The chancre in this case was a deep ulcer, acquired by 
 smoking the pipe of a companion. It was large, oval, ragged, and much 
 indurated. 
 
 Chancre of the nipple, acquired by nursing a syphilitic child, may 
 be a large, deep, indurated ulcer, a brawny excavation, an excoriated or 
 ulcerated, indurated fissure, or a flat, mucous papule more or less livid, 
 moist, or dry, scaly or scabbed, sometimes but little indurated. I have 
 reported ' a case where the last-named lesion occurred in a multiple form. 
 Both nipples were involved, four chancres being on one side, eight on 
 the other. Fournier * has published one case with seven on one nipple, 
 and sixteen on the other, and another case of extensive phagedenic 
 chancre of the nipple derived from contact with a mucous patch. The 
 mother of a child with inherited syphilis, although she may never have 
 shown any symptom of having had syphilis, cannot acquire chancre at 
 
 1 Archives of Dermatology, April, 1878, p. 
 5 Gaz. des hop., Dec. 1, 1877, p. 1109. 
 
 126.
 
 SYPHILIS. 89 
 
 the nipple by suckling her own child with mucous patches in its mouth 
 (Colles's law). 
 
 Urethral chancre. I have observed two cases of urethral chancre, 
 one of them through the endoscope. By the tube of this instrument the 
 inside of the urethra may be inspected, and the round flat ulcer seen. 
 Generally, urethral chancre is situated just within the meatus, one of the 
 lips of which it may involve. Occasionally, however, it occurs at a con- 
 siderable distance within the canal. In my own case ' the ulcer was sit- 
 uated upon the roof of the urethra, one and one-quarter inch from the 
 meatus. By exactly what mechanism the virus reaches such a deep posi- 
 tion, it is not easy to imagine. 
 
 Generally, urethral chancre discloses its existence by the presence of 
 a lump along the course of the urethra, usually painful upon erection. At 
 this spot some pain is apt to be complained of on urinating. A slight 
 discharge flows from the urethra, more mucoid than purulent, sometimes 
 bloody. This discharge commences at a considerable interval after the 
 sexual contact to which it was due. The slight discharge continues for 
 a number of weeks, and the scar left by the chancre may subsequently oc- 
 casion more or less stricture of the urethra. The inguinal ganglia are 
 indolently enlarged and indurated. 
 
 Syphilis without chancre does not exist, except as acquired by 
 inheritance, and possibly by mothers in the so-called choc en-retour pro- 
 cess. Under all other circumstances syphilis commences with some sort 
 of a lesion at the point of entry of the poison. Since concealed chancres 
 have been better understood, and the specific character of the enlarge- 
 ment of the lymphatic ganglia in the neighborhood of the primary lesion 
 more closely studied, it is easier to get upon the track of a chancre than it 
 was formerly. Chancres are known to occur at the orifice of the Eustachian 
 tube (by inoculation), upon the finger, in unexpected places, deep in the 
 vagina, in the rectum, in the urethra; they have been observed in all these 
 situations, and spontaneous syphilis (without chancre) is much less talked 
 about now than formerly. 
 
 The course of typical syphilitic chancre, uncomplicated, is about 
 as follows: The first sign of a positive result of an inoculation of syphili- 
 tic virus upon the skin of a healthy subject is a flat, dry redness, or a 
 raised, hard papule, red on top. Generally, upon a mucous membrane, an 
 excoriation or a small superficial ulcer is found from the start. Sometimes 
 a mass of induration forms first, and this afterward excoriates or ulcer- 
 ates. On a mucous membrane a vesicle or a pustule may precede the 
 shedding of the cuticle which leads to the excoriation, but its existence 
 is ephemeral; it is usually only an epiphenomenon. Induration of the 
 base may precede the breakage of the cuticle, and be excessive as com- 
 pared to the latter; or the opposite condition may obtain, there being 
 considerable ulceration after matters have progressed for a time, and 
 very little hardness. Exceptionally, the whole prepuce becomes stiffened 
 with a cartilaginous induration. An acute erysipelatous flush of the in- 
 tegument may precede this induration, or the latter may form gradually, 
 especially if the chancre involve the prepuce near the frenum. 
 
 In the female, around the ostium vaginas and on the labia, erosions, 
 often not appreciably indurated, excoriations, flat, raised mucous tubercles, 
 and the regular deep indurated ulcer, may each be encountered as the 
 herald of future syphilis. 
 
 1 Am. Journ. of Dermatology and Syphilography, 1871, p. 37.
 
 90 THE VENEKEAL DISEASES. 
 
 The erosion or ulcer increases in size for a varying period and to a 
 varying extent; from an erosion, through irritation, it often becomes an 
 ulcer. It remains unique, not poisoning the integument in the neighbor- 
 hood, and not giving any pain; yielding its watery discharge, attended 
 by its lymphangitis and its adenitis in the second week, and, after last- 
 ing from two or three weeks to as many months, it finally gets well, 
 leaving no trace in most instances. If the ulcer, however, has eaten 
 through the papillary layer of the skin, if it has been phagedenic at all, 
 then a scar is left, proportionate in extent to the amount of tissue de- 
 stroyed. These scars often remain indurated for a considerable period. 
 They are not customarily pigmented. 
 
 Auto- and hetero-inoculation of a syphilitic chancre are both 
 possible. So much has already been said upon this subject, in Part I., 
 Chapter III., that only a few words more are necessary. These few words 
 may be concisely arranged in the form of separate propositions, the truth 
 of which seems undoubted, in consideration of the experimental and clin- 
 ical evidence upon which they are based. 
 
 (1.) Hetero-inoculation of the watery discharge of an unirritated chancre 
 upon a healthy person produces only a syphilitic chancre after a period 
 of incubation, and the patient becomes syphilitic. 
 
 (2). Hetero-inoculation of pus, taken from a suppurating, ulcerated, or 
 irritated (Lee, Boeck) syphilitic chancre, upon a healthy person, produces 
 often an abortive pustule which gets well, and, after the natural incuba- 
 tion, syphilitic chancre at the same spot follows. If the person be in a 
 pyogenic condition the first abortive pustule may ulcerate, and the pus 
 from this first ulcer may be auto-inoculable through a few generations 
 (Daniellsen's case). 
 
 (3). Hetero-inoculation of pus from a suppurating, irritated, syphilitic 
 chancre, upon a person already syphilitic, generally produces an ulcer 
 quite freely auto-inoculable in generations, and much resembling chan- 
 croid (Boeck). Inoculation of pus from this lesion upon a healthy per- 
 son has produced an ulcer, in one case at least, which was auto-inoculable 
 and not followed by syphilis. An explanation of this occurrence has 
 been offered in Chapter I., Part I., p. 4. 
 
 (4). Auto-inoculation of pus from a suppurating chancre acts exactly 
 like hetero-inoculation upon a syphilitic subject, the extent of the ulcers 
 and amount of the suppuration being dependent upon the pus-forming 
 tendencies of the individual. 
 
 (5). Auto-inoculation of the watery discharge from an unirritated syphi- 
 litic chancre is absolutely negative, excepting under two circumstances : 
 
 (a). When the chancre is quite young, and the organism presumably 
 not saturated with syphilis, some of the poison taken from the patient's 
 own chancre may be successfully auto-inoculated, producing a second 
 characteristic chancre upon him (Puche, Wallace, Sperino, Bidenkap, 
 Lee, and others). This is no more than was to be expected ; for multi- 
 ple hetero-inoculation by scarification produces a number of simultaneous 
 chancres, and the same phenomenon is observed clinically, as in multiple 
 chancre of the nipple. Until the whole organism is saturated with syphi- 
 lis, both hetero- and auto-inoculation with the pure virus, unmixed with 
 pus, may produce another chancre with all the features of a true syphili- 
 tic primary lesion. 
 
 (b). Patients with a syphilitic eruption often have a lesion produced 
 at a point which has been subjected to local injury. A burn, friction, or 
 irritation, will call out a papule or tubercle, evidently syphilitic, which
 
 SYPHILIS. 91 
 
 may dry up and scale, or may excoriate and ulcerate ; and this lesion may 
 very closely resemble true chancre. This result has been produced by Wal- 
 lace experimentally, the virus from chancre being auto-inoculated upon 
 a patient in the eruptive stage. 
 
 Vaccine auto-inoculation offers an analogy to this seeming anomaly: 
 any number of simultaneous inoculations take, and auto-inoculations, 
 while the vesicles are yet young, give a positive result. Finally, when the 
 protection wears out, as it often does, reinfection is possible : the name 
 being changed, the story may be told of the disease we are discussing. 
 
 The specific syphilitic induration is a feature of chancre the im- 
 portance of which has been much overrated. It is not an absolute essen- 
 tial of syphilitic chancre to be indurated, although, unquestionably, it is a 
 very constant symptom. Induration occurs in three forms: 
 
 (1). The most common is the parchment-like induration found under- 
 lying an ulcer or an erosion, and often appreciated with difficulty, unless 
 the ulcer be pinched up laterally between the thumb and finger. This 
 variety of induration is common in the female ; it is rarely simulated in 
 other forms of disease; it does not involve the subcutaneous tissues, and 
 may be so filmy in character as to require considerable faith to find it. 
 
 (2). The next form is characteristic, but not very common. It is called 
 the split-pea induration. Immediately underlying the ulcer is a substance 
 of cartilaginous or woody hardness, like a split-pea, convexity downward. 
 Its size varies with the size of the surface lesion. It is very nearly, in- 
 deed often absolutely, insensitive to moderate pressure. It does not 
 shade off into the tissues around it. It is not adherent to the deep fascia, 
 but it ends abruptly in all directions, and is as cleanly defined as would 
 be a foreign body set into the skin attached to the ulcer by its upper 
 surface. 
 
 (3). The last form of induration is excessive. It resembles the split 
 variety in its quality and behavior as to the surrounding tissues, but it 
 may greatly surpass the limits of the surface lesion, be convex or concave 
 on its surface, or involve irregular areas of skin, as when the whole pre- 
 puce or a portion of it is involved in a wood-like hardness in connection 
 with chancre. 
 
 Induration often precedes the breakage of the skin, and very often, 
 where it has been excessive, outlasts the healing of the ulcer, continuing 
 perhaps for several months, or in the scar for years. It may be of only 
 short duration ten or twelve days, coming late and going early. The 
 thin, parchment-like induration is the most transitory. Once commen- 
 cing to disappear, induration may relapse, and occasionally outstanding 
 indurations appear in the neighborhood not connected with the initial 
 lesion, but formed around the lymphatic vessels, and these indurations 
 may possibly ulcerate (Fournier). 
 
 Phagedaena destroys induration. 
 
 Something like any of the above forms of induration may appear with 
 other lesions than chancre, and, indeed, upon persons not at all syphilitic. 
 It is never safe to depend upon this sign for a diagnosis. It is most 
 valuable as a corroborative symptom, and more constant, as a symptom of 
 syphilitic chancre, than any other one symptom, except the length of the 
 period of incubation; and this latter may be unattainable. Ordinary in- 
 flammatory induration, generally, is very different from specific induration. 
 It is red on the surface, painfully sensitive to pressure, adherent to the 
 skin and the parts beneath, losing itself gradually in the subcutaneous 
 tissue, with no clearly defined edge; yet, in spite of all the differential
 
 92 THE VENEREAL DISEASES. 
 
 characters, syphilitic induration may be so closely simulated by a non- 
 syphilitic lesion, that, alone and without strong corroborative evidence, it 
 is not of enough value to establish a diagnosis of syphilis. 
 
 The induration of a small gumma of the semi-mucous membrane of the 
 prepuce, as appreciated by the finger, is sometimes absolutely, and in all 
 respects, a typical induration as found in the best-marked cases of syphili- 
 tic chancre. 
 
 The complication of syphilitic chancre by phagedaena. Syph- 
 ilitic chancre is rarely complicated. Vegetations may grow up around 
 it and its new surface may granulate, or may take on a whitish pellicle and 
 become transformed into a mucous patch. Some amount of inflammatory 
 disturbance may complicate the ordinarily indolent and undemonstrative 
 chancre, leading to its swelling, pain, suppuration, and giving to it some' 
 of the features (auto-inoculability) of its more formidable local rival, chan- 
 croid. All of these complications need but to be mentioned to be under- 
 stood. The rarer complication of chancre with chancroid has been de- 
 scribed at p. 87 in (mixed chancre). 
 
 Phagedaena complicating syphilitic chancre occurs usually in the gan- 
 grenous form. If the whole base of the sore is involved, the induration 
 disappears in the phagedenic process. Sometimes the slower form of 
 phagedaena is found, but generally this variety is not very extensive, when 
 complicating a syphilitic primary lesion. A description of both forms of 
 phagedaena has already been given at p. 39, in connection with chancroid, 
 and nothing further need be added here except an allusion to the fact 
 that mercury internally, although harmful to phagedaana occurring upon 
 the patient who is not syphilitic, is decidedly beneficial to the phagedasna 
 attacking syphilitic chancre. 
 
 Bassereau puts the relative frequency of phagedaena as encountered 
 with syphilitic chancre at fourteen per. cent., and Fournier makes it 
 about the same. It is generally believed that a phagedenic chancre por- 
 tends a bad type of syphilis, and this is doubtless so, since phagedaena is 
 not a quality of the peculiar virus with which the patient has been poisoned. 
 The phagedaena is due to the patient's own quality of constitution, and it 
 is fair to suppose that such a constitution will suffer from an attack of 
 syphilis more seriously than another. A phagedenic chancre owes its 
 origin to an uncomplicated sore as a rule, and does not transmit phage- 
 dasna to another person. 
 
 TREATMENT OF SYPHILITIC CHANCRE. 
 
 Clerc's medical student, who washed himself after intercourse, found 
 no lesion for several days, and yet had chancre after twenty-eight days' 
 incubation; Diday's case of cure of a syphilitic chancre six hours after 
 its appearance, by applying caustic, where, in spite of the healing of the 
 sore, general syphilis followed; and Hill's ' very striking case, in which he 
 cauterized, with nitric acid, a torn frenum within twelve hours after in- 
 tercourse, destroying the raw surface, but not destroying the virus, which 
 showed itself at the cauterized point a month later, as a syphilitic indu- 
 ration, followed by secondary symptoms all of these cases go to prove 
 that when once the poison has had access to the absorbents, the patient 
 from that moment has syphilis several weeks before he has any chan- 
 cre at all. The folly, therefore, and the uselessness, of paining a "patient 
 
 1 On Venereal Diseases. London, 18G8, p 67.
 
 SYPHILIS. 93 
 
 with caustics or of mutilating him with a knife, appears obvious; yet the 
 subject is still under active discussion, and the last word has not been 
 spoken. 
 
 It is well known that cauterization will sometimes cure a syphilitic 
 chancre. Caustic does not do away with the induration, however, and the 
 latter may reulcerate after cicatrization. No claim can be substantiated 
 which demonstrates that burning a syphilitic chancre is of any value to 
 the patient, and therefore this plan of treatment has been practically 
 abandoned by the profession. A few still practise it, but they belong to 
 that extraordinary type of practitioner who burns every venereal sore he 
 encounters, and gives mercury at the same time, so as to feel pretty cer- 
 tain to hit right, to whichever variety of ulcer the sore happens to belong. 
 He treats the symptom and the possibilities, letting the diagnosis take 
 care of itself. 
 
 The excision of syphilitic chancres. The plan of treatment 
 which is exciting most interest at the present day is an attempt at the 
 radical cure of syphilis by excision of the chancre. The possibility of ef- 
 fecting cure in this manner is based upon the theory that the poison, after 
 being absorbed, lies latent locally throughout the period of incubation, and 
 then commences to increase in quantity, at first only locally. After a 
 period it reaches the lymphatic glands, and there increases and multiplies 
 again, remaining local in its new position, until, during the period of sec- 
 ondary incubation, it has had time to infect the general system, after 
 which it becomes general and manifests itself by an eruption. This the- 
 ory is not sustained by analogy. Other poisons absorbed into the body 
 seem to become diffused very promptly through the blood. 
 
 The most thorough essay upon the subject of excision of the primary 
 lesion of syphilis which has appeared, has been published by Auspitz. 1 
 Numerous attempts to cure syphilis by excising the primary lesion had 
 already been made by Meyer, 1840; Hueter, 1867; Ulrich, Coulson, Lan- 
 genbeck, Thiry, and Vogt, some deciding for, some against, the value of the 
 method. Auspitz reports thirty-three excisions, and, after excluding ten 
 for various reasons, founds his belief upon what he claims to be the results 
 in the remaining twenty-three. Out of these twenty-three he reports that 
 fourteen remained free from syphilis. Therefore Auspitz concludes that 
 the proper treatment of chancre is to cut it out carefully, removing all the 
 tissues involved in the induration, and those immediately around. He 
 further believes that, even after the inguinal glands have become indurated, 
 excision of the chancre alone may effect a cure, although the glands are 
 left undisturbed ; and finally he states as his opinion that, even if a cure be 
 not effected, the course of the subsequent syphilis is rendered more mild 
 by the excision of the primary lesion. 
 
 These last statements seem particularly extraordinary, but in fact the 
 whole essay is unsatisfactory upon close analysis. In the first place, 
 Auspitz is well known to be a unicist. He does not believe that there are 
 two poisons, one of which produces exclusively chancroid, and the other 
 syphilis. It is not stated for his twenty-three cases that confrontation 
 was used in them to substantiate the diagnosis of syphilis. The diagnosis 
 of syphilitic chancre was based solely upon the " initial sclerosis," as he 
 calls it a sign full of the possibilities of error; and, if the histories report 
 the cases accurately, several of them seem unquestionably to have been 
 simple chancroids with hard, inflamed bases. The period of incubation 
 
 1 Vierteljahresschrift f. Derm. u. Syph., IV., 1877, 1 and 2, p. 101.
 
 94 THE VENEREAL DISEASES. 
 
 was unknown in nine cases, or set down as less than ten aays; and several 
 of the cases were only observed a few months after excision a period 
 manifestly too short to make it safe to decide that no syphilis was present. 
 Altogether the report is full of inaccuracies, and, although in several of 
 the cases the date of apparent incubation and the appearance of the 
 chancre make it seem very probable that the patient had syphilis, while 
 no symptoms followed excision, yet the possibility of error was not guard- 
 ed against by confrontation, and the cases at best remain simply as nega- 
 tive evidence, while the nine positive cases, in which syphilitic symptoms 
 followed in spite of excision of the chancre, are not explained away by 
 Auspitz. 
 
 Still more recently, Kolliker ' has communicated eight cases of excision 
 of chancre for the prevention of syphilis. Of the eight, five had syphili- 
 tic symptoms in spite of the excision ; three remained free. In none of 
 the three was confrontation employed to establish the diagnosis. One of 
 them was observed less than four, the other two less than five months. 
 In Case V. the chancre was excised seven days after it appeared ; there 
 was no glandular swelling at the time, yet syphilis followed. In Case 
 VIII. excision was practised ten days after the chancre appeared ; there 
 was an enlarged inguinal gland (only one, it seems) on the right side at 
 the time, and syphilis did not follow. In one (successful ?) case the chan- 
 cre had existed two weeks ; but there was no ganglionic enlargement in 
 the groin, a circumstance which opens the nature of the chancre to ques- 
 tion. 
 
 Three cases have since been reported by Unna, in one of which syphi- 
 lis followed. The cases teach nothing new. 
 
 Hence it may seem that the matter is not yet proved. Doubtless 
 many experimenters are now at work investigating the subject. The 
 most certain demonstration would be for some gentleman, who had never 
 had syphilis and who believed in the value of excision, to allow himself 
 to be inoculated from an initial lesion upon another. If this inoculation 
 was followed by the proper interval of incubation, and then appeared as 
 a hard papule, the latter might be cut out and the result watched. 
 
 Up to this time, all that can be said in the present state of the question 
 is, that cutting o.ut the initial lesion of syphilis can do no harm, and may 
 do some good. It should be placed before the patient in this light, and, if 
 he elects excision and the chancre is in a suitable position for thorough 
 removal, it may be excised, precautions being taken first thoroughly to 
 disinfect the surface with carbolic acid, to use clean curved scissors and 
 hooked forceps, and to remove all the induration, and a certain portion of 
 healthy tissue, at a single cut. The after-dressing is unimportant. The 
 general excision of syphilitic chancres is yet to be justified, or condemned, 
 by the result of experiments. 
 
 At present the best local treatment for chancre seems to be black 
 wash, or dusting with calomel powder. In suppurating chancres iodo- 
 form is serviceable. The mixed sore must be treated like a chancroid. 
 Phagedaena attacking a true syphilitic chancre is favorably influenced by 
 the internal use of mercury. If the sore is not syphilitic, mercury is harm- 
 
 The internal use of mercury has a very favorable influence in shorten- 
 ing the duration of a syphilitic chancre ; but such treatment is hardly ever 
 
 iF^ 61 Elision der Byphilitischen Initialsklerose. Centralblatt f. Chirurgie, Nov. 
 oO, Io7o, p. 801.
 
 SYPHILIS. 95 
 
 advisable never unless the origin of the sore has been ascertained by con- 
 frontation, and all the points about the ulcer, its history, and its physical 
 characters, render ij beyond possible doubt that its nature is syphilitic ; 
 and even then, unless there is some excellent reason to the contrary, it is 
 better to wait for the first signs of general syphilis before commencing 
 treatment. 
 
 THE LYMPHANGITIS OF SYPHILIS. 
 
 This consists in an indolent thickening, with induration of the wall 
 of one or more lymphatic trunks. The thickening involves a certain 
 amount of the surrounding atmosphere of connective tissue occasionally. 
 These rigid cords with occasional knots upon them may be felt along the 
 sides or back of the penis, sometimes part way from the chancre back- 
 ward toward the root of the penis, sometimes only perceptible near the 
 pubic symphysis. The cords vary in size with the amount of infiltration of 
 the walls of the lymphatic trunks, and are larger, if any surrounding tis- 
 sue happens to be involved. Very rarely the inflammatory process around 
 the vessels goes on to suppuration. Generally, the lymphangitis, if it oc- 
 curs, precedes the inguinal adenitis by a few days. Rollet thinks it may 
 be found, if looked for, in almost twenty per cent, of all cases. It is, as a 
 rule, painless, and of not the least importance. It requires no treatment. 
 The integument over the thickened lymphatic trunks is not reddened. 
 There is no peculiar character by which this malady may be known from 
 a chronic mild lymphangitis of the larger lymphatic channels occurring 
 spontaneously, and having no connection with syphilis as a cause. I have 
 encountered this twice upon healthy persons, and seen it occur in connec- 
 tion with non-syphilitic lesions. All that can be said of syphilitic lym- 
 phangitis is, that if it occurs with syphilitic (uninflamed) chancre, it is 
 very certain to be peculiarly indolent and painless, and to be characterized 
 by a high degree of induration. Anatomically the walls of the lymphatic 
 channels are permeated with exudation corpuscles. Syphilitic lymphan- 
 gitis requires no treatment. 
 
 THE BUBO OP SYPHILIS. 
 
 The first set of lymphatic glands along the line of absorbents which 
 originate in the neighborhood of the initial lesion of syphilis, almost in- 
 variably become the seat of certain changes which stamp them with pecu- 
 liar value as aids to the diagnosis of the nature of the primary lesion. 
 The bubo of syphilis may therefore be situated anywhere upon the body 
 where there is a lymphatic gland, provided the radicals of the lymphatic 
 trunks leading to that gland originate in the neighborhood of the 
 chancre. Thus, chancre of the lip has its bubo under the jaw; chancre 
 high up on the cheek, in the pre-aural gland; of the hand, in the epitroch- 
 lear gland; of the breast, in the axilla; of the penis, in the groin, etc. 
 
 The syphilitic bubo almost invariably comes on during the second 
 week after the appearance of the primary lesion, between the eighth and 
 eleventh days in cases of experimental inoculation. One gland generally 
 first becomes enlarged, and then a number of others, until (in the groin) 
 a cluster of altered glands, not matted together, but lying separately, are 
 found, constituting what Ricord has termed a pleiad, and, when typical, 
 very distinctive of syphilis.
 
 96 THE VENEREAL DISEASES. 
 
 The number of glands in a pleiad varies from two or three to six or 
 eight. Where there are many, one is usually larger than the others. 
 Generally the glands in both groins are involved. Each of the little 
 glands of the altered group is quite hard, round or oval, painless on pres- 
 sure, not adherent to the skin or to the tissues lying under or around it, 
 and each is entirely distinct from the others. The skin lying over them 
 is not reddened, and the patient is unconscious of their existence. In 
 size each gland varies from that of a pea to that of a marble. Where the 
 number is considerable, the size of each is usually smaller than where there 
 are but few. Occasionally, instead of the pleiad there is one very large, 
 hard, oval gland, with one or two quite small ones; and still more rarely 
 the bubo is single; an enormous lump as large as an egg, existing in one 
 or both groins. Bassereau dissected one of these lumps, and found it 
 composed of a mass of indurated connective tissue enveloping a number 
 of indolently engorged glands of different sizes, between which ran the 
 thickened lymphatic trunks. 
 
 The swelling of these glands is called indolent because of their slow 
 course, their painless and non-inflammatory character. Very often, how- 
 ever, when they begin to swell they are slightly painful; and occasionally 
 they go on to suppuration, either centrally, or as a peri-glandular sup- 
 puration. Such abscess is always simple in its nature, and, if open, never 
 becomes chancroidal like the virulent bubo of chancroid. 
 
 While the syphilitic bubo is generally multiple, in certain situations 
 it is more apt to be single, as under the chin, under the jaw, at the elbow, 
 although in the latter situation there may be a secondary pleiad in the 
 axilla. 
 
 According to Rindfleisch, the ganglionic induration is due to an in- 
 crease in the cellular elements of the gland, more than to a thickening 
 of the parenchyma. These new cells undergo fatty metamorphosis after 
 a time, and are absorbed. 
 
 In very fat people syphilitic bubo is less marked than in others. In 
 about two per cent, of all cases examined Fournier found it entirely ab- 
 sent. He thinks that it may be absent when phagedaena attacks a 
 chancre. The duration of syphilitic bubo varies from a few weeks to a 
 number of months. Sometimes the glands never subside to their original 
 size. They are almost constantly present during the first eruption, and 
 at this time they occasionally grow somewhat larger and harder. 
 
 Certain observations have been made (Fournier) tending to show that 
 other groups of lymphatic glands, lying more centrally than those first 
 involved, become secondarily the seat of indolent engorgement, at an in- 
 terval after the enlargement of the first set of glands. Attention has 
 only lately been drawn in this direction, and the question is not yet fully 
 solved. Clinically it is not a matter of much importance, since such seta 
 of glands are generally beyond the reach of inspection. This is not 
 always the case, however, for in mammary chancre it is customary, first, 
 fcfr a few glands underlying the pectoralis, on the chest, to become in- 
 durated, and then the axillary glands; and it is not uncommon, after a 
 digital chancre, for the epitrochlear glandular enlargement to be followed 
 by multiple indolent bubo of the axilla. 
 
 The treatment of syphilitic bubo is that of general syphilis. No 
 treatment is called for until a general eruption comes on. Local meas- 
 ures are useless. If pain and inflammation appear as complications, the 
 symptoms are to be appropriately met.
 
 CHAPTER Y. 
 
 SYPHILIS. 
 
 A Table giving a Comprehensive View of the Features, Course, Symptoms, etc., of 
 Chancroid, as compared with Similar Conditions, when met with in connection 
 with Syphilitic Chancre. The Stages of Syphilis: Primary, Secondary, Tertiary. 
 Malignant Syphilis. The Second Incubation. Syphilitic Fever. Symptoms at- 
 tending the Beginning of General Syphilis. 
 
 A DIAGNOSTIC table, setting forth the main differential points of chan- 
 croid and chancre in typical cases, has already been given at p. 25. The 
 present table is inserted as a summary, and is intended to present a con- 
 densation of the whole subject for easy reference. This table will not 
 serve as a diagnostic table. A diagnosis, with any chance of being accu- 
 rate, can only be rendered about a typical sore. The previous table will 
 serve for this purpose. When a sore of either variety is irregular or com- 
 plicated, it may be attended by so many features of both sores that a di- 
 agnosis of its nature becomes absolutely impossible. In such a case it is 
 the part of wisdom to reserve judgment and wait for developments before 
 giving an opinion. No man, who has confidence enough in himself to be 
 willing to take the responsibility of a case of syphilis, should be ashamed 
 to confess ignorance as to the nature of a sore until he has had plenty of 
 time for studying its features and its course. The following table is ar- 
 ranged under each head, for typical as well as for irregular cases. 
 
 The typical description in the table is printed in italics, the irregular- 
 ities in ordinary type. 
 
 CHANCROID. 
 
 1. Nature. A local tissue disease. 
 
 2. Cause. Contamination with chan- 
 croidalpus in sexual intercourse; accidental 
 or designed auto- or hetero-inoculation of 
 chancroidal pus; pre-existing virulent bubo, 
 which, upon opening, becomes a chancroid. 
 
 3. Situation. Upon the genitals or in the 
 groin ; very uncommon elsewhere. 
 
 4. Number. Often multifile both in ori- 
 gin, and by spontaneous auto-inoculation. 
 
 5. Second attack in the same individual. 
 Entirely possible. 
 
 6. Auto-inoculability. Always possible 
 in generations. 
 
 7. Transmissibility to animals. Possible. 
 
 7 
 
 SYPHILITIC CHANCRE. 
 
 1. A general blood disease. 
 
 2. Contamination with syphilitic virus in 
 sexual intei'course ; hetero-inoculation upon 
 a non-syphilitic person, of the secretion of 
 a syphilitic chancre, of syphilitic blood, or 
 of the discharge from a mucous patch or 
 a secondary syphilitic lesion. 
 
 3. Upon the genitals; not uncommon 
 upon the lips, nipples, and fingers ; very 
 uncommon elsewhere. 
 
 4. Generally single* sometimes multiple, 
 from the start ; not usually spreading by 
 spontaneous auto-inoculation. 
 
 5. Almost impossible. 
 
 6. Impossible, unless the ulcer secretes 
 pus. 
 
 7. Quite probable.
 
 THE VENEREAL DISEASES. 
 
 CHANCROID. 
 
 8. Incubation. None. CJianges com- 
 mence wit/iin twenty-four hours. Ulcer is 
 fuUy formed on the third day. Sometimes 
 absorption is delayed, and the ulcer does 
 not appear until after the end of a week. 
 
 9. Appearance and course. Commences 
 as a pustule or an ulcer, and remains an 
 ulcer to the end. Advances rapidly \ heals 
 slowly. 
 
 10. Shape. Pounded, oral, or irregular, 
 if a fissure has been inoculated or several 
 ulcers have run into one. 
 
 11. Color. Dirty yellowish white or pale 
 pink. 
 
 1 2. Secretion. Creamy, free. 
 
 13. Edges. Perpendicular, often under- 
 mined. 
 
 14. Floor. Uneven, duU. 
 
 15. Pain. Often present. 
 
 16. Induration. Absent. In many 
 cases, however, a hardness, due to inflam- 
 mation comes on. This sometimes resem- 
 bles syphilitic induration, but usually is 
 quite distinct from it. 
 
 17. Phagedaena. An occasional com- 
 plication. 
 
 18. Lymphangitis. Not uncommon in 
 its simple inflammatory form, tery rare in 
 its virulent form. 
 
 19. Bubo. Occurs in about thirty-three 
 per centum of all cases, sometimes as simple 
 bubo, which may subside or may suppurate; 
 sometimes as virulent bubo, which necessarily 
 suppurates and becomes a cfiancroid. 
 
 20. Prognosis. Syphilis, as a result of 
 chancroid, is impossible. 
 
 21. Treatment. Local treatment all-im- 
 portant. 
 
 SYPHILITIC CHANCRE. 
 
 8. Never less than ten days ; usually 
 about three weeks ; occasionally a little 
 more than two months. 
 
 9. Commences as an excoriation or an in- 
 duration, and remains as a raw erosion or 
 an indurated ulcer ; advances slowly, heals 
 slowly. Sometimes it remains a dry pa- 
 pule, or is an ulcerated fissure throughout 
 its course. 
 
 10. Round, oval, or a fissure ; not apt to 
 be due to the fusion of several sores. 
 
 11. Livid red, or brilliant blood color, or 
 gray; sometimes dirty white, sometimes 
 scaly or scabbed. 
 
 12. Scanty, serous, sanguinolent, some- 
 times purulent. 
 
 13. Slanting, adJierent. 
 
 14. Smooth, bright, sometimes dull. 
 
 15. Generally absent. 
 
 16. Present, almost invariably, in the 
 male ; more often absent in the female. 
 
 17. A very rare complication. 
 
 18. Rather rare, always indolent, excep- 
 tions being phenomenal; never virulent. 
 
 19. Invariable (exceptions two per cent.), 
 always indolent; occasionally attended by 
 enough inflammation to end in suppuration, 
 but never becoming virulent. 
 
 20. Syphilis, as a result of chancre, is in- 
 variable. 
 
 21. Local treatment unimportant. 
 
 THE STAGES OF SYPHILIS. 
 
 Syphilis is not a continuous chain of symptoms. It is a broken se- 
 ries of outbreaks, varying in intensity, in duration, and in the length of 
 the intervals between them. During these intervals the patient may seem 
 perfectly well ; but, that he is well because he seems well, cannot be asserted. 
 The intervals are called periods of latency of the disease. During these 
 periods, when they occur early in the malady, it is quite evident that the 
 patient is not well. After inoculation the period of incubation is a period 
 of latency, but surely the patient is not then well. Toward the end of 
 the disease, however, the periods of latency become longer; and finally 
 one period arrives very often, which ends only with the patient's death 
 from some other cause than a return of his syphilis, and this period of la- 
 tency is in most cases one. of health; the patient is well. 
 
 That the poison continues active during the periods of latency (the 
 early ones) is evident from the fact that vaccinal syphilis has often been
 
 SYPHILIS. 99 
 
 acquired from the blood of a vaccinifer not at the time bearing any trace 
 of syphilis upon its person; that syphilitic women, during periods of most 
 absolute latency, have brought forth syphilitic children; that traumatisms 
 upon syphilitics, in a period of latency, often call out syphilitic lesions 
 (cauterisatio provocatoria, p. 78). 
 
 Therefore it becomes impossible to state absolutely that the disease 
 syphilis is naturally divided up at all. It may be one continuous malady 
 with remissions, but really continuing all the time. Yet facility of de- 
 scription, custom, and the peculiar character of the outbreaks of syphilis, 
 have justified its division into stages, and these stages are commonly 
 known as primary, secondary, and tertiary syphilis. The attempt to make 
 a separate, intermediary syphilis, between the second and third stages, has 
 not met with general favor, and the effort to christen the final phenomena 
 as quaternary has also miscarried. There remain, therefore, the three 
 stages of common adoption: the primary, the secondary, the tertiary. 
 
 Primary syphilis is all that portion of the disease lying between 
 the moment of infection and the time of appearance of the first general 
 eruption with its fever and general ganglionic engorgement; it therefore 
 includes the initial lesion with its accompanying lymphangitis and adeni- 
 tis, but nothing more. 
 
 Secondary syphilis. As soon as the secondary incubation has 
 passed, secondary syphilis begins. It may date as early as three weeks 
 from the time of appearance of the chancre; it generally does not com- 
 mence for six weeks or two months, and may be delayed much longer, 
 especially if mercury has been used in treating the primary stage. Most 
 of the symptoms of this stage are superficial. They are first congestive, 
 leaving no scar, and occurring on the mucous as well as on the cutaneous 
 expansions. Gradually, as time passes, the lesions become deeper-seated, 
 and finally the second merges so gradually into the tertiary stage that it 
 is impossible to fix upon a positive boundary between them. 
 
 It is just at this point that the French dermatologists have attempted 
 to group together an intermediary set of lesions liable to occur upon 
 the integument, and to call them intermediary syphilis; but it is more 
 customary in this country,"and equally accurate, to speak of these symp- 
 toms as late secondary symptoms, and the term is just as convenient per- 
 haps more descriptive. 
 
 The duration of secondary syphilis, like the duration of the whole 
 disease, varies so greatly that it is not only impossible, but even unwise, 
 to attempt to confine it within definite boundaries. In a general way, in 
 most cases the symptoms merge into the tertiary forms during the sec- 
 ond year; but secondary lesions continue in many cases to crop out occa- 
 sionally in the third year or later, intermingled with the deeper lesions of 
 tertiary disease. It is not at all uncommon for a patient with a gumma- 
 tous, destructive ulcer of the throat to have also upon his palm a superfi- 
 cial scaly patch very similar to what he may have had during the first year 
 of his disease. 
 
 And, on the other fiand, but more rarely, the symptoms legitimately 
 belonging to tertiary syphilis occasionally come on earlier, and appear 
 among the secondary symptoms. Gummata in various situations may 
 thus appear prematurely; nodes on bones, advanced symptoms of nervous 
 disease, hemiplegia, epilepsy, sometimes show themselves at the end of 
 six months, and are followed by secondary symptoms, instead of remain- 
 ing in their regular place and appearing during the second year, or 
 later.
 
 100 TELE VENEREAL DISEASES. 
 
 These irregular forms of syphilis have scandalized some observers, 
 and made them wish to give up secondary and tertiary distinctions of 
 symptoms, since the facts do not bear out the theories. But it is not 
 well to throw away a good thing simply because it will not serve every 
 purpose. The stages of syphilis are certainly very convenient, and afford 
 the student assistance in his observation of the disease, and in its treat- 
 ment. Therefore they should be preserved. The exceptions in syphilis 
 are its chief beauty; there is no monotony about it; and if descriptions 
 of the disease did not in their first plain statements practically ignore 
 exceptions, there could be no descriptions at all, for there probably is not 
 a single feature of syphilis, from the chancre to the most ultimate symp- 
 tom due to a visceral lesion, which may not be lacking in a well-marked 
 case of syphilis. 
 
 Tertiary syphilis commences on the boundary line of secondary 
 svphilis, somewhere in the second year usually, and embraces everything 
 which may happen afterward due to the disease. The lesions are infil- 
 trative, gummatous, often destructive, ulcerating, and include most of the 
 connective-tissue parenchymatous changes and gummy deposits which in- 
 volve the viscera. 
 
 In inherited syphilis the symptoms of both secondary and tertiary 
 stages are customarily more or less combined. The child, when born, 
 often has parenchymatous changes in its lungs, liver, kidneys, thymus, 
 and spleen, with changes in the epiphyses of the long bones, and at the 
 same time superficial, scaly, erythematous, papular, and excoriative 
 patches upon its integument and mucous membranes. 
 
 In acquired syphilis the whole of the tertiary stage may be absent. 
 The disease not uncommonly, under judicious treatment, ceases entirely 
 at the end of the secondary stage, and the patient lives for years without 
 another symptom, raising healthy children, and himself to all appear- 
 ances well. More rarely the secondary stage may be skipped entirely 
 this also usually under treatment and the disease may only show itself 
 after a longer or shorter period of latency in the tertiary gummatous 
 stage. I have seen a number of instances of this sort occurring after al- 
 most every variety of treatment, and after no treatment at all. 
 
 Malignant syphilis. This is. a final variety, in which the. disease 
 runs riot, respecting no stages, obeying no rules. Gummata may spring 
 into existence within a few months after chancre, and the most desper- 
 ate late lesions follow each other without any period of latency, and 
 respond very imperfectly to ordinary treatment. This style of disease 
 sometimes kills; but it bears this measure of comfort with it: that, if the 
 patient survive, he is apt, though mutilated with scars, to be rid of his 
 syphilis forever. The malady seems sometimes, in this way, to exhaust 
 itself in its fury, and to expend during a number of months that energy 
 which it sometimes stores up to carry itself over long periods of years. 
 
 THE PERIOD OP SECOND IXCUBA*TION. 
 
 The second incubation commences when the chancre appears, and 
 ends when general symptoms come on. This period often is not one of 
 latency, strictly speaking, since active symptoms of syphilis are usually 
 present upon the patient during the whole of it, for the chancre has 
 rarely healed before the first eruption comes out (unless treatment keeps 
 it back) ; and even if the chancre has gone, the inguinal glands are cer-
 
 SYPHILIS. 101 
 
 tain to remain engorged during a much longer time than the period of 
 secondary incubation. 
 
 The length of the second incubation in untreated cases varies from 
 twelve days, which is the shortest that has been observed, to between 
 four and five months ; but commonly, in untreated cases, it lasts about six 
 weeks. At the end of this time it is believed that the organism has be- 
 come so saturated with the poison, which has been multiplying within it, 
 that an explosion necessarily takes place in the way of general symptoms, 
 in order to enable the blood to get rid of some of the unnatural material 
 it contains. 
 
 During the second incubation the general health may appear flourish- 
 ing, but generally the patient commences to get pale and languid, or 
 more or less depressed. His red cells diminish in quantity in the blood, 
 and the number of white cells increases. The appetite is apt to falter and 
 the digestion to become less vigorous, yet there is often no positive fail- 
 ure of health until the eruptions appear, and sometimes no obvious fail- 
 ure even then. The patient may be about his affairs as usual, carrying 
 a chancre, which does not disturb him greatly, feeling in good health, and 
 yet covered with a roseola, which his physician discovers for him, of which 
 he himself has been totally unconscious, and which has not been ushered 
 in by any fever, or by any subjective symptom of which the patient has 
 taken note. 
 
 SYPHILITIC FEVER. 
 
 All descriptions of syphilis, from the earliest times, have referred to 
 fever as being one of the accompaniments of the disease ; but no thor- 
 ough knowledge of it was obtained by the profession until the laborious 
 investigations of Giintz, with the aid of the thermometer, had established 
 its finer details. In 1873, ' Guntz's results, many of which had appeared 
 in different articles in medical journals during the previous ten years, 
 were put into book form, and this volume is still the highest authority 
 upon syphilitic fever. 
 
 The fever of syphilis has been compared to that of the exanthemata. 
 It comes upon the patient unawares during the period of second incuba- 
 tion, and precedes the outbreak of the first eruption. It is this fever to 
 which the name syphilitic is given. Other febrile states due to syphilitic 
 lesions are not, as a rule, called by this name. With a true chancre some- 
 times a bubo suppurates, and the formation may be attended by a rise of 
 temperature ; but this would not be syphilitic fever. Again, in all the 
 cachectic conditions of tertiary syphilis, with the bone and visceral lesions 
 in brain syphilis, etc., a rise in temperature is one of the clinical features 
 of the affection ; yet this is not syphilitic fever. 
 
 The true syphilitic fever, according to Giintz, generally comes on at 
 about two months after infection sometimes as late as three months. 
 This would place its date of appearance, in average cases, during the early 
 part of the second month after the appearance of the chancre, and clini- 
 cally this is the date at which it is well to be on the watch for fever, so 
 as to be warned of the first eruption, which is about to appear. The type 
 of the fever may be continued, remittent, or intermittent. It may consist 
 of a single short outburst, or may last for days. Occasionally, it closely 
 resembles tertian ague ; and sometimes, when intense and accompanying 
 
 1 J. F. Giintz Das syphilitiscbe Fieber. Leipzig, 1873
 
 102 THE VENEREAL DISEASES. 
 
 syphilitic pains in the muscles and joints, it is indistinguishable from a 
 mild attack of inflammatory rheumatism. More rarely still, it is accom- 
 panied bv great prostration, attended by headache and epistaxis, and as- 
 sumes a type suggestive of typhoid fever. 
 
 Its occurrence is by no means uniform. Giintz believes it to be found 
 in only twenty per cent, of all cases. Lancereaux puts it at sixty-six per 
 cent. Fournier believes it more common in women. We may, therefore, 
 conclude that in not more than half the cases is it to be expected at all. 
 Clinically, it is certainly very rarely of any importance. If it is looked 
 for by aid of the thermometer, it will be often found ; otherwise it will 
 rarely be thought of either by the patient or physician, excepting in a 
 minoritv of cases where the prostration is great, or the range of tempera- 
 ture high. 
 
 The thermometer rarely marks higher than 102 Fahrenheit in syphili- 
 tic fever ; 104 has been pretty generally considered to be a point above 
 which it does not go. I am only aware of one case, reported by Bremer, 
 in which this limit was exceeded. 
 
 The symptoms attending the fever are very variable. Anaemia may be 
 quite marked, the pallor being due to the well-known diminution in the 
 liremoglobulin of the blood, first pointed out (1844) by Grassi. General 
 depression and a feeling of being sick is a common complaint. Pains in 
 the bones, in the joints, under the sternum, in the side and back, in the 
 head, all of them worse at night, are apt to be complained of. The night 
 headache is pretty constant and sometimes frightfully severe, the pain 
 coming on at a stated hour, and yielding at a stated hour, often with great 
 regularity. The joint pains may also get worse at night. They generally 
 do so, but not to the same extent as the head pains. Sometimes the joints 
 and the bursne under the insertions of the tendons (particularly at the el- 
 bow and knee) become the seat of effusion, and are very sensitive to hand- 
 ling. The patient's skin is bathed more or less profusely in perspiration, 
 the urine is acid and full of urates. In such a case, acute articular rheu- 
 matism is closely simulated. I have observed one very well-marked case 
 of this character in the Charity Hospital, which yielded a prompt response 
 to mercury. 
 
 Where the fever runs high and an eruption is coming out, the mistake 
 of confounding syphilis with measles, or even with small-pox, has been 
 made. 
 
 There may be enough shortness of breath and quickness of pulse to 
 suggest lung disease. The stomach symptoms may be the most promi- 
 nent. An unwonted excess in the appetite may be a feature of early 
 syphilis (boulimia). Fournier found it to be not very uncommon in 
 women. Nausea and inappetence are more common, with occasionally 
 light diarrhoea. 
 
 Jaundice may come on with syphilitic fever, due to catarrh of the bile- 
 ducts, from engorgement of the mucous membrane, or pressure upon the 
 ducts by enlarged glands (Lancereaux). 
 
 Pressure upon the lower third of the sternum will sometimes evoke a 
 pain not otherwise complained of, and the anaemia may be great enough 
 to give the soft, blowing character to the first sound of the heart. 
 
 Syphilitic fever usually disappears soon after the general eruption 
 comes out. Its own special features are so varied that its diagnosis de- 
 pends upon the previous (or actual) existence of a chancre and the pres- 
 ence of evidences of general syphilis, such as the falling of the hair, an 
 eruption, epitrochlear and post-cervical ganglionic engorgement. Its
 
 SYPHILIS. 103 
 
 treatment is that of general syphilis in the early months. Syphilitic head- 
 ache, the most serious symptom of this fever, may sometimes be controlled 
 by minute doses of mercury repeated at short intervals, as suggested by 
 Trousseau. One-twelfth of a grain of calomel every one or two hours, 
 for twenty-four hours, will sometimes overcome it. It is not well to con- 
 tinue these minute, but often repeated doses for any length of time, since 
 mercury given in this way is apt to excite speedy salivation in certain 
 people. 
 
 SYMPTOMS ATTENDING THE BEGINNING OF GENERAL SYPHILIS. 
 
 During syphilitic fever, or at the beginning of general syphilis, when 
 there is no fever, it is common to observe certain symptoms. These need 
 not be fully described here, since repetition is to be avoided. They may 
 be found under their appropriate heads; but, before going into syphilis as 
 affecting the tissues and organs, it is well to mention these symptoms, if 
 only by name. 
 
 With the scabs in the hair of early syphilis, and the mottling of the 
 skin, the ganglionic pleiad in the groin still remaining, and perhaps the 
 chancre being still raw, we generally find that one or both epitrochlear 
 glands are indolently indurated, resembling the glands in the groin, and 
 that certain glands in the posterior chain of the posterior cervical glands 
 are similarly affected. The glands most characteristic among these are 
 those lying on the occipital bone on either side of the nucha. These 
 glands, as well as the glands in the groin, generally disappear, with or 
 without treatment, as the disease advances, and it is not well to depend 
 upon them to corroborate syphilis after the first few months. 
 
 Another symptom is a generalized falling of the hair (syphilitic alo- 
 pecia). The hair thins out over the whole scalp, does not fall in patches, 
 and with this there may generally be noted a tendency to a fall of hair 
 from the beard and eyebrows, and more or less from the whole body in 
 severe cases. This alopecia, however, is often confined to the scalp. 
 When the hair falls late in syphilis, if the falling out of hair is general, 
 it is due to cachexia; if it is local, it is due to a local physical lesion (ulcer) 
 involving the papillae, and the hair does not generally return when the 
 disease gets well, as it does after the alopecia of early syphilis. 
 
 The throat symptoms erythema, mucous patches will be described 
 later. They are very characteristic, and should always be looked for in 
 the outbreak of general syphilis. 
 
 Certain analgesias of early syphilis have been much spoken of since 
 Fournier's description of them as they occur in women early in syphilis. 
 Inability to distinguish heat from cold, anaesthesia of certain limited areas 
 of skin, analgesias due to early syphilis, have been described mostly as 
 found in women. These symptoms do not seem to stay long; they are 
 rarely observed in ordinary practice, and do not call for any modification 
 in the general treatment. The backs of the hands and wrists seem to 
 suffer more often than other parts. Fournier has described this malady 
 in his admirable treatise on syphilis, studied especially in its relation to 
 women, Paris, 1873.
 
 CHAPTER VI. 
 
 THE GEXERAL TBEATMEKT OF SYPHILIS. 
 
 Syphilis a self limiting Malady. It gets well under all Treatments sometimes, but 
 yields the best Results to small Doses of Mercury continued for a long Time. 
 Syphilization and Tartarization. The Hot Springs of Arkanr-as. Preventive 
 Treatment of Syphilis. Excision of Syphilitic Chancre. The Hygienic Treat- 
 ment of Syphilis. The Hygiene of the Mouth. Hygiene of the Anus and of the 
 Genitals. Hygienic Medication. Kumyss. Specific Treatment of Syphilis. Gen- 
 eral Consideration of the Value of Mercury and the Different Kinds of Mercurial 
 Treatment. Salivation. Time at which the General Treatment of Syphilis 
 should be commenced. Detail of the Tonic Treatment of Syphilis by Mercury. 
 The Time at which a Tonic Course of the Mercurial Specific may be stopped. 
 
 SYPHILIS is naturally a self -limiting malady, and its general treatment 
 may be, and often is, left entirely to nature. Many a woman, and occa- 
 sionally a man, gets syphilis without knowing it, and runs through the 
 disease into health without any specific treatment at all. Indeed, it may 
 perhaps be justly doubted whether treatment of any kind can shorten the 
 duration of syphilis at all, for the disease will, and it does, crop out at re- 
 mote dates after any and all kinds of treatment (more often after certain 
 kinds of treatment than after others, I believe), and there is no positive and 
 certain test which can be applied to a person to determine whether he is, 
 after treatment, free from the disease or not. The cauterisatio provoca- 
 toria of Tarnowsky (p. 78), has been but a short time before the profes- 
 sion, but its pretensions have already been assailed by Auspitz and Kaposi. 
 
 There is no doubt whatsoever that certain drugs restrain the manifes- 
 tations of syphilis and cure the symptoms. Among these the different 
 preparations of mercury and of iodine undoubtedly hold the first rank; 
 but the opponents of the internal use of mercury claim that, by curing 
 the earlier symptoms, the disease proper is only being suppressed, that its 
 total duration is thereby prolonged, and its later symptoms rendered 
 more obstinate and more destructive. This assumption, however, is the re- 
 sult of the heat of controversy more than of any calm recognition of facts. 
 
 AN ho shall say, in a given case, how long syphilis is to last ? There is 
 no certain and reliable standard by which the disease may be judged or 
 the quality of its virulence predicated. This matter has already been dis- 
 cussed in the section on prognosis (p. 79), and need not be reviewed here; 
 but certain it is that there is an unknown element in syphilis which alone 
 can explain the endless irregularity of its forms and the picturesque vari- 
 ety of its symptoms. 
 
 One fact about syphilis is well known: it has symptoms, and certain 
 drugs will keep down those symptoms; and it is as wise and as just to say 
 that the quinine which breaks tertian ague only prolongs the disease by 
 suppressing the symptoms (and some do assert this), as it is to hold that 
 mercury prolongs syphilis by keeping symptoms in check.
 
 SYPHILIS. 105 
 
 Moreover, the use of mercury has been shamefully abused in times 
 past. Crusades have been preached against the drug by valiant cham- 
 pions of other and seemingly more simple and more natural methods, 
 yet always, century after century, the profession clings to mercury; and 
 to-day it heads the list of specifics, as being the most efficient for good of 
 ail known drugs, in the writings of a great majority of the recognized 
 authorities upon syphilis. The only question is how to use mercury so 
 that it shall inflict the greatest possible harm upon the disease without 
 injuring the patient. A solution to this problem is what is required. I 
 have done what I could toward solving it with what effect, time must 
 show. 
 
 It is not within the province of this volume to enter into a study of 
 the history of the treatment of syphilis. Probably all known drugs have 
 been at one time or other tried against it; but they have disappeared 
 one after another. It is generally a new vegetable product which claims 
 the power of eradicating syphilis. Sarsaparilla is still held in high es- 
 teem in some quarters, and guaiac in others. Cundurango bark came lately 
 upon the scene, but promptly disappeared. I believe that tuyuja is the 
 present novelty destined, doubtless, to share the fate of its predecessors. 
 Nearly all the natural mineral springs, especially the sulphur springs, 
 possess, it is claimed, the power of eradicating syphilis, or rather that mys- 
 terious entity known as " the effects of syphilis and of mercury," from the 
 sj'stem; and for some springs actual specific powers over the disease are 
 assumed, such as the Hot Springs of Arkansas, the Paso Robles Springs of 
 Colorado, the springs of San Diego in Cuba, and others. 
 
 Finally, all sorts of cures abound: water cures, dry cures, sweating 
 cures; cures by the grace of God (Diday) that is, where nothing is done 
 in mild cases beyond what is suggested by ordinary hygiene, the disease 
 being left to run itself out by nature; cures by syphilization and by tar- 
 tarization; and finally, by drugs, cathartics, diuretics, sudorifics, tonics, 
 mercury, iodine, etc. 
 
 When so many methods are strongly advocated, it seems fair to sup- 
 pose that the disease in question is incurable; but, on the contrary, pa- 
 tients get well, or seemingly well, under all these methods and under all 
 systems of treatment. The reason of this seems to me to be that the 
 disease is self-limiting and symptoms cease to appear, in a majority of 
 cases, in the long run, with treatment, without treatment, sometimes de- 
 spite treatment. 
 
 The aim of a rational treatment, therefore, must be: to suppress symp- 
 toms and prevent them from doing harm during their existence; to con- 
 trol symptoms and prevent relapse without harming the patient in any 
 way; and so to manage the disease that it may not be contagious dur- 
 ing its existence (by keeping down such symptoms as yield contagious se- 
 cretions), that the patient may be made able to marry as soon as possi- 
 ble and to produce healthy offspring, and that the symptoms of the disease 
 during their progress shall be restrained from leaving unsightly scars or 
 damaging the structure of tissues or organs during their existence. 
 
 These ends may be more certainly attained by the judicious use of the 
 preparations of mercury and iodine than by any other means; and this is 
 the reason why these drugs hold their place in medicine as anti-syphilitic 
 specifics, notwithstanding the fact that the disease goes on and runs its 
 full course in spite of their use, and notwithstanding the fact that much 
 harm has doubtless been done with the drugs by their unskilful use, and 
 that mercury has many powerful enemies who constantly cry out against it.
 
 106 THE VENEREAL DISEASES. 
 
 Of late, two German authorities, whose high position renders their 
 verdict worthy of respect Sigmund and Zeissl have declared themselves 
 rather in favor of Diday's way of regarding syphilis. 
 
 Sigmund ' thinks that many cases of syphilis do better without than 
 with general treatment. He even goes so far as to say that general treat- 
 ment sometimes does harm. He thinks that forty per centum of untreated 
 cases have such light eruptive outbreaks that the patients do not detect 
 their secondary symptoms at all, while ten per cent, of the cases having 
 obvious symptoms get well promptly by the use of local measures alone. 
 Sigmund thinks, therefore, that treatment should not be commenced until 
 secondary symptoms appear and not then, unless the symptoms threaten 
 to become serious. 
 
 The only deduction to be drawn from the above conclusions of Sig- 
 mund is, that he is fortunate in treating an exceptionally high average 
 of very mild cases of syphilis. The fact that so conservative an authority 
 still uses meroury for severe cases proves that he does not consider this 
 drug harmful when judiciously employed, and shows that he, with most 
 other modern authorities, are giving up the careless and lavish routine 
 use of mercury. They are using less mercury, but are still using it as a 
 specific. 
 
 Zeissl, " in a more studied essay, giving his present views about the treat- 
 ment of syphilis, states that by observing the evolution of syphilis, under 
 the expectant treatment, he learned that the malady was atypical, seem- 
 ing to depend, for the length of time it lasted and the severity of its symp- 
 toms, more upon the personal physical individuality of the patient than 
 upon the treatment to which he was subjected. 
 
 Therefore Zeissl adopts the expectant treatment for a time. He allows 
 the disease time to bloom to ripen, as it were. If the early eruptions go 
 down with reasonable promptness, he uses no mercury. If they hesitate 
 to disappear, he tries the iodides, and only in severe and obstinate cases 
 does he have recourse to mercurials at all. 
 
 In this way he thinks that the total duration of the disease is lessened, 
 and ultimate serious relapse rendered less probable. He believes that the 
 disease blows itself out, as it were, if allowed free play in its earlier stages. 
 In all severe cases, however, and in all obstinate ones, he still depends 
 upon the faithful services of friendly mercury. 
 
 In short, he too is giving less of the drug. From all sides testimony 
 is coming in, in one way or another, favoring a reduction in the amount 
 of mercury used in the treatment of syphilis. 
 
 Some of the symptoms of syphilis disappear under the influence of 
 intercurrent disorders. Thus, Mauriac has shown, 8 in studying the cuta- 
 neous symptoms of syphilis, that erysipelas occurring upon the surface 
 of a person with a syphilide acts generally as well as locally, portions of 
 the syphilitic eruption distant from the area occupied by the erysipelas 
 getting well just as those spots do over which the erysipelas passes; but 
 with this difference, that the more distant the situation of the spots from 
 the erysipelatous patch the less promptly do they get well. 
 
 This is not more strange than the disappearance of cutaneous lesions, 
 not syphilitic, on the advent of some internal malady tubercular menin- 
 gitis, typhoid fever, and others. 
 
 1 Wiener med. Wochenschrift, No. 10, 1879. 
 
 * Wiener med. Zeitung, Nos. 1, 2, 3, and 4, 1879. 
 
 3 Etude clinique sur 1'influence curative de 1'erysipele dans la syphilis. Paris, 1873.
 
 SYPHILIS. 107 
 
 Syphilization and tartarization, as remedies, belong apparently to this 
 class. By these methods of treatment the skin is constantly and repeat- 
 edly irritated up to the point of suppuration in numerous spots, until 
 finally no more suppuration can be produced by the irritants supplied 
 chancroidal pus, or that of irritated chancres, etc. Under this treatment, 
 eruptions very naturally disappear, and thus a cure of syphilis may be 
 claimed. But syphilization can never be generally popular. It produces 
 far more numerous and unsightly scars than the disease itself, and, rather 
 than use it, most people would prefer to let the malady run its course 
 until the third stage, and then use the iodide of potassium for the treat- 
 ment of gummata and threatened disease of internal organs, just as the 
 syphilizers themselves do. 
 
 THE HOT SPRINGS OF ARKANSAS. 
 
 These springs have of late become very popular, especially among the 
 people, and some estimate of their value must be given. I have not had 
 an opportunity to visit the springs personally, but I have had charge of 
 numbers of patients in all stages of syphilis, who have been to the springs 
 either before or during the term of my treatment, and have remained 
 there for periods varying from a few days up to several months. I feel, 
 therefore, reasonably familiar with the methods employed (as a rule) 
 at the springs, and capable of judging the results, on account of having 
 watched many patients since their return. 
 
 I have been unable to ascertain that there is any quality in the water 
 to which the result claimed to be attained may be ascribed, excepting 
 the heat. The water is certainly quite poor in mineral ingredients, while 
 its alleged magnetic qualities are imponderable. 
 
 When a patient goes to the hot springs in any stage of syphilis, he is 
 apt to be mercurialized to excess by the inunction of mercurial ointment. 
 There are excellent medical men at the springs, who use mercury judi- 
 ciously ; but, unfortunately, the fame of the place attracts some physi- 
 cians who make use of the supposed virtues of the waters to shield their 
 own incompetence, and the credulous patient suffers. In directing pa- 
 tients to the springs, in the cachectic stage of the disease for example, 
 where change is of great value to the patient he should be regularly con- 
 signed to a reputable physician, or his trip is apt to do him but little, if 
 any good possibly, to result in harm. 
 
 I believe, however, that all the physicians at the springs, even the very 
 best, use mercury by inunction or otherwise, in connection with the 
 baths, thus plainly avowing a disbelief in those specific and curative pow- 
 ers of the waters over syphilis which are generally ascribed to them by 
 popular superstition. Iodide of potassium internally is also used in large 
 amounts by the physicians at the springs. 
 
 I have found that patients who go to the hot springs with chancre, or 
 during the earlier periods of syphilis, do not prosper any more rapidly 
 than if they had remained at home, and the longed-for exemption from 
 relapse after a six weeks' course at the springs, with any amount of inunc- 
 tions, is far from being justified by the result. Relapse follows just as 
 certainly as after the same amount of mercury used at home in the same 
 way, and no more, and no less certainly, according to my experience. 
 
 Late along in the disease, however especially if the patient be broken 
 and cachectic ; if his appetite and his vitality require the influence of
 
 108 THE VENEREAL DISEASES. 
 
 change ; when he fails, perhaps, to respond at all to the iodides, and mercu- 
 rials, even in small doses, depress him then is the time to send the pa- 
 tient to the hot springs. The change alone is likely to benefit him, and 
 the waters certainly do seem to possess a tonic power over these cases, 
 which brings them up sometimes far more promptly than seems possible at 
 home, and helps to cure them not only of their active symptoms, but some- 
 times to restore them to good general health. 
 
 Patients sent to the hot springs in the later stages of cachectic syphi- 
 lis, generally return improved and gratified with their experience. Those 
 who go early are usually disappointed, and their disease not sensibly modi- 
 fied in any way. 
 
 If the springs are to retain any permanent value, it is well that the 
 public should be dispossessed of the absurd idea with which it is now so 
 thoroughly imbued, that the waters themselves possess specific qualities, 
 ami have the power to drive out syphilis completely, and prevent relapse. 
 The springs certainly have their value, but it is not this. 
 
 PREVENTIVE TREATMENT OP SYPHILIS. 
 
 It is hardly appropriate in this volume to touch upon the subject of 
 prostitution. Prostitution has probably existed from the beginning of 
 time, and it doubtless will continue to exist until the end of time. The 
 puritanical spirit which causes men to ignore this fact is to blame for a 
 certain amount of the syphilis now present in the world. The only way 
 apparently to put any check upon the spread of syphilis by prostitution, 
 is to legalize the latter occupation, and to subject it to close and constant 
 scrutiny by officers responsible to the State. The general spread of in- 
 telligence through the world will doubtless bring this about sooner or 
 later ; but, until then, the young men of the community, and through them 
 their wives and their children, stand in constant danger of the disease. 
 Reasoning from my own experience in a large city, syphilis is greatly on 
 the increase among the higher classes of the community. Very many 
 young men in the best walks of life get poisoned by their own folly, and 
 carry the germ of disease into their homes. Perhaps, as is said now to be 
 the case in Portugal, we shall some day, as a community, become so sat- 
 urated with syphilis, that the type of the disease will become very mild, 
 and we shall not consider it of much importance ; but it is rather revolting 
 to one's feelings to take this view of the case. 
 
 Leaving prostitution out of the question, and coming more directly 
 to the prophylactic treatment of syphilis, it may be asked, having been 
 exposed to the poison of syphilis, may the disease be prevented ? This 
 question has, as yet, no answer based upon well-observed facts. Cer- 
 tainly, if the syphilitic poison the secretion of chancre, for example 
 comes only into contact with the unbroken integument, it may be washed 
 away, and the individual remains sound. The same is equally true for 
 the mucous membranes. Cases of mediate contagion (p. 75) prove this 
 as well as those cases in which two healthy men have had intercourse 
 on the same evening with the same syphilitic woman, when one of the 
 men escapes infection, while the other, in due time, has chancre. Such 
 instances have been observed more than once. I have such a case among 
 my own patients. The explanation is simple. The poison deposited 
 beneath the prepuce in one case finds the semi-mucous membrane sound, 
 and does not effect an immediate communication with the absorbents.
 
 SYPHILIS. 109 
 
 It remains inert, and is washed or rubbed away by the patient. In the 
 other case an abrasion or little fissure exists in the surface epithelium, 
 the poison is promptly absorbed, and no amount of washing can then 
 save the patient from chancre, which will come on after the proper period 
 of incubation has passed. Whether the poison of chancre deposited 
 upon the unbroken epithelium, either of the skin or of the mucous mem- 
 brane, can in time, if retained in place, work its way through the epithe- 
 lium by a corroding process, and gain access to the absorbents, is not 
 known. 
 
 Now comes the question when once a chancre appears, may syphilis 
 be averted ? It is not proven that it can be, although the evidence of 
 some investigators goes a certain distance to show that it may be. The 
 whole question is at present involved in doubt, and is now the subject of 
 active inquiry and experiment in the medical world. Much difficulty at- 
 tends a just solution of the problem, particularly at this day, when so 
 much confusion exists about the quality of the poisons of chancre and 
 chancroid, their identity or otherwise; and because investigators still 
 trust to that single fallacious symptom induration and base their prog- 
 nosis of syphilis upon this alone, seeming to disregard the value of con- 
 frontation, and apparently forgetting to consider the varied forms of 
 pseudo-chancre, some of which show syphilitic induration in its most 
 typical form. Such a pseudo-chancre, of course, whether cut out or left 
 alone, will not be followed by any signs of early syphilis. 
 
 The question of the value of the excision of chancres need not be 
 reopened here; it has already been discussed at p. 93. It is simply cer- 
 tain that, at the present date, no positive assurance can be given to a 
 patient that, if his chancre be cut out, he will escape general symptoms. 
 When the chancre is suitably situated as, for instance, upon the edge 
 of the preputial orifice, or elsewhere in such position that it may be 
 easily and thoroughly extirpated, there is no harm that can follow cutting 
 it away; but it should be removed with a distinct understanding that an 
 intelligent experiment is being performed, and nothing more, and that 
 the chances are against success, if the chancre be a true initial lesion of 
 syphilis. 
 
 THE HYGIENIC TREATMENT OP SYPHILIS. 
 
 The hygienic surroundings of a patient influence his general health, 
 and upon the maintenance of good general health often depends the 
 quality of the syphilitic symptoms in a given case. This remark is not 
 absolutely true indeed, probably, no remark made about syphilis is abso- 
 lutely true. Some old men, with broken vitality, in the decline of life, get 
 syphilis, and have it in the very mildest form, while robust youths some- 
 times sink away promptly under a malignant onset of the disease. The 
 activity of the poison in babyhood is well known, and that, too, not in 
 cases of inherited syphilis alone. Epidemics of vaccinal syphilis clearly 
 prove the virulence of acquired syphilis in the infant. Then there are 
 apparently certain diathetic or constitutional peculiarities of the individ- 
 ual, which influence the quality of his syphilitic symptoms, and act inde- 
 pendently of hygienic surroundings and of everything else. This subject 
 has been discussed in the section on prognosis, p. 79. 
 
 Therefore it cannot be absolutely said that hygiene, when good, will 
 make syphilis mild, and when bad, will make it severe, for this is not the
 
 HO THE VENEREAL DISEASES. 
 
 case. It is possible, however, I think, to make the following assertion 
 with truth: that, other things being equal, the better the hygiene and 
 dietetics, the more creditably will the patient weather the storm, and the 
 more certainly will his disease get well without materially damaging him. 
 This assertion, of course, implies that, in addition to his hygiene and 
 dietetics, the patient shall make use of intelligent therapeutics. 
 
 The hygiene of syphilis is that of common every-day life. We no 
 longer confine patients to their beds for the treatment of syphilis, or 
 even to the house. The old notion, that it is such a serious matter for a 
 patient taking mercury to catch cold, cannot be held in force. Surely it 
 is wiser for a patient taking mercury not to catch cold, because the cold 
 'is apt to upset his stomach and to interfere with his treatment; but 
 bevond this I do not know any disadvantage likely to arise from taking 
 cold. And I do not believe that a patient taking mercury in a mild, 
 continuous wav, is any more apt to catch cold upon exposure, than 
 another under the same circumstances, not taking mercury. Mercury 
 may open the pores, as the popular notion is, for all that is known to the 
 contrary. Mercury certainly is excreted in minute amounts by the skin, 
 in the perspiration; but it means nothing to say that the pores are open 
 they undoubtedly always are open. Finally, to sum up, I believe that a 
 patient, while taking a mild, continuous course of mercury, may go out 
 in the cold, the rain, and the storm, exactly in the same way as if he 
 were not taking the drug. Precautions against taking cold are certainly 
 desirable in syphilis, as they are in any other general depressing malady. 
 
 Moreover, a cold taken in the active stage of syphilis may produce 
 sore throat, and this sore throat, due primarily to cold, may be the occa- 
 sion of a local outcrop of mucous patches, and syphilitic ulcers in the 
 throat, which may continue long and greatly annoy the patient, as well 
 as possibly aggravate his disease by interfering with swallowing, and 
 therefore, with nutrition. An accidental sore throat may produce syphili- 
 tic symptoms in the throat, just as smoking may. and just as a blister 
 placed upon the skin, or a sulphur-bath, may call out a syphilitic eruption 
 upon a patient whose skin until then has remained clear. 
 
 Therefore it is very desirable that a patient in the active stages of 
 syphilis should take all precautions not to take cold; but he should be 
 made to understand, that his cold, if he gets it, is his own fault, and not 
 to be blamed upon the mercury he is taking. Probably the best precau- 
 tions against taking cold are the use of hair-mittens every morning upon 
 the dry skin of the whole body, when there is no general eruption; soak- 
 ing the feet upon retiring at night, in cold water, washing the neck and 
 chest in cold water in the morning, and not wrapping up the throat 
 tightly while out of doors, as well as the avoidance of wet feet and 
 drafts. 
 
 Cleanliness of the whole surface of the body by frequent bathing is 
 very desirable during the whole continuance of the treatment of syphilis 
 warm water (not too hot), toilet soap, and a soft towel, being used. Of 
 exercise and air the patient should have an abundance. The function 
 of the stomach and the intestine should be ministered to by appropriate 
 food, and regularity as strict as possible should be observed in regard to 
 meal-times and the hours of sleep. 
 
 In regard to the kind of food to be used, no special restrictions need 
 be put upon the patient. He may eat what he chooses, and what he 
 knows will agree with him, in full .quantity, as if in ordinary health 
 a plain, mixed diet of meat, vegetables, bread, butter, and milk being
 
 SYPHILIS. Ill 
 
 most appropriate. There is no objection to the use of wine or beer, in 
 moderation, with the meals; but any excess in alcohol in any shape is ob- 
 jectionable, and drinking between meals should not be allowed. 
 
 Under certain circumstances the regulation of food becomes very im- 
 portant, namely, when the medicines which must be given to control 
 important symptoms irritate the stomach so that they cannot be borne. 
 The mercurials in any form, in some cases of weak digestion and irritable 
 bowels, cause more or less griping and colicky pain, and the iodides often 
 produce nausea and disability of the stomach. The mercury may be 
 made to remain quietly in the intestine by the aid of opium, but it is far 
 better to accomplish the same result, if possible, by means of a change of 
 food. 
 
 When, therefore, moderate medication, such as may be necessary to 
 keep down the symptoms, is found to produce pain and diarrhoea, all 
 fruit and green vegetables must be denied the patient. He should take 
 no beer, and but little fluid of any sort. He should eat stale bread and 
 butter, tender meat, rice and boiled milk, eggs and toast, and by the ex- 
 ercise of these simple precautions he will, often be able to continue his 
 mercury and avoid opium. If another medicine must be given, it is well 
 to commence with gr. x. doses of the subnitrate of bismuth; and if this 
 serves to comfort the intestine, and keep pain and diarrhoea in check, it 
 certainly is simpler and less apt to do harm than opium. Besides these 
 means, it may sometimes be necessary to employ opium as well; but, if 
 the opium can be escaped, it is to the patient's advantage. 
 
 The same general precautions in regard to diet may be employed 
 when the iodides disagree. The subcarbonate of bismuth may be tried 
 instead of the subnitrate in these cases. 
 
 The residence of the patient is not a matter of much importance, if 
 his general health and his appetite remain fair, and his symptoms yield 
 reasonable obedience to the medicines employed. Change of air, how- 
 ever, is always desirable occasionally, even to persons in ordinary good 
 health, and this is the more necessary when the patient is laboring under 
 a devitalizing disease. Therefore, even if the course of the malady leaves 
 nothing to be wished for, it is wise, for such patients as can afford the 
 time and the money, to make a change of residence for a certain period 
 of time each year, in the summer if they live in town, in the winter, if 
 their home is rural. 
 
 This change of air and surroundings becomes a matter of necessity in 
 some cases, particularly in the later periods of the disease, if there be any 
 tendency to cachexia. Under these circumstances medicines sometimes fail 
 entirely to improve the general or the local symptoms, while a change of 
 air, even with a cessation of medication, will yield excellent results. I have 
 known patients, both early and late in the disease, who fail to respond to 
 medication until that medication has been supplemented by a change of 
 air, when not only would the symptoms promptly mend, but the tone of the 
 stomach would improve, and medicines which could not be taken at all 
 without interfering with digestion could be borne without a murmur. 
 This is particularly the case with the iodides. 
 
 In one case under my care this effect was strongly marked. The pa- 
 tient had a node which threatened to destroy the nasal bones. He could 
 not take the iodides without having his stomach totally upset, while at 
 the same time the iodides produced a brilliant crop of purpura oa each 
 occasion when they were tried. I therefore sent the patient to the 
 country, with directions to continue his medicines there. A few days
 
 112 THE VENEREAL DISEASES. 
 
 sufficed. He bore the drug well, his purpura disappeared, his stomach 
 regained its tone, the node in his nose visibly diminished in size. He 
 therefore returned to the city, thinking himself safe; but a few days 
 convinced him to the contrary: his stomach again refused food, his pur- 
 pura returned, and he was obliged to go back to the country, and to re- 
 main there until his node disappeared, which it promptly did. 
 
 The advantage patients in the cachectic stage of syphilis often derive 
 from visits to springs, or to cities even, for the purpose of consulting 
 some special physician about their disease, is no doubt sometimes due to 
 the improved hygienic effect of their surroundings. This effect in Xew 
 York City seems to last about six weeks, after which patients become 
 used to the locality and fail any longer to improve in it from the effect 
 of climate alone. How long this improving effect of change lasts in other 
 localities, I do not know. 
 
 The hygiene of the mouth is of the first importance in the treat- 
 ment of syphilis. It is desirable to give mercury and to avoid salivation, 
 and the condition of the mouth and of the teeth is therefore of the first 
 importance. Mouth lesions and throat lesions form some of the most ob- 
 stinate features of the disease, and these lesions are less apt to be severe 
 when the mouth is kept clean and free from the contact of irritants. 
 
 At the very beginning of syphilis, therefore, before the mercurial course 
 is commenced, the patient should be sent to a dentist to have his teeth 
 put in thorough order. All the tartar should be carefully scraped away 
 from the necks of the teeth, and all old stumps extracted, and sharp pro- 
 jecting angles of teeth likely to come into contact with the tongue filed 
 off. The patient should be instructed that he will do well to visit the 
 dentist regularly every six months if the tartar tends to reaccumulate 
 quickly, as it does in some cases. During the whole of the treatment a 
 very soft tooth-brush should be used, for the stiff bristles of a hard brush 
 cut and injure the gums, and make them more apt to become irritated un- 
 der the influence of mercury than if a soft brush be used. Any tooth- 
 wash employed, or tooth-powder, should be strongly alkaline and a little 
 astringent. A good, simple tooth-wash is made by putting half a tea- 
 spoonful or more of bicarbonate of soda into a glass of water, and adding 
 a teaspoonful of tincture of myrrh. Ordinary white castile soap makes a 
 good and simple tooth-paste, and the mouth may be washed out after- 
 ward with some alum and water, or some tincture of krameria ( 3 j.) in 
 aquae gaultheria ( iv.). 
 
 By keeping the teeth in order and the mouth clean by these and sim- 
 ilar precautions, mucous patches become less annoying and easier to man- 
 age, and the effect of the amount of mercury given can be more closely 
 watched, since one is not apt to be misinformed as to the cause, should 
 the edges of the gums begin to grow soft and tender. 
 
 Smoking should be absolutely forbidden during the first year at least 
 of syphilis, and often for a much longer period. If the patient will per- 
 sist in smoking, he ought to be made to do so at his own risk, and should 
 be willing to pay up for the pleasure of his smoking by the pain of more 
 or less sore tongue and throat, and a great number more of mucous 
 patches and mouth lesions than he would otherwise have had. Chewing- 
 tobacco is in many cases even worse than smoking. It is well also for the 
 patient to avoid much highly spiced or stimulating food, since such 
 things also help to keep the mouth tender. 
 
 A pipe is a dangerous thing for a patient with syphilis to use, for he 
 runs the risk of infecting any friend who might use it, the secretions of
 
 SYPHILIS. 113 
 
 mucous patches and syphilitic ulcers in the mouth being particularly cou- 
 tagious. 
 
 The hygiene of the genitals and of the anus is also very impor- 
 tant in syphilitic cases. These parts in both sexes should be kept scrupu- 
 lously clean and dry, otherwise mucous patches and condylomata, excori- 
 ations and ulcerations, are to be looked for. Should there be any ten- 
 dency to moisture about these parts externally, they may be dusted with 
 dry powders, lycopodium, starch, bismuth, with or without a little calo- 
 mel. Moisture beneath the prepuce may be kept in check by the inser- 
 tion of a thin layer of absorbent cotton or of prepared lint beneath it, 
 twice a day, after it has been washed. It is well, in all cases, if possible, 
 to have the patient wash the anus with soap and water after each action 
 of the bowels. The umbilicus, also, in fat people, and the skin under the 
 breasts, in fat women, require frequent washing, drying, and dusting, to 
 preserve the parts in good condition during the eruptive period. 
 
 HYGIENIC MEDICATION. 
 
 All such medicines as are used in syphilitic cases, for the purpose of 
 maintaining the general health or regulating the functions, come more 
 justly under the head of hygiene than of specific medication. 
 
 All tonics find a fair field for their exercise in syphilitic subjects, and 
 do good not, perhaps, in curing the disease, but by holding the patient 
 up while the disease works out its periods. The effect of mercury, when 
 given in small doses for a long or for a short time, is undoubtedly tonic, 
 as I have shown; 1 but it is not at all on account of this tonic action that 
 mercury given in minute doses eliminates the syphilitic poison. Other 
 drugs are far more tonic in their action, but, having no specific power over 
 the symptoms of syphilis, they directly modify the disease but little, if at 
 all. The only advantage I have ever claimed for the long-continued use 
 of mercury in minute doses is that, while acting in minute doses as a spe- 
 cific, it has the great advantage to the patient of being at the same time 
 tonic. 
 
 Now, the ordinary tonics such as the long list of vegetable bitters, the 
 quinine group, iron, and analogous drugs, together with cod-liver oil and 
 similar blood-formers all of these serve a good part in the treatment of 
 syphilis, just as other hygienic means do. If employed with intelligence 
 and judiciously changed, they in a measure take the place of change of 
 air and selection of food, in those cases in which lack of money will not 
 allow the patient to alter his food or to get a change of air. Cod-liver 
 oil is a particularly useful adjuvant to treatment in those cases in which 
 the blood-making powers are defective, while the ability to digest fat 
 remains. } 
 
 In persons who lack blood, yet in whom the stomach refuses to accept 
 or to assimilate so concentrated a food as cod-liver oil, an excellent sub- 
 stitute is found in kumyss. 
 
 Kumyss, long known and extensively used in Europe, especially in 
 Russia, is fermented milk. In different countries it is made out of differ- 
 ent kinds of milk that of asses, mares, cows. In America, I believe 
 cows' milk only is used. This milk -beer is not unpleasant to the taste. 
 It resembles buttermilk well aerated with carbonic acid, more than any- 
 
 1 The Effect of Small Doses of Mercury, etc. Am. Journ. Med. Sci. , January, 1876.
 
 114 THE VENEREAL DISEASES. 
 
 thino- else. It is exceedingly light to the stomach, and seems not only to 
 digest itself (by the lactic acid it contains), but to help digest other food. 
 It constipates little or not at all, and does not, generally, produce head- 
 ache, as milk often does. It may be taken in indefinite quantities, but a 
 pint to a quart a day is enough for most people. It is an excellent rem- 
 edy in dyspeptic conditions, and generally agrees with a weak stomach, 
 whether the latter be due to syphilis or to other cause. Often, where 
 cod-liver oil cannot be taken, and milk does not agree, kumyss comes to 
 the rescue and helps to turn the scale in the patient's favor. Kumyss is, 
 of late years, extensively manufactured through the country, and may be 
 easily obtained in our larger cities of the East. It bears transportation 
 moderatelv well, but must be kept cold. Its management is rather diffi- 
 cult as put up by some manufacturers, on account of the amount of car- 
 bonic acid gas which it contains. I generally direct that a champagne 
 syphon be used to draw it from the bottle, and that the kumyss be taken 
 as a beverage, with or just after meals one or two claret-glasses at a 
 meal, according to the patient's fondness for it, and its effect upon him. 
 An appetite for the drink is generally soon acquired. 
 
 SPECIFIC TREATMENT OF SYPHILIS. 
 
 The specific treatment of syphilis is a treatment of the disease b}- those 
 drugs which are known commonly to control the symptoms in an imme- 
 diate manner. These drugs are many of the preparations of mercury and 
 of iodine. The latter are found to exercise much less influence over the 
 symptoms of early syphilis than mercury does; but, in revenge, they pos- 
 sess a controlling power over many of the tertiary manifestations of the 
 disease, particularly over those dependent upon gummatous deposit, no 
 matter in what tissue such deposit occurs. 
 
 Mercury, on the other hand, has undoubted value in all stages of 
 syphilis and over all its lesions, but less control over gummatous deposit 
 than over other lesions. Indeed, although sometimes it will (in form of 
 fumigation) influence a gummatous lesion (ulcer, for example) more pos- 
 itively and more promptly than the iodides, yet, as a rule, it cannot be 
 relied upon to overcome symptoms due to gummatous deposit. The io- 
 dides, in such cases, serve an excellent part to supplement the action 
 of mercury just here where it is the weakest. In treating a gumma, the 
 object is to dissipate the deposit as promptly as possible, so as to save 
 the tissues involved from damage by pressure, or by disintegration when 
 they are included in the gummatous mass; and this the iodides do speed- 
 ily if vigorously pushed and well borne by the stomach, while the mercu- 
 rials will often fail to do it. 
 
 The iodides, on the other hand, have little or no power to prevent 
 relapse; and, when they have done all their work, mercury often has to 
 be called in to endorse the cure and to prevent a return of the symptoms. 
 Thus the two specifics support each other. 
 
 These facts I think I have demonstrated in an essay on the " Inter- 
 nal Treatment of Syphilis," read before the Medical Congress in Phila- 
 delphia, in 1876, and contained in the printed transactions of that body. 
 therefore judge it to be unnecessary to reproduce the line of argument 
 here. 
 
 It is also equally foreign to a book of this character to go deeply into 
 the detail of scientific work. I shall therefore say little or nothing about
 
 SYPHILIS. 115 
 
 the counting of blood-corpuscles, and the steps which lead directly to the 
 conclusion that mercury is a tonic when administered in minute doses, no 
 matter over what length of time its administration may be continued. 
 This conclusion I believe I have demonstrated to be a fact in the essay 
 already alluded to upon the ' Effect of Small Doses of Mercury in Syphilis," 
 which appeared in the January number of the American Journal of Medi- 
 cal Sciences, in 1876. Those interested in following the study of the 
 blood and the course of argument derived from other facts which prove 
 that mercury in minute doses long continued is a tonic, while in large 
 doses it is atonic, diminishing the number of the red cells in the blood, 
 are referred to the two papers in question. There I think it will be found 
 to be demonstrated that mercury, properly used for a number of years in 
 Succession, cannot do any harm to a patient, while it certainly, in most 
 cases, controls his symptoms in a greater or less degree. I have but to 
 add here that the years which have passed since the appearance of those 
 papers have only served to strengthen my convictions in the correctness 
 of the conclusions there reached. The only modification I have made 
 has been to somewhat diminish the dose of mercury for continuous use, 
 making the tonic dose more often one-third rather than one-half of the 
 full dose; and, in revenge, I am inclined to extend the treatment into the 
 fourth year in a majority of instances, where such prolonged treatment is 
 practicable. 
 
 Relapses certainly do occur after this time, but, in my experience, they 
 have been invariably mild, and have come readily under the control of 
 specific medication. Mouth symptoms during this course are generally 
 more obstinate than any others, but I look upon the little scaly patches 
 upon the tongue and lips more as an evidence of local irritation, in a per- 
 son once syphilitic, than anything else, and I am now in the habit of treat- 
 ing them locally in many cases, without making any change in the inter- 
 nal dose which the patient may be taking at the time. 
 
 The coup sur coup plan of giving mercury I have never followed up, 
 being satisfied, from the results in the way of relapses I have seen in pa- 
 tients who have so taken the drug at competent hands, that this form of 
 treatment leaves much to be desired. The plan known as Fournier's treat- 
 ment, which consists in the interrupted use of mercury in mild form (a 
 gentle coup sur coup method), with stated definite intervals in which no 
 treatment is used, seems to me to rest upon no foundation stronger than 
 theory, since syphilis, a malady of interruptions undoubtedly, has its in- 
 terruptions at indefinite and irregular intervals. Notwithstanding that 
 intervals of latency in the malady exist, periods of apparent immunity 
 from the disease, yet there is nothing to prove that the patient is free 
 from the poison during those intervals, but everything to show that he is 
 still suffering. The cauterisatio provocatoria of Tarnowsky (p. 78) is 
 founded upon this assumption. A blister or a local irritant (vaccination) 
 will sometimes make latent syphilis active a woman seemingly perfectly 
 healthy will often produce a syphilitic child. What conclusion can there- 
 fore be reached except that syphilis is a mild, continuous disease, with 
 periods of passive latency and periods of active outbreak ; and what 
 treatment, therefore, recommends itself more to common sense than a mild, 
 long-continued, uninterrupted treatment by a specific known to have 
 power over the symptoms, with an increase in the quantity of that speci- 
 fic during the periods of outbreak ? 
 
 And this becomes especially apparent when it can be shown, as I think 
 I have done, that the continuous use of the mild specific acts as a general
 
 116 THE VENEREAL DISEASES. 
 
 tonic (as well as performing its work as a specific) during the whole period 
 of its administration. 
 
 The method I propose, indeed, has all the advantage of the coup sur 
 coup method, but its coup is mild. It hurts only the disease, never the 
 patient. The " blow " falls only during the period of active outbreak of 
 the disease, while the general treatment has the further advantage of acting 
 continuously as a specific in eliminating the poison of syphilis, and prevent- 
 ing it from causing outbreaks in the way of serious symptoms. This treat- 
 ment constantly tends to keep the disease down, and to keep the patient 
 up. It does not cure the disease so much as it conducts the patient safely 
 through the periods of the disease. It does not prevent relapse later in 
 life with certainty, for occasional cases of such relapse do certainly occur; 
 but it ensures one, I believe, more positively against relapse, than any 
 other form of treatment at least, than any other with which I am fa- 
 miliar. 
 
 Salivation I believe to be harmful. Much of the odium which rests 
 upon mercury is undoubtedly due to the harm it has done to the mouths 
 and stomachs of patients in times past, by salivation. In the days when 
 it was considered that the patient never had arrived at his proper dose of 
 mercury until he was caused to spit at least a pint in twenty-four hours, 
 how much damage must have been done, and how justly has mercury paid 
 the penalty by falling into popular disgrace, and by being distrusted by a 
 large number of intelligent gentlemen, in the profession as well as out of it. 
 
 That salivation may occasionally do good in desperate conditions of 
 disease late in syphilis, I do not deny; but certainly it has no value as a 
 means of general treatment, and I think it can never happen to a patient 
 early in the disease without doing him positive harm. 
 
 The time at -which the general treatment of syphilis shall be 
 commenced is a question of great importance. Unquestionably it should 
 be commenced as soon as the disease is diagnosticated; but the difficulty 
 is that diagnosis, before the eruptive stage positively absolute diagnosis 
 is rarely possible without confrontation, and even then there is a chance 
 for error found in the possibility of infection through another source, or 
 in mediate contagion. 
 
 Practically, therefore, the treatment should not be commenced until 
 the first general symptoms of syphilis appear; the chancre with the accom- 
 panying glandular engorgement is not enough to go by. If treatment is 
 commenced while any doubt exists, that doubt remains, and the patient 
 may continue in doubt for the rest of his life, to his great discomfort; 
 therefore, although he may demand treatment, and beg for it when he has 
 a chancre, the surgeon will do him a kindness by refusing internal specific 
 measures until the first general symptoms begin to appear. 
 
 In the rare cases in which diagnosis can be positively made, with- 
 out the chance for the least possible doubt as, for instance, when a hus- 
 band poisons his wife or his child treatment may and should be com- 
 menced at once, without waiting for general symptoms; otherwise it is 
 safer for all parties to wait. The patient's mind may be satisfied, mean- 
 time, by cutting out his chancre, and he may be medicated, to his advan- 
 tage doubtless, with tonics of all kinds; but mercury should be denied 
 him. 
 
 I have in the past often deviated from this rule, and probably with 
 advantage to the patient in most instances; but occasionally I have en- 
 countered a case which has afterward given me much anxiety, and made 
 me dcrabt ray diagnosis greatly. Such cases always make one feel the ad-
 
 SYPHILIS. 117 
 
 vantage of a rule which forbids any specific treatment until general symp- 
 toms have declared themselves. In one case which I remember well, there 
 was no possible room for doubt about the patient's syphilis. Every phys- 
 ical feature of the sore was perfect, the incubation accurate, the ingui- 
 nal pleiad typical; and, at the patient's urgent request, I commenced 
 treatment. All went well for a year, but not a solitary symptom of syphi- 
 lis appeared. During the second year, treatment having been kept up 
 continuously, and the patient being in perfect health, my faith began to 
 waver, and for several months I thought it possible that 1 had made a 
 mistake, and that my patient had no syphilis at all. I finally appointed a 
 night, and told him that, if no symptoms of syphilis had appeared before 
 that date, I should stop all treatment. Fortunately for the patient and 
 for my diagnosis, at his next visit he showed me a most characteristic 
 mucous patch upon his throat, and the treatment was continued. Much 
 anxiety in this case, both on the part of the patient and of myself, might 
 have been avoided by waiting six weeks or two months after the chancre, 
 before commencing treatment. 
 
 X 
 
 DETAIL OF THE TONIC TREATMENT OF SYPHILIS BY MERCURY. 
 
 I have called the method about to be described the tonic treatment of 
 syphilis, to distinguish it from other methods. It is tonic, and therefore 
 the term is correct; but it does not cure syphilis because it is tonic. It 
 cures the symptoms because it is a specific, and the tonic action is only 
 an accidental one found to attach to the method. Even if it were not 
 tonic, it would be proper to use mercury in the treatment of syphilis; and 
 indeed, mercury often is given, and properly given, in such a way as to be 
 a specific devoid of tonic properties, in that it is used in large doses doses 
 which I have shown by blood counting to be anything but tonic. When, 
 however, the specific medicine can be used so as to be at the same time 
 a tonic, I think that a step in advance over the older methods has been 
 made, and that is the reason why I have called this method the " tonic 
 treatment of syphilis." 
 
 The idea of this treatment is best carried out by using the same drug 
 continuously in varying doses. If the preparation has to be changed and 
 great accuracy is aimed at, it is necessary to make a new set of tests in 
 order to find the tonic dose. The preparation which I have used the most, 
 and with which I am entirely satisfied, is the proto-iodide of mercury put 
 up in France by Gamier and Lamoureux, in the form of sugar-coated 
 granules, containing exactly one centigramme each (fa of a grain). The 
 advantages of this preparation are that it does not change by climate ; the 
 proto-iodide remains fresh inside the sugar coating, and the latter, being 
 thin over the small granules, always dissolves in the stomach readily; the 
 preparation is a solid one, and easy to carry around, and to take without 
 causing comment; a liquid might be used, but it would be harder to man- 
 age; the quantity of the drug in the pills (one centigramme) seems to be 
 reliable, and to be accurately graded in the different pills; the preparation 
 is clean and dry, and many doses may be carried in a little box or bottle 
 in the pocket, without taking up much room; finally, this preparation has 
 very little of the griping quality possessed by many specimens of the 
 proto-iodide found in the shops. The French granules are quite cheap. 
 
 Many preparations doubtless possess all the good qualities I have as- 
 cribed to Garnier's granules; but, having been well served by these, I 
 have not thought it well to change. A number of American manufac-
 
 118 THE VENEREAL DISEASES. 
 
 turers now make gelatin-coated granules of proto-iodide of mercury in 
 doses of gr. , -, \, and many of them are good preparations. They may 
 be obtained anywhere in the country. 
 
 In some cases the proto-iodide produces griping pain in the intestine, 
 even when it is given in very small doses; but these cases I find are quite 
 rare when the French granules are employed. 
 
 Other preparations of mercury, however, must be at hand to be em- 
 ployed when the proto-iodide does not agree. Perhaps the drug most 
 bland and most certain to be found everywhere is blue pill. The size of 
 pill most convenient for use I find to be one-half a grain, and these may 
 be made up alone, or combined with a fifth, a quarter, or a half-grain of the 
 dried sulphate of iron, according to the formula so long successfully in 
 use by the profession. 
 
 If pills are objected to by the patient, he may take gray powder, the 
 standard powder to use in finding the dose being one-third or one-half a 
 grain; or, if liquids must be taken, owing to the patient's caprice, I know 
 of no improvement upon the old-fashioned combinations of corrosive 
 chloride with compound tincture of cinchona, or, if iron be needed with 
 the tincture of the sesquichloride of iron, the dose being so regulated that 
 one-fiftieth, or, perhaps better, one-hundreth part of a grain of the bichlo- 
 ride shall be the standard dose until the tonic dose has been found out. 
 
 In short, any preparation or combination of mercury may be used, 
 provided it does not contain opium, the addition of which would make it 
 impossible to decide accurately what the tonic dose is. The standard 
 dose must be a minute one. 
 
 To bring a patient under the tonic treatment, if there be time, the fol- 
 lowing is the best course: Let him take one standard dose of mercurial 
 (one granule of the proto-iodide, for example) after each meal for two 
 or three days. On the fourth day one extra standard dose is added at 
 the mid-day meal; now four standard doses (granules) are taken daily, 
 and this is to be continued for three days. 
 
 On the succeeding fourth day another standard dose is added, the five 
 daily standard doses being taken two in the morning, one at noon, and two 
 at night. On the next following fourth day, always counting from the last 
 fourth day, another dose is added, two standard doses being now taken 
 after each meal six (granules) a day. 
 
 In this way the amount of mercurial given is gradually increased, 
 while the patient uses bland food in moderate quantity and regulates his 
 habits as far as may be, and the dose is slowly increased every third or 
 fourth day, or even every second day, if the patient is pushed for time 
 and the presence of an eruption makes haste an object, until the irrita- 
 ting or the poisonous action of the drug begins to manifest itself. 
 
 If in any given case the symptoms are so pressing that there is not 
 time to get the patient quietly under this treatment, there is no objection 
 to treating him by any of the older methods until his symptoms abate. 
 He may be rapidly brought under the mild influence of mercury until the 
 drug shows faintly along the edge of the gums, either by inunction, by 
 daily fumigations, or by gr. -fa doses of corrosive chloride in tincture of 
 bark, taken diluted, after meals; and when finally the urgent symptom 
 has fairly declined, all medication may be suspended for a week or more, 
 ami then under less pressure the mercurial course may be instituted as 
 directed above. 
 
 f )ne advantage of the French proto-iodide granules, which was not 
 alluded to above in the list of its virtues, is that, although it does not
 
 SYPHILIS. 119 
 
 gripe when given in small quantities, yet it does show its irritating ef- 
 fects, usually, upon the intestine, before it produces any trouble in the 
 mouth. This is not always the case, but it is the rule; consequently, 
 during this course of granules, diarrhosa and griping pain are to be 
 watched for. A slight looseness of the bowels is unimportant. Such a 
 looseness often comes on during the early days of the course; but, by 
 holding the drug at the same dose, it subsides, and then the doses may 
 be increased as before. 
 
 When a dose of six to nine, or even twelve granules a day in some 
 cases, has been reached, it will produce a very positive attack of diar- 
 rhoea, with pain in the intestines; and occasionally at the same time the 
 breath will begin to have the mercurial fetor, and the livid line will begin 
 to show faintly along the edge of the gums at the necks of the teeth, 
 while the teeth themselves become a little sensitive on being snapped 
 sharply together, and the saliva flows more freely. These latter symp- 
 toms are generally not much marked with the proto-iodide, and they may 
 be absent entirely while the griping and diarrhosa are quite positive, and 
 this feature I consider an advantage in favor of the proto-iodide. 
 
 When either of these sets of symptoms occur, the patient has reached 
 his limit. He is taking what I have called his " full dose " a dose 
 which he may continue to take with the aid of selected food and a little 
 opium, and may, indeed, in most cases, continue to take without becom- 
 ing salivated. This dose is anything but tonic. If it be continued, the 
 patient surely suffers in time, both in the stomach and in the quality of 
 his blood, while his strength and physical powers are diminished by it. 
 This " full dose," therefore, is only to be used in case of necessity. It is 
 specific, and possesses fully the antagonistic influence to syphilis which 
 the mercurials enjoy; and the patient may take this dose for a consider- 
 able period without injury, if his symptoms require it, with the aid of a 
 little opium to give him comfort, or, I think, preferably without opium, 
 by changing his food, drinking boiled milk, and eating rice. 
 
 This " full dose," the size of which varies greatly in different individ- 
 uals, may be maintained until the activity of any existing symptoms de- 
 clines, and then it should be dropped, and the " tonic dose " of mercury 
 substituted. 
 
 One-half of the "full dose" is a "tonic dose," and may be continued 
 steadily during several years without injury to the patient; if anything, 
 apparently rather to his advantage, for he feels well under it in most 
 cases, he eats well, his functions go on perfectly, and his blood is richer 
 in red corpuscles than it was before. The condition is an unnatural one, 
 however. Nature is being outraged by the constant use of a foreign 
 substance, the use of which is only allowable in order that it may coun- 
 teract another foreign substance the poison of syphilis and the less of 
 the drug that can be used with safety to the patient, the better. There- 
 fore, of late years, I have been in the habit of using, as a continuous 
 dose, a quantity somewhat smaller than the regular tonic dose a quan- 
 tity, for instance, equal to one-third instead of one-half of the " full 
 dose." This dose is also tonic, and with it I endeavor to persist without 
 interruption, for a long period of time, in the endeavor to eliminate the 
 syphilitic poison gently, and to keep its explosive outbreaks within rea- 
 sonable limits. The idea of the tonic dose is that it shall be continued 
 daily, year in and year out, for, in round numbers, about three years, or 
 longer alterations, of course, being occasionally made meantime, accord- 
 ing to the varied necessity of the different cases.
 
 120 THE VENEREAL DISEASES. 
 
 During the existence of all ordinary moderate symptoms, isolated 
 patches of eruption, disappearing general eruptions, mucous patches, etc., 
 the tonic dose may be maintained unvaried, or slightly increased, accord- 
 ing to the surgeon's judgment, while local measures are brought to bear 
 upon the local lesions. If more severe symptoms come on at any time, 
 the tonic dose may be immediately increased to the full dose, already 
 ascertained; and after the full dose has done its work, it in turn may be 
 again dropped to be replaced by the tonic dose. In these emergencies, 
 instead of increasing up to the full dose, the tonic dose may be maintained, 
 and inunction or fumigation resorted to until the emergency has passed. 
 
 These simple directions meet the wants of most cases, until some ter- 
 tiary symptom arrives if, indeed, any tertiary symptoms at all come on, 
 for they may be escaped entirely. Tertiary symptoms call for a variation 
 in the general treatment. The mercury may be dropped entirely, one of 
 the iodides being substituted if the lesion be purely gummatous; or the 
 mixed treatment may be called for, according to the symptom. Under 
 the heads of the various symptoms, it will be indicated which of the 
 special forms of treatment is required. When the mixed treatment is 
 indicated, one of the best combinations is a solution of the biniodide of 
 mercury in a solution of the iodide of potassium. This is a reasonable 
 chemical combination. The granules of the proto-iodide may be con- 
 tinued, if thought best, while the iodides are given separately; but this 
 treatment may result in the formation of a certain amount of the binio- 
 dide of mercury (a very active preparation) in the stomach, and the other 
 course is therefore preferable. 
 
 After the mixed treatment or the iodides alone have accomplished 
 what was expected of them, it is well that the patient should return again 
 to his tonic dose of the granules, and continue them until it is thought 
 best to stop all treatment. 
 
 In case of any intercurrent malady not syphilitic in nature, coming on 
 during a long mercurial course, the latter may be stopped at once and 
 resumed when the intercurrent malady has passed away. The mercury 
 should be stopped also during any attacks of acute indigestion, diarrhoea, 
 and the like. 
 
 The time at -which a tonic course of the mercurial specific 
 may be stopped. This, like all other points in connection with syphilis, 
 is subject to variation. About three years is a full course for most peo- 
 ple, while two years and a half, or even two years, answers well enough 
 in some cases. Six months of entire immunity from symptoms, at the 
 very least, or, better still, a year's freedom from evidences of the disease, 
 is desirable before the tonic treatment is stopped. In some cases where 
 smoking is persisted in, an occasional scaly patch on the side or tip of 
 the tongue, or inside the lips or cheeks, need not be regarded as a symp- 
 tom serious enough to make the six months test invalid. It is better 
 that no symptom whatsoever suggesting syphilis should have occurred; 
 but it becomes a matter of special judgment in some cases whether the 
 persistence of these mild mouth lesions, for cause (smoking), may not be 
 disregarded, provided there is and has been nothing else about the pa- 
 tient for a long time to suggest the persistence of the existence of syph- 
 ilis. Occasionally, non-syphilitic patients are found in whom smoking 
 will produce erosions and scaly patches within the mouth absolutely iden- 
 tical with the lesions found in syphilis. Should such a patient get the 
 disease, it is not fair to let his constitutional peculiarities be ascribed to a 
 syphilitic cause.
 
 SYPHILIS. 121 
 
 If relapses occur after the cessation of treatment, they must be man- 
 aged according to their necessities, generally best by the mixed treat- 
 ment; and then, finally, a tonic mercurial course may be instituted for a 
 few months, more or less, according to the judgment of the surgeon, and 
 proportionate to the intensity of the relapse and its obstinacy. 
 
 Many patients will not follow continuously the strict course which has 
 been detailed; but many others do follow it conscientiously, the more 
 readily as they are intelligent and have the nature of the disease ex- 
 plained to them, together with the theory of the treatment.
 
 CHAPTER VII. 
 
 THE GENERAL TREATMENT OF SYPHILIS CONTINUED. 
 
 Mercurial Fumigation. Simple Method of taking a Bath at Home. The Inunction 
 of Mercury. Other Methods of giving Mercury. The Treatment of Salivation. 
 The Local Treatment of Syphilitic Lesions of the Integument ; of Mucous Mem- 
 branes. The Iodides and the Preparations of Iodine. The Evil Effects of the 
 Iodides. The Dose of the Iodides. The Mixed Treatment. When to cease giv- 
 ing the Iodides. Zittman's Decoction. 
 
 Mercurial fumigation. Before making use of the standard dose, 
 in order to find the full dose, and the tonic dose, in a particular case; or, 
 after the tonic dose has been ascertained and where it is desirable to sud- 
 denly increase the mercurial influence in order to counteract sone ten- 
 dency to activity on the part of the syphilitic symptoms instead of put- 
 ting the patient upon his full dose of mercury, he may be retained at the 
 tonic dose, and the mild but certain influence of mercurial fumigation 
 brought to bear upon him. 
 
 Mercury in vapor acts very promptly and very kindly. The obstacles 
 to its extended use are the difficulty of its application, the time required 
 to give a bath, the impossibility of using it secretly at home (for syphi- 
 litic patients are always shy of being discovered while taking medicine), 
 and the expense if the baths are taken in an outside establishment. 
 
 The value of the vapor, however, is so considerable, in many cases, that 
 its use for emergencies should be placed within the reach of all. In many 
 ulcerated and pustular lesions, and in cases where persistent and chronic 
 relapse occurs in a patient with irritable stomach and general debility, 
 the vapor-bath renders invaluable service. When pushed too far, mer- 
 curial vapor may cause salivation or diarrhcea, but it rarely does so when 
 watched; a sense of weakness, with general depression, attended by more 
 or less trembling (perhaps positive mercurial tremor), is one of the more 
 common indications that the baths are being pushed too rapidly. 
 
 In a regular mercurial bathing establishment, the patient sits naked 
 in a box, sometimes with the head in (if the fumes are not disagreeable 
 and do not induce coughing), sometimes with the head out. A little steam 
 is let into the chamber, the temperature is raised to 90 F. or thereabouts, 
 and when the body is damp and warm, the mercurial to be used is vola- 
 tilized, and, permeating the chamber, settles upon the moist skin, where it 
 becomes precipitated changed probably into the bichloride by contact 
 with the perspiration, and as such absorbed. If the head is in the fumiga- 
 ting chamber, a certain amount of the vapor is directly absorbed by the 
 lungs. 
 
 Fifteen to twenty minutes is ample time for such a bath, which should 
 be terminated sooner if the patient grows faint. The best form of mer- 
 curial for the bath I believe to be the black oxide, in a dose for volatili-
 
 SYPHILIS. 
 
 123 
 
 zation, at first, of one drachm, afterward of two drachms. Calomel is 
 often used, and the sulphuret of mercury, in doses of 3 i- 5 but both of these 
 substances irritate the lungs of some patients, and may induce violent 
 coughing. When they are used, therefore, the head should be kept out- 
 side the fumigating chamber. 
 
 Twice a week is generally often enough to repeat the bath. In some 
 eases, where they are well borne, I have repeated them daily, for a time, 
 watching the patient carefully for the effect of mercury. 
 
 After the bath the patient should wrap himself up in a warm blanket, 
 and rest quietly for an hour or more, until he has become thoroughly dry 
 without the use of a towel. 
 
 The form of bath above described is a good one, but it is an expen- 
 sive luxury, and not to be obtained at all by patients in the country. 
 Under circumstances calling for a bath, where the bathing establishment 
 may not be suitable, an excellent substitute, answering all purposes, may 
 be taken by the patient in his own house, at a merely nominal cost. The 
 appropriate essentials for such a bath are: an alcohol-lamp with one or 
 two good burners, and a piece of tin bent into the form of a table (Fig. 
 1), of such height that the flame will spread itself evenly upon the under 
 surface of the tin. The figure represents the flames of the lamp as being 
 by far too small. I have 
 found upon such a table, 
 that one good flame of 
 a spirit-lamp will vola- 
 tilize half a drachm of 
 calomel in four and one- 
 half minutes, and the 
 same amount of cinnabar 
 in six minutes. One flame 
 is therefore ample, and it 
 need not be a very large 
 flame if the sheet of tin 
 be reasonably thin. 
 
 Both calomel and cinnabar volatilize quite easily by this method; the 
 oxides require more heat and more time. I have sometimes used gray pow- 
 der, which does very well. Both calomel and cinnabar (and especially the 
 latter) may cause coughing, but generally the bath can be so managed 
 that the patient is not materially discomforted by it. If cinnabar be used, 
 the patient may keep his head out, and retire into another room immedi- 
 ately after the bath. On the whole, my experience leads me to prefer 
 calomel in this form of bath, commencing by volatilizing a powder of twenty 
 grains, and working up to a drachm. 
 
 Domestic vapor-bath. The simple method of taking the bath is as 
 follows: the patient sits naked on a cane-bottomed chair, holding close 
 around his neck, under his chin, a couple of blankets, which may be 
 pinned in place so as to envelop the patient and the whole chair down 
 to the floor. Under the blanket is placed the little tin table beneath the 
 chair, with its spirit-lamp unlighted, the dose of calomel lying on top of 
 the tin table. Under the chair, also, is placed a pan of hot water. 
 
 The patient sits quietly over the hot water until his skin has become 
 warmed up and slightly moist, then he stoops down, lights a match, lifts 
 the edge of the blanket, and lights the spirit-lamp. He may leave this 
 light burning until the bath is finished, if he desires, or he may extinguish 
 it in five or ten minutes, according to the amount of calomel to be voiatil- 
 
 Fio. 1.
 
 124 THE VENEREAL DISEASES. 
 
 ized and the degree of heat he experiences. He then sits quietly for per- 
 haps ten minutes longer in the fumes, occasionally opening the front of 
 the blankets to breathe a whiff, if the vapor does not irritate the air-pas- 
 sages, and his bath is over. He now wraps himself up in the inside blan- 
 ket in which he has taken his bath, and remains so wrapped, lying down 
 until he has cooled off, after which, without using a towel, he goes to bed. 
 In the morning he may take a soap and warm water bath if he desires it. 
 
 The effects of mercurial vapor by inhalation may be obtained when a 
 patient is unable to leave his bed, by volatilizing calomel or cinnabar near 
 his nose upon a sheet of tin, or even upon a hot brick. Inhalations of 
 this sort are of incalculable value in some cases of mouth and throat 
 lesions, when the patient can make the inhalations without coughing, 
 which he generally can do if they are commenced mildly and often re- 
 peated, minute quantities of mercury being volatilized at a time. 
 
 These simple means place the mercurial vapor within the reach of all; 
 and I think the more the vapor is used in emergencies, the more highy 
 will it be esteemed. 
 
 MERCUBY BY INUNCTION. 
 
 Inunction is the best method of introducing mercury into the bodies 
 of infants, and many believe that it is the best method' in the adult. The 
 main objections to it are that it is dirty, and so irritates the integument 
 in some cases that it cannot be used for any great length of time. 
 Where it agrees it is an excellent method, especially to use in conjunction 
 with the tonic internal treatment, to meet such emergencies as call for 
 an increase in the amount of the mercurial employed. It is as good a 
 method as that by fumigation, for sparing the stomach, and is very useful 
 in those cases in which that organ must be restricted to its natural func- 
 tion, the digestion of food. It has the advantage over fumigation that it 
 may be carried out in the utmost secrecy. 
 
 There are many methods by which mercury may be introduced through 
 the skin into the blood. Ordinarily, the process is one of friction; and 
 in this country the patient generally does the rubbing for himself, with his 
 own bare hand. In some parts of the world inunction is practised by 
 professional rubbers, who often wear gloves. 
 
 The amount of absorption which takes place by the skin is very vari- 
 able in different individuals. A prompt effect is produced in some patients, 
 a very slow effect in others; consequently, where the course must be long 
 or the dose at all accurate, this method is obviously inappropriate. More- 
 over, skins differ materially in their irritability upon the contact of mer- 
 curial preparations. Some patients will wear a patch of mercurial oint- 
 ment bound upon the skin for weeks without showing any local redness 
 of the skin, while in others each inunction is followed by local redness and 
 itching, and a persistence of the application by an outcrop of the so-called 
 mercurial eczema which distresses the patient considerably by its itching, 
 and is, relatively, quite chronic in character and slow to disappear. 
 
 In the friction method of inunction three preparations are in common 
 use : mercurial ointment, the different oleates, solutions of corrosive sub- 
 limate. Of these three the mercurial ointment is cheap, most easily pro- 
 cured, and generally preferred. Corrosive sublimate is cheap also and 
 clean, but the element of danger which its use involves is a bar to its gen- 
 eral employment. The oleates are nicer preparations, but are more ex- 
 pensive.
 
 SYPHILIS. 125 
 
 When mercurial ointment is to be rubbed in, from half a drachm to a 
 drachm is a dose, to be used once daily, preferably at night. The skin to 
 be anointed should be thin, for the absorption of mercurial ointment is 
 not active ; therefore, the flexures of the various joints are usually chosen, 
 although any part of the integument will answer. Thus, Sturgis, of New 
 York, prefers the soles of the feet, and the patient does his own friction 
 while walking about. 
 
 The portion chosen for inunction is to be slowly and firmly rubbed 
 with the ointment by means of the bare fingers or the whole hand, for 
 something like twenty minutes or half an hour, preferably at night. The 
 task is laborious if properly done. After rubbing the ointment in as 
 thoroughly as possible, the part may be bound up in dry flannel and left 
 for twenty-four hours, when it should be carefully washed with soap and 
 warm water, and another friction performed upon another portion of the 
 integument. By the time all the flexures of the joints have been gone 
 over, the spot first used will be ready for service again, and so on until 
 the occasion for inunction ceases. 
 
 When the oleates of mercury are used, the five, ten, or twenty per 
 centum preparations may be employed, according to the irritability of the 
 skin and the effect it is desired to produce. 
 
 The twenty per cent, preparation is most commonly employed. It is 
 absorbed more easily than mercurial ointment, and, therefore, has more 
 effect; but it is equally irritating to most skins. It may be rubbed in 
 anywhere upon the surface, commencing with a half-drachm dose and in- 
 creasing to a drachm, and treating the surface in all respects as has been 
 suggested above for mercurial ointment. If mercurial 'eczema occurs, it 
 may be treated with any bland ointment oxide of zinc, for example. 
 The five per centum oleate may be rubbed upon the spot daily, in many 
 persons, without creating any marked disturbance of the skin. 
 
 The process of cutaneous application of the bichloride of mercury is 
 to simply wash the skin with a watery solution of corrosive sublimate and 
 allow it to dry on. From one-quarter to one-half a grain, or more, may 
 be used at a time in this way, dissolved in a dessert-spoonful or a table- 
 spoonful of water. It is dangerous to use an actively poisonous drug in 
 such quantities generally, especially if there be any erosions of the skin, 
 such as might be found in an early general syphilitic eruption. Detmold, 
 of New York, praises this plan highly. 
 
 Corrosive sublimate is used in a full bath sometimes, especially for 
 children; but it can hardly be safe for general adoption. 
 
 Teale's method of inunction, as it is called, consists in binding upon 
 an arm or a leg a piece of bandage (or flannel cloth), upon which mercu- 
 rial ointment has been thickly smeared. The bandage is kept in place at 
 discretion, the surface of the skin beneath it being inspected daily, and 
 the bandage removed and placed elsewhere when the skin begins to show 
 any signs of redness, or the patient complains of local itching. By this 
 means there is a continuous action of the mercury upon the skin day and 
 night, until the ointment dries up, when it must be freshened with oil, 
 or a new plaster applied. 
 
 This method is mild and continuous in its action, and with certain 
 skins works admirably. 
 
 Of the other methods of introducing mercury into the body, that by 
 rectal suppository, which has been abandoned by its originator, Zeissl, is 
 not so good as by the skin or by fumigation; and that by subcutaneous 
 injection, even of the albumiuates of mercury, though undoubtedly prompt
 
 126 THE VEXEREAL DISEASES. 
 
 and effective, is painful, and apt to be followed by local inflammatory in- 
 durations, and even abscesses, which practically make it unsuitable for 
 general use, even during emergencies, since we possess so many better 
 methods. 
 
 The direct local influence of mercury has been proved by subcutaneous 
 injection of the drug, since it has been found that, if a patch of eruption 
 be injected, it gets well, while a similar patch, more or less distantly sit- 
 uated, is not modified by the general effect upon the system of the small 
 amount of mercury employed. 
 
 Among the special methods of giving mercury, the plan known as 
 Trousseau's must not be forgotten. By this plan minute doses of calo- 
 mel, anywhere from the sixtieth to the tenth of a grain, are given hourly, 
 or at short intervals, with great effect in some cases in overcoming the in- 
 tense headache of early syphilis, and for the purpose of rapidly bringing a 
 patient under the full influence of mercury. One-tenth of a grain, hourly, 
 will show in the mouth, in the case of some patients, within twenty-tour 
 hours. 
 
 THE TREATMENT OP SALIVATION. 
 
 In a properly regulated treatment salivation should never occur. In 
 ascertaining what the "full dose "of mercury is in a given case, the gums 
 may be touched, as the expression is; but this condition cannot fairly be 
 called salivation, although it is the first stage of it. In maintaining the 
 full dose, the mouth is kept constantly in a condition of mild irritation, 
 and necessarily so, in some instances, when the symptoms are severe. 
 Under these circumstances, especially if it seems probable that the full 
 dose will have to be maintained for a considerable period, certain precau- 
 tions should be taken with the mouth in order to allow the mercury full 
 chance without in any way encouraging its disagreeable effect upon the 
 mouth. 
 
 The teeth, it is presumed, have been properly attended to, and the tar- 
 tar removed by a dentist. All the precautions detailed in speaking of 
 the hygiene of the mouth (p. 112) should also be put in force. Besides 
 these precautions, only three others need to be insisted upon ; they are : 
 the bath, a diuretic, and the internal use of the chlorate of potash. 
 
 The bath should be used quite hot at night, and the patient advised 
 to remain for a number of minutes in the warm water. Then he should 
 dry his skin under very smart friction with a soft towel. In this way the 
 circulation of the skin is rendered active, and the dead epidermis rolled 
 off in quantities by the friction. The function of the skin as an excretory 
 organ is intensified, and more mercury than usual escapes in this direction, 
 thus taking off some of the work from the mouth. 
 
 A diuretic acts in the same way, increasing the excretory activity of 
 the kidney, and allowing more mercury to escape from the body by this 
 channel. 
 
 ^ Finally, the well-known soothing influence of the chlorate upon the 
 irritated mouth and fauces should be called into play. About a drachm 
 of the chlorate of potash in twenty-four hours is generally enough to be 
 taken. 
 
 9 . Potass, chlorat 3 i. 
 
 Aquae gaultheriae iij, 
 
 M. 
 
 S. Teaspoonful hourly in a tablespoonful of flaxseed tea.
 
 SYPHILIS. 127 
 
 If double doses are taken in the early morning and during the even- 
 ing, about the proper amount in the twenty-four hours will be consumed. 
 
 As salivation approaches, the signs noticed, as indicating that the gums 
 are touched, become intensified. The stale odor of the breath becomes 
 positively offensive, quite peculiar and characteristic the mercurial fetor, 
 as it is called. The tongue becomes heavily coated, and the peculiar, bit- 
 ter, coppery taste of which the patient has been complaining, grows sensi- 
 bly more intense and more disagreeable, especially upon awakening in the 
 morning. The gums grow puffy, soft, and fungating along the line of the 
 necks of the teeth, more livid in color, bleeding easily upon the lightest 
 touch, as during brushing the teeth, even with the softest tooth-brush. 
 Finally, the flow of saliva grows more and more profuse, partly watery 
 and partly tenacious. It flows over upon the patient's chin, and soils his 
 clothes. At night it runs out from the angles of his mouth, and wets his 
 pillow. With these signs the stomach is often badly upset, diarrhoea 
 comes on, the complexion becomes pallid, livid, the appetite fails, and 
 headache is often present, with great depression of spirits. 
 
 At last the tongue may swell so as to be too large for the mouth, and 
 with it the lips and cheeks become tumid. Ulcers appear all over the in- 
 side of the mouth and along the gums. The purple gums bleed freely, the 
 loosened teeth project, and drop from their sockets, while more or less ex- 
 tensive portions of bone, or of the soft parts, necrose and slough away. 
 
 Such an intense condition of salivation as that last depicted is very 
 rarely encountered at the present day, but it need not be waited for; all 
 conditions of active salivation demand prompt measures for their relief. 
 
 All the means of relief already detailed under the head of hygiene of 
 the mouth, p. 112, and directed for the restraint of salivation when the 
 gums are mildly touched, should be kept in force, as far as may be, and 
 atropine used in solution under the skin. 
 
 No one remedy perhaps acts as kindly as this. Of the following solu- 
 tion 
 
 3 . Atropue sulph gr. i. 
 
 Aquse i. 
 
 M. 
 
 five minims may be thrown under the skin, the effect upon the pupil 
 watched, and the dose repeated every four to six hours, until the pupils 
 are widely dilated. The effect of this remedy upon the salivary secretion 
 is often very prompt, and the general influence over salivation quite 
 marked. 
 
 Chlorate of potash in solution, in cold tea, about one or two drachms 
 to the pint, with a scruple of carbolic acid, according to the sensitiveness 
 of the swollen mouth, should be constantly used as a mouth-wash, and 
 gradually, as they can be borne, stronger and more astringent washes. 
 To all of these a little carbolic acid should be added, for the mouth and 
 its secretions are most foul and need sweetening greatly. A reasonably 
 good mouth-wash is the following, diluted at first with warm water, should 
 it prove too astringent: 
 
 B. Acid, carbolic gr. x. 
 
 Acid, tannic 3 i. 
 
 Tr. my rrhse 3 i j. 
 
 Potassas chloratis 3 V). 
 
 Mellis 3 ij. 
 
 Aquae menth. pip q. s. ad viij.
 
 128 THE VENEREAL DISEASES. 
 
 Labarraque's solution diluted, or a mild solution of borax or of perman- 
 ganate of potash, may be used as a substitute for the carbolic acid prepa- 
 rations should the latter be offensive, as tbey are to some patients. 
 
 Diarrhoea in these cases may be disregarded, unless it is exceptionally 
 severe. Nourishment must be maintained mainly by milk, eggs, soups, 
 and soft food. 
 
 THE LOCAL TREATMENT OP SYPHILITIC LESIOXS. 
 
 The local treatment of syphilis, although subordinate to the general 
 treatment, is nevertheless of great importance in many cases. This is 
 especially true in regard to mouth lesions, and those occurring about the 
 anus and genitals in either sex. It is often equally important in connec- 
 tion with a general syphilitic eruption, where spots on the face and on 
 the hands must be removed with all possible speed, and in some cases of 
 ulcers which require local as well as general treatment for their prompt 
 removal. 
 
 In connection with a description of the varied local lesions, some of 
 the local measures of treatment most appropriate to them will be alluded 
 to; but, for the sake of avoiding endless repetition, it is well to group 
 under one head all general remarks about the local treatment of the 
 varied lesions of syphilis, only repeating afterward where the treatment 
 is to be emphasized. 
 
 In general, then, it may be said that all the local expressions of syphilis 
 should be treated with respect, not irritated by much handling, by dirt, 
 by allowing the secretions to be retained and to undergo decomposition. 
 Ulcers should be kept clean, discharges of all sorts should be frequently 
 washed away, tobacco prohibited where mouth lesions exist. 
 
 LOCAL MEASURES APPLICABLE TO LESIONS ON THE SKIN". 
 
 The local treatment of chancre is detailed along with the description of 
 the lesion. The early general eruptions require no local treatment other 
 than cleanliness, unless it be for such portions of the eruption as appear 
 upon the face and hands. These portions, therefore, may be treated top- 
 ically while the rest of the eruption is allowed to subside under general 
 medication. 
 
 The best topical applications for all the forms of secondary and inter- 
 mediary syphilis appearing upon the skin are the different preparations 
 of mercury. Most of the tertiary lesions do well also under a local use of 
 the mercurials; but some ulcerative forms seem to thrive better when 
 dressed with iodoform or choral. 
 
 The mercurials, to be effective of good by local application, should be 
 graded in strength so as to stimulate without irritating the surface. Con- 
 sequently there must be a range in the strength of all applications em- 
 ployed, and it is well in a given case to begin with a mild ointment, in- 
 creasing its strength according to its effect. Dry lesions call for more 
 strength in the local application than excoriated surfaces require. 
 
 The preparations from which I have derived the most service are the 
 following : ' 
 
 1 Most of these have appeared in a monograph on the " Tonic Treatment of Syphi- 
 lis," published in 1877, p. 76.
 
 SYPHILIS. 129 
 
 R. Hydrarg. oleat 5 or 10 per cent. 
 
 Or 
 
 R. Hydrarg. chlorid. corrosiv gr. i. v. 
 
 Glycerinae 3 ss. 
 
 Spts. rect., 
 
 Aquae ros aa ss. 
 
 M. 
 Or 
 
 ]J . Hydrarg. chlorid. mitis 3 i. ij. 
 
 Ungt. aquae ros. * i. 
 
 M. 
 Or 
 
 $ . Hydrarg. ammoniat 3 i. ij. 
 
 Ungt. aquae ros i. 
 
 M. 
 Or 
 
 ]J . Hydrarg. oxid. rub 3 ss. ij. 
 
 Ungt. aquae ros i. 
 
 M. 
 Or 
 
 ]J. Ungt. hydrarg. nitratis q. s. 
 
 To be used in the beginning much diluted. 
 
 Or 
 
 3 . Hydrarg. iodid. virid gr. xv. 1. 
 
 Ungt. aquae ros i. 
 
 M. 
 Or 
 
 ]J . Hydrarg. oxid. flav gr. xx. 3 iss. 
 
 Ungt. aquae ros | i. 
 
 M. 
 
 Among these preparations, perhaps the best are the lotion of the bi- 
 chloride, the white precipitate and the citrine ointments. One or the other 
 of them will be found to serve a good purpose in the case of the different 
 cutaneous lesions, dry or moist. The bichloride solution, I think, acts 
 best for dry, scaly patches upon the palms or elsewhere. 
 
 Mucous patches about the angles of the mouth, upon the lips and 
 face, generally do well under the local application of the solution of the 
 bichloride of mercury. If this does not hurry them away, one or two 
 light applications of the acid nitrate of mercury usually leaves nothing 
 to be desired in the way of efficiency. 
 
 When mucous patches occur about the anus, under the foreskin, on 
 the sides of the scrotum, or about the vulva, between the toes, under the 
 breast in the female, in any region where overlying portions of the skin 
 keep the surfaces of the lesions sodden, retain their secretion and encour- 
 age putridity of the moisture as it collects in any of these contingencies, 
 soap and warm water, followed by a mild dilution of Labarraque's solu- 
 tion, of permanganate of potash, or of carbolic acid, are great aids to 
 treatment. 
 
 1 Any other bland excipient may be used. Vaseline is perhaps the best if the oint- 
 ment is to be teptfor any length of time, since it does not become rancid. Ointments 
 made with vaseline, however, are somewhat less active than if another fat is used aa 
 an excipient. 
 9
 
 130 THE VENEREAL DISEASES. 
 
 The lesions must also be kept dry, if possible, either by interposing 
 layers of thin old linen, absorbent cotton, or prepared lint, between the 
 surfaces which lie in contact, or by a plentiful use of some absorbent 
 powder, such as lycopodium, starch, oxide of zinc. A very effective way 
 of treating these lesions is to dust them plentifully and often with pure 
 calomel, or with calomel in varying proportions combined with one of the 
 inert dry powders mentioned above. 
 
 All that is required besides this, even in bad cases, is to touch the sep- 
 arate moist lesions with solutions of nitrate of silver of varying strength, 
 gr. x. 3 j. to the ounce of water ; or lightly with the solid stick of lunar 
 caustic; or, perhaps better still, to use the solution of the bichloride of 
 mercury already recommended for skin lesions. 
 
 Ulcerated lesions upon the integument, due to late syphilis, gener- 
 ally improve under various local mercurial applications. The black and 
 yellow washes of the pharmacopoeia serve a good purpose, as does also 
 a mild solution of the bichloride of mercury, or dusting the surface with 
 calomel. 
 
 Gummatous and serpiginous ulcers sometimes improve under these ap- 
 plications, but sometimes they do not. In such case it is well to try iodo- 
 form in fine powder, or rubbed up into a paste with gylcerine, or dissolved 
 in chloroform, remembering that the chloroform solution is sometimes a 
 painful application. 
 
 A watery solution of chloral hydrate does very well in some old, slug- 
 gish cases, from gr. v. gr. xv. to the ounce of water. 
 
 Ulcers on the leg, if old and chronic, often improve at once upon the 
 use of Martin's rubber bandage, or Fox's rubber tubing, or any other 
 species of strapping, while some phagedenic forms of ulcer ought to be 
 allowed the chance of benefit promised by the continuous submersion 
 system described at p. 43. Chronic syphilitic ulcers with hard edges do 
 well if their edges are scarified and poulticed at first. Ulcers communi- 
 cating with necrosed or carious bone, or with sinuses leading into joints, 
 cannot be expected to get well until the deeper-seated lesions have been 
 overcome. 
 
 LOCAL MEASURES APPLICABLE TO SYPHILITIC LESIOKS UPON THE MUCOUS 
 
 MEMBRAXES. , 
 
 Great cleanliness is the first requisite in treating syphilitic lesions of 
 mucous membranes. The mouth must be subjected to all the rules men- 
 tioned in connection with the hygiene of the mouth (p. 112), and the use 
 of astringent mouth-washes, as well as some of the other measures sug- 
 gested in cases of salivation (p. 126), might be called for. The use of to- 
 bacco must be stopped in the case of mouth lesions; the vagina and vulva 
 should be syringed and washed frequently in the event of lesions in this 
 quarter; constipation must be avoided, and cleanliness enjoined whenever 
 the rectum is threatened with trouble, or becomes the actual seat of 
 lesions. 
 
 Mouth, lesions are the most common and most apt to be protracted. 
 Steaming the throat and mouth, gargles of hot milk, of infusion of flax- 
 seed, of warm tea, with or without a little borax, gr. x. xx. to i., or 
 chlorate of potash, gr. v. xv. to i., have an excellent soothing effect in 
 these cases. A certain amount of chlorate of potash should be swallowed,
 
 SYPHILIS. 131 
 
 that, by returning into the mouth in solution in the saliva, it may keep up 
 a constant, mild, soothing action upon the various lesions. 
 
 One excellent expedient, in cases where mouth lesions are constantly 
 recurring, is to give whatever mercury may be required for general treat- 
 ment in the form of compressed pills of sugar-of-milk and bichloride of 
 mercury. Such pills of varying strength are made by Dunton and by 
 Wyeth. The two-milligramme pill is a good one for general use. These 
 pills are allowed to dissolve slowly in the mouth, the saliva being swal- 
 lowed. In this way the local effect of a solution of corrosive sublimate 
 upon the mouth lesions is obtained at the same time with the carrying out 
 of general treatment. The only objection to this expedient is that the 
 taste of bichloride, while the pill is slowly dissolving in the mouth, is very 
 coppery and offensive to some patients. 
 
 The best local applications to make upon syphilitic mouth lesions are 
 solutions of corrosive chloride of mercury. 
 
 ]J. Hydrarg. chlorid. corrosiv gr. ij. v. 
 
 Spts. rect 3 i. 
 
 M. 
 
 To be painted over the affected surfaces with a soft brush daily; 
 
 Or, the acid nitrate of mercury, pure, in small quantity, touched upon 
 the lesion twice a week; 
 
 Or, applications of the nitrate of silver, or of the nitrate of zinc, solid 
 or in solutions of varying strengths; 
 
 Or, the daily use of a solid lump of pure sulphate of copper, which is 
 to be lightly rubbed over the lesion. 
 
 Mercurial fumigations (p. 124) are of the utmost value in many forms 
 of mouth lesion. 
 
 In cases of pure gummata of the mouth and throat, it is best not to 
 waste time with mercurial local applications, since attention in this way 
 may be diverted from the main Jiope in such cases the unsparing use of 
 the iodide of potassium internally. 
 
 Upon the vulva, vagina, beneath the prepuce, and elsewhere, the same 
 general line of treatment is to be followed as for similar lesions within the 
 mouth cleanliness being perhaps of more value than any other one local 
 method of treatment. Pedunculated condylomata, or other vegetations, 
 may be snipped off, and the base from which they grow cauterized. 
 
 THE IODIDES AND PREPARATIONS OF IODINE. 
 
 Several of the iodides with alkaline bases hold a high rank in the 
 treatment of syphilis, especially of its later symptoms; and justly, for 
 the prompt effect produced upon certain symptoms, especially where the 
 lesion is gummatous, by a free use of the iodides, is often very striking. 
 To be effective, however, the iodides must be used wisely; and it is well 
 known what they can do and when they may be trusted. 
 
 Unfortunately, the popular dislike to mercury is shared by many 
 physicians; and these gentlemen, in looking around for a specific for 
 syphilis which is not mercury, often fall upon the iodides and administer 
 them in different vegetable infusions and tinctures from the very begin- 
 ning of syphilis, praising themselves and calling for the applause of 
 their patients in that they give no mercury. It is better, doubtless, to
 
 132 THE VENEKEAL DISEASES. 
 
 treat early syphilis -with iodide of potassium, than not to treat it at all; 
 but exactly how much better, it is hard to estimate. The iodides have 
 little power in postponing erruptions, or promptly modifying them after 
 they have appeared early in syphilis. They certainly have little or no 
 power in preventing relapse either early or late in the disease. I think 
 that I brought out this point satisfactorily in the paper I have already 
 alluded to, read before the International Congress at Philadelphia, and 
 need not reproduce here the line of argument there followed. The 
 iodides have their place, and a very important place it is; but I think it 
 unfortunate that they are accredited with much curative power over syph- 
 ilis, since this notion naturally leads to their abuse, and tends to bring 
 them into disrepute. 
 
 Whenever the lesion is gummatous, in most of the intermediary and 
 late syphilides, and whenever the proliferative changes of connective tis- 
 sue so common in advanced syphilis in the internal organs are going on, 
 the iodide of potassium is a power, and an enormous power, which may 
 be used to the great advantage of the patient, either alone in very large 
 doses in appropriately selected cases, or in combination with mercury, in 
 more moderate doses, constituting what is known as the mixed treat- 
 ment. 
 
 When, however, the symptoms for which the iodide is used have been 
 fairly and entirely overcome, then the mercurials resume sway, and it is 
 better shortly to drop the iodides, holding them in reserve for other emer- 
 gencies. 
 
 The preparations of iodine most valuable in syphilis are the iodides of 
 potassium and of sodium. The iodides of calcium, starch, and ammonium 
 are also used, and iodine as tincture, simple and compound, and in the 
 shape of iodoform internally. I shall speak of these last first, in order to 
 dispose of them. 
 
 I have been disappointed in obtaining any marked effects from iodo- 
 form internally given in doses of a fraction of a grain up to three grains 
 at a time. I have given a single dose of half a drachm, but without 
 obvious effect, in a case at the Charity Hospital. I cannot, therefore, from 
 personal experience recommend it, or give any special indications for its 
 use. It is spoken well of, however, in some high quarters, used in rather 
 small doses in combating gummatous disease as of the tongue (Hill). 
 
 The tincture of iodine, and the compound tincture in starch-water 
 (forming the fresh iodide of starch), I have used at times with undoubted 
 advantage. It is very dark to look at, and not pleasant to the taste, 
 being flat, rather nauseating than otherwise; but it is, on the whole, bland 
 and rather easily digested, and I certainly have seen decided advantage 
 follow its use in cases where the iodides of potassium or sodium were badly 
 borne by the stomach. I have usually commenced with the tinctures in 
 doses of ten drops in a tablespoonful or more of starch-water, and in- 
 creased up to eighty drops in a claret-glass of the diluting fluid. I am not, 
 however, at all willing to trust to the iodide of starch in an emergency. 
 
 The iodide of ammonium is generally used in combination with other 
 iodides, under the idea advanced by Paget and sustained by Hutchinson, 
 that the carbonate of ammonia given in combination with the iodide of 
 potassium intensified the action of the latter. I have not used the iodide 
 of ammonium alone in large doses. 
 
 The iodides of potassium and of sodium hold the first rank among the 
 preparations of iodine as specifics against syphilitic gummata. Of these 
 the first-named is the more powerful, but it has the disadvantage of be-
 
 133 
 
 ing decidedly more irritating to the stomach than the iodide of sodium. 
 Both of these iodides act alike, and both are of great value in the treat- 
 ment of syphilis. 
 
 These iodides, however, like most other good things in the world, have 
 their own peculiar bad qualities. Perhaps not the least of these is the 
 fact that the drugs are expensive; while, unfortunately, it is necessary to 
 use them in large, often heroic, doses. As a consequence, the iodides are 
 generally much adulterated, especially in the smaller shops; and the poor 
 man, who perhaps needs the drug more than his more wealthy fellow-suf- 
 ferer, often gets in his dose as much bromide as he does iodide of potas- 
 sium. 
 
 The bitter, coppery taste which the iodides produce in the mouth of 
 the patient taking the drug in any considerable quantity, and most offen- 
 sively tasted in the morning upon first awaking, is a drawback in some 
 cases to the free use of the remedy. Occasionally the mouth is made 
 sore by long-continued use of the iodides, the gums get tender and spongy, 
 they swell as in true salivation, and a certain amount of soreness in the 
 teeth is complained of, together with an increased flow of saliva the 
 whole, indeed, forming a sort of spurious salivation. These two lesser 
 evils may be measurably abated: the first, by the use of peppermint in 
 some form, both at the time of taking the dose and upon awaking in 
 the morning; the second, by the use of astringent mouth-washes, diuretics, 
 and such remedies as are generally useful in true salivation. 
 
 Besides these lesser evils sometimes attending the use of the iodides, 
 there are five other serious discomforts which are attached to their em- 
 ployment: acute catarrh, headache, iodism, cutaneous eruptions, and irri- 
 tation of the stomach. 
 
 Acute catarrh, to the extent occasionally of rendering the patient 
 very miserable, sometimes comes on at the very beginning of the use of 
 the iodides. The patient sneezes and coughs, the eyes grow red and 
 watery, the nose runs, and with this sometimes comes an intense pain 
 across the brow, and perhaps severe headache. This symptom, like most 
 of the others due to the iodides, varies in intensity with the strength of 
 the dose. Unlike some of the other symptoms, it often wears off as the 
 iodide is continued in use, or at least the patient gets accustomed to it 
 and complains less. 
 
 The treatment of this catarrh is to keep the skin active by the use of 
 warm baths, to give the patient plenty of bland fluids to drink, and to 
 encourage the action of the kidneys, the proper channels of exit for the 
 iodides. Belladonna internally, in small quantities, has a certain amount 
 of influence in controlling the amount of secretion from the nose and 
 throat. 
 
 The headache produced in some people by the use of the iodides is 
 quite intense. It usually occupies the brow, or the side or the whole top 
 of the head. The headache comes on sometimes after a single dose of 
 the offending drug, and sometimes is so intense that it constitutes a posi- 
 tive bar to the continued use of the remedy. Fortunately, cases of this 
 sort are quite rare. 
 
 The only treatment, so far as I know, able to remedy this condition, is 
 to give a mild diuretic in combination with the iodide, and to add some 
 of the bromide of potassium to the mixture, or even a little opium. Fortu- 
 nately, this idiosyncrasy of having headache when taking the iodides is 
 not always an affair of a lifetime; the patient generally outgrows it in 
 time.
 
 134 THE VENEREAL DISEASES. 
 
 Iodism, properly speaking, includes the headache and catarrh already 
 alluded to; but the main feature in iodism proper is a peculiar and intense 
 nervous depression, with irritability. This occurs in certain individuals 
 when they take the iodides. With this depression there may be more or 
 less ringing in the ears, pain in the bones, etc. 
 
 Iodism is difficult to overcome by treatment; usually all efforts fail. 
 The general means mentioned above for the headache of iodine may also 
 be tried here. 
 
 The cutaneous eruptions produced by the iodides are numerous. 
 Erythema, with considerable scaling of the skin, and acne, with boils 
 about the face, nose, neck, back, shoulders, and buttocks, are not uncom- 
 mon results of their use. Purpura hfemorrhagica is produced by the 
 iodides, especially in debilitated, anaemic persons who have taken the drug 
 for a long time. A peculiar form of pemphigoid eruption occurring in 
 groups, and sometimes called hydroa (Hutchinson), is another of the evil 
 results of the iodides upon the skin of some patients. 
 
 The irritation produced in the stomach, and sometimes in the in- 
 testine by the iodides, especially when used in large doses, is another seri- 
 ously bad quality which they possess. In this way nausea and lack of 
 appetite may be induced, going on, sometimes, to diarrhoea, and leading 
 to anaemia and loss of strength misfortunes which, by so much, go to 
 counteract the good effects produced by the drugs. 
 
 This irritation of the stomach and skin attaches often to an imperfect 
 elimination of the drug by the kidneys. When a patient is under full 
 doses of the iodides, his urine is full of them, as may be demonstrated by 
 pouring a little nitric acid into a test-tube containing some of the urine. 
 The stronger acid attacks the salt and liberates the iodine, which colors 
 the urine, lying above the layer of acid. If the kidneys do not do their 
 duty properly, some of the cutaneous expansions of the body must suffer: 
 it may be the membrane of the nose; it may be the skin of the face or 
 back, or the glands this skin contains; or it may be the stomach. The 
 stomach is also particularly exposed to irritation by direct contact with 
 the medicine. This direct contact the stomach always resents, especially 
 if the drug be presented to it in a concentrated form, when it is empty. 
 
 The natural deduction'from all this is that the kidneys must be kept 
 always active, when the iodides are being administered, by the use of 
 plenty of water and bland fluids on the part of the patient, as well as by 
 diluting the drug largely when it is taken, and giving it always upon a 
 full stomach. If these means do not suffice, the dose of the iodide may 
 be combined with a more active diuretic such as the acetate of potash, 
 or the infusion of digitalis, or both. 
 
 Sometimes, in spite of all precautions, the iodides cannot be taken by 
 the stomach. Under such circumstances I have sometimes succeeded in 
 using the rectum, giving ten and fifteen grain doses of the iodide of so- 
 dium dissolved in an ounce of warm beef-tea. I have tried iodoform in 
 suppository gr. vi. at a dose but have failed to get any good systemic 
 effect from the latter drug. When the stomach fails, the iodide of starch 
 may often be borne, and should have a trial. 
 
 Above all, it must be borne in mind that the iodides should never be 
 given solid (in pill form) when their use in large quantities is required. 
 Small doses in pill form do very well in some cases, as high as gr. v. of 
 the iodide in each pill; but such pills should only be given upon a full 
 stomach, or, perhaps better, taken during the middle of a meal. 
 
 When it becomes absolutely necessary to push the iodides, it should
 
 SYPHILIS. 135 
 
 be done in spite of all obstacles to the contrary. I succeeded, in one such 
 case, in arresting a destructive gummatous ulcer by confining my patient 
 exclusively to boiled milk and rice as food, and giving bismuth inconsid- 
 erable quantities, while the iodide was being pushed. The addition of 
 opium, or anything else to make the drug act, is allowable under these 
 circumstances. 
 
 The dose of the iodides is about five grains, to commence with in an 
 ordinary, ijntried case, where the effect of the drug has never been tested, 
 and when there is no emergency to deal with. This five-grain dose will 
 generally indicate in what way, if at all, the patient is to be uncomfortably 
 affected by the iodides. An occasional pimple of acne on the forehead 
 or temple is generally all that will be seen, with perhaps a little excess of 
 secretion from the mucous membrane of the nose during the first few 
 days of the course. For an ordinary case, where there is no haste and 
 the stomach is to be respected, the dose of the iodide may be pushed by 
 an increase of two and a half grains in the dose each week. By such a 
 gradual increase, with a little care, the stomach need not be injured, the 
 skin is not apt to give much trouble, and the weekly increase in the dose 
 may be suspended when the symptoms have fairly yielded. 
 
 No such caution, however, can be indulged in when an emergency is 
 at hand. When the soft palate is threatened with rapid destruction by a 
 perforating gummy ulcer, when the bones of the nose are crackling under 
 the touch, when the functions of the brain are involved or life threatened, 
 then there is no time for hesitation or delay, and it is not necessary to 
 ask whether the iodide will agree or not. If it does not agree, it must be 
 made to agree a process which may tax the resources, the ingenuity, and 
 the patience of the surgeon to the utmost. Under such circumstances, a 
 dose of ten grains every four hours is a moderate beginning, and in one 
 or two days, according to the surgeon's judgment and the patient's neces- 
 sities, the dose ma}' be increased by five or ten grains, and so on, indefi- 
 nitely, until the symptoms yield or the stomach refuses to receive the 
 drug. 
 
 In such a case the stomach must be managed with all care in the man- 
 ner suggested above, and opium, if need be, bromides, or diuretics, with 
 bland food, judiciously joined to the iodides in such a way that the stom- 
 ach shall have no excuse for rebellion. Limit to the dose there is none: 
 the signal to stop increasing the dose in a desperate case is unconditional 
 surrender on the part of the symptoms. If the diagnosis has been accu- 
 rate and the stomach can be managed, this result will follow as surely as 
 the night follows day. The physician need have no fear, there need be 
 no hesitation. If the stomach holds out, and the drug is boldly and intel- 
 ligently pushed, victory is the one and only result. All minor symptoms 
 of iodism may be disregarded, the eruptive troubles, the catarrh, even the 
 headache and depression of spirits, although these last make some patients 
 desperate, so that they seem rather willing to suffer anything from the 
 disease than to be compelled to continue their medicine. 
 
 The limit to the dose which may be given I do not know. It is cer- 
 tain that more than an ounce of the solid salt has been taken daily by a 
 single patient, and continued a number of days with advantage, and this 
 has been done a number of times in various cases by different physicians. 
 It is rarely necessary, however, even in the most desperate cases, to go 
 higher than three or fotir drachms a day; and such a quantity is better in 
 its results if administered in six than in three doses, always well diluted 
 with water.
 
 136 THE VENEREAL DISEASES. 
 
 When small quantities are to be given for a considerable time, and 
 the stomach has been first tested with a solution to try its temper, the 
 medicine may be given in pill form for the sake of convenience. It is not 
 easy to make good pills out of the iodide of potassium, on account of the 
 tendency they have to become moist by contact with the atmosphere, to 
 stick together and disintegrate. Pills of varied strength up to five grains 
 of the pure iodide of potassium are now found in the shops in the com- 
 pressed form. They bear transportation well if kept in bottles stoppered 
 with a cork. To make up a pill, however, of any strength, a little pep- 
 per, gum tragacanth, and glycerine make excellent excipients. Such a 
 pill when well made grows solid, smooth, and quite hard; but its hardness 
 is no obstacle to its digestion, since the affinity of the iodides for water 
 is very great, and such pills readily break up in the stomach. A fair for- 
 mula is the following : 
 
 $ . Potassiii odidi 3 i j. 
 
 Pulv. pip. nig 3 i. 
 
 Gum tragacanth ) 
 
 Glycerinae j *" ' 
 
 M. Ft. pil. no. xxiv. 
 
 These pills are not unnaturally large, each one contains five grains of 
 the iodide, and they should be taken with or immediately after each meal. 
 In many cases they do not disagree, in others they certainly do. 
 
 A favorite method of giving the iodides is in combination with some 
 bitter vegetable tincture or infusion, which serves the double purpose of 
 masking the peculiarly pungent, bitter taste of the drug, as well as in a 
 measure assisting its digestion. The taste of the iodide may be still further 
 covered up by the addition of ginger, peppermint, or bitter orange, to the 
 solutions in one form or another, and the dose thus made actually agreea- 
 ble. Some ammonia may be added, if thought best, out of respect to the 
 general conviction that the presence of this drug enhances the therapeu- 
 tical activity of the iodide. Such a formula as the following is rarely ob- 
 jected to : 
 
 IJ Potass, iodid 3 i j. 
 
 Ammonias subcarb 3 ss. 
 
 Tr. cinchonas co 3 iv. 
 
 Glycerinae 3 i. 
 
 Syr. aurantii cort iss. 
 
 M. 3 
 S. Teaspoonful largely diluted with water after each meal. 
 
 For convenience of administration, where the dose of iodide is to be 
 constantly and rapidly push'ed, it is well for the patient to have two pre- 
 scriptions: one something like the one given above, and another a satu- 
 rated solution of the iodide of potassium in distilled water: 
 
 $, Potass, iodidi i. 
 
 Aquas destillatae q. s. ad fl. ^ i- 
 
 M. 
 
 Of this solution one minim measured in a minim-glass represents a 
 grain of the iodide of potassium, and it may be very conveniently used,
 
 SYPHILIS. 137 
 
 a teaspoonful of the pleasantly tasting mixture being mingled with 
 water, and as many minims extra of the saturated solution of the iodide 
 being added to each dose as may be required to make the dose of the 
 iodide sufficient, in cases where this is varied a little from day to day. 
 
 It will be noticed in the foregoing prescription that only enough 
 water is ordered to make an ounce of fluid in all. As commonly writ 
 ten, the prescription reads: 
 
 3 . Potassii iodidi f i. 
 
 Aquse destillatas i. 
 
 M. 
 
 Such a formula makes more than an ounce of fluid nearly an ounce 
 and a half, in fact and it takes about seven minims to equal five grains 
 of the iodide of potassium. 
 
 All the remarks thus far made have referred to the iodide of potas- 
 sium, nothing having been said of the iodide of sodium. The potassium 
 compound is the stronger, being just about twice as effective as the so- 
 dium combination. It is therefore to be preferred, and in all cases 
 should be commenced with first. When, after fair trial and reasonable 
 effort, it has become apparent that the potassium iodide is not suitable, 
 and that the stomach will not bear it, then the sodium iodide may be 
 substituted, often with very good effect, since in this, as in many other 
 cases, the soda salt is more comforting to the stomach than the potash 
 salt. All that has been written, therefore, concerning the iodide of 
 potassium is equally applicable to the iodide of sodium for those cases in 
 which the stronger drug is not well borne. 
 
 'MIXED TREATMENT. 
 
 The mixed treatment is a combination of one of the iodides with a 
 mercurial. It is one of the commonest forms of treatment, and one of 
 the most useful, when intelligently directed. It is of no value at the 
 beginning of the disease. The over-zealous young practitioner, in his 
 early efforts to do all he can for his patient, is quite apt to overshoot the 
 mark in trying to obtain for his patient all the good possible out of all 
 kinds of medicine. He frequently gives the mixed treatment (mercury 
 and potash, as he commonly calls it, instead of mercury and iodine, 
 which it more properly is), ordering it as soon as he decides that a given 
 chancre is syphilitic. 
 
 There is no advantage in such a course. Mercury is all-sufficient in 
 the beginning, and anything like polypharmacy is of doubtful wisdom, 
 since the stomach and its integrity constitute the sheet-anchor of the 
 syphilitic patient in the long run. He may have much medication to 
 endure, and it is well to spare him in the beginning. Many stomachs 
 submit to the prolonged use of the iodides without a murmur, for years; 
 but there are others which gradually fail in digestive capacity, and reduce 
 the patient to a condition of anaemia, with great general nervous irrita- 
 bility and prostration, and that, too, without giving rise to any marked 
 active evidences of dyspepsia. The iodides, long continued, are fully as 
 apt, or more apt, I think, to do harm than the mercurials. It may be- 
 come necessary, during a prolonged and obstinate attack of syphilis, to
 
 138 THE VENEREAL DISEASES. 
 
 use not only the mercurials for a long 1 time, but the iodides also; and 
 when it becomes necessary, let it be done. But this is not an excuse for 
 using the iodides out of place, or calling upon the stomach for extra 
 work where it is not required. 
 
 The mixed treatment is appropriate in all the slower, more chronic 
 symptoms of the intermediary and late stages of syphilis. The basis of 
 the treatment is an appropriate iodide, either of sodium or of potassium, 
 as the case may be, and with it a mercurial. The treatment may be 
 effectually carried out by giving a suitable dose of the iodide, as directed 
 in the last section, and adding the mercury by fumigation, inunction, or 
 separately in pill. It is a little more appropriate, however, and perhaps 
 more accurate in dosage when giving the mixed treatment, to mix the 
 drugs themselves in the same pill or potion. The best drug to mix 
 with the iodides is the biniodide of mercury. Most other forms decom- 
 pose, and the resulting compound is an uncertain amount of biniodide of 
 mercury with an equally uncertain quantity of the other mercurial, how- 
 ever much there may be which has escaped decomposition. 
 
 The biniodide of mercury, therefore, may be added to any of the pills 
 or fluids already referred to in the section on the iodides, in a dose vary- 
 ing from one-thirtieth up to a tenth of a grain. The new ingredient in 
 the combination will make no difference in its form or taste, but often 
 makes a great difference in its effect upon the patient. 
 
 Some of the compressed pills found in the market are made so as to 
 represent the mixed treatment, containing varied proportions of the 
 iodide of potassium and the biniodide of mercury. 
 
 In using the mixed treatment, it is often desirable to continue the 
 mercury at a given rate while the iodide is steadily pushed. This con- 
 stitutes what is called mixed treatment with iodides in excess, an expres- 
 sion which will be found to occur several times in this book when speak- 
 ing of the treatment appropriate to some of the various lesions. Such a 
 treatment may be conveniently carried out by adopting a certain fixed 
 formula for the mixed treatment, preferably one which shall not be dis- 
 tasteful to the patient, and furnishing him besides this with a minim- 
 glass, and a saturated solution of the iodide of sodium, or potassium, as 
 the case may be. In this way the dose may be easily regulated to suit 
 any emergency. 
 
 I find the following to be an excellent standard to use as a base of 
 operations: 
 
 R. Hydrarg. biniodidi gr. ss. i. 
 
 Potassii iodidi 3 ij. 
 
 Ammonii iodidi 3 ss. 
 
 Syr. aurantii corticis ij. 
 
 Tr. aurantii corticis 3 j. 
 
 Aquae destillatae q. s. ad iv. 
 
 M. 
 S. Teaspoonful well diluted in water after each meal. 
 
 When to cease giving the iodides is a question of importance. 
 They are useful, most useful, against certain symptoms in syphilis, but 
 they cannot claim power to prevent relapse. Therefore we" should use 
 them, and vigorously too, against those symptoms which they control, 
 but should not depend upon them for any more work after the symptoms
 
 SYPHILIS. 139 
 
 have yielded. The main difficulty in the case is, therefore, how to tell 
 when the symptoms in question are thoroughly controlled. A gumma- 
 tous infiltrated patch may gradually melt away under the bold use of the 
 iodides, and seem to be entirely gone; yet, if the iodides be discontinued 
 too soon, this patch will relapse in many cases. How can it be, then, that 
 the iodides do not prevent relapse ? 
 
 I think that the answer to this question may be found by analogy in 
 the study of other infiltrations. Gummatous processes are infiltrations, 
 and the tertiary connective-tissue proliferations, the parenchymatous hy- 
 pertrophy of organs, is an analogous change. These diseased conditions 
 of the tissues extend farther than is evident to the naked eye. In the 
 same way cancerous infiltrations and epitheliomatous nodules far outreach 
 their limits as apparent to ordinary inspection. An epithelioma may be 
 burned upon the surface, and the nodule apparently destroyed so much, 
 indeed, that a thin, unhealthy scar may form over the spot; yet the mor- 
 bid tissue, although apparently all gone, often remains in the outlying tis- 
 sues, and in such a case local relapse is inevitable. The same is true of 
 lupus, and the effect of local applications upon it; and of carcinoma, and 
 the cutting operations to which it is subjected. 
 
 In the same way with syphilitic infiltrations: the remedy which removes 
 them, the iodic preparations, must be long and patiently continued after 
 the local trouble is apparently under control, or local relapse is certain. 
 It is customary, therefore, to continue the mixed treatment for months 
 after all evident need for the iodides has passed, and then gradually to 
 drop the iodides and resume the mercurial at the tonic dose. Eventually 
 the mercury itself may be gradually dropped after a number of months, 
 differing in varying cases, according to the judgment of the physician. 
 
 In some cases of old syphilis, especially the nervous forms, where the 
 iodides have been long given in large doses, the symptoms may, after a 
 time, fail to yield to the drug, while the patient gradually grows thin, 
 nervous in the ordinary sense of the term, tremulous perhaps in his move- 
 ments, unable to sleep, to digest food, to perform mental work. I have 
 treated one such case, where the patient finally became unable even to 
 sign his name so that the writing would not be questioned, while yet 
 some of the symptoms of nervous syphilis were still upon him. 
 
 In such a case, specific treatment, so called, loses its value. The pa- 
 tient I allude to above got perfectly well by dropping his specifics entire- 
 ly, taking the hypophosphites, giving up work, and going to the country 
 for several months. He became well, and has remained so for the past 
 two years, although just before leaving off his treatment he had had gum- 
 matous deposit within the orbit, with paralysis of the internal rectus. 
 Another patient, totally incapacitated for work by a prolonged treatment 
 with the iodides, on account of serious syphilitic cerebral symptoms, re- 
 covered entirely upon leaving off all medication, and going to the dry cure 
 in Lindeweisse, in Austrian Silesia, for six weeks. 
 
 Such patients sometimes get well under the homoeopathic cure (i. e., 
 without medicine), or by syphilization, or by going to one mineral spring 
 or another, or (quite often) in water-cure establishments. These patients 
 are very appropriate for a course at the hot springs. 
 
 The main difficulty in the case of patients of this sort is to determine 
 just at what time they may safely give up the use of the iodides. They 
 are a source of great solicitude to the physician in charge, and his best 
 judgment is seriously taxed in their management. 
 
 For these cases, tonics, change of residence, freedom from annoyance
 
 140 THE VENEREAL DISEASES. 
 
 and from mental work or worry, are essential; and a course at some of 
 the hot mineral springs, or at a water-cure establishment, is often of the 
 greatest value. 
 
 ZITTMAN'S DECOCTION. 
 
 In terminating the general remarks upon the routine treatment of 
 syphilis, something must be said about Zittman's decoction. This remedy 
 has long held a respectable place in the minds of the profession, and the 
 formula by which it is prepared, in a stronger and a weaker decoction, 
 retains its place in the dispensatories. It is a remedy of undoubted value 
 in many conditions of late syphilis attended by cachexia, loss of appetite, 
 anaemia, and irritable stomach, especially when the iodides disagree. Its 
 action is probably largely dependent upon the laxative influence of the 
 senna which it contains, and upon the general combination which makes 
 the mercury in it acceptable to the stomach. 
 
 There have always existed two great drawbacks to its general use: (1) 
 it is difficult to prepare, containing a host of ingredients which must be 
 so concocted that much time is consumed in their proper preparation; 
 and (2) its use according to the rules formerly laid down is too irksome 
 to be endured by most patients, while the quantities necessary to produce 
 any effect (a pint and more a day) cannot be conveniently mastered by 
 many patients with delicate stomachs. Then, also, the rules about prepara- 
 tory purgation, rest in bed, hot water with one decoction at one time in 
 the day, and cold water with another decoction at another time of day, 
 smack really more of the wizzard than of the sage, and tend to bring the 
 remedy into disrepute with honest-minded persons, lay as well as profes- 
 sional. 
 
 The truth is probably that judicious purgation, with a light tonic 
 purge containing a mercurial, and that too in fair dose, is what does the 
 good. In McDonnell's lectures on surgery in 1871, l I noticed a modified 
 Zittman's decoction which did away with much of the apparent nonsense 
 of the older preparation. This I used for a time, but, finding even this 
 too clumsy, with its larger and smaller dose, and cold and hot water, I 
 have reduced it to a single combination, from which in many cases I have 
 derived great advantage. I generally order a teaspoonful as a dose, to 
 be taken as it is without water, three or four times daily, regulating the 
 quantity by the purgative effect. The following is the formula I employ : 
 
 IJ. Hydrarg. chlorid. corrosiv gr. i. 
 
 Aluminis 3 ss. 
 
 Extr. sarsse fl. ij. 
 
 Glycerinae i. 
 
 Syr. sennae | iss. 
 
 Spts. anis 3 i. 
 
 Extr. glycyrrhizae 3 i. 
 
 Aquae foeniculi q. s. ad viij. 
 
 M. 
 
 S. Tablespoonful at a dose. 
 In my hands it has answered as well as the original formula. 
 
 1 Page 114.
 
 SYPHILIS. 141 
 
 Lockwood, in the London Lancet, 1879, gives two cases illustrating 
 the good effect upon obstinate syphilis, of injecting one-sixth of a grain 
 of nitrate of pilocarpin under the skin every other day, in combination (in 
 the worst case) with a continuance of mercurial treatment, which until 
 then had not been effective. Piffard, of New York, has suggested the 
 same idea. 
 
 The treatment of inherited syphilis, and of syphilitic women during 
 pregnancy, will be given under their own sections.
 
 CHAPTER VIII. 
 
 SYPHILIS OF THE SKIN. 
 
 Special Characters of the Syphilides : Polymorphism, Color, Form, Absence of S ab- 
 jective Symptoms. Characters of Scabs, Ulcers, Cicatrices in Sj'philis. The 
 Syphilides : Erythematous, Papular, Pustular. Ecthymatous, Pigmentary, Vesic- 
 ular, Squamous (Circinate, Palmar and Plantar), Tubercular (General, in Groups). 
 Tertiary Syphilides. Rupia. Tertiary Pustular Syphilide. Ecthyma. Pustu- 
 lar Syphilide in Groups. Tertiary Syphilitic Ulceration. Gumma of the Skin. 
 
 SYPHILIS appeals to the public and to the patient most strongly through 
 its effects upon the skin. The temporary or possible permanent disfig- 
 urement caused by it upon the outside envelope is what lends it most of 
 its horror in the mind of the ordinary patient. The more serious affec- 
 tions occurring later have no terrors for those who ignore their existence; 
 and generally the patient, once free from his symptoms of the skin and 
 mucous membranes, considers himself well, and, often to his cost, stops 
 his medical treatment under the idea that his malady has ceased to exist. 
 
 The symptoms upon the skin and mucous membranes have also given 
 the physician his best field for studying syphilis; and since the dermatol- 
 ogist has brought his powers to bear upon a study of the numerous le- 
 sions of the skin produced by syphilis, much peculiarity has been found 
 to exist in all the lesions due to the disease, and much distinctiveness in 
 form, color, grouping, etc., so that the class of eruptions produced upon 
 the skin by syphilis, and known as syphilides (Biett), has come to be quite 
 well known. The syphilides are generally capable of being diagnosti- 
 cated by the aid of simple inspection. A good clinical student of syph- 
 ilis can usually do this without asking a single question or touching the 
 patient; and although it is not wise to jump at a diagnosis, yet the fact 
 that it is possible to do this makes it at once evident that all the eruptions 
 due to syphilis must be possessed of some very marked characters, capa- 
 ble of easy detection and distinguishing them from other eruptions. This 
 is the case, and before going into the detail of description of the different 
 eruptions it will be well to consider the general characters which are 
 shared by them in common. 
 
 Certain effects are produced upon the skin by syphilis which are not 
 at all peculiar to the disease, but may be just as well produced by other 
 causes, and these effects naturally do not share in the general peculiari- 
 ties belonging to lesions due exclusively to the effect of the syphilitic 
 virus. The changes in the skin referred to are the sallowness, the branny 
 condition, the lack of lustre in early syphilis, the flabbiness in cachexia, 
 the general tawny hue often seen in the same stage, the seborrhrea, the 
 dryness none of these features found upon a syphilitic patient differ 
 materially from the same conditions when encountered upon a patient 
 rendered ill by the action of some other debilitating cause. They, there-
 
 SYPHILIS OF THE SKIN. 143 
 
 fore, are not peculiar, are not to be diagnosticated by inspection indeed, 
 are not syphilitic, except in that they have become so by accident. 
 
 The peculiar characters of syphilitic lesions of the integument those 
 which they possess collectively as a group of affections maybe best stud- 
 ied by examining them in detail. They are polymorphism, color, form, 
 and the absence of subjective symptoms in connection with them; the 
 grouping of the lesions, the characters of the scabs and ulcers, arid the 
 appearance and behavior of the cicatrices. 
 
 Polymorphism is quite a distinctive feature in the early syphilitic 
 exanthemata. Generally, it is supposed that a cutaneous eruption will 
 be uniform in the type of its lesion. It is expected to be purely erythema- 
 tous, going on to the formation of scales (roseola autumnalis), or pustular 
 preceding scabs (impetigo), or vesicular terminating in an oozing surface 
 (eczema); but this does not hold fora syphilitic exanthem. The evolution 
 of the syphilitic eruption is in successive crops of lesions, and some of these 
 go on to a fuller development than others; therefore, in one and the same 
 syphilitic eruption, at almost any period in its course, it is often possible 
 to find the most varied lesions associated side by side: the macule, the 
 papule, the vesicle, the pustule, the scale, and the pigment spot. 
 
 Polymorphism does occur in other cutaneous diseases, but it is so con- 
 stant in the syphilitic exanthemata as to be worthy of special remark. 
 The same morbid spot upon the skin, in going through its evolution, assumes 
 the form of several lesions; but, in the general eruption, there is always 
 an excess of one lesion or another, and this type lesion names the erup- 
 tion, causing it to be called after its name (papular, pustular, vesicular, 
 etc., syphilide). 
 
 Color. The color of syphilitic eruptions is peculiar. The earlier and 
 more acute eruptions are pink and red, a color much like that seen in 
 ordinary inflammatory states. As the freshness dies out of these erup- 
 tions, however, they assume the syphilitic tint, and, in some instances, 
 they possess it from the start. This tint is simply a certain lividity min- 
 gled with red. It has been called by many names, but that which suits 
 it best is the raw ham color. Swediaur's term, copper color, has taken a 
 greater hold upon the profession, but is less accurate in expressing the 
 tint of syphilitic lesions in their period of activity. The copper color is 
 found to perfection in many of the lesions after they become pigmented, 
 and it often remains for a long time in scars left by lesions, and in the 
 areolar border of the latter. 
 
 The color is not due to the syphilitic poison, but to the subacute, or 
 indeed, chronic quality of the inflammatory process which produces and 
 attends the lesions. The superficial vessels become dilated, and continue 
 so over circumscribed areas for a considerable period. A certain number 
 of red blood-cells wander out into the tissues through the walls of these 
 vessels, and these cells, while passing through the changes which precede 
 their absorption, give up their coloring matter, which becomes modified, 
 and the pigment deposits and shows through. 
 
 This congestion and small amount of pigment makes the raw ham 
 color. It is rarely absent in any of the syphilides. As the congestion 
 goes down and the vessels return to their natural size, the pigment be- 
 comes more obvious, and then the copper color appears. Finally, nothing 
 is left but pigment in greater or less quantity, and the color may be that 
 of bronze. 
 
 These shades of color are found exactly copied in some forms of psoria- 
 sis, in certain chronic eruptions on the skins of gouty people, in eruptions
 
 144 THE VENEREAL DISEASES. 
 
 on the legs of many persons neither gouty nor syphilitic, in many cachec- 
 tic conditions, and upon certain dark skins with almost any eruption. 
 On the other hand, fair skins sometimes show little of the ham color in 
 their syphilitic eruptions, and none of the copper color or subsequent pig- 
 mentation of scars. 
 
 Hence, it becomes evident that there is nothing specific either in color 
 or in pigment; yet, the peculiarities of color and of pigment are so uni- 
 form, and so well marked in most cases, that they constitute a feature 
 which should be always looked for in eruptions of suspected syphilitic 
 origin, and to which considerable importance may justly be attached. 
 The pigmentation remaining behind after syphilitic lesions is not perma- 
 nent. It clears away promptly in light cases, more slowly in others. It 
 remains longest on the lower extremities. It clears up from the centre 
 peripherally, leaving any cicatricial tissue which it may have involved 
 more white than the surrounding skin. Occasionally, especially around 
 a cicatrix in the lower extremity, it remains permanently. 
 
 Form of the lesions and their distribution. The earlier erup- 
 tions are generalized more or less over the whole body, each separate le- 
 sion showing a tendency to assume the rounded form. Later, the lesions 
 tend to cluster into circles, and segments of circles, and to be symmetri- 
 cal in their distribution. The latest lesions show little or no tendency to 
 symmetry, but preserve in a marked degree the rounded form. Gumma- 
 tous ulcers are often composed of the confluence of several gummata, and 
 the borders of the ulcer consequently are made up of segments of large 
 circles. 
 
 Absence of subjective symptoms is a marked feature of syphilitic 
 eruptions. In nearly every case, and in nearly every class of eruption, 
 from the macule to the most extensive ulcer, there is customarily an entire 
 absence of any itching or pain. This rule, like all others in syphilis, has 
 its exceptions. An acute outbreak of an early syphilide commonly occa- 
 sions a little tingling, but rarely any itching. Ulcers, if connected with 
 bone, or upon the lower extremities, often pain considerably, sometimes 
 excessively. On the other hand, the scrofulides, and many gouty erup- 
 tions, with most of the forms of lupus, are equally devoid of subjective 
 symptoms, so that these peculiarities of syphilitic eruptions cannot be con- 
 sidered to be pathognomonic. Nevertheless, the conspicuous absence of 
 itching and pain is a feature of great diagnostic value in connection with 
 the syphilides. 
 
 The possibility of the coexistence of an irritable skin and some pruri- 
 tic condition, not syphilitic, in connection with a syphilide, must be re- 
 membered, together with the fact that more or less itching is quite apt to 
 accompany any eruption upon the scalp, of whatever nature. Even ordi- 
 nary acne of the scalp itches sometimes. 
 
 The scabs and ulcers of syphilitic lesions have some peculiarities. 
 The scabs are apt to be thick, rough upon the surface, set into the skin 
 at their edges, and adherent, unless undermined with pus, as in rupia. 
 There is generally also a marked greenish tint in the scabs, whether the 
 latter are dark or light colored. This green tint is often due to the ad- 
 mixture of a certain amount of blood with the pus forming the scab. The 
 ulcers of syphilis resemble chancroidal ulcers. Their borders are some- 
 times undermined, but generally adherent. The floor is pale, uneven, 
 more or less pultaceous, the discharge purulent. The edges are abrupt, 
 perpendicular. The base may be either hard or soft. 
 
 The cicatrices of syphilitic lesions are quite uniform in their charac-
 
 SYPHILIS OF THE SKIN. 145 
 
 ters. They are round, depressed, smooth, thin, and not adherent, unless 
 lying over bone. They are dark at first, from the pigment they contain ; 
 and as this clears off centrally, the scar grows white and shining, its white- 
 ness intensified, and set off by the dark frame of pigment which lingers 
 as an areola about the circumference of the cicatrix. The cicatrices of 
 ulcers upon scrofulous patients, and of rupial ulcers on all patients, are apt 
 to be puckered, drawn, bridled, thickened in parts, and adherent, like the 
 scars of scrofulides. 
 
 THE SYPHILIDES. 
 
 The eruptions found upon the skin in secondary and intermediary 
 (late secondary) syphilis are seven. The last three occupy the border- 
 line, and may, any of them, be found long after the patient has suffered 
 from well-marked tertiary gummatous lesions of bone, or of the other tis- 
 sues. These three occur also just as well entirely within the secondary 
 period, and are best classed along with secondary lesions, since they re- 
 quire mercury in their treatment generally much more than they do 
 iodine. These seven eruptions are named according to the prominent le- 
 sion which characterizes them. They are : 
 
 1. The erythematous syphilide (roseola). 
 
 2. The papular syphilide. 
 
 3. The pustular syphilide. 
 
 4. The pigmentary syphilide. 
 
 5. The vesicular syphilide. 
 
 6. The squamous syphilide. 
 
 7. The tubercular syphilide. 
 
 The lesions belonging to the tertiary period, all of which are prone 
 to run on to ulceration, to destroy tissue, and leave scars, are three in 
 number : 
 
 1. The pustulo-bulbous syphilide (rupia). 
 
 2. Pustular syphilide : \ ?' th infiltrated base (ecthyma). 
 
 ( 0, in groups. 
 
 ( a, as infiltration : -j J' non-nloenttive. 
 
 3. Gumma : -j (2, ulcerative. 
 
 ( b, tumor. 
 
 In connection with all of these occur lesions on the mucous membranes, 
 which will be considered in their proper place, and varied general symp- 
 toms : glandular engorgement, fever, alopecia, etc., some of which have 
 already been considered. No one patient can well have all the syphilides, 
 but he may have a number of them successively. 
 
 THE ERYTHEMATOUS SYPHILIDE. 
 
 This is the most common and the earliest of the general syphilides. 
 It may come on within the month after the appearance of chancre ; gener- 
 ally it dates at six weeks or two months, sometimes later, especially if de- 
 layed by treatment. It first appears upon the lower part of the thorax in 
 front, and at the sides, over the belly, and in the flanks. To see it at the 
 10
 
 146 THE VENEREAL DISEASES. 
 
 commencement, it is sometimes necessary to let the light fall sideways upon 
 the skin, freshly exposed to the cool air by lifting the shirt. A roseola 
 detected in this manner, of course, could not be pronounced upon as being 
 certainly syphilitic ; but, by examining a patient in this way, often the 
 very commencement of the eruption may be detected some time before it 
 otherwise would have been found out. A very hot bath will frequently 
 develop it several days before its natural date of outbreak. A sulphur- 
 bath is particularly effective to this end. Patients do not feel the erup- 
 tion, since it does not itch, and generally are unconscious of its existence 
 until the physician points it out to them, unless they have been closely 
 on the lookout for it, in which case they generally mistake the natural 
 marbling of the skin, due to exposure to cool air, for roseola, and get 
 frightened before their time. 
 
 The eruption comes out as a series of rounded macules, varying in di- 
 ameter from one-eighth to half an inch, at first red, then tawny, then pig- 
 mented. At first the patches are flat, then they often become covered 
 with minute papular elevations, and sometimes some of these papules go 
 on to vesiculation, occasionally even to mild pustulation (although this is 
 exceptional). The patch, therefore, is flat or raised, as the case may be. 
 At first, pressure of the finger causes the mottling entirely to disappear; 
 later, a slight, livid staining remains behind after the removal of pressure; 
 finally, when the spot is fading, and has become slightly coppery from 
 pigment, pressure has no more effect upon it. 
 
 The spots are never confluent healthy skin always exists between the 
 macules; but upon this skin there maybe found a few other lesions some- 
 times, such as a papule or a pustule. 
 
 The hands and face, where the skin is tougher, often escape the erup- 
 tion entirely. 
 
 The lesion is due (Biesiadecki) to capillary dilatation, escape of blood- 
 cells and their accumulation along the vessels, and a growth of nuclei in 
 the walls of the latter. 
 
 The duration of roseola is from a few days to six or eight weeks. It 
 may relapse. An annular variety of large patches in groups, tending to 
 run into the scaly form, is found occasionally at the end of the first year 
 of syphilis. It runs a slower course than the roseola, occurring soon after 
 chancre. If treatment (mercurial) has been commenced before the ap- 
 pearance of the eruption, its outbreak is postponed, and it may consist 
 merely of a few scattered macules upon the trunk, requiring some dili- 
 gence to find them. 
 
 The diagnosis of roseola due to syphilis is easy. The erythematous 
 eruptions due to arsenic, bromine, mercury, belladonna, quinine, have dif- 
 ferent situations and groupings, and are attended either by internal fever 
 or local itching. Copaibal ervthema itches badly. Roseola autumnalis is 
 attended by fever, and measles by its pathognomonic prodromata. The 
 glandular, epitrochlear, and post-cervical engorgement, the existence of 
 chancre and the throat symptoms (erythema and mucous patches), to- 
 gether with the scabs in the hair, the night pains, and the syphilitic fever, 
 if present, make syphilitic roseola one of the easiest to diagnosticate of 
 all the lesions due to syphilis. 
 
 Treatment is the general treatment of secondary syphilis by mercu- 
 ry, p. 117.
 
 SYPHILIS OF THE SKIN. 
 
 147 
 
 THE PAPULAR SYPHILIDE. 
 
 This eruption may be combined with a roseola, or follow the latter; or 
 it may appear as the first syphilitic affection upon the skin after chancre. 
 Its date of appearance is therefore about the same as that of roseola. The 
 papules vary in size, from a minute acuminated papule, such as is seen 
 upon the macules of roseola, to a broad, flat papule as large as a dime. 
 A common form is the flat, lenticular papule, of about the size of a large 
 split-pea. These papules are scattered about, not grouped, occupy the 
 flanks, the trunk, the extremities, and 
 very often the face. Fig. 2, from 
 plate 101 of Fox's photographic se- 
 ries, shows the generalized distribution 
 of the eruption. 
 
 The characteristic flat papule, which 
 is the most common form, commences 
 small, and grows in all directions ex- 
 cept in height. It is hard and smooth 
 upon its surface at first, later it is 
 sometimes slightly depressed centrally. 
 It is pink or red at the commence- 
 ment, but very soon takes on the syph- 
 ilitic livid tint. It sheds its epithelium 
 on top, or the latter dries down quite 
 early and cracks around the circum- 
 ference of the papule. The broken, 
 rough edge of the thickened epidermis 
 then curls away, like a dirty lace collar, 
 from the base of the flattened papule, 
 giving the lesion a very characteristic 
 appearance. The papules gradually 
 sink away, leaving pigmented spots, 
 but no scars. They come out succes- 
 sively, and may be found in different 
 stages of development upon different 
 parts of the skin. 
 
 On the palm of the hand the pap- 
 ules seem to abort, on account of the 
 thickness of the scarfskin. A thick- 
 ening of the scarfskin seems to take 
 place, of the size of a papule. Then 
 the epithelium gets yellow and dry, 
 cracks, and drops out, leaving a clean- 
 cut, punched-out circle in. the palm, of 
 the size of a split-pea, with a pink, 
 soft, dry floor, covered with thin epithelium, and an undermined, whit- 
 ened border of thick, raised epithelium, surrounded often by a red areola. 
 This is the syphilide cornee of Hardy. These spots often get well with- 
 out spreading. They differ from the scaly syphilide of the palm, which 
 usually occurs later in the disease. Sometimes, however, these spots are 
 attended by fissuring and undermining of the epidermis laterally, and 
 several spots may coalesce. This is not the rule, but exceptional. 
 
 There is a large, flat form of papular syphilide sometimes encountered
 
 148 THE VENEREAL DISEASES. 
 
 upon the body, but most apt to be found upon the face and scalp. The 
 papules are as large as the finger or thumb-nail. In the scalp they itch. 
 They are of a pale pink color, desquamate readily. Around their edge 
 the epidermis gets raised by a slight effusion of serum, while the adhe- 
 rent cuticle, bound down centrally in the large lesion, gives the whole an 
 appearance of umbilication which is characteristic, and not found, so far 
 as I am aware, in a lesion due to any other cause than syphilis. 
 
 A flat, livid papule, sometimes excoriated, sometimes dry, is occasion- 
 ally found indifferently situated upon the skin. 
 
 When papules lie in creases in the skin, so that they are constantly 
 covered by other portions of integument (under the breast in the female, 
 in the groin in fat persons), and are thus kept warm and subject to fric- 
 tion, they are apt to become very large and flat. They sometimes run 
 together into patches, and become moist on the surface. They may be- 
 come exuberant and granulate. Under these circumstances, the papule 
 becomes the mucous patch of the skin the flat condyloma. They are 
 common about the anus, the scrotum, the labia. The gray pellicle upon 
 the surface of these lesions recalls the typical mucous patch of the mucous 
 membranes very exactly; and the rank, offensive odor of their discharges, 
 when retained, about the anus, genitals, groins, under the breast, or be- 
 tween the toes, has something characteristic about it, which is almost as 
 distinctive as is the smell of small-pox. The true mucous patch of mu- 
 cous membranes is indeed a papule, and the papule on the skin is custom- 
 arily associated with the mucous patch upon the mucous membranes. 
 
 Just as mucous patches upon mucous membranes may ulcerate, the 
 ulcer eat into the substance of the tissue bearing it, and a scar result, so 
 may it happen to a moist condyloma of the skin; and the ulcer, once 
 started, may spread far beyond the limits of the original lesion. This, 
 however, is not a common occurrence. It is more apt to happen to mu- 
 cous tubercles about the throat, the anus, or the genitals, than elsewhere. 
 
 Dry papules of the skin sometimes run together and scab over, their 
 surface being somewhat warty and covered with crusts. This condition is 
 best seen in the furrows bordering the upper lip, and in the moustache 
 about the nose. Occasionally large patches of papules run together and 
 vegetate, resulting in a raised raw surface, which finally scabs over and 
 eventually scales. 
 
 The secretions from moist papules on the skin are contagious, and, on 
 account of their widespread distribution, these papules are more danger- 
 ous than even the primary lesion of syphilis. The discharge is also auto- 
 inoculable, especially if the surface of the papule be irritated and made 
 to discharge pus. Under such circumstances auto-inoculation may pro- 
 duce an ulcer resembling chancroid. Spontaneous auto-inoculation of a 
 moist syphilitic papule produces another moist syphilitic papule. This is 
 frequently seen clinically. 
 
 The papules in the syphilitic negro are generally hyper-pigmented on 
 their summits or around the base. Taylor 1 has reported (Fig. 3, after 
 104, Fox) two cases in the negro, showing the white color produced in 
 some cases by the scales upon the papules during desquamation. 
 
 The duration of the papular syphilide is very variable. It may 
 come out as the first eruption, either alone or mixed with the roseola, 
 and continue for a period varying from a few weeks to many months. 
 When apparently getting well, it sometimes suddenly relapses without 
 
 'Am. Jour, of Syph. and Derm., Vol. IV., No. IL, p. 107.
 
 SYPHILIS OF THE SKIN. 
 
 149 
 
 apparent cause. The lesions on the palms and soles, especially if they 
 run together into patches, are particularly obstinate. 
 
 Treatment greatly affects the duration of all forms of papular syphi- 
 lide. Local treatment is often especially valuable (p. 128), particularly 
 for papular lesions upon the cheeks or forehead (corona veneris) situa- 
 tions very apt to be occupied by papules, which seem to run an especially 
 slow course in these localities. Local treatment, 
 properly adapted to the lesion, certainly modifies 
 all forms of syphilitic eruption. 
 
 Syphilitic papules, unless they ulcerate, leave 
 no scars. They frequently leave pigmented areas 
 behind, marking the site of the lesion. The 
 pigment slowly disappears with time, sometimes 
 centrifugally leaving a pigmented margin, which 
 may persist long after the centre has become 
 whiter than the surrounding skin. The color is 
 most apt to be marked in dark-skinned persons 
 upon the naturally pigmented skin about the 
 anus and genitals. 
 
 The | diagnosis of papular syphilide is very 
 easy in typical cases, especially if the eruption 
 is copious, and other concomitant signs of early 
 syphilis are present. 
 
 Difficulties may arise, however, when there 
 are only a few papules. A few acuminated pap- 
 ules can with difficulty, if at all be distinguish- 
 ed from indolent papules of acne, found after 
 middle life in gouty people of dark complexion. 
 The pigmented area surrounding the site of a 
 papule which has run its course is suggestive, but 
 not pathognomonic, of syphilis. In some cases 
 the result of treatment alone will justify a diag- 
 nosis. A mixed treatment cures the late scattered 
 syphilitic papule in every case where the stomach 
 is in a fair state, while the acne upon a rheuma- 
 tic, gouty patient is not at all favorably influenced 
 by such a course. 
 
 Flat papules, when occurring in an isolated 
 way, late in syphilis, are also indistinguishable 
 from similar isolated accidental lesions, due to in- 
 different causes, upon rheumatic subjects. Treat- 
 ment here again becomes the most valuable aid to 
 diagnosis, or better still, observation, since iso- 
 lated syphilitic papules do not reproduce themselves indefinitely, while upon 
 certain gouty subjects they recur from time to time with reasonable regu- 
 larity. 
 
 Lichen plamis, of all eruptions, is with the most difficulty differen- 
 tiated from a papular syphilide. The color is identical, and many other 
 features are the same. The most positive distinguishing marks are the 
 umbilication of many of the solid papules of lichen planus, their wide dif- 
 ference in size, their very marked tendency to run into patches, and their 
 tendency to arrange themselves in lines with healthy skin between the 
 different lesions rather than in circles, as is the case in syphilitic disease. 
 Moreover, with lichen planus there are no concomitant symptoms of syphi-
 
 150 
 
 THE VENEREAL DISEASES. 
 
 lis found in the lymphatic glands or on the mucous membranes, which 
 could hardly be the case in an eruption of syphilitic papules of like inten- 
 sity. The palms and soles are much more apt 
 to be spared in lichen planus than in a syph- 
 ilitic papular eruption. 
 
 The flat -raised papule (condyloma lata) 
 generally accompanies other syphilitic lesions, 
 and is relatively easy of diagnosis. When 
 seen alone about the anus, as in Fig. 4 (after 
 29, Fox), a doubt sometimes arises as to 
 whether the lesions may not be the ordinary 
 vegetations, the so-called venereal warts, which 
 are apt to be found in connection with gonor- 
 rhreal, leucorrhceal, and other discharges in- 
 deed, complicating all manner of unclean- 
 ness. 
 
 The venereal wart is more uneven on the 
 surface than the condyloma lata, more split 
 up and segmented into pointed papillae, like 
 the ordinary "seed wart." A large cluster 
 of them may grow off from the skin in a pe- 
 dunculated manner. Their color is apt to be 
 more brilliant than that of the syphilitic pap- 
 ule, and their situation is less frequently the 
 anus or scrotum. They lie most often within 
 the ostium vaginae in the female; under the foreskin in the male. Men- 
 tion will be made again of these warts in connection with the study of 
 gonorrhoea. They may occur as a complication of true mucous patches 
 under the foreskin, in the vagina, at the anus. 
 
 Treatment is that of secondary syphilis by mercury. 
 
 Fio. 4. 
 
 THE PUSTULAR SYPIIILIDE. 
 
 The pustules of early syphilis are found in two varieties: (1) small, 
 scattered or grouped, arising within a follicle, or occurring independently 
 upon an intervening portion of skin; (2) upon an inflamed base, but still 
 superficial, not gummatous (superficial ecthyma). 
 
 The small pustule has no very distinctive marking. It is apt to be 
 generalized over the whole body in early syphilis, and usually indicates 
 such a pus-forming quality of constitution in the patient, that the course 
 of his subsequent syphilis may with reasonable confidence be expected to 
 be bad. 
 
 The pustular syphilide may come on as the earliest eruption at six 
 weeks, but it does not usually appear before as many months. The scat- 
 tered pustules found among a number of vesicles, papules, and erythema- 
 tous spots in the polymorphism of the first eruption, do not constitute a pus- 
 tular syphilide. In the latter the type lesion is the pustule, grouped or 
 discrete. The lesions are found scattered over the whole body, in the 
 scalp, upon the face, upon the fingers and palms, over the whole trunk and 
 extremities. Very often the sebaceous follicle is involved, and then a hair 
 is seen to project from the summit of each pustule. They vary greatly 
 in size, take severally from one to three weeks to reach perfection, and 
 then they usually break and scab, or dry down and heal up under the lit-
 
 SYPHILIS OF THE SKIN. 151 
 
 tie crust. When they run together into superficial patches, they behave 
 in much the same way. 
 
 When the dried-up scabs fall away the livid thickening of the skin 
 remains for a considerable period marking the sites of the lesions. 
 These livid papules (for such they are) may be marked by a central de- 
 pression the hole left by the suppurated follicle if the pustule has been 
 pierced by a hair; or they may remain ulcerated on top for a time, finally 
 yielding a thin, white, round scar. A ring of pigment around each sepa- 
 rate healing lesion in pustular syphilis is rather the rule than the ex- 
 ception; but the pigment finally disappears, and the scars are often so 
 faint that it becomes hard to detect even traces of them in later years. 
 Groups of superficial pustules are much more rare than numbers of dis- 
 crete pustules. 
 
 The pustular syphilide is slow. Crops of pustules come out at differ- 
 ent times, relapses are not uncommon; and, unless treatment aided by 
 tonics shortens the duration of the affection, it is apt to drag itself along 
 during several months. 
 
 The diagnosis of superficial pustular syphilide is generally easy from 
 the concomitant symptoms and history. Iritis is apt to complicate it. 
 The bronzed areola of the subsiding lesion is a great help to diagnosis. 
 A generalized, pustular, superficial, discrete eruption is very rarely due 
 to any other cause than syphilis, and the appearance of such an eruption 
 should immediately suggest an inquiry into the patient's previous history. 
 
 The superficial ecthymatous syphilide (Fig. 5) is a little deeper, 
 a little more intense, being more deeply seated than the simple early 
 pustular syphilide. It indicates that the patient has a bad type of 
 syphilis, especially if it comes on early. It generally appears as late as 
 during the second year late enough to be called tertiary; but in bad 
 cases it often comes on early, within a few weeks of chancre, and it 
 leaves a faint scar, not indicating any considerable destruction of tissue. 
 Occasionally, on the other hand, it accompanies early malignant lesions in 
 very bad syphilis, and destroys considerable tissue, which of course neces- 
 sitates a deep scar. 
 
 This syphilide starts as an infiltration of a limited area of skin capped 
 by a pustule, or of a patch of skin upon which several pustules appear, 
 at first discrete, later confluent. These pustules are generally large and 
 flattened; they may even be umbilicated, resembling variola. The pus- 
 tules develop rather slowly, with little or no pain, and finally scab, an 
 ulcer existing under the scab for some time -after the latter has formed. 
 The pigmented areola comes on during the latter part of the develop- 
 ment of the pustules. The scar remains long purple, often raised and 
 thick, generally pigmented, and sometimes pitted, the pits representing 
 different follicles which have suppurated. Finally the scars become per- 
 fectly white, more slowly upon the lower than upon the upper extremities. 
 
 The diagnosis of this form of syphilis is not difficult except in occa- 
 sional cases where, as sometimes occurs, fever runs high with the first 
 outbreak of the pustules, and where umbilication is marked. A mistake 
 has been often made in such cases, and the patient has been sent to a 
 small-pox hospital. Several instances of this error have come under my 
 notice. The mistake may be avoided by noticing the more sluggish de- 
 velopment of the syphilitic pustules in crops, the absence of intense pain 
 in the back, the history of the case, and the concomitance of other (mouth 
 and glandular) evidences of syphilis. 
 
 Cachectic ecthyma upon a young person with a dark skin often
 
 152 
 
 THE VENEREAL DISEASES. 
 
 cannot possibly be differentiated from superficial syphilitic ecthyma by a 
 study of the lesion alone. The areola of pigment may be perfect upon 
 the cachectic, probably lousy, pauper encountered in hospital practice, 
 and suffering from simple ecthyma. A close study of the history and 
 accompanying symptoms is the only guide to a safe diagnosis. Anti- 
 
 Fio. 5. After 7, Fox's photographs. 
 
 syphilitic treatment, quite effective in syphilitic superficial ecthyma, is 
 powerless to oppose a continuance of the cachectic form. 
 
 The superficial ecthyma of early syphilis differs from the deep ecthyma 
 of late syphilis, in that the latter is a gummy infiltration of the true skin, 
 has a livid, hard base, and always leaves a depressed, round, white, thin, 
 smooth, unpitted scar. 
 
 Treatment is that of secondary syphilis by mercury (p. 117 ). 
 
 THE PIGMENTARY SYPHILIDE. 
 
 This eruption, the very existence of which is questioned by some 
 authors, while its syphilitic character is doubted by many who acknowl-
 
 SYPHILIS OF THE SKIN. 153 
 
 edge its existence, was first accurately described by Hardy, later by Four- 
 nier. Quite recently Atkinson, ' of Baltimore, and G. H. Fox, 4 of New- 
 York, have contributed valuable essays to the literature of the subject. 
 
 This syphilide is simply a coloration of the integument, varying from 
 a light dirty brown color to almost a black, a mottling formed of patches, 
 light and dark. The light areas of skin are sometimes of a natural hue, 
 sometimes whiter than the original integument, meriting for the affection 
 the title of vitiligo, according to Fox, who has one dark-skinned Italian 
 patient among his photographs, illustrating the blanching of the skin 
 upon the sites of the lesions without hyper-pigmentation around. 
 
 The conclusions arrived at by Fox, as to the method of formation of 
 the pigmentary syphilide, are very interesting. They are based upon the 
 close study of several cases, and, although 
 not proved yet, they are so plausible that / \ 
 
 their truth seems more than probable. ( J I 
 
 The accompanying diagrammatic sketch ^ ^ 
 
 has been furnished me by Dr. Fox. If these 
 views stand the test of observation by the 
 profession at large, another of the minor 
 mysteries of syphilis will have been solved. 
 
 In Fig. 6, the round spot 1 represents 
 the red syphilitic macule or papule; 2 is the 
 pigmentation which follows in many cases; 3 /*"* "\ 
 
 is the dark centre, the " bull's eye," as Dr. * 3 
 
 Fox calls it, which he has noticed to remain 
 in the centre of the white area as the pig- 
 ment was being absorbed peripherally; 4 
 shows the " bull's eye " also absorbed, as 
 well as all the pigment originally occupy- 
 ing the site of the lesion, while there re- 
 mains generalized peripheral hyper-pigmen- 
 tation in the intermacular spaces. 
 
 The dark patches are quite irregular and 
 vary much in size, their festooned borders 
 running into each other and making the ir- 
 regular mottling already referred to. The 
 eruption is generally found upon the sides 
 
 of the neck, in front, and on the upper part of the chest; exceptionally 
 elsewhere, as upon the trunk, the hands. It is generally ignored by the 
 patient, and often only discovered through accident by the physician, or 
 after careful search. Lymphatic, fair-skinned women, according to Hardy 
 and Fournier, are most apt to have this eruption ; but men also have it, 
 and sometimes very dark-skinned patients (Fox). 
 
 No one has ever watched it develop; but Fox has marked certain 
 papular lesions on the neck, and found the white mottlings, afterward, to 
 correspond to the sites marked out by the forerunning eruption. The 
 lesion has been considered, also, to be the lesion left behind by a roseola, 
 and at best it is an obscure affection of but little moment. As corrobora- 
 tive of past syphilis, it may be of some value. It comes on anywhere in 
 the second half of the first year after chancre, and may last many months, 
 but it always finally disapears. It is totally devoid of any subjective 
 
 1 Trans. Am. Dermatological Society, 1878. 
 * Am. Journ. Med. Sci., April, 1878, p. 356.
 
 154 THE VENEREAL DISEASES. 
 
 symptoms, and absolutely uninfluenced by treatment. It cannot possibly 
 be mistaken for anything except dirt, pityriasis versicolor, freckles, or 
 leucoderma. The first of these washes off; the second itches faintly, is a 
 little branny, and furnishes spores for microscopic diagnosis; the third are 
 more yellow, and never confined to the limited region of the sides of the 
 neck and upper part of the chest. Leucoderma of the common sort has 
 a different distribution. 
 
 THE VESICULAR SYPHILIDE. 
 
 This eruption is rare. Its date of appearance is late in the secondary 
 period, generally during the second year after chancre. 
 
 The vesicles may be of varied size, but generally are small, acuminated, 
 scattered about the trunk and extremities (the face being spared), or clus- 
 tered into groups in circles, or segments of circles, upon a livid base of 
 characteristic syphilitic color. Each of the lesions may be surrounded by 
 an areola, at first livid, then coppery, and the vesicles may dry up and scale, 
 or become purulent and scab over. 
 
 There is a form of vesicular syphilide coming on earlier (within six 
 months after chancre), the vesicles being large, umbilicated, upon a red- 
 dened base, with an areola at first livid, then coppery. The vesicles quickly 
 become purulent. 
 
 All the vesicular syphilides are slow in evolution and apt to be pro- 
 longed by successive outcrops cf new vesicles and clusters of vesicles con- 
 tinuing to appear as the first dry up. The livid spots left by the vesicles 
 gradually whiten and leave either no scar or pitted cicatrices, each pit rep- 
 resenting the original site of a vesicle. 
 
 The diagnosis is easy. The umbilicated vesicle may suggest varicella, 
 but there is no itching except in the scalp, and other syphilitic lesions are 
 apt to accompany this umbilicated form of the eruption, which comes on 
 early in the disease if at all. The generalized vesicular syphilide does not 
 become confluent and yield an oozing surface as does eczema. The color, 
 the areola, the grouping, the absence of itching, distinguish it easily from 
 other vesicular eruptions. Treatment is that of secondary syphilis by 
 mercury (p. 117). 
 
 THE SQUAMOUS SYPHILIDE. 
 
 The squamous syphilide, except upon the palms and soles, is usually a 
 papulo-squamous or a tuberculo-squamous eruption in infiltrated rounded 
 patches of livid form, or with a circinate distribution recalling ringworm 
 (Fig. 7, after 226, Fox). The scaling which occurs as the last stage, in a 
 variety of eruptions due to syphilis, cannot be called a squamous syphi- 
 lide, and the pityriasis accompanying alopecia due to syphilis is manifestly 
 unworthy to be called a squamous syphilide. 
 
 The papulo-squamous syphilide occurs toward the end of the first year 
 of syphilis, or at any period later. It may come on long after the tertiary 
 stage has set in, after gummata have appeared, after bone disease has been 
 inaugurated and cured. Long after the patient thinks himself well, sev- 
 eral years perhaps after the appearance of any symptom due to syphilis, 
 an elevated patch of squamous syphilide may appear upon the face and be 
 unjustly called a lupus by the physician, or a circinate scaly eruption
 
 SYPHILIS OF THE SKIN". 
 
 155 
 
 comes out upon the scrotum, and here the patient looks upon it as a ring-- 
 worm. 
 
 Solid patches of squamous syphilide may occur upon the face or any 
 part of the body. The skin is thickened, more or less livid, often not dis- 
 tinctly papulated, but infiltrated. The size and shape of the patches vary 
 greatly, from small dots to broad, rounded sweeps of eruption as large 
 as the hand. The livid surface is covered with fine white scales, which 
 are not tightly adherent. These scales shed off and are replaced by new 
 crops, until finally the infiltration disappears and the patch gets well, leav- 
 ing no scar. If the patch has been positively tuberculated as well as 
 scaly, round scars, not much, if at all, pig- 
 mented, are apt to be scattered over the livid 
 scaly area covered by the eruption, and these 
 scars remain permanent after the affection 
 gets well. 
 
 The circinate form may come on early 
 or very late in syphilis, attacking any part of 
 the body, but most common upon the scro- 
 tum, or about the genitals, in either sex. The 
 circle, or segment of a circle, starts of a given 
 size, and does not increase like ringworm. 
 A number of segments of circles often run 
 into each other, making a festooned, gyrate 
 figure. The border of the circle forming the 
 eruption varies in breadth up to about a 
 quarter of an inch; generally it is but little 
 wider than an eighth of an inch on the scro- 
 tum. The skin enclosed by the segments of 
 circles remains sound. The border of the 
 circle is generally distinctly papulated, some 
 of the papules being dry, some moist, some 
 scaly, some scabbed. About the genitals patients sometimes assert that 
 the eruption itches. 
 
 When this eruption occurs early in syphilis, it is apt to coincide with 
 other manifestations of the disease; later, it may be solitary. The later 
 it appears, the slower it is in evolution. It does not leave a scar. 
 
 Diagnosis in squamous syphilis is often difficult. Coincident symptoms 
 of syphilis, and the history, together with the common situation along 
 the roots of the hair on the forehead, about the genitals, etc., help to make 
 a diagnosis which the effect of treatment will promptly justify if it has 
 been accurate. In color, on the other hand, and general arrangement, 
 patches of squamous syphilide are sometimes quite indistinguishable from 
 some forms of psoriasis, and a localized patch on the face is sometimes 
 nearly enough like erythematous lupus to deceive a practitioner not ex- 
 pert in the differential diagnosis of skin diseases. The circinate, scaly 
 syphilide cannot long be mistaken for ringworm, since in syphilis the cir- 
 cle does not grow by centrifugal enlargement. 
 
 The palmar and plantar squamous syphilides are lesions of the 
 first importance in connection with syphilis. There are several varieties 
 of this eruption. One of them has already been described (p. 147), namely, 
 the round, livid, dry spots on the palm, looking as if a piece of the epithe- 
 lial layer had been cut out with a punch (Fig. 8, after 73, Fox), and the 
 borders of the scarfskin afterward slightly undermined. Besides these 
 spots, which are best observed in connection with a generalized papular 
 
 FIG. 7.
 
 156 
 
 THE VENEREAL DISEASES. 
 
 syphilide, other rounded and oblong scaly patches of the palm and sole 
 are encountered in syphilis at almost every stage of the disease. 
 
 These are, with few exceptions, round and oval. The different lesions 
 commence as livid, red areas, or as round, epidermal patches of a yellow 
 color, according as congestion of the surface vessels or epithelial hyper- 
 
 FIG. 8. 
 
 trophy is the more pronounced pathological process. As the lesion pro- 
 gresses it spreads centrifugally, the epidermis fissures and scales off, and 
 the different lesions run into each other (Fig. 9, after 77, Fox), making a 
 large patch with irregular, rounded border. The centrifugal spread of 
 the patches leaves a livid, pink centre, free from any special lesion other 
 
 Fro. 9. 
 
 than hyperaemia. Upon such central reddened spots, other rounded lesions, 
 like those in which the affection originated, spring up, and in their turn 
 spread centrifugally. In the natural furrows of the palm or sole, and at 
 their border, deep fissures are apt to form in the edges of the eruption, 
 due primarily to motion, and extending down into the bleeding true
 
 SYPHILIS OF THE SKIN. 157 
 
 skin. These cracks are aggravated by motion, and are the seat of con- 
 siderable pain at times. 
 
 Friction upon the palm, as in rowing, using tools, etc., is an active, 
 exciting cause of squamous syphilides in this region; much walking and 
 ill-fitting shoes act in the same way upon the sole. In the latter region 
 about the heel, in the very thick epidermis of that locality, the squamous 
 syphilide sometimes occurs as a dirty, yellow, fissured condition of the 
 epidermis, cropping over upon the thin skin under the ankle as a livid, 
 scaly eruption bordered by segments of circles. In this region the scaly 
 syphilide is often attended by pain, due to fissuring of the true skin, and 
 is very slow in its evolution. Elevated livid tubercles, more or less scaly, 
 also occur in patches upon the palm. 
 
 Symmetry is not the rule in either palmar or plantar syphilis. 
 
 Diagnosis of squamous syphilide of the palm and sole is difficult in 
 some cases. Some forms of lichen urticatus, of eczema, and of psoriasis 
 resemble it very closely. In the first and last of these affections, how- 
 ever, the plantar or palmar lesion is never found alone. The character of 
 general eruption upon the rest of the body, therefore, clears up all doubt 
 concerning the lesion in question. An eczematous patch, however, may 
 be found exclusively confined to the palm. It is apt to itch, it is thinner 
 at the edge, shades off into the surrounding integument more than the 
 syphilide does. It is not so livid in color, and has no purple border, as is 
 sometimes the case in the syphilide. Eczema is more irregular, less 
 rounded in outline, much more chronic in duration, as a rule, and apt to 
 extend out over the palm upon the softer skin around. 
 
 Local treatment is of great value, as well as general treatment, in 
 this affection. The tuberculo-squamous patches generally require mixed 
 treatment (pp. 117, 128, 137). 
 
 THE TTJBEECULAE SYPHILIDE. 
 
 This syphilide occurs in two forms generalized, or in groups. The 
 generalized form is quite unusual, that in groups very common. The 
 former rarely occurs before the second half of the first year, from chancre; 
 the latter quite exceptionally before the second year. Isolated patches 
 of tubercle may come on at any date, many years after all traces of the 
 disease have disappeared. 
 
 The general tubercular syphilide is not the papular syphilide in 
 which the papules are large. The tubercle is really a gummatous product. 
 It develops deeply down in the tissue or the true skin beneath the papillary 
 layer. It is not a gummy tumor of the subcutaneous tissue. When it 
 occurs as a generalized eruption, it does so as an eruption of patches 
 and groups of clustered lesions in circles and segments of circles. Some 
 of the patches are the result of a confluence of many tubercles, and then 
 the patch is a solid livid elevation of the skin, uneven on the top, and cov- 
 ered with scales. Each separate lesion, if it stands alone (Fig. 10, after 
 103, Fox), is livid in hue, capped with a scale or a small pustule, and 
 often surrounded by a livid areola, afterward becoming coppery. The 
 different tubercles vary in size from a grain of rice to a good-sized pea, 
 and they usually leave a cicatrix when they disappear, whether their sur- 
 face has been ulcerated or not. The scar is at first livid, then often pig- 
 mented, then white, round, thin, smooth, depressed, not at all retractile.
 
 158 
 
 THE VENEREAL DISEASES. 
 
 The diagnosis is easy. It is hard to imagine an eruption with which 
 the tubercular syphilide could be confounded. 
 
 The tuberculo-squamous or tuberculo-ulcerated syphilide in 
 groups is a late lesion. It is, indeed, positively tertiary, but often oc- 
 curs upon the border-line. The face is a favorite seat of the eruption, but 
 it may occupy any part of the body, as shown in Fig. 11, after 108, Fox. 
 Livid patches of thickened skin constitute the eruption. 
 
 Scales upon these patches are quite obvious, but the tubercles may be 
 
 Fio. 10. Generalized tubercular syphilis. 
 
 scarcely so, perhaps not visible at all. Sometimes the only reason one 
 has to call the affection tuberculo-squamous, is the existence of round, 
 white, depressed scars upon the surface in among the scales, of the size 
 of a pea, marking the site of tubercular infiltrations of the true skin, with 
 gummatous material, the interstitial absorption of which has produced the 
 white scars. Generally the tubercles are quite plainly visible upon the 
 surface. Sometimes they stand apart, sometimes they run together and 
 enclose areas of healthy skin within raised circular borders.
 
 SYPHILIS OF THE SKIN". 
 
 159 
 
 The evolution of the patch is by the circumferential growth of new 
 tubercles. Those first formed disappear, leaving scars without previously 
 ulcerating, and upon the old spots where 
 former tubercles have flourished and 
 gone away new ones may crop out later 
 and go slowly through their changes, 
 leaving scars behind. Ringworm may 
 be simulated by circinate patches of 
 tuberculo-squamous disease. 
 
 This syphilide is maintained by the 
 successive outcrop of new tubercles, 
 and a single patch may thus be pro- 
 longed for years. Sometimes the gum- 
 matous infiltration which forms the tu- 
 bercle goes on so rapidly that the in- 
 tegrity of the integument is compro- 
 mised, ulceration takes place, and a 
 serpiginous ulcer results, as after the 
 pustular syphilide in groups. 
 
 The diagnosis of tubercular syph- 
 ilide in groups is very easy if atten- 
 tion be paid to the central cicatrices 
 in the patch. These are round, white, 
 smooth, and not puckered. In tuber- 
 cular non-ulcerative lupus this quality 
 of Scar is not observed, the cicatrix . 
 being puckered and linear. This fea- 
 ture alone is all that is required to make a distinction. The lividity of 
 color is much more marked in syphilis than in lupus. 
 
 Treatment is mixed, both iodide of potassium and mercury being re- 
 quired (p. 137). Local treatment is serviceable (p. 128). 
 
 PIG. 11. 
 
 TEETIAEY SYPHILIDES. 
 
 The final three sets of eruptions to be considered rupia, ulcerative 
 syphilis, and gumma are strictly tertiary; they all call for mixed treat- 
 ment, and generally for the iodide of potassium in excess, if it is desired 
 to subdue them promptly. They all occur habitually in the second year 
 of the disease and later, and they uniformly and inevitably destroy the 
 structure of the true skin and leave scars. Treatment postpones their 
 outbreak, or may prevent them from appearing at all. 
 
 Eruptions of this kind may be ushered in while the patient is enjoying 
 apparently the most flourishing health. They are all painless, unless they 
 involve a bone or joint, as well as the integument. Sometimes they ac- 
 company that profound cachexia, produced by syphilis, which is often ob- 
 served in hospitals upon patients with visceral disease due to late syphi- 
 lis. The cachexia always indicates a profound alteration of some of the 
 internal organs, when it appears late in syphilis, and does not usually 
 stand in any immediate relation of cause to the eruption, or of effect 
 of the eruption, be it rupia or ulcer, for the same cutaneous lesions may 
 be found upon patients who present no evidences of cachexia whatsoever. 
 Rupia, however, whether the patient shows cachexia or not, indicates a
 
 160 
 
 THE VEKEREAL DISEASES. 
 
 very bad quality of constitution, and calls for tonic remedies and cod-liver 
 oil, as well as for the mixed treatment, suitable to the stage of the dis- 
 ease in which it occurs. 
 
 THE PUSTULO-BULBOUS SYPHILIDE (BUPIA). 
 
 A scattered bulbous eruption has been occasionally encountered in 
 secondary syphilis, about the hands, feet, and elbows, but it is met with 
 so rarely that it may be considered a pure exception. In inherited syphi- 
 lis the bulbous lesion is not uncommon, and it will be described in connec- 
 tion with that branch of the subject. 
 
 Rupia, Fig. 12 (after 27, Fox), the eruption now under consideration, 
 sometimes starts as a flat pustule, sometimes as a bulla. The patient may 
 look fat and seem healthy, but he is not so, or he could not have rupia. 
 If a bulla first forms, it runs on quickly to suppuration, and blood becomes 
 mingled with the pus. The first lesion thus formed scabs over, and under 
 the scab ulceration commences, yielding pus, which raises the scab from 
 its bed. Meantime around the scab first formed an epidermal raised ring 
 appears, filled with sero-pus. This dries down into a blackish green scab, 
 enlarging the first crust, while ulceration goes on beneath the whole. A 
 new sero-purulent sub-epidermal collar forms again around the lesion, and 
 the process goes on repeating itself. 
 
 The new layers of pus supplied from beneath, raise and thicken the 
 
 FIQ. 12. 
 
 scab, and if this process continues long without much increase in the area 
 of the patch by the formation of circumferential bullae, as may be the case, 
 a horn -may be formed sometimes an inch long or more, and in any case 
 the roughened crust comes to bear a close resemblance to an oyster-shell. 
 
 This oyster-shell is attached at the borders, but not by its under sur- 
 face, and pressure upon it generally causes pus to ooze out at one of the 
 edges of the sore. If the 'scab gets detached another may form, or the 
 lesion may progress as an open or a partly scabbed ulcer, with a livid or 
 pultaceous base and sharp-cut borders. Sometimes cicatrization goes on 
 under the scab, which finally falls off, leaving a livid cicatrix, generally 
 covered with ridges, drawn and puckered in part, sometimes surrounded 
 by a coppery areola, sometimes having only a livid border. In almost all 
 cases the scars eventually become white. 
 
 Treatment must be tonic in all ways and mixed with iodides in ex- 
 cess. Local treatment of the ulcers, when the scab falls, is of considera- 
 ble value (pp. 128, 137).
 
 SYPHILIS OF THE SKIN. 
 
 161 
 
 THE TERTIARY PUSTULAR SYPHILIDE. 
 
 In tertiary disease the pustular syphilide is found in two forms. As 
 a pustule with an infiltrated base, ecthyma, and as a patch of pustules 
 beneath which destructive ulceration goes on. 
 
 The deep ecthymatous pustule is a general gummy infiltration of the 
 skin, capped with a pustule, which usually goes on to ulceration. 
 
 The gummatous thickening of the skin is obvious in the case of single 
 isolated ecthymatous lesions, but it becomes lost as the single lesion ulcer- 
 ates, or the patch of ecthymatous pustules spreads. When this thick- 
 ening is present it exists as a lurid, painless, hard lump, often surrounded 
 by a bronzed areola, especially 
 upon the lower extremity, as the 
 isolated ecthymatous spot gets old. 
 
 The thick green crust which 
 forms upon the top of an ecthy- 
 matous pustule resembles a rupial 
 crust. Its edges are thin, and fre- 
 quently are depressed beneath the 
 level of the surrounding skin, ma- 
 king the latter look like a setting 
 which holds the scab in place. 
 These scabs are quite adherent, 
 and may remain attached until ci- 
 catrization is complete. The ec- 
 thymatous lesions of the patch in 
 Fig. 13 (113, Fox) are partly scab- 
 bed, partly cicatrized. 
 
 The cicatrix of a single deep 
 ecthymatous spot is the typical 
 syphilitic scar, smooth, thin, white, 
 depressed, non-adherent. At first 
 it is livid, and it remains in most 
 cases surrounded for a long time 
 by a border of pigment. 
 
 The favorite seat of deep ecthy- 
 ma is the lower extremities but 
 it may be found anywhere upon 
 the body, and is not uncommon on 
 the face. 
 
 When several ecthymatous le- 
 sions run together, an ulcer may 
 result, which may become serpigi- 
 nous, and creep over a considerable extent of surface, often getting well 
 on one side as it advances toward the other. 
 
 In ecthyma the mixed treatment is appropriate, together with mercu- 
 rials locally (pp. 128, 137). 
 
 Ecthyma does not necessarily indicate a bad condition of the patient. 
 
 The pustular syphilide in groups generally comes on late in syphi- 
 lis. A red spot appears, which quickly becomes covered with small pus- 
 tules. These run together and scab, and beneath the scab ulceration 
 goes on. As the ulcer grows, so does the scab, and if the latter falls off, 
 or is removed, a new one forms. The secretion beneath the scab is scanty, 
 and the crust, therefore, does not become rupial. 
 11 
 
 Fis. 13.
 
 162 
 
 THE VENEKEAL DISEASES. 
 
 Fio. 14 (Pox, 40). 
 
 Finally, when the patch has reached a considerable size in some cases, 
 the new pustules around the edges upon the livid areola cease to form, 
 the whole patch dries up and contracts, cicatrizing under the crust. When 
 
 the latter falls, a livid scar is left, with 
 a bronzed areola. The centre whitens, 
 the areola generally, but not always, dis- 
 appears. 
 
 A serpiginous ulcer may result from 
 this lesion, as it may from ecthyma, or 
 from rupia. 
 
 An error in diagnosis is not probable. 
 The pustular scrofulide generally comes 
 early in life, and the lesion with its ulcer 
 have different characters. 
 
 Treatment is mixed internally, with 
 the iodide in excess (p. 137). Local treat- 
 ment is quite effective in this eruption, 
 and its rapid influence is much to be de- 
 sired, since the eruption may occupy the 
 face. 
 
 The syphilitic tertiary ulcer is 
 not an especial affection. It is a second 
 stage of rupia, ecthyma, patches of tu- 
 bercles, or of pustules, or a sequence of 
 gummy infiltration, or of gummy tumor 
 of the skin. Figs. 14 and 15 indicate favorite sites and appearances of 
 syphilitic tertiary ulcers ; Fig. 16 represents moderately well the appear- 
 ance of typical syphilitic scars. 
 
 The ulcer always has similar characters, whether destroying in depth, 
 or running superficially up- 
 on the surface (serpiginous 
 ulcer). The ulcer has per- 
 pendicular edges, hard, liv- 
 id, (generally) adherent bor- 
 ders, a livid, pultaceous floor 
 (sometimes smooth and shin- 
 ing), and often a hard base. 
 These lesions are painless for 
 the most part, unless they 
 involve the periosteum from 
 being situated over it, as on 
 the shin, or unless they be- 
 come inflamed from injury, 
 or by position, as on the 
 lower extremity. 
 
 The syphilitic ulcer may 
 remain stationary, it may 
 eat downward, exposing a 
 bone, destroying the perios- 
 team and leaving a piece of ^^ 
 
 bare bone in the floor of the 
 
 ulcer. This bone, at first white, becomes black. It often dies, gradually 
 separates from the healthy bone beneath, and is thrown off. The deep, 
 destructive ulceration which deforms the nose generally follows a gum-
 
 SYPHILIS OP THE SKIN". 
 
 163 
 
 my tumor or gummatous infiltration. The same may be said of the de- 
 structive ulcer of the penis. 
 
 Serpiginous ulcers are those which spread superficially, either in all di- 
 rections, or, advancing in one direction, get well in the other. 
 
 Around joints, and on the lower extremities, syphilitic ulcers may re- 
 main for years, perhaps, untreated, until the end of life. They yield, 
 however, to well-directed internal mix- 
 ed treatment, with iodides in excess, 
 and to intelligent local means, pressure, 
 mercurials, iodoform, etc., p. 130. 
 
 Great care must be exercised to dis- 
 tinguish a tertiary ulcer upon the 
 tongue or lip from an epithelioma, 
 upon the penis from a phagedenic 
 chancroid or an epithelioma, upon the 
 nose or face from an ulcerative lupus 
 or a rodent ulcer. The peculiar char- 
 acters of syphilitic ulcers, so often al- 
 ready detailed, ought to be sufficient to 
 guide to a diagnosis in most cases. In 
 all cases of doubt the touchstone of 
 treatment, if intelligently applied, will clear up the question promptly. 
 In nearly all cases of tertiary ulceration, except when it occurs upon the 
 lower extremities, and is already old, and when it comes on in connec- 
 tion with profound cachexia ; in nearly all other classes of cases internal 
 treatment alone is promptly effective of good results, although local 
 measures may greatly aid the healing of the sore. 
 
 Fio. 16 (Fox, 110). 
 
 GITMMA OF THE SKIN. 
 
 Tubercular and ecthymatous patches are certainly the seat of gumma- 
 tous infiltration. There is also a true gumma of the skin, which appears 
 as a general infiltration, and another form which takes the shape of a cir- 
 cumscribed tumor. Either form may ulcerate; the latter habitually does 
 so unless arrested by treatment. 
 
 Diffuse gummatous infiltration of the skin is not common. It 
 occurs as a patch of livid redness, hard, raised, somewhat scaly on the 
 surface, perhaps for a long time smooth and shining. Upon this surface, 
 little prominences may appear, which quickly ulcerate. The ulcers run 
 together and behave like the syphilitic ulcers already described, remain- 
 ing stationary, or becoming serpiginous, but not destroying in depth. 
 Rarely the patch sinks away, leaving a general thinning of the skin be- 
 hind, but no distinct scar, as such. 
 
 Gummatous infiltration of the skin presumably precedes all ulceration 
 of the serpiginous sort, whether coming on as a sequence to rupia, ecthyma, 
 or any other lesion; and the infiltrated patches bearing tubercles, scales, or 
 pustules, owe their infiltration undoubtedly to an analogous pathological 
 condition. 
 
 The gumma proper of the skin is, strictly speaking, the syphilitic 
 tubercle. The gummy tumor, yielding an ulcer on the skin, is generally 
 a localized accumulation of gummatous cells in the subcutaneous con- 
 nective tissue. These are first noticed as hard, shot-like bodies beneath 
 the skin. They are absolutely insensitive upon manipulation. The skin
 
 164 THE VENEREAL DISEASES. 
 
 is freely movable over them, and they themselves are not attached firmly 
 to the surrounding or underlying parts. In this state a subcutaneous 
 gumma may remain for months, and sometimes gradually disappear, even 
 without treatment, leaving no apparent trace of its former existence. 
 Generally, however, unless treatment intervenes, the lump gradually en- 
 larges, attaches itself to all the surrounding tissues, softens centrally, and 
 the detritus of gummy matter slowly but surely ulcerates its way to the 
 surface. . 
 
 The skin over the tumor, in such a case, becomes livid and thin, the 
 soft central spot finally gives way, and the contents of the tumor escape, 
 not as pus, but as a more or less thick, honey-like material, of a grayish 
 yellow color tinged with green, and mingled with more or less blood. 
 This detritus is composed of broken-down gummatous cells, and the de- 
 bris of the intervening tissue which was infiltrated with those cells. 
 After discharging, the gumma remains open as a deep syphilitic ulcer, 
 which generally gradually heals, leaving a characteristic scar. Subperios- 
 teal gummata are often painful. They may remain long- stationary, and, 
 finally ulcerating, be followed by the death of large portions of bone, gen- 
 erally the superficial layers, which become, later, slowly necrotic. 
 
 Gummata of the nose are very apt to lead to perforation, destruction 
 of bone, and permanent deformity. Gummata occur over the whole body. 
 Local traumatisms seem sometimes to call them into existence. 
 
 Wherever the gumma occurs, the tissue which is implicated is certain 
 to be destroyed. The new round and fusiform cells are usually incapable 
 of organization beyond a certain point, and when the tumor lias reached 
 a certain size it deliquesces, and its wasted elements and the tissues lying 
 between them seek a way to the surface, or they are absorbed first the 
 watery, later the solid parts through the instrumentality of granulo-fatty 
 degeneration. The remains of the solid parts may become cretaceous and 
 encysted, and continue in this state indefinitely. Sometimes gummatous 
 exudation is entirely absorbed, leaving behind a cyst containing a little 
 fluid. This termination is exceedingly rare. 
 
 Sometimes gummy deposit undergoes fibrous transformation (around 
 the dura mater, interstitially in the different organs, notably the lungs), 
 but this peculiar form of retrogressive metamorphosis does not seem to 
 obtain in the case of gummy tumor of the skin. 
 
 Treatment of gumma, wherever it occurs in the body in the form 
 of a distinct tumor, is by the iodide of potassium; all the iodides are the 
 natural specific enemies of gummatous deposit.
 
 CHAPTER IX. 
 
 SYPHILIS OF MUCOUS MEMBRANES. 
 
 Erythematous, TJlcerative, Mucous, and Scaly Patches, and Guminatous Ulcers of the 
 Mucous Membranes of the Mouth, Nose, and Fauces. 
 
 THE mucous membranes of the body, as well as the outside integument, 
 are affected by various lesions in the course of syphilitic disease. These 
 lesions are few in number. Some of them occur early, some late in the 
 disease, others at all times. They are, in the mouth, throat, and nose: 
 
 1. Erythematous patches with erosions and superficial ulcers (occurring 
 at all times). 
 
 2. Mucous patches (occurring in the typical form only during second- 
 ary syphilis). 
 
 3. Scaly patches (occurring only late in syphilis). 
 
 4. Gummatous ulcers (occurring only late in syphilis). 
 
 EEYTHEMATOUS PATCHES, EROSIONS AND SUPERFICIAL ULCERS. 
 
 These lesions, most notable during the earliest general outbreak of 
 syphilis, may yet appear in modified form throughout the disease, either 
 in connection with the various eruptions, or independently. Often, during 
 the syphilitic fever, when the lymphatic glands behind the neck just begin 
 to be perceptible, before any eruption can be made out upon the trunk, 
 careful inspection will show that the fauces are covered with a uniform 
 redness, suggestive of a common sore throat. The main difference be- 
 tween this erythema and ordinary sore throat is that in the former the 
 blush often occupies more particularly the under surface of the soft palate 
 and is apt to be very distinctly punctate in character (recalling the ery- 
 thema of scarlatinal sore throat). This redness may extend out of sight 
 up into the nares and down below the pharynx. The Schneiderian mem- 
 brane may be pretty uniformly involved, as in a common cold. More or 
 less tonsillar hypertrophy accompanies this condition. 
 
 With this erythema the patient generally complains of more or less 
 pain, and he may be temporarily deaf, or lose his voice for a few days. 
 
 In connection with this redness, excoriations may occur upon the lips, 
 upon the throat, along the edges, upon the dorsum, and at the tip of the 
 tongue. These excoriations, however, have nothing characteristic about 
 them. They are much more apt to come on at indefinite periods late in 
 the disease. Little, yellow, round, superficial ulcers, behind the lips, or on 
 the tip or sides of the tongue, are matters of daily observation in a vene- 
 real clinique, at all dates of syphilis. 
 
 Peculiarly common after the lapse of several years, is an angry red- 
 dened excoriation of the sides of the tongue, far back near the root, on
 
 166 THE VENEREAL DISEASES. 
 
 both sides. This may exist for months without ulcer or scaly patch. It 
 is kept up by smoking, and by rough edges of teeth, but occasionally oc- 
 curs without the aid of either of these exciting causes. All of these ex- 
 coriations are likely to be somewhat sensitive, especially that form occur- 
 ring on the sides of the tongue, during the second year and later, in which 
 the papillae seem to be angry and irritated. 
 
 Local treatment is of the first importance in all mouth and throat 
 lesions belonging to this class. These local means have been detailed in 
 connection with the discussion on general treatment, p. 130. 
 
 MUCOUS PATCHES. 
 
 The typical mucous patch is a lesion found only in syphilis and in 
 perfection, usually, only in early syphilis. It may come on simultaneously 
 with the first erythema of the throat, and continue to appear from time 
 to time throughout the secondary period; but it is commonly seen in 
 greatest perfection in connection with the general papular syphilide of 
 the integument. The forms occurring late in the secondary and during 
 the tertiary period are usually scaly patches and excoriations, resembling 
 the squamous syphilide more than the papule. The true mucous patch 
 is a flat papule with a sodden epithelium capping it. Its connection 
 with the papule has been touched upon in the description of the flat pap- 
 ular syphilide, where it was shown how any flat syphilitic papule, kept 
 moist and sodden, becomes a mucous papule of the skin. 
 
 Cornil l has recently studied the " opaline mucous tubercle " minutely. 
 As found upon the tonsil, he relates that the ] apillse are hypertrophied, 
 the epithelium thickened, the deeper tissues infiltrated with new cells. 
 In the superficial epithelial cells he found cavities sometimes containing 
 pus-corpuscles and numbers of nests of pus-cells between the epithelial 
 scales. These little abscesses open from time to time upon the surface, 
 and yield the secretion of the mucous patch. When many of the little 
 abscesses break down together and become confluent, a disintegrated ul- 
 cerated surface remains. Upon the surface of this ulcerated mucous 
 patch there may be a false membrane, but, according to Cornil, this 
 membrane does not contain the microscopic organism found in diphthe- 
 ritic membrane. The closed follicles, when the tonsils are the seat of 
 mucous patches, are inflamed, the whole gland congested and hyper- 
 trophied. 
 
 Clinically speaking, the mucous patch is a round, or irregularly round- 
 ed, raised patch of a dirty white color, sometimes red and granulating, 
 covered with a more or less puriform secretion. In size, they vary from 
 a point to large, irregular surfaces, generally produced by the confluence 
 of several patches, and capable of reaching almost any dimensions. 
 They occur about the tonsils, and upon all the pharynx, within the lips, 
 or upon the tongue, within the nose, and down in the larynx and trachea, 
 where they have been repeatedly observed with the laryngoscope. Un- 
 less ulcerated or attended by surrounding erythema, they are painless. 
 Often the patient is unconscious of their existence. When they ulcerate 
 or inflame, they may become quite painful. 
 
 They relapse frequently, and continue to come out upon the mucous 
 
 OA ' .Communication to the French Academy. Referred to in London Lancet, August 
 ** Io7o.
 
 SYPHILIS OF THE MUCOUS MEMBRAISTES. 167 
 
 membranes, either spontaneously, or, more often, as the result of local 
 irritation a rough tooth, smoking. 
 
 Mucous patches do not leave any scars unless they ulcerate, and even 
 then, the ulceration being superficial, the scars are not well marked. 
 
 Something has already been said about mucous patches on the skin, 
 at p. 148, in connection with the description of the papular syphilide. In 
 addition, it may be said, when there is present a generalized, flat, papular 
 syphilide, any of these papules may become a mucous patch upon the 
 skin, if subjected to heat and moisture. Hence, the mucous patches 
 about the scrotum, the anus, between the toes, in the groin, about the 
 umbilicus in fat persons, and under the breast in the female. Under the 
 prepuce, in the vagina in the female, and about the anus, mucous patches 
 often arise independently of any general eruption. They are not uncom- 
 mon upon the delicate skins of children. In short, wherever two surfaces 
 lie together, especially if there be any secretion, and the parts be allowed 
 to become dirty, if the patient is in the early stages of syphilis, mucous 
 patches may be looked for. If the secretions from these patches be re- 
 tained, they undergo prompt decomposition, and emit a foul odor. They 
 may ulcerate about the anus, or between the toes, and become very pain- 
 ful. Vegetations may spring up around them, and they themselves may 
 grow up so as to be large, pedunculated, flat warts (condyloma lata). 
 It cannot be too often repeated that the secretions of mucous patches are 
 laden with the poison of syphilis, and as capable of transmitting the dis- 
 ease as is the secretion of a chancre. A man or woman, with a mucous 
 patch upon or just within the lip, is far more dangerous to the community 
 as a focus of disease than two or three individuals with chancre. The 
 local treatment of mucous patches, both of the skin and of mucous mem- 
 branes, is very important. It may be found under the head of general 
 treatment, p. 129. 
 
 SCALY PATCHES. 
 
 Scaly patches upon the throat, tongue, and the inside of the lips and 
 cheeks, are very common during the second year of syphilis and later. 
 They take the place of mucous patches, and are frequently called by that 
 name. They may occur early enough in syphilis to be associated with 
 the true mucous patch, but their natural position is later in the disease. 
 
 They appear as flat, rounded, irregularly shaped patches of a bluish 
 white color anywhere within the mouth, but by preference at the angles 
 of the lips, and on the tip, sides, and dorsum of the tongue. They are quite 
 flat and insignificant-looking; but the patient learns to know them, and they 
 cause him much uneasiness. They are manifestly due to epithelial thicken- 
 ing, and their whiteness depends upon this fact. Sometimes a limited patch 
 (particularly under the tongue) will take on extensive overgrowth and 
 yield an adherent white patch of epithelium as thick as a piece of blotting- 
 paper, looking exactly like the disease called tylosis or icthyosis of the 
 tongue. Sometimes these occur also in the angles of the mouth due to 
 syphilis. Sometimes the entire dorsum of the tongue becomes covered with 
 this scaly syphilide, giving it a mottled white and blue-white appearance 
 which is not simulated by any other disease with which I am familiar. 
 
 These patches cannot be scraped off. They are not ulcers. If roughly 
 handled they bleed. They are generally sensitive, although not seemingly 
 inflamed, and when large patches exist in the mouth the contact of condi-
 
 168 THE VENEBEAL DISEASES. 
 
 merits causes pain, and eating is only accomplished at the expense of great 
 discomfort. Occasionally one of these scaly patches ulcerates, but this 
 is not the rule. 
 
 These patches occur also in the vulva. 
 
 Smoking, chewing tobacco, all irritants applied to the mouth, the 
 rough edges of teeth, lack of cleanliness, are exciting causes of the scaly 
 syphilide of the mouth. These patches often occur long after all signs of 
 syphilis have disappeared, and they yield to local treatment and do not 
 call for a renewal of internal remedial measures. They do not necessa- 
 rily indicate that the malady, perhaps long latent, is again to become ac- 
 tive; but they do indicate that the syphilitic diathesis is not yet dead. 
 
 These patches sometimes so closely resemble true ichthyosis of the 
 tongue, that a diagnosis by the physical characters alone is impossible. 
 Generally the icthyosis has been of longer duration and is less sensitive 
 than the syphilitic patch. 
 
 The mingled excoriations and scaly patches found not infrequently 
 upon the tongue and in the mouth of persons having a tendency to dry 
 eczema, once seen, could not be mistaken for a scaly syphilide. This con- 
 dition is not common, and is encountered most often in the mouths of anae- 
 mic women. It is almost invariably aggravated at each menstrual epoch. 
 Nothing of the kind obtains in syphilitic scaly disease of the tongue. 
 
 GTJMMATOUS ULCERS OF THE MOUTH AND FAUCES. 1 
 
 Besides the slight round ulcers and the irregular erosions of the mouth 
 common to the whole period of syphilis, three other forms of ulcer claim 
 description here, namely: the stationary, chronic, infiltrated ulcer; the 
 serpiginous ulcer; and the ulcerative gummy tumor. All of these occur 
 late in syphilis. The infiltrated ulcer is also found early in the disease. 
 
 The deep, ragged, brawny ulcer of the tonsil, found in syphilis, 
 may be encountered early and late in the disease, alone and coincidently 
 with other symptoms. It may originate in a mucous patch in early syph- 
 ilis, or may start spontaneously in both stages of the malady. The ulcer 
 occupies the tonsil by preference, usually is oval, with its long axis paral- 
 lel to that of the tonsil. It may extend over upon either of the half arches, 
 or upon the soft palate. It may, indeed, occur spontaneously at the an- 
 gles of the mouth, inside the cheeks, or elsewhere. The base is pulta- 
 ceous, the borders cut away, generally livid, sometimes pink, usually hard 
 and accompanied by a sodden, livid condition of cedematous infiltration of 
 all the surrounding tissues. 
 
 The ulcer remains stationary or progresses slowly. It often occasions 
 great pain, especially upon swallowing, and is apt to be accompanied by 
 a feverish state of the body, a furred tongue red at the tip, and often by 
 considerable continuous, spontaneous pain, especially in early syphilis. 
 
 But little tissue is destroyed by these ulcers, and the resulting scars 
 are not deep. Secretions from such ulcers in early syphilis are conta- 
 gious. 
 
 The serpiginous ulcer occurs later in the disease, and is manifestly 
 a gummatous infiltration. The seat of these ulcers is varied. The edge, 
 er the upper part of the soft palate, is not infrequently involved, and 
 
 1 Gummata of the tongue will be considered under the head of syphilis of the di- 
 gestive organs.
 
 SYPHILIS OF THE MUCOUS MEMBRANE'S.) 169 
 
 quite often the back of the pharynx, high up, is the seat of disease. 
 More rarely other parts of the mouth are affected. Not infrequently, 
 with this form of ulcer in the pharynx, the larynx is the seat of tertiary 
 syphilitic disease. 
 
 These tertiary, serpiginous ulcers do not constantly advance. They 
 sometimes remain stationary for months, even years, upon the pharynx, 
 giving very little pain, causing the patient to spit up a few bloody scabs 
 in the morning, and attended by a dryness and an uncomfortable feeling 
 in the throat. Sometimes it is necessary to hook up the soft palate with 
 a carved probe, in order to find such an ulcer, or to use the laryngoscopic 
 mirror. 
 
 Sometimes these ulcers advance rapidly, eating off the uvula in a few 
 days, and destroying large portions of the soft palate by eating it away 
 from the edge inward. When such ulcers get well they occasionally leave 
 the pharynx much distorted by cicatrices. 
 
 The gummy, stationary, or serpiginous ulcer of the pharynx generally 
 goes with a bad type of disease, and is often associated with profound 
 syphilitic cachexia. 
 
 The local treatment of this form of ulcer is not very important. Fu- 
 migations are of some service, and the iodides internally are impera- 
 tively called for. Cleanliness is of great value, and the abandonment of 
 tobacco. 
 
 GUMMY TUMOR OF THE MOUTH. 
 
 Gummy tumors may appear anywhere within the mouth. Gumma of 
 the tongue will be described later. The gumma of the hard or soft palate 
 is not uncommon, and is very dangerous on account of the damage it is 
 likely to cause if unchecked. 
 
 A subrnucous, round, insensitive swelling first appears, not attended 
 by pain. Perhaps the gummatous infiltration is diffuse over a limited 
 area, and not concentrated into a single nodule. The growth of the gum- 
 matous material may be slow at first, but it is often rapid from the start. 
 
 When the tumor has reached a certain size, the mucous membrane 
 over it becomes osdematous and rapidly gives way, disclosing a cavity 
 which constitutes a gummatous .ulcer like that seen upon the skin, with 
 perpendicular edges and a deeply -situated grayish yellow floor. The dif- 
 fuse infiltration in a similar manner may soften suddenly, and rapid ulcer- 
 ation sweep away quite an expanse of tissue. 
 
 The gummatous ulcer once formed destroys all the tissues in its path 
 which have been infiltrated. Bone and cartilage offer no barriers to its 
 Kiarch. Extensive destruction of tissue may ensue unless treatment inter- 
 vent, and large portions of the roof of the mouth may be sacrificed to ob- 
 scurity of diagnosis or lack of therapeutical boldness. 
 
 The odor of the ulceration in these cases, when the bone is involved, 
 has something in it which is nearly pathognomonic. The same may be 
 perceived when the bones of the nose are involved in gummatous syphili- 
 tic disease. 
 
 Whether" these extensive throat-ravages, caused by syphilis, may not 
 also be sometimes due to other pathological conditions (scrofula, lupus), 
 has long been a question. My personal experience inclines me to the 
 opinion that syphilis is their sole and only cause; but I am very well 
 aware that there is excellent authority for the opinion that a scarred phar-
 
 170 THE VENEREAL DISEASES. 
 
 ynx, like that so often seen in syphilis, inherited or acquired, may be due 
 to the previous existence of lupus of the pharynx, or of tubercular ulcer- 
 ation which has gotten well. 
 
 Atkinson, of Baltimore, in connection with an excellent case of ignor- 
 ed syphilis, has reviewed this question very ably, in the January (1879) 
 number of the American Journal of Medical Sciences. 
 
 The local treatment of gummatous, destructive ulcers of the mouth 
 and fauces is unimportant. The unsparing internal use of the iodides is 
 the patient's main salvation. Any temporizing with such a case, or at- 
 tempts to cure by local means, is unjustifiable. Sometimes enormous 
 doses of the iodides are borne by these throat cases. When cachexia is 
 far advanced, some of them become incurable.
 
 CHAPTER X. 
 
 SYPHILIS OF LYMPHATIC GLANDS, 
 
 OF HAIEY PAETS, OF THE FINGEKS AND TOES, OF MUSCLES, TENDONS, 
 APONEUBOSES, BUBS^E, JOINTS, BONES, AND CARTILAGE. 
 
 Epitrochlear and Post-cervical Indolent Glandular Engorgement. Syphilitic Alopecia. 
 Syphilitic Onychia and Paronychia. Dactylitis. Syphilitic Myostitis, Conges- 
 tive, Diffuse, Gummatous. Syphilis of Tendons, Sheaths of Tendons, and Apon- 
 euroses. Syphilis of the Bursse. Syphilis of Ligaments and Joints. Syphilis of 
 Bones. Osteocopic Pains. Nodes, Dry Caries, Gummy Tumor of Bone. Mercury 
 as a Cause of Bone Disease. Syphilis of Cartilage. 
 
 As has already been stated, the lymphatic glands receiving the absorb- 
 ents from the region occupied by the initial lesion of syphilis undergo 
 indolent engorgement. Then follows a rest (second incubation period), 
 and then general syphilis. 
 
 At the commencement of general syphilis, usually before the outcrop 
 of any general eruption, certain glands become indolently engorged and 
 constitute valuable corroborative evidence of the syphilitic nature of any 
 other symptom which may subsequently appear. Occasionally, all the 
 lymphatic glands in the body seem to undergo slight enlargement at this 
 period, but such changes are not pathognomonic. 
 
 The glands which are of clinical value in the diagnosis of general syph- 
 ilis are the epitrochlear and the posterior superficial chain of the post- 
 cervical glands, especially the highest two of the chain, those lying on the 
 occipital bone, one on either side of the nucha. The post-aural glands 
 are also often involved, and the lateral glands in the neck, but they mean 
 nothing especial. 
 
 The enlargement of these epitrochlear and post-cervical glands is not 
 due to any eruption, as is so often stated in text-books. Truly, the exist- 
 ence of an eruption may intensify their hardness and increase their size; 
 but it is very common to find them in a typical state of indolent engorge- 
 ment, when no eruption whatsoever has occupied the surface from which 
 their absorbent radicles are derived. For the post-cervical glands it may 
 be objected that the eruption is overlooked in the hair; but this surely 
 cannot be said of the epitrochlear glands, since the palms and forearms can 
 be minutely inspected. It is certainly the free poison in the blood which 
 effects the indolent engorgement of these glands. Why these particular 
 glands are especially modified by the disease, no one has attempted to ex- 
 plain. Some of the internal lymphatic glands are also involved in the 
 earlier periods of syphilis, as has been proved by post-mortem examina- 
 tions Biirensprung, Virchow. By pressure of glands so enlarged, an 
 attempt has been made to explain the jaundice occurring early in second- 
 ary syphilis.
 
 172 THE VENEREAL DISEASES. 
 
 The glands themselves need a little description. 
 
 They are as hard as bullets under the skin, freely movable in all direc- 
 tions, and not adherent to the skin. The integument over them is not 
 colored, and they are insensitive to pressure, with occasional excep- 
 tions, when they first come out. They rarely get larger than a good-sized 
 pea. 
 
 The duration of these glandular indurations is quite protracted. They 
 appear about six weeks after chancre, and habitually last for months but 
 little, if at all, affected by treatment. Sometimes a trifling enlargement 
 continues permanently, but all the characteristic syphilitic features of the 
 glands disappear during the first year. Consequently, one should not ex- 
 pect the corroborative evidence of these glands in the case of an eruption 
 supposed to be syphilitic, occurring later than the end of the first year 
 after chancre. 
 
 I have seen symmetrical suppuration of the epitrochlear glands coming 
 on spontaneously and having no connection with syphilis, but I have 
 never seen the indolent engorgement of syphilis above described go on to 
 suppuration. 
 
 Other glandular lymphatic engorgements do occur constantly in syphi- 
 lis in various regions. In connection with mouth lesions, or spontane- 
 ously, one or more glands of the neck indifferently situated may suddenly 
 swell up, remain enlarged for a long time, perhaps finally suppurating, or 
 abscess may promptly form in a gland, running on to a speedy opening and 
 discharge. Such abscesses in early syphilis generally get promptly well. 
 Later, in scrofulous patients, they remain open and partake of the mixed 
 characters of scrofulous and syphilitic ulcers, getting well very slowly, 
 and yielding a scar possessing the mixed characters of syphilitic and 
 scrofulous scars. I have seen such an ulcer upon a patient which had lasted 
 more than a year. The patient had had a crop of glands successively ul- 
 cerating, the attack having lasted him five years when I first saw him. 
 This long duration of his trouble had been due to inappropriate treat- 
 ment, for he promptly rallied after efficient means had been employed. 
 
 Sometimes these glandular enlargements reach a great size, soften, 
 but fail to discharge, and, not being opened, their contents dry up and are 
 absorbed, a caseous, cretified mass being left behind. 
 
 These same changes in the lymphatic glands may occur in the groin, 
 axilla, and elsewhere, but are most common in the neck. 
 
 Finally, tertiary glandular gummata are encountered in various glands, 
 internal as well as external, which may ulcerate externally, forming 
 gummatous ulcers, and may disappear by absorption, especially in re- 
 sponse to treatment. The abdominal glands will be referred to again in 
 connection with visceral syphilis, and the consideration of syphilis of the 
 spleen and of the supra-renal capsules will be more appropriate there. 
 Lancereaux speaks of enlargement and fatty degeneration of the thyroid 
 body, due to syphilis, and gummy tumors have been found in it. 
 
 SYPHILIS OF THE HAIRY PARTS. 
 
 The alopecia of syphilis is a feature of early secondary disease, very 
 often observed in connection with syphilitic fever and with the first erup- 
 tion. It varies greatly in degree, being generally quite moderate and con- 
 fined to the scalp, from which it thins out the hairs to a greater or less 
 extent, while occasionally it is very severe, implicates the whole body,
 
 SYPHILIS OF LYMPHATIC GLANDS, ETC. 173 
 
 and perhaps causes the shedding of all the hairs, even down to the 
 lanugo. 
 
 This shedding of the hair in early syphilis is a mere accident, and not 
 intrinsically a syphilitic symptom. It is the result of the anaemia of early 
 syphilis, and is due to a failure of a full supply of nutrition to the hair- 
 papillae. The hairs dry up, lose their lustre, and numbers of them thin 
 out just as they do after scarlet or typhoid fever. The scalp is either 
 unaltered or covered with fine scales (pityriasis alba), or with masses of 
 sebaceous matter mixed with scales (seborrhoea), with which the follicles 
 around the hairs are stuffed. This loss of hair is never permanent when 
 occurring in a young person. 
 
 Later in syphilis from cachexia, there may be a similar thinning of 
 the hair, and in these cases the hair is less apt to grow again. 
 
 Finally, in cases of ulcerative disease, involving the hair-papillae and 
 destroying them, localized areas of baldness ensue, which are necessarily 
 perpetual. 
 
 The treatment of syphilitic alopecia is a general treatment of syphi- 
 lis the treatment of that stage in which the alopecia occurs. There is 
 much value in mercury both as a preventive to the fall of hair, and to 
 arrest the fall after it has commenced in the alopecia of early syphilis. 
 The cachectic form occurring later generally calls for mixed treatment 
 combined with tonics. 
 
 One fact must be impressed upon a patient who demands a cure for 
 his alopecia. At the moment of his application, many hairs are already 
 dead, which still adhere to the head. They are retained in connection 
 with the scalp by the root-sheaths, but are no longer united to their pa- 
 pillae. These hairs are doomed. No power on earth can preserve them, 
 and the sooner they are out the better, for the follicle will the sooner be 
 ready to produce a new hair. Hence the patient's folly maybe made clear 
 to him, when he objects to brushing his hair or washing his scalp, on the 
 ground that, when he does this, his hair comes out in handfuls. Let it 
 come. These hairs must fall out. The patient deceives himself by sup- 
 posing that he is injuring his prospects by brushing the dead hairs away. 
 No amount of brushing or washing will dislodge a healthy hair, and the 
 unhealthy ones call for speedy removal. 
 
 Consequently the patient should be told to wash his scalp thoroughly 
 once or twice a week, either with soap, or with borax 3 i- to the ij. of 
 hot water, or with liquor ammoniae, a drachm to the pint of hot water, 
 according to the dirtiness of the scalp and the amount of seborrhceal exu- 
 dation which it is desired to remove. Rather hard brushing with moder- 
 ately stiff brushes is to be recommended. 
 
 Finally, a stimulating lotion should be rubbed every night, in small 
 quantities, well upon the scalp, and into the follicles under the hair. Such 
 lotions add a little to the chance of preserving the vitality of some of the 
 hairs whose life is only threatened, and encourage the growth of the new 
 hair. The following are good lotions: 
 
 3 Chloral hydrat 3 iss. ii j. 
 
 Tr. capsici 3 vj. xiv. 
 
 Glycerinee 3 i j- 
 
 Spts. myrciae q. s. ad vi. 
 
 M. 
 
 Instead of the glycerine and bay-rum, oil of sweet almonds with co-
 
 174 THE VENEREAL DISEASES. 
 
 logne water may be preferred, as below; it is slightly more stimulating, 
 and leaves the hair softer and less sticky. 
 
 $. Tr. cantharidis 3 iiss. iv. 
 
 Ol. amygdal. dulcis 3 ij. 
 
 Aquae cologniensis q. s. ad f iij. 
 
 M. 
 
 I have seen patients express great satisfaction with a lotion composed 
 of equal parts of refined petroleum and lime-water, scented to suit. 
 
 SYPHILIS OF THE KAILS. 
 
 The nails are epithelial appendages to the integument, very similar to 
 the hairs, and the results of syphilis upon them is analogous to what is 
 observed in the case of the hair. If the early eruptions are intense the 
 nails are apt to get thin, and to lose their lustre, to show more white dots 
 than usual, and to become more brittle and liable to crack. Later in the 
 disease, when the matrix of the nail is more positively influenced by the 
 disease, all of these changes in the nail may be more marked, constituting 
 a true dry onychia. 
 
 In onychia the nail first thins behind at the lunula. As it grows for- 
 ward, ridges and furrows are seen upon it, parallel at first, and then con- 
 verging. The nail, in this way, gets dry, brittle. It looks dirty and 
 cracks easily, and is thin, wavy and irregular, from lunula to tip. This 
 form of onychia, which Fournier has well described, is rare, but less rare 
 than another form also observed by Fournier, in which, instead of thinning, 
 the nail ceases to grow entirely, its tip continues to grow forward, but 
 its posterior edge terminates abruptly in a free, jagged margin. In this 
 manner the whole nail may grow off and be shed. A new nail, perhaps 
 normal, possibly distorted in various ways, ultimately is produced to take 
 the place of the lost nail. 
 
 A more common form of dry, syphilitic onychia, than either of the 
 above, is that in which the nail, usually first at one side of the forward 
 edge, becomes thickened, friable, crumbly, of a dirty, yellowish-white 
 color. The whole thickened surface of the altered part of the nail cracks, 
 fissures, and splits away in pieces, until a portion of the matrix at the 
 side has been left dry and bare. Sometimes a portion only of the nail, 
 sometimes the whole nail, is involved in this process. The nail which is 
 finally reproduced is nearly always normal in structure and appearance. 
 
 All the forms of onychia which have been described are dry and pain- 
 less. The patient usually ascribes them to an injury, but they are not 
 infrequently symmetrical on both hands. They always get well with or 
 without treatment, and their course is invariably very slow. 
 
 Treatment. Internal mercurial treatment certainly modifies dry 
 onychia favorably; but the effect of treatment is very slow, owing to the 
 chronic nature of the process and the peculiar structures involved. I 
 think I have seen advantage slowly fofiow the local use of mercurials. 
 The five or ten per cent, oleate of mercury (Squibb) may be anointed 
 upon the dry, rough nail at night, and the parts protected by a glove- 
 finger. Fortunately it is uncommon for more than one nail upon a hand 
 to be involved at the same time, and the patient usually manages to con- 
 ceal the deformity until time has relieved him. I do not think that the
 
 SYPHILIS OF LYMPHATIC GLANDS, ETC. 175 
 
 iodides exercise so favorable an influence upon dry onychia as the mer- 
 curials internally; but, as the affection often comes on at the end of the 
 second year, or later, the combination of some form of iodine with the 
 mercurial administered internally, is not inappropriate. 
 
 Paronychia due to syphilis is somewhat more common than dry 
 onychia. A mucous patch may appear under the nail, or in the sulcul 
 alongside of the nail, and, ulcerating, involve the matrix. Ulcerative and 
 papulo-squamous lesions may grow up to the border of the nail, and in- 
 clude the matrix in a fissure or an ulcer. A papule on the fold of skin 
 above the lunula leads to alteration in the nail. An ulcer preceded by a 
 small, painful, livid swelling, may start at one side of the nail, and run 
 around the border, involving the nail, and causing it to be shed by sup- 
 puration of the matrix. Such ulcers are apt to be attended by the for- 
 mation of exuberant granulations at the borders of the undermined nail. 
 The secretions are retained in such cases long enough to putrefy in part, 
 and they become thin and offensive in odor. The whole or only a por- 
 tion of the nail may come away, and the ulcer which takes its place may 
 eat down into the matrix deeply enough to destroy it. The whole toe or 
 finger may inflame (dactylitis), and the ungual phalanx may be involved 
 in necrosis. When the ulcer is deep enough to involve the matrix to a 
 considerable extent, a healthy nail is not again produced, but, after heal- 
 ing, which always takes place, the nail may be represented by a deformed 
 substitute, or by uneven bands of cicatricial tissue containing varied 
 amounts of nail-substance. A gummy tumor commencing in the matrix, 
 (usually near the lunula), sometimes occurs, terminating in ulceration, 
 sweeping away the nail, and threatening the whole phalanx. 
 
 The diagnosis of syphilitic onychia and paronychia is difficult. The 
 dry onychia in its different forms is, in many cases, difficult to distinguish 
 from similar conditions produced by eczema and psoriasis. The ulcera- 
 tive form resembles ingrowing nail, but in the syphilitic disease the matrix 
 is usually involved first, and not secondarily, as in ordinary ingrowing 
 nail, or in common runround. The gummy tumor is not apt to be taken 
 for anything else. 
 
 The treatment of paronychia, and of ulcerated matrix generally, is 
 to keep the parts scrupulously clean by washing with warm water and 
 soap, by means of a camel's hair brush; to remove all dead and raised 
 portions of nail (often, with advantage, the whole nail), and to treat the 
 stage of syphilis in which the malady occurs with the remedies appropri- 
 ate to that stage. The best local applications for the ulcers are pure 
 iodoform freely used, black and yellow wash, mild oleate of mercury, and 
 the judicious use of poulticing, pressure, and nitrate of silver if the granu- 
 lations are exuberant. 
 
 DACTYLITIS. SYPHILIS OF THE FINGERS AND TOES. 
 
 This is an important form of syphilis. It falls naturally into place 
 here, since many tissues are involved at the same time in the affection, and 
 the malady cannot well be described under the head of any of them alone. 
 Syphilitic dactylitis did not receive much attention until a few years 
 since, but now enough cases have been minutely recorded to make its his- 
 tory a clear one. It occurs in two forms: the one involving the joint 
 and more superficial tissues, the other the bone and joint. Both are 
 gummatous.
 
 176 THE VEITEKEAL DISEASES. 
 
 The first form is a gummy infiltration of the periosteum and subcuta- 
 neous tissues. But one phalanx (generally the proximal) may be involved, 
 or the whole finger may share in the morbid process. I am now treating 
 a case of six months' duration, in which the disease commenced as a tuber- 
 culo-squamous eruption upon the thenar eminence. The thumb became 
 involved in a spread of the eruption, and then suddenly all of its tissues 
 became infiltrated in almost a painless way, until the thumb was more than 
 twice the size of its fellow, and much crippled as to the movements of its 
 joints. The eruption, meantime, continued upon the thumb, and remained 
 there after the latter had been reduced by treatment very nearly to the 
 size of the thumb of the other hand. 
 
 The swelling in this form of dactylitis is firm, ends abruptly, and does 
 not shade off into the surrounding skin. It is not attended by pain ex- 
 cept on motion, which is generally mechanically interfered with by the 
 swelling. The color of the integument is often a livid, light red, whether 
 there is any eruption upon the skin or not. If the disease is allowed to 
 progress, the ligaments of the joint next become involved. Effusion into 
 the joint is exceptional in this form of disease. Finally, the cartilages 
 erode and the joint is destroyed, the bones becoming implicated at this 
 time. 
 
 The course of the affection is slow, and relapse not uncommon. Per- 
 
 FIG. 17. Dactylitis of the toe. 
 
 sistent treatment is always curative, but, if the cartilages have been in- 
 volved or the joint disintegrated, loss of function necessarily follows. 
 
 Fig. 17, after Taylor, represents a toe which is the seat of this dif- 
 fuse dactylitis. 
 
 The other form of dactylitis is a gummy tumor of the bone, starting 
 sometimes under the periosteum, sometimes in the medullary membrane. 
 One or more phalanges may be attacked. Fig. 18, after Berg, repre- 
 sents the common seat of the tumor in a typical case, the proximal pha- 
 lanx. Effusion may take place into a joint, and the latter may be in- 
 volved in the disease even to a greater extent than the intervening pha- 
 lanx. I had one such case at the Charity Hospital, in which the meta- 
 carpo-phalangeal joint of the thumb and of the great toe on the right 
 side bore the whole brunt of the disease. 
 
 The superficial and surrounding tissues often escape implication in an 
 extraordinary way. The skin may be of a livid pink from tension, but
 
 SYPHILIS OF LYMPHATIC GLANDS, ETC. 
 
 177 
 
 not at all structurally altered; the nail generally escapes, even when the 
 ungual phalanx is the seat of disease. 
 
 The natural evolution of this malady seems to be that it culminates 
 after a time, and the gummy tissue, not being organized, is reabsorbed 
 without breaking down. Very rarely does the gummy tissue disintegrate 
 and ulcerate its way to the surface. As a result of this interstitial ab- 
 
 FIG. 18. Berg's finger. 
 
 sorption, the bone atrophies visibly and the phalanx shortens. When 
 two bones and an intervening joint have been involved, the shortening 
 due to absorption is so considerable as to reduce the whole finger greatly 
 in length. In a case of McCready's, which he kindly showed to me and 
 which has been pictured by Taylor * (Fig. 19), the deformity produced by 
 
 FIG. 19. 
 
 this absorption was very striking. There had been noulceration reaching 
 the surface in this case, and the functions of the fingers were compara- 
 tively good. 
 
 When the centre of a phalanx only is involved in the disease, absorp- 
 tion of the gummy material may leave the bone separated in its centre. 
 
 ' Am. Journal of Dermatology and Syphilography, January, 1871. 
 12
 
 178 THE VENEREAL DISEASES. 
 
 In such a case the two ends generally come together as a false joint, and 
 the skin over them contracts, so as to conform itself to the new order of 
 things. There is no pain at all, as a rule, in this form of dactylitis. 
 
 The diagnosis in dactylitis is very easy. The first diffuse variety 
 can hardly be mistaken for any other malady. Gout and all ordinary in- 
 flammations are too painful to be confounded with it. The second form 
 might be mistaken for enchondroma, which also is painless, and apt to 
 appear upon the phalanges. Enchondroma grows more slowly, and pre- 
 fers the palmar aspect of the bone as a point of origin, while dactylitis 
 starts more often upon the dorsum of a bone (in the periosteal form). 
 A close study of the course of the affection will clear up the diagnosis. 
 
 Prognosis. Syphilitic dactylitis, even if left to itself, always gets 
 well; but it is apt to do so at the expense of deformity and more or less 
 interference with function. Its progress may be arrested at almost any 
 stage by a bold and efficient treatment. 
 
 Treatment. The diffuse form requires mercury in combination with 
 iodide of potassium or some other iodide, which (the iodide) must be un- 
 sparingly pushed as rapidly as the stomach will allow. The second form 
 needs no mercury, but, like all pure gummata, yields generally a very 
 ready response to the vigorous use of the iodides. They should be com- 
 bined with a vegetable bitter, and given lavishly. In the way of local 
 treatment, inunctions of mercurial ointment, or of the oleates, seems to 
 help along, and I have thought that pressure was sometimes of service. 
 The effect of treatment in any case is slow. 
 
 SYPHILIS OF THE MUSCLES. 
 
 Syphilis attacks the muscles by involving their connective-tissue at- 
 mosphere in congestive and hyperplastic' processes, or by the formation, 
 in this atmosphere, of gummatous deposit. The contractile function of 
 the muscle is always interfered with while under the influence of the at- 
 tack. The diffuse hyperplastic form tends to produce cirrhosis of the 
 muscle and atrophy; the gumma destroys the part of the muscle it occu- 
 pies. 
 
 There are three forms of syphilis of the muscle: the congestive, the 
 diffuse hyperplastic, the gumma. 
 
 The ' congestive myositis may be, and doubtless is a mild degree 
 of the diffuse hyperplastic form. Notta ' first called attention to it as a 
 peculiar affection of the biceps, and Mauriac J recently has collected 
 eighteen cases (nine of them personal), out of which he constructs a new 
 subdivision of syphilitic myositis. 
 
 The malady in question appears to involve mainly the lower end of 
 the biceps cubiti. Other muscles also suffer notably, the triceps in the 
 arm. The malady comes on between the sixth and the tenth months, 
 oftener in light than in severe syphilis, and usually in patients who have 
 suffered from pains in the muscles and fibrous tissues previously in the 
 disease. Mauriac observed it more often on the left side, and accompany- 
 ing dry rather than moist cutaneous lesions. Usually the affection is 
 unilateral, or, if bilateral, of unequal intensity on the two sides. 
 
 It comes on insidiously, and advances slowly. In the biceps its 
 
 1 Archiv. g^n., 1850, p. 413. 
 
 LeconH sur lea myopathies syphilitiqnee. Paris. Delahaye, 1878. pp. 
 
 208.
 
 SYPHILIS OP LYMPHATIC GLANDS, ETC. 179 
 
 muscle of election the malady shows itself by an inability to straighten 
 the arm completely, on account of the pain caused by the effort at the 
 lower point of attachment of the muscle. Flexion is normal. When the 
 triceps brachialis is simultaneously involved, the elbow becomes fixed 
 (muscular anchylosis). 
 
 In this affection, according to Mauriac, all the tissues about the joint 
 are normal, except the tendon of the biceps, which is short, hard, stiff, 
 prominent. The muscular fibres appear to be semi-contracted a condi- 
 tion increased by forced extension or voluntary flexion. Occasionally, 
 there are dull pains in the muscle by night. The pain on forced exten- 
 sion is referred to the upper, inner part of the lower tendon of the biceps. 
 If the triceps is also involved, there is another focus of tenderness above 
 the olecranon. These points are generally sensitive to pressure. 
 
 Untreated, this affection continues for several months occasionally, 
 several years but always gets well eventually, without altering the mus- 
 cular structure. Mauriac believes the lesion to be hypersemia. 
 
 The diffuse form of connective-tissue hyperplasia is a chronic myo- 
 sitis of specific nature. The parenchyma of the muscle becomes thick- 
 ened by the development of new round and fusiform cells, which go on 
 to organization into fibres, lose their succulent character, contract like 
 cicatricial tissue (as in cirrhosis) upon the muscular elements, and, un- 
 treated, in the end lead to atrophy of the muscle, with more or less short- 
 ening and loss of function. 
 
 In this affection there is no pain, but the muscle gradually shortens, 
 diminishes in size, and becomes more fibrous in texture. Muscles of the 
 upper extremity (particularly the flexors) and of the face are more often 
 involved than those of the lower extremity. 
 
 Treatment is of advantage in some cases, even after atrophy has com- 
 menced. All cases treated early are favorably influenced by a combina- 
 tion of mercury with the iodides. 
 
 GUMMA OF THE MUSCLE. 
 
 A gummy tumor may form in any muscle among the connective-tissue 
 elements, or in the sheath. A gumma here is, as it is elsewhere, at first a 
 collection of nucleated, round and spindle cells, which finally become ab- 
 sorbed, or remain as a mass of cheesy debris, or soften and find their way 
 to the surface, acting just as gumma does when its seat is in the subcu- 
 taneous connective tissue. 
 
 No muscle is exempt from liability to attack, but certain large muscles, 
 gluteus, pectoralis major, sterno-cleido-mastoid, trapezius, the heart, are 
 most commonly the seat of the new growth, or certain delicate muscles, 
 those of the tongue, larynx, pharynx, soft palate. 
 
 The symptoms of gumma of a muscle are at first only a tumor in the 
 muscle, which is painless, and often of considerable size when first dis- 
 covered. In a large muscle the tumor is found to be stationary, when the 
 muscle is thrown into contraction; at other times movable (Nelaton). The 
 skin is normal over the tumor until the latter approaches the surface and 
 begins to soften, and then there may be complaint of some pain, especially 
 at night. 
 
 The termination of gumma is in destruction of all the muscular fibre 
 involved in the new growth, whether the gumma becomes cheesy, or soft-
 
 180 THE VENEREAL DISEASES. 
 
 ens and discharges. Prompt treatment alone can arrest destruction of 
 tissue. 
 
 The symptoms of gummata of the pharynx, larynx, and tongue are de- 
 tailed elsewhere. 
 
 The diagnosis of a muscular gumma is only possible, in many instan- 
 ces, by aid of the history and concomitant symptoms, and by the effect of 
 treatment. 
 
 Treatment with iodides in large doses is generally promptly effective 
 of a cure in the earlier stages of gumma. After the mass has softened, 
 treatment is sometimes incapable of preventing perforation of the skin 
 and discharge of the syrupy and cheesy debris. 
 
 SYPHILIS OF TENDONS, SHEATHS OP TENDONS AND APONEUROSES. 
 
 Verneuil first, and later Fournier, have described affections of the 
 sheaths of tendons due to syphilis. The sheaths of the tendons on the 
 back of the wrist in secondary syphilis may become the seat of effusion, 
 swelling up in triangular form, with the base toward the fingers, or the 
 effusion may be less generalized. The swelling fluctuates, and usually is 
 unattended by pain. Occasionally, however (Fournier), pain, heat, red- 
 ness, and interference with function, are as great as in inflammatory ten- 
 osynitis. 
 
 Other tendons about other joints may be involved in a similar process, 
 but the affection at best is a rare one, and the back of the wrist its point 
 of election. 
 
 Treatment is mercury internally, and it is usually promptly effective. 
 
 Tendons are sometimes involved in syphilitic diffuse interstitial con- 
 nective-tissue thickening, and extensive gummata of nearly all the large 
 tendons have been placed on record. Gummata of tendons are painless 
 until they create irritation by their size, or by commencing to soften. 
 When they become painful, the muscle from which they spring generally 
 refuses to act. 
 
 The aponeuroses are subject to the same changes as the tendons. 
 
 Treatment is that of tertiary syphilis : mixed treatment for the dif- 
 fused form of disease; iodides alone for gummata. 
 
 SYPHILIS OF THE BUKS^B. 
 
 Verneuil has reported an interesting observation of simple dropsy of 
 the bursa behind the olecranon, without thickening of the walls of the 
 bursa, and due to secondary syphilis. Verneuil and Moreau have given 
 cases of tertiary syphilitic affections of the bursje. I have reported ' 
 several cases of tertiary syphilitic bursitis, and observed a number of 
 others since the publication of my paper upon the subject. 
 
 Tertiary syphilitic housemaid's knee is the most common apparently 
 of all forms of syphilitic bursitis. Next in liability to attack seems to be 
 the bursa at the inner side of the knee. The bursa behind the olecranon 
 follows. The other bursae are attacked on the whole very seldom. The 
 malady is far from common in any of its forms. 
 
 Figs. 20 and 21 represent two cases of tertiary syphilitic housemaid's 
 
 1 Syphilis <u affecting the Burae : Am. Jour, of Med. Sci. , April, 1876, p. 349.
 
 SYPHILIS OF LYMPHATIC GLANDS, ETC. 
 
 181 
 
 knee taken from my paper upon the subject. Fig. 20 shows the first 
 form of the affection, that commencing from without. A deep tuber- 
 culo-squamous, perhaps ulcerative, syphilide appears first over the knee 
 and involves the integument covering the bursa. The skin thickens, 
 is livid, rough on the surface, perhaps ul- 
 cerated. It becomes sometimes almost 
 elephantiasic in thickness, and shows deep 
 lateral burrows due to the motions of the 
 joint, but the physical characters of the 
 eruptions and ulcers upon the surface mark 
 the process as syphilitic. 
 
 After the morbid changes have reached 
 this height, and sometimes long before it, 
 when there is only an eruption lying over 
 the bursa in front of the patella, the tissues 
 surrounding the latter become involved in 
 the disease. The walls of the bursa some- 
 times thicken enormously and a gummatous 
 infiltration invades its whole structure and 
 grows into its cavity. The tendency of this 
 newly formed tissue is to become soft, gela- 
 tinous, and to work its way by ulceration 
 to the surface, where it discharges as a 
 puriform material containing the debris of 
 the bursa. In this way the morbid material 
 eliminates itself, and cicatrization effects a 
 cure, although fistula may remain leading 
 through the skin to the site of the former 
 bursa for a considerable period. 
 
 The second form, Fig. 21, commences from within. It is an infiltra- 
 tion of the bursa, with gummy material, primarily, the surrounding tissues 
 and the skin being spared until the tumor formed by the bursa has soft- 
 tened, contracted adhesions, and prepared to discharge externally. The 
 affection comes on insidiously, is often discovered 
 by accident, is absolutely painless until softening 
 sets in. 
 
 The diagnosis of the first described form 
 of syphilitic housemaid's knee is easy on account 
 of the accompanying eruptive phenomena upon 
 the integument over the knee. In the second 
 form diagnosis is almost impossible except from 
 the history. The tumor may be symmetrical, but 
 if so, is usually uneven on the two sides; the 
 bursa is as hard as a nut at first and throughout, 
 until the gumma begins to break up and the skin 
 to adhere. Only occasionally can any fluctuation 
 be felt before this time. These features may 
 distinguish some cases from common housemaid's 
 knee, but certain indolent forms of the latter 
 resemble it greatly, even in the peculiar woody 
 hardness which the syphilitic variety always possesses in a high degree. 
 
 For the other bursae, when implicated in syphilitic disease, concomi- 
 tant symptoms, study of the case and of the history, must be depended 
 upon to clear up the diagnosis. 
 
 FIG. 20. 
 
 FIG. 21.
 
 182 THE VENEREAL DISEASES. 
 
 The course of tertiary syphilitic bursitis is very protracted; months or 
 years may be involved in the evolution of the disease, and a syphilitic 
 ulcer or sinuses may persist almost indefinitely after the bursa has soft- 
 ened and discharged externally. 
 
 Treatment should be mixed. The iodides are more powerful in dis- 
 persing the tumor than mercurials, but the effect of treatment is not 
 promptly observed, and the combination of mercury with the large doses 
 of the iodides seems to increase the effect of the latter. The free local 
 use of the oleate of mercury at five or twenty per cent, strength, accord- 
 ing to its effect upon the skin, has certainly a positive value. Treat- 
 ment is of advantage in shortening the duration of the affection in all its 
 stages, the ulcerative as well as the others; but it is very desirable to bring 
 treatment to bear upon the tumor before the skin has become involved, 
 since in this manner absorption of the gumma can generally be effected, 
 and prolonged suppuration as well as the subsequent scarring may be 
 avoided. 
 
 SYPHILIS OF LIGAMENTS AND JOINTS. 
 
 The joints are involved occasionally, both in secondary and in tertiary 
 syphilis. The joint affection in the former case is attended by pain, spon- 
 taneous and on pressure, and by fever, which may run to such a height 
 as to make the malady assume the form of acute articular rheumatism, 
 especially as sweating is apt to be a feature of the malady, with acid urine 
 full of urates; this of course in severe cases. The pains felt so commonly 
 in the joints during secondary syphilis are not necessarily located in the 
 joint itself. They may be due to changes in the bursae, in the tendons, in 
 the periosteum about the joint. When the joints are involved in early 
 syphilis, there is generally some effusion of fluid. The affection always 
 gets well and yields to mercury. 
 
 The acute form may also occur, according to Duffin,' Biiumler,* late in 
 syphilis. Its diagnosis (Duffin) is always easy, since the fever accompany- 
 ing it is decidedly intermittent, with nocturnal exacerbations, and this 
 fever as well as the rheumatism yields a quick response to antisyphilitic 
 treatment. 
 
 A chronic hydarthrosis, due to tertiary syphilis, without any thicken- 
 ing of the structures forming the joint, is occasionally encountered. I 
 have seen two such cases. Both of them yielded very promptly to the 
 iodide of potassium. 
 
 Gummatous infiltration of the small joints, terminating in their disin- 
 tegration and destruction, sometimes with opening and discharge exter- 
 nally, sometimes without it, has been referred to in connection with dac- 
 tylitis. 
 
 The larger joints also suffer in tertiary syphilis, their ligaments, capsule, 
 and the surrounding tissues becoming the seat of gummatous infiltration. 
 A number of cases have been reported in which various joints have been 
 involved. 
 
 The knee suffers far more frequently than any other joint. A gummy 
 deposit takes place in the capsule, in a diffused form, with localized areas 
 of greater thickening the extra deposits being often in the loose portion 
 
 1 Trans, din. Soc. of London, Vol. II., 1869, p. 81. 
 
 * Ziemasen's Cyclopedia (Am. Translation), Vol. III., p. 177.
 
 SYPHILIS OF LYMPHATIC GLANDS, ETC. 183 
 
 of the capsule, extending above the knee in front under the tendon of the 
 quadriceps muscle. Together with this thickening of the capsule, there 
 occurs slowly an inconsiderable effusion into the joint. This effusion 
 may be absorbed and form again a feature, according to Richet, of diag- 
 nostic value for the syphilitic form of synovitis. There is no pain early 
 in the disease, and no fever. The joint feels weak, but motion at first is 
 not painful, only the joint gets tired sooner than its fellow. 
 
 The malady is usually unilateral. As the changes progress, nocturnal 
 pains often set in, the joint assumes more or less of a fusiform shape, re- 
 calling white swelling, with which it is ordinarily confounded. The knee 
 becomes distinctly hot to the hand. 
 
 Finally the cartilages soften and disintegrate, gummatous material 
 fills the cavity of the joint. Softening of the gumma takes place with 
 discharge externally, or even, in the case of absorption, the joint has be- 
 come disorganized, its functions forfeited, and anchylosis ensues. 
 
 The diagnosis of syphilitic arthropathy of the knee is with white 
 swelling. In white swelling (strumous fungous arthritis) the patient is 
 generally young, the joint becomes hot and painful early in the disease, 
 and uniformly involved in the general oval thickening of the tissues from 
 the first. There is not so insidious an onset as in syphilis, and no local- 
 ized hard bodies in the loose capsule above the joint, in the beginning, 
 suggestive of loose cartilages in the joint. The peculiar indolence of the 
 syphilitic arthropathy is its chief diagnostic feature an indolence which 
 allows painless motion to the joint many months after all motion would 
 have ceased had the disease been due to another cause. I have seen a 
 number of cases of syphilitic arthropathy of the knee, among them one 
 had been long treated as a white swelling, another as rheumatism, another 
 was amputated, another ignored. Unfortunately, syphilis as affecting the 
 joints is not sufficiently well known among the profession to be carefully 
 looked for, and many cases go badly by default. 
 
 Treatment. Mixed treatment, with the iodides in excess, yields won- 
 derful results in this malady. Few cases are so bad that they cannot be 
 benefited, and in almost any case where the cartilages have not been 
 eroded, no matter for how many months the affection of the joint has 
 lasted, a cure may be pretty confidently expected by an active treatment 
 pushed rapidly at first, and prolonged in a milder form for a considerable 
 period after apparent recovery. The local use of mercurial plasters and of 
 the oleate, and the employment of pressure locally assist in the rapidity 
 of the cure. All things considered, treatment may be expected to act with 
 considerable promptness in these cases. After disintegration of the joint, 
 or anchylosis, the effect of treatment can do no more than arrest the dis- 
 ease. It cannot cause the formation of a perfect joint. 
 
 Effusion into a joint may take place in connection with syphilitic dis- 
 ease of one of the bones entering into its structure, and that without any 
 physical lesion of the joint, except hyperaemia. Such symptoms depend- 
 ent upon disease of the bone yield when the latter gets well. 
 
 SYPHILIS OF THE BONES. 
 
 The bones may be involved in secondary, as well as in late syphilis. 
 The epiphyseal changes in the long bones will be noticed under the head 
 of inherited syphilis. Mauriac ' has observed nodes in secondary syphilis 
 
 1 Affections syphilitiques precoces du systeme osseux. Paris, 1872.
 
 184 THE VENEREAL DISEASES. 
 
 upon a number of different bones, and other investigators have reported a 
 few cases. These nodes, however, are not the destructive gummata of late 
 syphilis ; indeed, rather rarely do they even go on to organization and hy- 
 perostosis, the common termination of ordinary nodes in tertiary disease. 
 The secondary syphilitic node is often only a subperiosteal oedema and hy- 
 persemia coming on suddenly, perhaps as the result of local injury, disap- 
 pearing promptly under treatment, and leaving behind no trace of its ex- 
 istence. 
 
 Some few of the secondary subperiosteal swellings, however, do lead 
 to local thickening of bone, which remains permanent. 
 
 OSTEOCOPIC PAINS 
 
 commonly occur in secondary syphilis, and often in late syphilis as well. 
 They are pains of a splitting, boring, bone-breaking character, coming on 
 at night in certain bones, sometimes with great regularity and terrible 
 fierceness, and ceasing toward morning. These pains are probably due 
 to slight periosteal swellings in secondary syphilis, attended by considera- 
 ble subperiosteal hyperaemia. Ordinarily tolerable, they are sometimes ex- 
 cruciatingly painful in character. The warmth of the bed seems to inten- 
 sify them (Ricord), and sometimes the weight of the bed-clothes cannot be 
 borne upon a bone which is the seat of pain. Baiimler thinks that it is 
 not the heat of the bed, or the night time, which causes the pain, but a 
 febrile exacerbation coming on toward evening, which dilates the periph- 
 eral blood-vessels. Occasionally, but very rarely, the pains come on by 
 day, and cease by night. In such cases no thermometric observations 
 have been made, so far as I am aware. 
 
 These osteocopic pains are often relieved somewhat by pressure. They 
 occur about the head and neck, the shoulders, elbows, and knees, and in 
 the continuity of the long bones. The previous use of mercury has noth- 
 ing whatsoever to do with the causation of these pains, which, on the con- 
 trary, are not apt to come at all if mercury has been commenced early 
 enough, and which disappear more quickly under the use of mercury 
 than under the employment of any other drug. 
 
 In connection with the pains, sometimes, when the bone is superficial 
 (cranium, tibia), the periosteum is apparently raised a little, and gives to 
 the fingers an obscure sense of fluctuation. Often, on the other hand, in 
 early syphilis, the osteocopic pains lie at the attachment of the tendons 
 of muscles into the articular ends of bones. 
 
 The night headache of early syphilis is usually an intense osteocopic 
 pain. 
 
 Treatment. Osteocopic pains early in syphilis are favorably influ- 
 enced by both mercury and the iodides, but mercury has decidedly the 
 more power over them. When the pains are only moderate, they do not 
 call for any deviation in the general treatment which the stage of the 
 disease calls for in which they occur. When they are intense, however, 
 mercury in minute doses, frequently repeated, will sometimes relieve them 
 very promptly. This is known as Trousseau's plan of treating early 
 syphilitic headache. It is often of value in the treatment of other in- 
 tense osteocopic pains. From one-fifteenth to one-tenth of a grain of 
 calomel may be given in this treatment hourly, for twenty-four hours. 
 Then it is well to arrest treatment for one day, and then repeat a similar 
 course. The object of interupting treatment is the fear of salivation or
 
 SYPHILIS OF LYMPHATIC GLANDS, ETC. 185 
 
 of intestinal disturbance, of which there is some danger when this method 
 is pushed in susceptible cases. 
 
 When osteocopic pains come on in late syphilis, they generally indi- 
 cate a tendency to serious disease of bone, and call for the iodides in 
 large doses. The mercurials are also of advantage here, but the iodides 
 outrank them. 
 
 Of the serious lesions of bone produced by syphilis, three require de- 
 scription : the node, dry caries, and the gummy tumor. 
 
 THE NODE. 
 
 A node is an inflammatory osteo-periostitis, terminating generally in 
 new formation of bone. The subperiosteal tissues first become con- 
 gested, then there is a new formation of soft, round, and spindle cells. 
 By this proliferative cell-formation, the periosteum is raised over a vari- 
 able area in the form of a rounded lump, which gradually shades off into 
 the surrounding tissues. This lump is soft, and at first quite painful, 
 especially upon pressure. Manipulation proves it to be attached to the 
 bone. The skin over it is freely movable, and not discolored. There is 
 often oadema, especially in young nodes of large size. The pain in these 
 nodes is sometimes considerable, spontaneously, especially if they are 
 situated on the shin, and if the patient walks or stands much. The pain 
 is quite certain to be intensified at night. 
 
 The bones most often involved are the flat bones (cranium) and 
 superficial bones (tibia, clavicle, ulna). Local injury, a blow, will some- 
 times cause a node to appear, but neither situation nor local violence is 
 necessary for their production, for they sometimes grow from the inner 
 table of the skull, where they cause great damage by pressure, and they 
 are occasionally found upon a deep-seated bone (femur, vertebral column) 
 well down among the muscles. 
 
 The date of appearance of nodes is late in syphilis. Early forms do 
 occur, as already mentioned; but they are not important, and generally 
 disperse, leaving no trace. 
 
 The course of a node is generally slow. After remaining soft for a 
 varying period, they become firmer, and gradually disappear by absorp- 
 tion under treatment or (sometimes) spontaneously, leaving no trace 
 behind, or only a depression surrounded by a hard border of new bone, 
 which has formed at the circumference, while no bone-salts have been de- 
 posited centrally. Occasionally a node softens centrally, the skin over 
 it beoomes involved, red, adherent. The softened node discharges and a 
 syphilitic ulcer remains, the floor of which is bone denuded of its perios- 
 teum. This bone becomes black or brown where it is exposed, and often 
 a superficial flake necroses, separates in due time, and comes away, after 
 which the ulcer heals. On the skull the outer table comes away generally, 
 the inner table remaining, perhaps perforated by a number of holes 
 through which the dura mater may be seen and felt. 
 
 Sometimes a node will remain as a hard, fibrous lump, perfectly pain- 
 less, and as solid as wood for a number of years, causing no inconvenience. 
 In such a lump bone-salts are not deposited; the mass consists of spindle 
 cells, round cells, and connective tissue. Such a node, after existing for 
 years, may suddenly soften and melt away, involving the bone in destruc- 
 tion, large portions of the superficies of which necrose in the floor of the 
 ulcer. I have seen one such case where a fibrous syphilitic node, as large
 
 186 THE VENEREAL DISEASES. 
 
 as an egg, remained stationary for eleven years upon a man's skull, and 
 finally softened after a severe attack of typhoid fever, and caused the loss 
 of a number of square inches of the outer table of the skull. 
 
 The scars left by nodes which have softened and discharged are white, 
 puckered, attached to the bone, often pigmented at the circumference. 
 The loss of bone by necrosis is not made up, but the old bone at the edges 
 of the ulcer may be thickened. 
 
 Finally and most commonly, a node, having existed some time, under- 
 goes partial transformation into true bone in its under layers and circum- 
 ferential portions. Such new formations of bone cannot be removed by 
 treatment. They remain permanent; but after a time they lose their sen- 
 sitiveness and constitute simple exostoses. 
 
 Besides periostitis there may be a general proliferative osteitis (usually 
 of a long bone) involving a portion or the whole of a bone in a painful 
 general thickening. The increase in size remains permanent. 
 
 The form of bony outgrowth due to syphilis has been called epiphy- 
 sary exostosis. It is an irregularly shaped ridge or prominent peduncu- 
 lated bony formation occurring about the epiphysary ends of long bones, 
 recalling the outgrowths seen in rheumatic gout. 
 
 Diagnosis of nodes is not difficult. When young and soft they may 
 possibly be mistaken for oedema or abscesses; but the course of the 
 growth, and particularly the nocturnal pains, suggest a search for a syph- 
 ilitic history, and put the physician on the right track to discover the na- 
 ture of the affection. 
 
 Treatment. Nodes respond very readily to treatment, as a rule. 
 The iodides are called for in doses large enough to control nocturnal pain. 
 They should be kept up for several weeks or months, after an apparent 
 disappearance of the node or relapse is to be feared. The length of this 
 after-treatment depends upon the age of the node. 
 
 DRY CARIES. 
 
 Virchow has described this affection after profound study of the path- 
 ological process. The frontal and parietal bones of the skull are most 
 often involved; indeed, the affection is almost confined to the cranium, 
 the external table alone, or both tables of the bone being implicated. The 
 outer coat of the blood-vessels perforating the bone is the matrix in which 
 the new growth of cells takes place in caries sicca, as shown by Rindfleisch 
 and Virchow. This new cell-formation is gummatous. Its development 
 by pressure causes an atrophy of the bone surrounding the vessel, while 
 at the outer edge of the little collection of cells the subperiosteal cell 
 formation lifts the periosteum, and therefore does not cause enough pres- 
 sure to produce atrophy. This circumferential portion of the little tumor, 
 therefore, becoming ossified, creates a raised ridge, while ultimately that 
 portion of the minute gumma which occupied the adventitia of the vessel 
 is removed by absorption, and leaves a cavity produced by the previous 
 atrophy of bone. The periosteum sinks into this cavity and adheres to 
 its floor. The bone surrounding such a minute depression in the skull and 
 the diploe about it become sclerosed. 
 
 The skull sometimes is perforated by caries sicca. More often upon the 
 inner table localized thickenings of bone are found and bony osteophy tes, 
 with, not unfrequently, fibrous thickening of the adherent dura mater.
 
 SYPHILIS OF LYMPHATIC GLANDS, ETC. 187 
 
 Occasionally, caseous yellow deposits have been found at these spots at- 
 taching the pia to the dura mater. 
 
 The final scar in the bone is a stellate, puckered depression, with an 
 eburnated, raised border. 
 
 Symptoms. Caries sicca comes on only in late syphilis, and an- 
 nounces itself by localized pain without swelling. In the atrophic stage 
 the worm-eaten depressions in the skull may be readily felt through the 
 scalp. They are pathognomonic of syphilis and by themselves are suffi- 
 cient to establish a diagnosis. Without them the history must be relied 
 upon in the main for diagnosis. 
 
 Treatment is that of gumma of bone. 
 
 GUMMA OF BONE. 
 
 A gummy tumor late in syphilis may form anywhere in a bone under 
 the periosteum, in the medullary membrane, interstitially as in caries 
 sicca. 
 
 The subperiosteal gumma is found chiefly upon the clavicle, skull, 
 sternum, ribs, tibia, ulna. It commences like a node, and indeed a node 
 is a gumma, but the true gummy tumor forms more rapidly, is less diffuse, 
 and tends always to soften, while the less active node tends naturally to 
 remain organized. The gumma is an acute process, like the osteitis and 
 periostitis already described, but much more active. Consequently, it is 
 more serious, more destructive. 
 
 The gumma, commencing like a node and advancing rapidly, softens, 
 attaches itself to the skin and discharges, its puriform debris remaining 
 as an ulcer with dead bone at the bottom. The pain in superficial gumma 
 of bone is generally slight, or absent entirely. Instead of discharging, 
 gumma of bone may remain a soft mass for a time, finally becoming cheesy; 
 and even a softened gumma, instead of discharging, may calcify. 
 
 Gumma of the medullary membrane in the long bones is uncommon. 
 It is usually attended by intense pain, worse at night; the whole bone 
 swells, and finally gives way. Ultimate atrophy of the portion of bone 
 involved is to be expected. 
 
 Medullary gumma of the short bones is not very uncommon. A type 
 of such formations is seen in dactylitis, already described at p. 175. 
 
 The diffuse thickening of bone, already referred to in connection with 
 syphilitic osteo-periostitis, is often a gummatous process, the connective 
 tissue around the vessels permeating the bone, in the Haversian canals 
 and canalicules, being the matrix in which gelatinous, gummatous hyper- 
 plasia occurs, afterward drying up and being absorbed, leaving the en- 
 larged bone very porous, or remaining degenerated in the form of yellow 
 or cheesy deposits. 
 
 In the flat bones, and particularly in the diploe of the skull-cap, syph- 
 ilitic gumma takes the form of an infiltration, widening the bony lacuna-, 
 cutting off the vitality of the thin plates of bone involved, and, by its 
 gradual increase, separating the two plates of condensed bone from each 
 other. Finally, a piece of condensed bone may die, and gradually exfoli- 
 ate. The external table of the skull over a considerable area may perish 
 in this way, and, when the necrosed portion has exfoliated, its under 
 surface is found to be very much worm-eaten and roughened. This is due 
 to the nature of the morbid process which effects the separation. At the 
 circumference of these morbid processes, as elsewhere in bone syphilis.
 
 188 THE VENEREAL DISEASES. 
 
 eburnation, condensation, and thickening of bone take place with more or 
 less tendency to osteophytic and hyperosteal formations. Sometimes the 
 inner table of the skull necroses in connection with diffuse gumma of the 
 diploe, leading to changes in the dura mater and brain, and to the most 
 serious nervous symptoms. 
 
 When the very thin bones are attacked by gummatous changes they 
 ulcerate and in part necrose, portions of dead bone coming away entire. 
 This is the rule in the case of the thin bones of the nose, palate, etc. 
 
 The disease of bones in these regions, indeed, is often only a complica- 
 tion of gummatous ulcers commencing in the soft parts, which, during 
 their progress, have involved the bone. The same result sometimes com- 
 plicates gummatous ulcers of the integument, as already detailed (p. 162); 
 but the bones of the nose are peculiarly liable to destruction from syphi- 
 litic processes, a fact well known among the laity, who look upon every 
 destructive disease of the nose as an evidence of syphilis, and generally 
 expect that any one with syphilis stands in hourly danger of losing his 
 nose assumptions as false as they are general. 
 
 As secondary results of the changes in bone produced by syphilis, 
 may be mentioned a fragility of the porous bone, rendering its fracture 
 very easy, and its repair slow and imperfect. Damage may also be caused 
 through pressure, by hyperostoses, upon soft parts, cranial nerves, spinal 
 nerves, the eye in orbital exostosis. 
 
 MERCUBY AS A CAUSE OF BONE DISEASE. 
 
 Finally, it is necessary to emphasize the fact that mercury has nothing 
 to do with disease of the bone. The cry with many in the profession and 
 nearly all among the people is, mercury destroys the bones. Very intelli- 
 gent men coolly sit down and state that they are unwilling to take mer- 
 cury for their symptoms, for fear that their bones will become diseased; 
 and medical men keep up the terrorism of the people by attempting to 
 cure syphilis without mercury. No statement is more unfounded in fact 
 than that the syphilitic bone symptoms of syphilis are caused by mercury. 
 The node of the skull, mentioned at p. 185, which softened after typhoid 
 fever, and swept away the outer table of half a parietal bone, occurred in 
 the person of a physician in the country who was afraid of mercury, and 
 never had taken it for his disease. Nodes and bone disease occur in all 
 forms of practice. Patients treated without mercury frequently suffer 
 very seriously from bone syphilis. Patients in Norway, who have been 
 "syphilized" and taken no medicine for their disease at all, certainly 
 suffer from bone syphilis, as Boeck himself has remarked to me; and 
 finally most convincing proof the bone lesions of inherited syphilis are 
 so common as to be almost uniform in their occurrence, in greater or less 
 intensity, and surely the unborn babe has had little chance of exposure to 
 the supposed noxious influence of mercury. 
 
 Mercury given in excess to the point of salivation may, and cer- 
 tainly does, threaten the maxillary bones, especially the alveolar process, 
 with destruction; but aside from this, mercury does not cause any symp- 
 toms which might be, and usually are, produced by the poison of syphilis. 
 
 The researches of Kussmaul ' concerning the influence of mercury upon 
 workers in the metal, settle this question from one standpoint, while hon- 
 
 1 Untersuch. iiber d. const! t. MercurialismuB. Wiirzburg, 1861.
 
 SYPHILIS OF LYMPHATIC GLANDS, ETC. 189 
 
 est clinical observation settles it with equal force from another. Tho 
 traditions of the people, and the ignorance of some and quackishness oi 
 others in the profession, are responsible for the continuance of this error. 
 Mercury given in a proper manner does no ultimate harm to the individual, 
 and sometimes bone symptoms will get well more promptly under mer- 
 cury than under the iodides. 
 
 Treatment. As a rule, all forms of bone disease, from the painful 
 spot to the gumma, respond to the iodides. Mercury is also beneficial, 
 especially in osteocopic pains and all lesions occurring early in the dis- 
 ease; but in the true gumma, and in the node of tertiary syphilis, mercury 
 can generally be dispensed with, and full reliance placed upon large doses 
 of the different iodides. Sometimes, when the iodides fail, or after a time 
 cease to act, mercury becomes efficient in removing the morbid process, 
 even when it is gummatous; but mercury certainly holds the second place 
 in most cases. 
 
 SYPHILIS OF CAETILAGE. 
 
 Cartilage of incrustation does not suffer immediately from syphilis. 
 When a joint is involved, or syphilis attacks the expanded end of a bone 
 capped by cartilage, the latter naturally softens, becomes eroded, and is 
 destroyed by the neighboring disease. Of the other cartilages, the fibro- 
 cartilage of the ear is often invaded by an ulcerative, tubercular syphilide 
 starting in the superficial tissues. The laryngeal cartilages are a very 
 common seat of syphilitic perichondritis, occasionally gummatous deposits 
 involve their vitality, and portions of the cartilage may fall into necrosis, 
 just as a bone does under similar circumstances. The trachea may be 
 implicated in the same manner. Gummata upon the costal cartilages act 
 like the same lesions on bone. The inter- vertebral fibro-cartilages are rarely 
 ever attacked, but sometimes they, as well as the bones of the vertebral 
 column, are involved in gummatous processes.
 
 CHAPTER XL 
 
 SYPHILIS OF THE RESPIRATORY SYSTEM. 
 
 THE DIGESTIVE TBACT, ABDOMINAL GLANDULAR ORGANS, AND THB VASCU- 
 LAR SYSTEM. 
 
 Syphilis of the Nose. Syphilis of the Larynx ; non-Ulcerative Ulcerative. Syphilis 
 of the Trachea, Bronchi, and Lungs. Syphilis of the Digestive Tract. Gumma 
 of the Tongue. Syphilis of the (Esophagus. Syphilis of the Stomach and Intes- 
 tines. Syphilitic Stricture of the Rectum. Syphilis of the Peritonaeum. Syphilis 
 of the Pancreas. Syphilis of the Liver. Diffuse and Circumscribed Hepatitis. 
 Gamma of the Liver; Amyloid Degeneration. Syphilis of the Spleen. Syphilis 
 of the Thymus, of the Supra-renal Capsules, and the Abdominal Glands. Syphilis 
 of the Heart. Syphilis of the Arteries, Veins, and Capillaries. 
 
 IN the nose, in early syphilis, erythematous lesions and mucous patches 
 are apt to occur. Their symptoms are those of catarrh, with more or 
 less discharge, some scabbing within the nose and ulceration, more or 
 less redness, with thickening and fissuring at the orifice of the nose. 
 Young people suffer more than adults from nasal symptoms, and babies 
 with inherited disease most of all. The mucous patch and the erythe- 
 matous lesions have the same physical characteristics here as they have in 
 the throat (p. 166). 
 
 In tertiary syphilis, gummatous ulcers upon the mucous membranes of 
 the nose involve its cartilages below and its thin bones above in destruc- 
 tion; and gummy tumors, originating either subcutaneously or within the 
 cavity of the nose, are quite certain to destroy the bridge and large por- 
 tions of the internal bony skeleton of the nose, unless arrested by treat- 
 ment. After cure in these cases, the bridge of the nose is permanently 
 sunken, and its point turned up, giving a physiognomy which is almost 
 pathognomonic of late syphilis. 
 
 While the destructive process involving the bone is going on within 
 the nose, the patient has what is called syphilitic ozena. This is a catarrh 
 more or less purulent in character, the pus being usually mixed with blood. 
 Often blood-scabs may be blown from the nose, or drawn down into the 
 pharynx through the posterior nares. The odor of the breath in these 
 cases is peculiarly offensive. On examining the inside of the nose, while 
 the process is going on, yellow and black dry scabs are found closely ad- 
 hering to ragged edges of ulcers, or to perforations through the septum 
 or elsewhere. Sometimes there is considerable pain complained of in these 
 cases, especially at night; often there is little or none. Thin pieces of 
 bone are frequently discharged through the nostrils, and the malady is 
 often kept up long after the dead pieces of bone have separated, on account 
 of the fact that these sequestra, being partly enclosed in new bone, cannot 
 escape and remain like splinters in a fester to keep up the local irritation. 
 
 In connection with the inflammatory changes accompanying gummatous
 
 SYPHILIS OF THE RESPIRATORY SYSTEM, ETC. 191 
 
 disease within the nasal cavity, the nasal duct often gets shut up, leading 
 to abscess of the lachrymal sac, conjunctivitis, necrosis of lachrymal bone. 
 Again, the Eustachian tube may be closed, and inflammatory trouble in the 
 middle ear be set up, leading to deafness. 
 
 If the disease is situated high up in the nasal cavity, the olfactory 
 sense may be destroyed or temporarily impaired. 
 
 The diagnosis of the lesions above described rests upon their course 
 and obvious clinical characters. No other disease behaves in like manner. 
 There is, however, one condition which may be readily mistaken for syphi- 
 lis in the nose, namely, a round perforation of the cartilaginous septum, 
 low down, generally about the size of a lead-pencil. I have encountered 
 this several times as a result of catarrh (apparently) in patients who un- 
 doubtedly were not syphilitic. I have known a patient to possess this de- 
 formity and to be ignorant of it, and have seen it diagnosticated as syphi- 
 litic, much to the patient's distress of mind. The borders of this round 
 hole cicatrize, and it causes no discomfort. I have seen the hole a num- 
 ber of times, but never during its forming stage. 
 
 The treatment of tertiary lesions of the nasal cavity is by the 
 iodides in large doses. Local treatment is unreliable, and generally un- 
 necessary, until it becomes evident, by the use of the probe, that there is 
 a loose piece of dead bone ready to come away, but detained by surround- 
 ing healthy tissues. For the removal of these, I know of nothing so ser- 
 viceable as the dental burr upon one of White's dental engines. I have 
 seen this instrument used with great success in these cases, by Dr. Good- 
 willie, of this city. 
 
 SYPHILIS OP THE LARYNX. 
 
 The mucous membrane of the larynx suffers from erythema and mu- 
 cous patches in early syphilis. The latter have been repeatedly seen 
 in the larynx by aid of the laryngoscope. These lesions are the same 
 here as elsewhere on the mucous membranes (as already described). 
 They are the better for local treatment, but get well without it. Mercu- 
 rial inhalations sometimes hasten their disappearance. They leave no 
 scars behind. 
 
 The syphilitic laryngitis which interests the practitioner is the ter- 
 tiary variety. It occurs in a constructive and in a destructive form in 
 the cartilages of the larynx, and as tertiary gummatous ulcerations upon 
 the mucous membrane, the vocal cords, and in the muscles of the larynx. 
 
 Non-ulcerative laryngitis, due to syphilis, is a chronic, construc- 
 tive, connective-tissue hyperplasia, involving the cords as well as all the 
 tissues within the larynx. The newly-formed material contracts here as 
 elsewhere, binds, and draws together the tissues within the larynx, stiff- 
 ens the vocal cords into unyielding rigidity in the closed state, and, 
 finally, may obstruct respiration entirely, no previous ulceration having 
 occurred. The cartilages do not become necrotic in this affection, and 
 there is no loss of tissue, except of muscular tissue, by atrophy from 
 pressure. 
 
 The symptoms of this affection are a hoarseness, lasting for months, 
 even years, slight pain on pressure over the larynx, gradually increasing 
 dyspnoea, the voice finally being reduced to a whisper, the patient be- 
 coming enfeebled, cyanotic, emaciated, gasping, praying for death to 
 relieve him from his distress. The laryngoscope finds the larynx stenosed. 
 the mucous membrane livid, the intra-laryngeal tissues thickened, but 
 shows no ulceration and no cicatrices. Rapid oedema of the glottis is
 
 192 THE VENEREAL DISEASES. 
 
 liable to come on at any time in this affection, and quickly to strangulate 
 the patient. 
 
 The diagnosis is with chronic laryngitis a malady which is always 
 tubercular or pseudo-tubercular, when not syphilitic. In the former case 
 there is generally consolidation at the apex of the lung, and the laryngo- 
 scope generally detects surface ulceration in the larynx. Papilloma of 
 the vocal cords gives all the symptoms of syphilitic laryngitis. Diagno- 
 sis with the laryngoscope is easy without it, next to impossible. 
 
 Treatment is mixed mercury with the iodides. It must be long 
 continued. If commenced early, it is promptly curative; later, it is 
 slower in its action, and less effective. In the stage of stenosis, trache- 
 otomy is sometimes necessary, to avoid impending suffocation. In such a 
 case, a permanent tube must be worn until treatment makes it safe for 
 the patient again to breathe through his larynx. I have tracheotomized 
 a patient on one occasion, in this condition, who was cyanotic, and in the 
 last stages of suffocation. Two silver tubes were worn out in as many 
 years; but, under treatment, the patient finally recovered entirely, and 
 dispensed with the tube. 
 
 Tertiary ulcerative laryngitis may accompany the affection last 
 described, or occur independently of it. 
 
 The ulcers are like tertiary, gummy ulcers of the pharynx, already 
 described, and may occur anywhere within the larynx, on the cords, be- 
 hind the epiglottis, running down in connection with ulcers in the throat, 
 or occurring independently. 
 
 The ulcers may start as in the pharynx, upon the surface and eat in, 
 or a gumma may form beneath the perichondrium of a larnygeal cartilage 
 and eat out; in either case, especially the latter, a portion of the cartilage 
 is liable to be involved in necrotic changes and to exfoliate. A gumma 
 of the larynx may work its way out externally, giving rise to fistula. 
 
 The ulcers, surrounded by considerable oedema, are visible with the 
 laryngoscope. The final cicatrization after cure in these cases may lead 
 to the most extensive distortion of the laryngeal cavity, or even to its ob- 
 literation. 
 
 The symptoms are those of chronic laryngitis intensified. Pain is 
 common, with expectoration of pus, mixed perhaps with blood and portions 
 of sloughy tissue. 
 
 Diagnosis. The symptoms easily localize the disease, and the diag- 
 nosis lies with ulcerative tubercular laryngitis and destructive cancerous 
 laryngitis. In the former affection the lungs will almost always be found 
 to be in an advanced state of tubercular disease, and in the latter, the non- 
 ulcerated masses of new growth can often be seen with the aid of a 
 laryngoscope. 
 
 Treatment is with the iodide of potassium in large doses very large 
 doses, run up as rapidly as the stomach will take it for an imporant 
 organ is threatened. The effect of treatment is often brilliant. Trache- 
 otomy may be called for on account of impending suffocation from oedema. 
 Cicatricial changes are not favorably affected by treatment, and may be 
 so seriously obstructive to respiration as to demand tracheotomy and a 
 permanent tube. 
 
 SYPHILIS OP THE TRACHEA, BRONCHI, AND LUNGS. 
 
 The trachea and larger bronchial tubes are subject to the same mor- 
 bid conditions as the larynx, but less commonly so. Ulcerative changes
 
 SYPHILIS OF THE RESPIRATORY SYSTEM, ETC. 193 
 
 in the trachea occur by preference low down near the bifurcation. Ulcers 
 on the surface may eat through the trachea into surrounding structures, 
 the aorta 1 or pulmonary artery,* but such accidents are exceptionally un- 
 common. 
 
 The symptoms of tracheal syphilis are uneasiness or pain behind the 
 sternum, cough, more or less rales, expectoration, blood, etc., tickling in 
 the throat. 
 
 The diagnosis is with tubercular troubles, and rests mainly upon the 
 history and concomitant symptoms. 
 
 The treatment is like that for similar conditions in the larynx. 
 
 The lungs are affected by syphilis in two ways: in the form of diffuse 
 connective-tissue hyperplasia. leading to consolidation by interstitial 
 changes in the parenchyma; and in the form of gummy tumor. 
 
 Syphilitic pulmonary fibrosis is very common in inherited dis- 
 ease. It is often generalized in both lungs in the infant. In the adult 
 it is more commonly circumscribed. The change in either case is an in- 
 terstitial thickening of the connective tissue between the air-cells, which 
 may go on to a total obliteration of the latter in the fibroid transforma- 
 tion of the new cells, and cirrhotic shrinkage of the morbid tissue. 
 
 The portions of lung involved in the disease are stiff, non-crepitant 
 upon pressure, solid, depressed below the level of the surrounding lung. 
 They cut like fibrous tissue; the section is seen to be interspersed with 
 yellow points; and the bronchial tubes, variously dilated and contracted, are 
 found with thickened yellowish walls. The pleura over these spots is apt 
 to be involved in the thickening. 
 
 In the child, when the whole lung is diseased, it is found dense and 
 marbled on the surface, bearing the imprint of the ribs. The solid, almost 
 fibrous tissue (white hepatization of Virchow), sinks in water, and the 
 lung, although perhaps partly inflated in some portion less diseased than 
 the rest, is manifestly unfit for respiratory purposes. The bronchial 
 glands are usually enlarged and hard, sometimes with central cheesy de- 
 generation. 
 
 The symptoms of pulmonary fibrosis are not pathognomonic. They 
 have been the subject of much dispute, which cannot be reproduced here. 
 In the infant the changes take place in intra-uterime life, and there are 
 no symptoms after birth except dulness on percussion, shortness of 
 breath and cyanosis, if, indeed, the infant has enough lung-tissue left in a 
 distensible condition to support life for a little while. In the adult, 
 however, the symptoms are identical with those of chronic phthisis. 
 Any portion of the lung, apex or base, may be involved, and there are 
 usually the accompaniments of fever, short breath, cowgh, emaciation, 
 night-sweats, etc. 
 
 The diagnosis in the adult is with ordinary phthisis. The history is 
 of great service here, because syphilitic fibrosis is often very dry and 
 the breathing in it harsh, tubular especially the inspiratory sounds. 
 There may be little or no fine crepitation, perhaps no rales at all. In re~ 
 gard to dyspnosa, haemoptysis, and the character and quantity of the sputa, 
 there is no agreement among authors. My own experience leads me to 
 believe that these signs vary in different cases greatly. I have seen 
 haemoptysis with profuse expectoration and little dyspnoea, in a case 
 which got well under antisyphilitic treatment; and the opposite state of 
 
 1 Wilks : Trans. London Path. Soc. XVI., p. 52. 
 'Kelly: Ibid. XVIII., p. 45. 
 13
 
 194 THE VENEREAL DISEASES. 
 
 great dyspnoea, with dry cough and no blood, is certainly common. The 
 possibility of the origin of ordinary phthisis from the irritation in the air- 
 cells and fine tubes, produced by their getting filled up with secretions, 
 whidh are discharged from diseased syphilitic conditions of the larynx 
 and trachea, must be borne in mind. 
 
 The truth is that diagnosis always rests mainly on the history, and 
 treatment is consequently for the most part tentatively experimental. 
 
 Treatment is mixed with large doses of the iodides. Mercury, in 
 mild courses long continued, is of very great value. Entire and perma- 
 nent cures are possible in this disease, when occurring in the adult. 
 
 Gummata in the lungs may coincide with fibrosis, or come on in- 
 dependently. They necessarily go on to destruction of the tissues they 
 implicate. They are rare in adult life, as well as in inherited disease. 
 
 The gumma is the same here as elsewhere: at first a tumor formed 
 of gray succulent cells, then getting yellowish white, more or less fibrous, 
 surrounded by a wall of condensed connective tissue; finally, being ab- 
 sorbed, leaving a depressed, fibrous cicatrix, or remaining in a state of 
 cheesy degeneration, or softening, breaking down, becoming puriform, 
 and discharging its debris by the nearest route to a free surface, through 
 the assistance of the ulcerative process. When these tumors form near 
 the surface of the lung, the pleura over it becomes thickened and adher- 
 ent to the costal pleura. 
 
 There are no fixed symptoms for gumma of the lung. The tumor is 
 solid at first, and may be made out by percussion, if it is large enough. It 
 may suppurate, and, discharging into a bronchus, leave a cavity which may 
 be revealed by physical signs. A syphilitic history does the rest to estab- 
 lish a diagnosis. There is no pain, and the subjective symptoms are not 
 at all distinctive. General health may be fair, or cachexia pronounced. 
 
 Treatment is rapidly effective of relief, which is permanent so far as 
 the tumor itself is concerned. The iodides in large doses are all that is 
 required, with such attentions to the stomach as shall insure their assimi- 
 lation. 
 
 SYPHILIS OP THE DIGESTIVE TRACT. 
 
 The secondary and tertiary lesions of the buccal cavity and pharynx 
 have been already studied in connection with the cutaneous manifesta- 
 tions of the same periods (Chapter IX.). 
 
 GUMMY TUMOR OF THE TONGUE. f 
 
 Gummatous lesions of the tongue are especially important and worthy 
 of study, because they frequently come on long after all evidences of 
 syphilis have disappeared, and are so suggestive of epithelioma of the 
 tongue as to require oftentimes much care to arrive at a differential 
 diagnosis. 
 
 A gumma may commence in any portion of the tongue except its 
 under surface, and may be encountered at any time of life. Not very 
 unfrequently it is bilateral, or there may be multiple foci of gummatous 
 deposit. The gumma commences without any pain, as a lump deep 
 among the muscles of the tongue, or under the mucous membrane; never 
 superficially at first, like an epithelioma. The lump grows, the mucous 
 membrane over it becomes stretched and livid, finally the tumor softens
 
 SYPHILIS OF THE RESPIRATORY SYSTEM, ETC. 
 
 195 
 
 centrally, ulcerates its way through the mucous membrane, and remains 
 open as a gummatous ulcer, with a deep, sloughy cavity, hard base, fis- 
 sured, ragged, thick, abrupt borders, often undermined at iirst, but always 
 bound down and adherent later on. The ulcer progresses slowly. The 
 course of the affection in any case is much protracted, but the tendency 
 is to ultimate self-limitation, even without treatment, if the general 
 health be good; and to cicatrization, with more or less loss of tissue, ac- 
 cording to the extent and duration of the ulcer. 
 
 The discharge is slight, even when the ulcer is at its height; but there 
 is considerable dribbling away of saliva. Pain is absent or inconsiderable, 
 and the functions of the tongue not much disturbed. The lymphatic 
 glands escape implication, or are involved only in an inflammatory way. 
 The general health may be very little disturbed, or there may be marked 
 cachexia. 
 
 The diagnosis is with epithelioma of the tongue, and with tubercular 
 ulceration. The latter is very little known. Portal, Trelat, Fereol, have 
 recorded cases. Dr. Van Buren related to me the description of a case 
 which he saw at the Hague, in the summer of 1876, and Millard, in the 
 Lancet of May 25, 1878 (from L'Union medicale), details a case in which 
 there were about a hundred separate ulcers. These tubercular ulcers com- 
 mence as white excoriations without antecedent tumor. The excoriations 
 enlarge and deepen. Gelade is referred to as speaking of a case where 
 the superior maxilla became invaded and carious. 
 
 These tubercular ulcers advance slowly and are very obstinate and hard 
 to heal. Excision of the tongue has been performed several times on ac- 
 count of them, and the wound has healed kindly. Nearly always the 
 lungs contain cavities. 
 
 The differential diagnosis between epithelioma and gumma of the 
 tongue can be best presented in tabular form. I have abbreviated a table 
 from Fournier, and modified it as follows: 
 
 Diagnostic Table. 
 
 ULCERATED EPITHELIOMA OP THE 
 TONGUE. 
 
 1. Occurs generally late in life. 
 
 2. Possible cancerous antecedents. 
 
 3. The ulcer sometimes occupies the seat 
 of former icthyosis of the tongue. 
 
 4. Commences superficially and ulcerates. 
 
 5. Lesion is unique. 
 
 6. Occurs on any part of the tongue. 
 
 7. Edges everted, tuberculated, irregular, 
 bleeding easily when touched, or spontane- 
 ously. 
 
 8. Discharge free, ichorous, putrid. 
 
 9. Pain spontaneous, shooting toward 
 ear (Fournier). 
 
 10. Tongue rigid, painful, functionating 
 badly. 
 
 11. Microscopic characters those of epi- 
 tkelioma. 
 
 1. Occurs at any age. 
 
 2. Syphilitic history. 
 
 3. Nothing of the sort. 
 
 4. Commences deep in the tissues, feel- 
 ing like a bullet beneath the mucous mem- 
 brane. It softens centrally, and on reach- 
 ing the surface, discloses a deep ulcer. 
 
 5. Sometimes multiple and bilateral. 
 
 6. Found only on the back and sides of 
 the tongue, never beneath. 
 
 7. Edges abrupt, uneven, hard, adherent, 
 covered with slough, not tuberculated, not 
 bleeding easily. 
 
 8. Discharge slight. 
 
 9. Ulcer usually painless. 
 
 10. Functional troubles generally slight. 
 
 11. Microscopic characters those of a 
 degenerating gumma.
 
 196 
 
 THE VENEREAL DISEASES. 
 
 ULCEKATED EPITHBLIOMA OP THE 
 TONGUE. 
 
 12. Lymphatic glands become involved. 
 
 13. Antisyphilitic treatment of no value, 
 possibly harmful. 
 
 14. Termination: death by cachexia and 
 inanition. 
 
 15. Returns if cut out. 
 
 ULCERATED GUMMA OP THE TONGUE. 
 
 12. Lymphatic glands generally remain 
 exempt. 
 
 13. Antisyphilitic treatment generally 
 promptly beneficial. 
 
 14. Death does not occur from this cause 
 alone. Spontaneous cure without medicine 
 possible. 
 
 15. Does not return if cut out entirely. 
 
 Treatment. Gumma of the tongue usually yields a rapid response 
 to iodide of potassium in large doses, if the remedy is given before the 
 tumor has softened. After ulceration, the effect of treatment is less ra- 
 pidly brilliant, but, nevertheless, is generally quite prompt. In cachectic 
 conditions, and when the stomach will not bear the iodides, the result of 
 treatment is slow and often unsatisfactory. 
 
 SYPHILIS OF THE (ESOPHAGUS. 
 
 Ulcers from the pharynx occasionally extend into the oesophagus, but 
 gummatous deposits may originate in the cesophageal walls. 
 
 These lesions are very rare. Their symptoms are pain on swallowing, 
 with evidence of some obstruction in the canal. When the ulcers get 
 well, the resulting cicatrices cause stricture, which requires treatment by 
 dilatation, oesophagotomy, or gastrotomy. 1 N 
 
 SYPHILIS OP THE STOMACH AND INTESTINES. 
 
 Early in syphilis, especially during the fever, nausea, indigestion, and 
 other functional troubles of the stomach, are not uncommon. Presumably 
 there is erythema; possibly there are mucous patches in this stage, 
 
 Thickening and ulceration of the stomach have been ascribed to ter- 
 tiary syphilis, but have not been clearly defined. 
 
 Late in syphilis, with the cachexia there often occurs a diarrhoea char- 
 acterized by great prostration, and by the obstinacy with which it resists 
 medication. Sometimes black stools of partly digested blood will be 
 voided, or clots, or even bright blood will be passed in variable amounts. 
 With this there may be more or less nausea, vomiting, inappetence, at- 
 tacks of temporary fever, with circumscribed areas of pain due to local- 
 ized peritonitis over the site of an ulcer in the intestines. 
 
 This diarrhoea, and all of these symptoms are due to gummy ulcers of the 
 intestines. Such ulcers may be single, or multiple, and may occur in the 
 small or the large intestines. They have been reported by a number of 
 observers, Meschede, Oser, Wagner, Lancereaux, and others ; but their 
 occurrence is uncommon, and opportunities of observing them after death 
 quite rare. Meschede found pigmenteu ulcers, Oser infiltration of Peyer's 
 patches, with central ulceration. Klebs 2 quotes a case from Yirchow's 
 
 1 But little is known of syphilis of the oesophagus. Consult Knott : Pathology of the 
 (Esophagus, p. 156 et seq., containing West's excellent cases from the Dublin Quarterly. 
 Dublin, 1878. 
 
 * Path, Anat., 2 Lief., S. 261 et seq.
 
 SYPHILIS OP THE RESPIRATORY SYSTEM, ETC. 197 
 
 Archives, where fifty-four ulcers were found in the small intestine of a 
 syphilitic man of 3(5, and some circular stellate scars on pigmented bases, 
 with tough fibrous nodules on the corresponding peritoneal surfaces. 
 Klebs refers also to two cases of gummy submucous growth in new-born 
 children, and has a personal case of numerous intestinal ulcers, with thick- 
 ening of the peritoneal surface, in a man dying with acute symptoms. 
 
 In a personal case, which I watched with Dr. Van Buren during a 
 number of months, in which the patient had much cachexia and pro- 
 longed attacks of diarrhoea, often voiding black stools looking like partly 
 digested blood, death finally came about suddenly from the giving way of 
 one of the ulcers of the ileum into the peritoneal cavity. Shock termi- 
 nated life, attended by profuse black vomit. A large amount of blood was 
 found in the peritoneal cavity, intestines, and stomach. A circular ul- 
 cer, as large as a penny, had given way, having cut cleanly through the 
 peritoneum. 
 
 A number of scars of other ulcers were found, round and oval, the in- 
 testine being somewhat constricted where they had occurred. The mus- 
 cular coat had been involved, but not eaten through. The peritoneum 
 under these ulcers was not thickened, the scars themselves were round, 
 smooth, flat, not puckered, not pigmented. This patient had also had an 
 ano-rectal syphiloma, diagnosticated during life; the autopsy showed that 
 this affection had been practically cured, although traces of cicatricial 
 change were visible upon the mucous membrane. 
 
 Peyer's patches have been found in a state of characteristic syphilitic 
 fibrosis by Forster in inherited disease, and other observers have found 
 ulcers and fibroid changes in the small intestine in inherited syphilis. 
 
 Syphilis of the large intestine has been the object of much study, es- 
 pecially in the rectum. In the colon, syphilitic ulcers may occasionally 
 occur ; and, when these are situated near the origin of the rectum, dysen- 
 teric symptoms are the result a dysentery which sometimes yields to an- 
 tisyphilitic treatment. The contest between those claiming that the so- 
 called syphilitic stricture of the rectum so common in women, so very rare 
 in the male is always the result of chancroid, and the advocates of a true 
 syphilitic stricture in this region, is practically ended. The unbiased 
 student must now admit that syphilis as well as chancroid does cause rec- 
 tal stricture, but in a different way. Chancroid in the female is generally 
 due to the accidental poisoning of an abrasion at the anus by the dis- 
 charges from a vagina already the seat of chancroid, which discharges run 
 from the posterior vaginal fourchette over the anus, as the patient lies upon 
 her back. Such an ulcer extends up the anus, lasts a long time, and, 
 finally, leads to stricture, which is in the main cicatricial. 
 
 Syphilitic stricture is not at all analogous to chancroidal stricture 
 in its method of formation. Fournier calls it ano-rectal syphiloma. It is 
 due to an infiltration of the submucous connective tissue of the rectum 
 and that lying between the muscular elements, and is dependent on active 
 cell-proliferation. The lesion is slow in forming, and without surface 
 ulceration. Eventually, here as elsewhere, this tissue becomes fibrous 
 in character and contracts, producing a dense fibroid stricture without 
 previous ulceration of the walls of the gut. Ulceration of the mucous 
 membrane may occur in connection with the infiltration of the wall of the 
 intestine, but this is not an essential part of the malady. 
 
 The best clinical account of this affection is given by Fournier. 1 The 
 
 1 Syphilome ano-rectaL Paris, 1875, pp. 73.
 
 198 THE VENEREAL DISEASES. 
 
 infiltration comes on insidiously with some loss of power in the sphincter, 
 a discharge of mucus, and occasionally a little blood at stool. This is 
 followed later by difficulty of defecation, small stools, constant mucous 
 discharge, and all the symptoms of stricture. 
 
 Examination shows a series of livid, flat, semi-elastic, non-ulcerated 
 infiltrations extending from the outside within the cavity of the rectum 
 and up the gut. There may be outside, besides these livid infiltrations, 
 flat or pedunculated condylomata, and perhaps ulcerated mucous patches. 
 Occasionally an ulcer extends into the anus, but this is rare. 
 
 The finger passed through the sphincter recognizes that this muscle 
 has lost a good deal of its contractile power, from infiltration of its sub- 
 stance with the syphilomatous material. Farther up the gut the surface 
 is found velvety, of livid color, excoriated, and often the seat of punctate 
 congestion. The mucous .membrane seems itself soft, but to be bound 
 down upon a very hard, semi-elastic, thickened, underlying tissue, which 
 is rather indistensible, and the walls of the gut often feel as if they were 
 the seat of infiltrations in the shape of broad, hard, linear bands, running 
 parallel to the long axis of the gut and not around it, as in ordinary 
 fibrous stricture. 
 
 The tightest part of the stricture is apt to be above, at the top of the 
 new formation. The last phalanx of the index finger can generally be in- 
 troduced through it, but I have seen it situated as high as four inches 
 from the anus. There may or may riot be surface ulceration at the top 
 of the stricture and above it. After syphiloma of the rectum has lasted 
 several years it becomes fibrous and unyielding, often very tight. 
 
 Trelat ' thinks that the formation of dry fistulae below the point of 
 actual stricture, cicatrizing shortly after they form and extending from 
 just without to just within the anus, are pathognomonic of syphiloma of 
 the rectum. I have only seen this once among perhaps ten cases of the 
 affection which I have examined. 
 
 Besides the ano-rectal syphiloma in the rectum, syphilitic ulcers may 
 exist, due to the ulceration of mucous patches at the anus, and such ulcers 
 may destroy considerable tissue and lead to permanent stricture by cica- 
 trization. True gummy tumor of the rectum has also been observed. 
 Zeissl has reported such a case. 
 
 The diagnosis of troubles of the rectum due to syphilis is very diffi- 
 cult. Great differences of opinion still exist in the profession as to the 
 possibility of pure syphilitic stricture of the rectum. The stricture of the 
 rectum found in women after difficult labor in early life seems much to 
 resemble the ano-rectal syphiloma, excepting that in the former the flat, 
 livid infiltrations around the anus do not exist. When ulceration has pre- 
 ceded stricture, it is difficult to differentiate the chancroidal form from that 
 occasioned by ulcerated mucous patches. 
 
 The true ano-rectal syphiloma, however, is easily recognized. No 
 other malady produces the livid, flat, softish, semi-elastic external patches 
 extending into the sphincter and weakening its power, attended by the 
 denser infiltration higher up, with little or no surface ulceration and com- 
 paratively little pain. 
 
 Treatment. In all the tertiary syphilitic affections of the digestive 
 tract dietary expedients and precautions are nearly as essential as spe- 
 cific treatment. The effect of mercury in all of these conditions is good; 
 but the drug should be administered either in the form of the mercurial 
 
 1 Le prog, med., Jane 22, 1878, p. 473.
 
 SYPHILIS OF THE RESPIRATORY SYSTEM, ETC. 199 
 
 bath or by inunction, so as to spare the stomach and intestines as much 
 as possible. The iodides should be combined with the mercurial treat- 
 ment. They should be commenced in mild doses and pushed with cau- 
 tion, largely diluted with water, after meals consisting of boiled rice and 
 boiled milk, preceded by large doses of the subnitrate of bismuth. In 
 this way the obstinate diarrhoea of tertiary syphilis maybe often checked, 
 and the intestinal ulcers which presumably give rise to it often brought 
 to a successful cicatrization. 
 
 The troubles produced by syphilis at the anus and in the rectum re- 
 quire local as well as general treatment. Mucous patches and ulcers, 
 whenever they occur, demand excessive cleanliness, washing with soap 
 and warm water and careful drying, with soft rags. After this there is 
 no treatment better than dusting the surfaces freely with dry calomel, 
 lodoform in powder is also excellent, if its odor is not objected to, and the 
 judicious use of a point o'f nitrate of silver upon the ulcers and fissured 
 creases about the anus materially aids the rapidity of cure. 
 
 For ulcers within the rectum nothing is better than suppositories of 
 iodoform from four to eight grains, rubbed up with butter of cacao into a 
 soft mass, which should be deposited by means of a suppository tube and 
 repeated once or twice a day. I think that a grain or even two grains of 
 mercurial ointment in such a suppository increases its efficacy without 
 producing irritation. Trelat thinks well of meshes of lint soaked in gly- 
 cerine containing a little tannin or other astringent, introduced into the 
 rectum. In syphilitic stricture of the rectum stools should always be ob- 
 tained by the aid of enemata, preferably a thin solution of flaxseed tea. 
 When the ano-rectal syphiloma is advancing, moderate pressure twice a 
 week, used very gently with a soft bougie, is attended by comfort, and, I 
 think, some advantage. Later on, when the contraction of the new tis- 
 sue is producing fibroid changes in the wall of the gut, the bougie is indis- 
 pensable; and in the last stage of unyielding fibrous contraction linear sec- 
 tion of the whole thickness of the altered tissue with the knife, ecraseur, 
 or electro-cautery, alone offers a chance of cure and holds out hope of 
 comfort to the patient. 
 
 At any stage of the complaint great advantage may be derived from 
 intelligent treatment, local as well as general. In the case referred to at 
 page 197, where a post-mortem examination confirmed the fact of cure, 
 the patient had already been subjected to two cutting operations for stric- 
 ture of the rectum, by a surgeon who had not recognized the cause of his 
 trouble and had cut and burned away the flat, external anal tumors. He 
 was little, if at all, relieved by these measures; but eventually cured of 
 his trouble mainly by internal means. The unfortunate perforation of 
 one of his intestinal ulcers terminated the case and allowed an inspection 
 of the rectum, although material improvement in this direction had al- 
 ready been indicated by a cessation of most of the functional derange- 
 ments of the part. In another personal case I found internal and local 
 means of no avail until I had divided all the thickened tissues posteriorly 
 with the knife, under ether, to the extent of fully four inches up the gut. 
 
 SYPHILIS OF THE PERITONEUM. 
 
 Syphilis generally spares the peritoneum, even when the viscera cov- 
 ered by this membrane are attacked. Often, however, in connection 
 with syphilitic (especially gummatous) changes in the liver, spleen, intes-
 
 200 THE VENEREAL DISEASES. 
 
 tines, ovaries, the peritoneum becomes thickened and adherent to neigh- 
 boring layers of peritoneum. Interference with the portal circulation 
 from such causes might occasion ascites. 
 
 SYPHILIS OF THE ABDOMINAL GLANDS. 
 
 In this connection all the glands of the abdomen, excepting those of 
 the genito-uriuary system, come up for consideration. 
 
 SYPHILIS OP THE PANCREAS. 
 
 This gland, like the salivary glands, is very rarely touched by syphilis. 
 Lancereaux has found, after death, parenchymatous connective-tissue 
 proliferations in the pancreas, and gummy tumors in one case; and Vir- 
 chow discovered fatty degeneration in inherited disease. Birch Hirsch- 
 feld 1 found the pancreas very often indurated, in autopsies upon cases of 
 inherited syphilis. 
 
 SYPHILIS OF THE LIVER. 
 
 The changes in the liver due to syphilis are true to the two types of 
 syphilitic tissue alteration: the one constructive a diffuse, parenchyma- 
 tous, cellular hyperplasia, ending in contraction and induration; the 
 other destructive the gummy tumor. Amyloid changes in the liver are 
 also ascribed to syphilis. 
 
 Diffuse syphilitic hepatitis, in which the connective tissue of the 
 whole gland is involved, does not occur, except in infants with inherited 
 disease. The whole gland grows large, heavy, hard, of a flinty gray color, 
 the glandular structure being more or less obliterated so much so that, in 
 some cases, it cannot be made out with the naked eye. The new tissue 
 is connective-tissue hyperplasia in the parenchyma, and new cells and 
 nuclei along the capillaries. The liver-cells are compressed, distorted, 
 atrophied by the new-formed tissue, and often in a state of granular de- 
 generation. Softening and breaking down of tissue does not occur in 
 this affection. 
 
 On opening the abdomen of a child dead with inherited syphilis, an 
 enormous liver is often found, which has undergone the changes above 
 detailed. It is hard, tense, elastic. A piece of it, cut out, slips away 
 when pinched between the thumb and finger. The organ may be so 
 dense that the finger can only bore a hole in it with difficulty. Collapsed 
 and thickened vessels show on the pinkish brown surface of section as 
 white knots, from which radiate thin whitish streaks. The vessel-walls 
 are sometimes the seat of amyloid degeneration. A dark spot may mark 
 an obliterated bile-duct. The contents of the gall-bladder are sticky and 
 pale (Gubler). 
 
 In a circumscribed form, the same diffuse parenchymatous changes 
 occur in the liver of adults with acquired syphilis. It goes on to final 
 atrophy and cirrhosis of the part involved, the cicatrix formed by the 
 wasted tissue contracting deeply into the organ. If many of these 
 contracted spots exist in the same liver, they may pull it down into very 
 
 1 Archiv f. Heilkunde, 1875, Heft 2.
 
 SYPHILIS OF THE RESPIRATORY SYSTEM, ETC. 201 
 
 small dimensions, the liver-tissue jutting 1 out between the puckered, con- 
 tracted spots in a singular manner. The tissue in these limited glandu- 
 lar areas may be normal, or in amyloid degeneration. 
 
 The cicatricial circumscribed areas, representing old, diffuse hepatitis, 
 may contain cheesy masses at their centre, such as are left behind by 
 the degenerative changes affecting true gummata, and, indeed, gummy 
 tumors may coincide with the diffuse patches of syphilitic parenchyma- 
 tous hepatitis. The peritoneum over the depressed cicatricial areas oc- 
 cupying the sites of old disease, is generally thickened. Sometimes the 
 two layers of peritoneum are adherent. 
 
 Gummy tumor of the liver occurs as a dense, connective-tissue, 
 radiate mass, with cheesy deposits scattered through it, or as a round, 
 cellular tumor, degenerated at the centre, and separated from the liver 
 substance by a capsule formed of condensed connective tissue. Gummata 
 commence in the walls of the vessels between the lobules. They thus 
 envelop the lobules, which they destroy. Virchow, who, with Frerichs 
 and others, believes that local violence has something to do as an im- 
 mediate, exciting cause with syphilitic changes in the liver, has called 
 attention to the fact that, in the line of the suspensory ligament of the 
 liver, a broad band of connective tissue, interspersed, perhaps, with gum- 
 mata, is apt to extend between the two lateral lobes, looking as if the vio- 
 lence done to the tissue, by traction upon the ligament during exercise, 
 might be the exciting cause of the changes in this particular locality. 
 
 Gummata of the liver may be solitary or occur in great numbers, and 
 of varied size, interspersed through the organ. It is rare for them to soften. 
 Wilks and Moxon have reported cases to the London Pathological Society. 
 They generally undergo fibro-molecular and cheesy degeneration. 
 
 Amyloid and fatty degeneration of the liver are found in connec- 
 tion with other changes due to syphilis, or independently of them. Amy- 
 loid degeneration of the liver, kidneys and spleen is so often encountered 
 coincidently with syphilitic cachexia in tertiary disease, that the change 
 must be looked upon as in some way brought about by syphilis, although 
 not in its own nature syphilitic, since the same degeneration occurs in 
 many patients who are not at all syphilitic. The change begins in the 
 walls of the small arterioles, and may continue confined to the vessel- 
 walls. 
 
 Symptoms of syphilis of the liver. The changes in size of the 
 liver due to hepatitis may be appreciated by percussion. Inequalities due 
 to extensive cicatricial puckering of the organ may sometimes be made 
 out by palpation. Some pain may be complained of, but as a rule, symp- 
 toms in connection with syphilis of the liver are very moderate or absent 
 altogether, the lesion or its cicatrix being encountered after death. Jaun- 
 dice is the exception rather than the rule, but sometimes comes on and 
 lasts long. Jaundice early in syphilis may be due to catarrh of the bile- 
 ducts, or pressure from enlarged lymphatic glands. Late in syphilis, again, 
 large abdominal lymphatic glands may occasion jaundice, and cicatricial 
 contractions may do the same, as well as cause ascites late in syphilis. 
 
 Such digestive, haemorrhoidal and anasarcous troubles as accompany 
 cirrhoses of the liver may be due to a similar condition of the organ, pro- 
 duced by syphilis. Albuminuria and cachexia often accompany syphilitic 
 degenerative changes of the liver. When these two symptoms coincide 
 with an irregularity of form and indurated lumps, or a fissured edge of 
 the liver, which may be felt, Lancereaux considers them to be pathogno- 
 monic of syphilis.
 
 202 THE VENEREAL DISEASES. 
 
 Treatment is that of late syphilis in the adult a mixed medication 
 with a preponderance of the iodides, especially if there is reason to sus- 
 pect that the lesion is gummatous. In the infant, treatment by inunction 
 is appropriate; but not much can be expected from it if the malady be far 
 advanced. 
 
 SYPHILIS OF THE SPLEEN. 
 
 Four varieties of textural change may be produced in the spleen by 
 syphilis: (1) a parenchymatous diffuse splenitis, general or partial; (2) 
 gummy tumor; (3) an increase in the pulp of the organ; (4) amyloid de- 
 generation. 
 
 The parenchymatous change is a diffuse, connective-tissue, cellular hy- 
 perplasia, going on to the formation of fibres which contract and leave 
 pale, depressed spots, with the peritoneum over them adherent to neigh- 
 boring organs. 
 
 The gummata are fibrous nodules of varying size, cellular and fibrous 
 at the circumference, granular and degenerated centrally; pinkish gray at 
 first, finally a dirty, yellowish white. 
 
 The amyloid degeneration coincides with similar changes in the liver 
 and kidneys. 
 
 The increase in the pulp has been noticed by Lancereaux, and doubt- 
 less is the condition which prevails in the enlargements observed early in 
 syphilis by Weil and Weber, and in the soft enlargement of the spleen 
 described by Virchow. 
 
 In inherited disease, the spleen may be larger and harder than usual, 
 but gummata are rarely found in it. Eisenschutz ' thinks that enlarge- 
 ment of the spleen, easily detected by palpation, is a diagnostic symptom 
 of latent inherited syphilis. 
 
 Symptoms. There are no symptoms of enlarged spleen due to syphi- 
 lis, unless the anaemia of the first period is in some way due to it. Weil s 
 has called attention to an enlargement of the spleen, which he states 
 comes on very constantly in the early stages of acquired syphilis, and dis- 
 appears under treatment; and Weber 3 reports that this enlargement may 
 be detected between the eighth and the twelfth week after infection; in 
 most cases, in from one to two weeks after the appearance of general 
 symptoms. It is said to continue for from one to two months, and to be 
 favorably influenced by mercurial treatment. 
 
 SYPHILIS OF THE THYMUS, THE SUPEA-RENAL CAPSULES, AND THE ABDOM- 
 INAL LYMPHATIC GLANDS. 
 
 The thymus, which usually atrophies as the child develops, in inher- 
 ited disease has been found hardened, enlarged, broken down centrally 
 into a puriform material, the seat of diffuse connective-tissue hyperplasia, 
 and of gumma. 
 
 Enlargement, gummata, and fatty degeneration of the supra-renal cap- 
 sules, are met with in acquired syphilis. 
 
 1 Das latente Stadium der hereditaren syphilis. Wien. med. Wochenschrift, 48, 49, 
 1873. 
 
 * Denfesoh Archiv f. klin. Med., May 15, 1874. 
 1 Ibid., 4, 5, 1876.
 
 SYPHILIS OF THE RESPIRATORY SYSTEM, ETC. 203 
 
 In neither of these conditions are there any positive symptoms causing 
 the affection to be recognized with certainty during life. 
 
 The abdominal lymphatic glands are subject, in late syphilis, to con- 
 siderable enlargement and to gumrnatous deposits, which may atrophy or 
 become amyloid, or cheesy, or may soften and discharge, generally upon 
 the cutaneous surface, leaving ulcers and fistulous channels of varying ex- 
 tent and duration. The pressure of these larger glands may interfere with 
 digestion or give rise to jaundice. 
 
 Such glandular swellings may be diagnosticated when they can be felt, 
 and are best treated by the iodides, with a certain amount of mercury by 
 inunction. 
 
 SYPHILIS OF THE VASCULAR SYSTEM. 
 
 All parts of the vascular system are liable to suffer from syphilitic le- 
 sions; the heart most frequently, the veins very seldom. 
 
 Syphilis of the heart. A diffuse pericardial thickening and a gumma 
 of the pericardium have been occasionally noted after death. Wagner 
 has described as syphilitic certain miliary granules found on the pericar- 
 dium. 
 
 Diffuse parenchymatous myocarditis also occurs, and most often, either 
 with the diffuse cellular infiltration or independently, gumma of the mus- 
 cular structure. 
 
 Grenouiller, 1 in a thesis on cardiac syphilis, drawing his conclusions 
 from twenty-four cases, collated from various sources, finds that syphi- 
 litic myocarditis generally commences as a small gumma, and ends as a 
 patch of sclerosis. Gummy tumor was found, in eighteen out of the twenty- 
 four cases, once during the first year after infection at an average, how- 
 ever, of ten years. The thick wall of the left ventricle was the commonest 
 seat of the deposit. There were no special symptoms during life, although 
 heart disease was sometimes suspected. About two-thirds of the cases 
 terminated in sudden death. 
 
 Anatomically, the gumma of the heart is a collection of small round 
 cells (like a sarcoma), encapsulated and yellowish white on section, often 
 cheesy at the centre. If near the surface, the pericardium or endocardium 
 over them is thickened. They are often multiple. 
 
 A general weakening of the heart's action, without any valvular irreg- 
 ularity, attended by slight enlargement of the organ and dilatation of its 
 cavities, seems to be the only symptom upon which a diagnosis can be 
 based. Lancereaux believed that he diagnosticated one case which got 
 well under treatment. 
 
 The possibility of embolism, due to bursting of a softened gumma into 
 the cavity of the heart (Oppolzer, Lancereaux), must be remembered. 
 
 Treatment is mixed, with preponderance of the iodides. 
 
 Syphilis of the arteries. The arterial lesions of syphilis have been 
 the object of much study during the past few years. Gelatinous nodules, 
 growing from the middle coat of the pulmonary artery, have been found, 
 and smooth, softish tubercles, all presumably syphilitic. The changes in 
 the large vessels, however, which are most common, are atheromatous de- 
 posits; and these, when they are found in a syphilitic subject early in life, 
 before they can be accounted for by senile changes, are generally set down 
 as being due to syphilis. 
 
 1 Paris, 1878.
 
 204 THE VENEREAL DISEASES. 
 
 A diffuse general thickening of the arterial wall, commencing (Heub- 
 ner) as an endo-arteritis, and sometimes going on to the extent of occlud- 
 ing the lumen of the vessel, appears to be a process very common among 
 the small arteries in syphilis, especially the arteries of the brain (Heub- 
 ner), although other causes besides syphilis may produce this same arte- 
 rial thickening (Cornil, Ranvier, Koster, Friedlander). Lancereaux and 
 others have observed this thickening of the vascular wall to a marked ex- 
 tent in the carotids. 
 
 As a consequence of syphilitic arterial changes, brain symptoms 
 (Heubner) are not uncommon, due to a cutting off of a portion of the 
 brain from its blood-supply on account of partial or entire closure of the 
 lumen of an artery through thickening of its walls. Cerebral apoplexy is 
 sometimes due to syphilitic arterial changes, and pulmonary apoplexy as 
 well (Weber), while aneurisms are so much more common upon syphilitic 
 patients than upon others, that the relation must be more than mere coin- 
 cidence. 
 
 There are no positive diagnostic signs by which the syphilitic nature 
 of a presumed or a positive (aneurism) arterial change can be established. 
 When such changes occur upon a syphilitic subject, a mixed treatment, 
 with a preponderance of the iodides, is indicated. The effect of treatment 
 upon arterial lesions is not brilliant; but often treatment is of enough 
 value to make it well worth while to push it with firmness and continue 
 it with long patience. 
 
 Of the effect of syphilis upon the veins, little is known. J. Hutchin- 
 son, in his report on syphilis to the London Pathological Society, thinks 
 that he has observed inflammatory changes about varices and around 
 healthy veins in syphilitic subjects quite frequently, and he infers that 
 these sometimes must be of specific nature. 
 
 Of the capillaries it may be stated that their external walls are the 
 habitual starting-points of gummatous tumors, and Lancereaux states 
 that their walls become fatty in conditions of syphilitic cachexia. 
 
 The amyloid changes found in late syphilis attending the cachectic stage 
 commence usually in the walls of the blood-vessels, generally the smaller 
 ones, and sometimes remain confined to them.
 
 CHAPTER XII. 
 
 SYPHILIS OF THE NERVOUS SYSTEM. 
 
 General Pathology of Nervous Syphilis. Syphilis of the Brain, Pachymeningitis, Gum- 
 mata of the Meninges, Encephalitis, White Softening, Gummata of the Brain. 
 Syphilis of the Cerebral Arteries. General Symptoms of Brain Syphilis, Prognosis, 
 Treatment. The Special Aifections produced by Syphilitic Lesions of the Brain. 
 Syphilitic Hemiplegia, Epilepsy, Generalized Paralysis, Catalepsy, Chorea, Aphasia, 
 Insanity. Brain Syphilis simulating Sunstroke often followed by Desire to Sleep. 
 Syphilis of the Cord. Syphilitic Paraplegia. Syphilitic Locomotor Ataxia. 
 Syphilii of Special Nerves, of Nerves of Special Sense, and Nerves of Motion. 
 Syphilis of the Sympathetic. 
 
 SYPHILIS attacks the nervous system, as it does all other organs, through 
 its connective tissue and its blood-vessels. There is a constructive form 
 which does not soften, but contracts after its formation, and by pinching 
 the delicate nervous cells and tubes gives rise to the most varied symp- 
 toms. There is also the gummatous destructive form of disease, which 
 destroys all the tissues implicated by softening or cheesy metamorphosis, 
 and by its own pressure occasions numerous symptoms. 
 
 The brain, the cord, and the nerves are also exposed to injury, on ac- 
 count of pathological processes occurring in surrounding structures. The 
 meninges of the brain and cord are liable to inflammatory thickening and 
 to gummatous deposits, the bones of the cranium and of the spinal column 
 may be the seat of necrosis or caries, nodes may grow upon the bones 
 and press upon the delicate nervous structures within. The nerves, as 
 they leave the great centres, are exposed to pinching by a syphilitic 
 thickening of the bony channels through which they escape, and after 
 they are among the tissues by interstitial syphilitic lesions within their 
 sheaths (gummata), and by implication in other syphilitic processes along 
 their track (gummata, pressure by nodes, etc.). 
 
 Finally, a large number of symptoms of brain disease, which formerly 
 were seemingly beyond the possibility of explanation, are now found to 
 be due to changes in the walls of the arteries supplying the brain. This 
 has been made very clear of late, by the admirable treatise of Heubner, 1 
 and the researches of other observers who have followed him. Apoplexies, 
 blood-cysts, occlusion of arteries, and consequent softening of portions of 
 the brain, or at least interruption of the function of such parts, may all be 
 explained easily by the arterial lesions. No greater step toward the com- 
 prehension of the effects of syphilis has been made for many years than 
 this one of the recognition of the possible result of syphilis upon the 
 arteries, and the consequent interference of function in the tissues whose 
 blood-supply has been thus cut off or lessened. 
 
 1 Die Luetische Erkrankung der Hirnarterien. Leipzig, 1874.
 
 206 THE VENEREAL DISEASES. 
 
 The sympathetic ganglia are also exposed to injury by changes anal- 
 ogous to those which affect the brain. 
 
 SY.PHILIS OF THE BRAIN. 
 
 Changes in the bones surrounding the brain may occasion ner- 
 vous symptoms. Such changes commonly are nodes from the inner table, 
 and necrosis (involving the meninges in inflammatory disturbance). 
 Thickening of the periosteum or disease of the bone, about any of the 
 foramina through which the cranial nerves find exit, leads to loss or im- 
 pairment of the function of that nerve. 
 
 The meningeal lesions are pachymeningitis and gummatous deposits. 
 
 Pachymeningitis. This is a connective-tissue cellular proliferation 
 going on to organization into fibrous thickening of the tissues involved. It 
 generally occurs over the anterior lobes of the cerebrum, on the convex 
 surface, or at the base. The dura mater is most often involved, the pia ma- 
 ter next, the arachnoid least often. There may be disseminated patches of 
 disease, or a large area may be generally implicated. When the pia mater 
 is involved, the arachnoidal surfaces may adhere, and the underlying brain 
 surface be included in a uniform sclerosis, the thickened, tough membranes 
 being adherent to the brain, so that the}' cannot be lifted without lacer- 
 ating the surface of the latter. 
 
 Gummatous deposits in the meninges are found as scattered, yellow, 
 softened or cheesy nodules, amidst the sclerosed patches of pachymenin- 
 gitis, or spread out in yellow layers between the thickened meninges, or 
 in the shape of distinct tumors between the dura mater and the bone, in 
 the substance of the membranes, or on the surface of the brain. Such 
 tumors, at first cellular, gray and soft, become gelatinous, with fibrous 
 envelopes, then fibro-granular, finally cheesy. 
 
 The lesions of the brain-substance are: a diffuse encephalitis, a white 
 softening, gummata. 
 
 Encephalitis is a new cellular formation in the delicate connective 
 tissue of the brain, and along the vessels. Like the same process else- 
 where, it finally goes on to form a sclerosed patch pinching the tender 
 nerve-elements. 
 
 White softening occurs over a limited area, which may have become 
 deprived of its blood by the obliteration of the artery supplying it, on ac- 
 count of syphilitic deposits in its walls. 
 
 Gumma of the brain forms in the outer coat of the small arteries, 
 and spreads from thence. Gummata are not common in the brain-sub- 
 stance, and when found, it is most often in the cerebrum near the surface. 
 The tumors exist as fibrous masses with cheesy centre, or as a soft accumu- 
 lation surrounded by a wall of condensed connective tissue; occasionally 
 the contents are absorbed and a cyst remains. The whole gumma may 
 be absorbed, leaving a fibrous cicatrix. 
 
 SYPHILIS OP THE CEREBRAL ARTERIES. 
 
 Heubner's monograph on syphilis of the cerebral arteries has called 
 attention to the frequency of this lesion in syphilis, and explained many 
 of the cases which formerly had to be ranked as nervous syphilis sine 
 materia, because no lesion could be found. Doubtless there is a nervous
 
 SYPHILIS OF THE NERVOUS SYSTEM.' 207 
 
 syphilis sine materia. The analgesia and anaesthesia of secondary syphilis, 
 and some of the paralytic attacks coming on a few months after chancre, 
 are doubtless due to the direct effect of the poison, or to irregularities in 
 the circulation of the nerve-centres, dependent essentially upon the in- 
 fluence of the poison of syphilis, without tissue-change. Analogous phe- 
 nomena occur in nervous gout. It is not well, however, to make any di- 
 vision of a set of symptoms, under the head of nervous syphilis without 
 physical lesion, because the classification tends to encourage negligence in 
 pathological diagnosis. Very possibly lesions will be eventually found to 
 cover all cases, since the arterial lesions already account for many nervous 
 syphilitic troubles, formerly incomprehensible, so far as their pathology 
 was concerned. 
 
 The customary lesion of the arteries produced by syphilis is, according 
 to Heubner, an endo-arteritis commencing as a round-celled deposit in the 
 intima between the endothelium and the membrana fenestra. The growth 
 of these cells forms a lumpy swelling, which diminishes the calibre of the 
 artery. Later on, all the coats of the vessel become the seat of a round- 
 celled infiltration. 
 
 As a result of these changes, the proximal side of the vessel is apt to 
 become dilated, rupture, and hemorrhage may occur or thrombus may form 
 at the constricted spot. Atrophy of the normal elements of the vessel- 
 wall results from the presence of- the new growth. Spontaneous cure 
 occurs by obliteration of the vessel. 
 
 The carotid arteries and their branches are more often involved in this 
 process than the basilar. Syphilitic arteritis is always a late lesion. Heub- 
 ner only encountered it once within six months of chancre; and in this 
 case it seemed quite probable that the patient's syphilis had antedated his 
 supposed chancre by several years. 
 
 Symptoms of brain syphilis. Symptoms of the most varied char- 
 acter are produced by syphilis of the brain symptoms involving the in- 
 tellect and all of the functions of the body, symptoms simulating a variety 
 of cerebral diseases. 
 
 Headache is a prominent symptom in all stages of syphilis. Early in 
 the disease it may be neuralgic, or due to anaemia or hyperaemia. Later 
 it implies lesions of the bones of the cranium, or gummatous processes, or 
 pachymeningitis. It is generally intense in all stages of the disease, and 
 worse at night. 
 
 Vertigo early in syphilis is believed to be due to congestive or anaemic 
 conditions of the brain; later to material lesions of all sorts, particularly 
 arterial degenerations. 
 
 Convulsive seizures, especially unilateral spasm (Jackson), epilepsy, 
 vomiting, photophobia, strabismus, varied lesions of the eye, dementia, 
 weakness, loss of consciousness all these are symptoms apt to be con- 
 nected with peripheral lesions, pachymeningitis, and gummatous processes 
 near the surface of the cerebrum or cerebellum, or at the base of the 
 brain. 
 
 Gummata of any size are apt to produce symptoms similar to those 
 k due to other cerebral tumors similarly situated. 
 
 Encephalitis may give rise to disturbance of the intellect, mania, in- 
 sanity, paralysis, epilepsy without aura, convulsions without unconscious- 
 ness, often slow in coming on. 
 
 Arterial lesions may occasion aphasia, hemiplegia, and troubles of the 
 intelligence. 
 
 Death from syphilitic brain trouble may be the result of the bursting
 
 208 THE VENEREAL DISEASES. 
 
 of a vessel, gradually progressive enfeeblement and cachexia; to wast- 
 ing of the nerve-force or to encaphalitis. 
 
 The symptoms of syphilis are greatly varied, and are not proportionate 
 to the extent of the lesion or to its situation. Frightful attacks of nerv- 
 ous symptoms terminating life sometimes reveal nothing to the patholo- 
 gist more serious than arterial lesions; while, on the other hand, tumors 
 and extensive meningeal troubles connected with lesions of bone are 
 found after death, when there has been little more than local pain during 
 life to direct the physician's attention to the brain. Occasionally, serious 
 lesions 'are found attended by symptoms during life, where there has been 
 no complaint of pain. 
 
 Indeed, syphilis is picturesque and irregular in its nervous expressions, 
 as well as in its other symptoms; and it is often, by this very quality of 
 irregularity in the grouping of the nervous symptoms, that a diagnosis of 
 syphilitic brain disease can be made. 
 
 Certain groupings of symptoms are believed to be pathognomonic of 
 syphilis. One of these is unilateral spasm commencing in the fingers or 
 thumb, running up one limb and down the other, without unconscious- 
 ness, sometimes terminating in a general convulsion with loss of conscious- 
 ness (Jackson). Speech may or may not be involved, and partial paraly- 
 sis may or may not follow on the side which was the seat of the hemi- 
 spasm. 
 
 Optic neuritis and mydriasis very often attend syphilitic nervous symp- 
 toms due to syphilis. 
 
 Balfour 1 calls attention to the fact that a coexistence of facial neu- 
 ralgia, with paralysis of any of the nerves going to the muscles of the eye, 
 forms strong presumptive evidence of cerebral syphilis, since the cavernous 
 sinus, the only point where these different nerves run near each other, is 
 a favorite seat of syphilitic deposit. 
 
 In general, an irregular grouping of nervous symptoms is suggestive 
 of syphilis, such as paralysis of a group of muscles of one arm and the 
 leg of the opposite side, coinciding with mydriasis or optic neuritis. The 
 explanation of this is that the lesions of syphilis are scattered and varied, 
 all tissues are liable to suffer from its influence, and many of them at the 
 same time. 
 
 The mental disturbances of syphilis are very varied. Certain qualities 
 of mental derangement in connection with physical (paralytic) symptoms 
 are so often encountered together as to have in them something almost 
 clinically pathognomonic. There is a certain quality of brain-weariness 
 which is constantly complained of. The patient cannot fix his mind upon 
 anything intently; his brain gets tired at once. Sometimes he cannot 
 even read a newspaper, he cannot cipher, often he cannot write a letter, 
 while he can talk and laugh as well as ever, and to a careless observer 
 does not appear to be at all deficient in brain-power. 
 
 There is also, generally, a tendency to emotional excess in patients 
 whose brains are weakened by the physical lesions of syphilis. Such in- 
 dividuals will laugh or cry at the very slightest provocation, they get 
 gloomy and frightfully depressed sometimes without cause, while other 
 patients seem to be made careless and happy by their malady, their whole 
 character being changed. This latter result is less common than the 
 others. 
 
 Finally, there is a hebetude, a dementia quite common in connection 
 
 1 Edin. Med. Jour., Oct., 1875, p. 289.
 
 SYPHILIS OF TIIE NERVOUS SYSTEM. 209 
 
 with advanced brain lesions due to syphilis. The patient will exhibit a 
 slowness of apprehension which is phenomenal. He will be painfully 
 slow in grasping ideas which are presented to him, and equally deliber- 
 ate in expressing his own ideas in reply. Such patients look blank and 
 stupid in the face. The muscles of expression seem to be powerless. A 
 stupid, dull stare greets the inquirer in response to every idea presented 
 to the patient. In these cases the patient, who is perhaps paralyzed 
 on one side, will sit with his mouth open and saliva dribbling upon his 
 coat, until he is told to shut his mouth, when he will slowly and stupidly 
 obey. He will leave food in his mouth uiimasticated, seeming to forget 
 it, and yet may retain his reasoning powers, his speech, and all his intel- 
 ligence much blunted, of course, but not absent. 
 
 When any of these three varieties of intelligential variation, emotional 
 excess, brain-weariness, hebetude, coincide with mydriasis, localized mus- 
 cular paralysis, and tender shins, syphilis may be predicated as a cause of 
 these phenomena, with nearly absolute certainty of making a correct di- 
 agnosis. Pain in the head, worse at night, makes the diagnosis more cer- 
 tain, and improvement under antisyphilitic treatment removes any lin- 
 gering doubt which may have arisen from failure to find physical evidences 
 of past syphilis, or a history of the disease. 
 
 The prognosis of the nervous symptoms of syphilis is always rela- 
 tively good. That is, no matter what, or how severe, or how extensive, 
 or how long standing the symptom, there is, as a rule, more hope of 
 effecting its cure, if syphilis can be made out to be its cause, than if it 
 originated from any other malady. Apparently hopeless cases of the 
 most profound coma, symptoms resembling brain-softening in all respects, 
 paralyses of the most varied kinds, blindness and deafness, furious 
 epilepsy, violent mania, insanity, general paralysis, dementia none of 
 these conditions in their worst form involve more than a reserve in their 
 prognosis, if syphilis is their cause. Many cases, which, on account of their 
 long standing, cannot be perfectly cured, are yet capable of vast improve- 
 ment, by the judiciously vigorous employment of an active anti-syphilitic 
 medication, including a trial of the iodides pushed unsparingly. 
 
 As to the liability of occurrence of nervous symptoms due to syphilis 
 in a given case of the disease, it is impossible to speak with much assur- 
 ance. There is a general impression which Broadbent ' has formulated, 
 citing Gros and Lancereaux, Braus, Buzzard and Moxon, as corroborating 
 his opinion, that it is chiefly when secondary symptoms are light, or 
 when tertiary symptoms come on very early, that symptoms due to lesions 
 of nerve-tissue are to be feared. There is some foundation for this, 
 doubtless, but it is far from being a rule. Many cases are very light at 
 first, and very severe at the end; others seem to extend their violence in 
 the cutaneous outbreaks of the first eighteen months of the disease, and 
 then cease entirely; but an absolute rule is very impossible in this, as in 
 most other general questions regarding syphilis. 
 
 Syphilis acts differently, according to the physical predisposition and 
 the constitution of the person who suffers from it. Gouty and rheumatic 
 patients, and those with general nervous tendencies, certainly are more 
 apt to suffer from brain syphilis than others, and these patients are 
 just the ones who habitually have light, but protracted attacks of 
 superficial papulo-squamous lesions throughout the existence of their 
 malady. It is not because they have light early syphilis, that Tater on 
 
 1 Lancet 1874, 1 nos., 2-6. 
 14
 
 210 THE VENEREAL DISEASES. 
 
 they get brain disease, but both the results arise from one and the same 
 predisposing constitutional cause, and not at all from any peculiarity in 
 the quality of the syphilitic virus which they have absorbed, or its quan- 
 tity. Such patients are apt to have more pains and neuralgic symp- 
 toms early in their attacks, than others ; headache, side-ache, bone-ache, 
 anaesthesia, analgesia, vertigo, etc. 
 
 Treatment. The general treatment of nervous syphilis keeps in 
 view the delicate nature of the structures which are threatened. The 
 gummatous exudation which is pressing upon nerve cells and fibres must 
 be speedily removed at any cost, the congested periosteum must be re- 
 strained in its tendency to construct a bony node, or to thicken into an 
 irritative patch upon the cerebral surface, the thickening in the arterial 
 wall must be arrested before it closes the calibre of the vessel or delicate 
 nerve-tissue will be destroyed, which no human power can restore. Con- 
 sequently, great vigor is called for in the employment of the means we 
 have at hand, and great judgment and care in the management of all the 
 surroundings of the patient, his diet, his habits, his hygiene. 
 
 The light congestive lesions which give symptoms early in syphilis get 
 well on mercury alone; those of the later variety require large doses of 
 the iodides often, preferably combined with the mercurials. 
 
 Refinements in diagnosis, however, are not always possible, or proper, 
 in face of probable grave lesions threatening important functions ; and it 
 is better in all cases of serious nervous disease due to syphilis to employ 
 both the mercury and the iodides, and to push them both boldly until the 
 symptoms yield. Mercury should be given by the vapor-bath or by inunc- 
 tion, the stomach being reserved for the iodides. The latter should be 
 used without stint, commencing at a gr. x. or gr. xx. dose, according to 
 the severity of the symptoms and the date of the attack from chancre, 
 and increasing rapidly up to the point of tolerance, using all precautions 
 to protect the stomach (p. 134). 
 
 After the symptoms have yielded, treatment should be continued for 
 a long time, and then be slowly dropped, tapering off the course of the 
 iodides, and continuing with the mercurials, watching the patient for any 
 evidences of possible relapse. 
 
 THE SPECIAL AFFECTIONS PRODUCED BY SYPHILITIC LESIONS OF THE 
 
 BRA1X. 
 
 A few words, setting forth some of the peculiar qualities which attach 
 to certain affections of the nervous system when due to syphilis, will make 
 it easier to differentiate them from analogous affections dependent upon 
 morbid processes, the nature of which is not syphilitic. 
 
 SYPHILITIC HEMIPLEGIA. 
 
 Hemiplegia due to syphilis is usually observed in patients who are 
 comparatively young, since it generally occurs within a few years of 
 chancre, and- chancre is more often acquired by the young than by the 
 old. It has been observed quite early in syphilis. Taylor ' reports a case 
 
 1 Journal of Nervous and Mental Diseases, January, 1876, p. 20.
 
 SYPHILIS OP THE NERVOUS SYSTEM. 211 
 
 in the fifth month from chancre, but it is more common after several years. 
 There are three varieties of attack : 
 
 1. Sudden loss of motion in one side without any previous warning 1 , 
 excepting, perhaps, persistent pain in the head, worse at night. In con- 
 nection with Professor Van Buren, I have reported a number of instances 
 of this variety of attack. 1 Under these circumstances there is commonly 
 no loss of consciousness with the paralytic stroke. 
 
 2. Hemiplegia may come on very slowly, taking perhaps several weeks 
 to beome complete. The face may become paralyzed, and then, gradu- 
 ally, the upper extremity. Finally, the loss of power extends to the thigh 
 and leg, or the lower extremity may be spared altogether. In this form 
 also there is no loss of consciousness with the attack. 
 
 Finally, 3, hemiplegia may be due to syphilitic degeneration of an ar- 
 tery which, thinned by gummatous deposit, or dilated behind an obstruc- 
 tion, may give way and occasion true apoplexy. This form of syphilitic 
 hemiplegia may be attended by loss of consciousness, like ordinary apo- 
 plexy. 
 
 Headache localized in one spot very often precedes the seizure by sev- 
 eral weeks. The intensity of this headache is sometimes extreme, parti- 
 cularly at night ; and if the lesion be peripheral, pressure upon the bone 
 over it increases the pain. 
 
 Of the hemiplegia itself, it may be partial or complete. Motion and 
 sensibility may both be abolished, but sensibility is commonly less im- 
 paired than motion. Sometimes one side is paralyzed in its sensibility 
 alone, motion being normal. Hemispasm of the affected side may pre- 
 cede the paralysis. Several mild attacks of hemiplegia may follow each 
 other at short intervals, and, finally, be succeeded by a full attack, which 
 remains permanent. 
 
 Other general nervous symptoms, intelligential or emotional, such as 
 have been described (p. 208), generally accompany syphilitic hemiplegia; 
 but upon this point there is no certain rule. 
 
 I have seen one case of partial syphilitic hemiplegia in a young girl 
 with inherited disease. 
 
 Early treatment is sometimes followed by rapid and complete cure. 
 
 SYPHILITIC EPILEPSY. 
 
 Epilepsy generally comes on several years after chancre. Bumstead 
 has observed a case within a few months from the primary lesion, and 
 Althaus * has reported a case in a child with inherited disease. The con- 
 vulsive attacks in this affection are not exactly like those of true epilepsy, 
 and the patient is generally a grown man, instead of a youth, as he com- 
 monly is in true epilepsy. The convulsion in syphilitic epilepsy is rarely 
 preceded by an aura. It nearly always commences in unilateral spasm. 
 There are night and day attacks, as in true epilepsy, and, in syphilis, a 
 tendency to an explosion, as it were, a number of attacks occurring in 
 rapid succession, followed by a considerable interval of calm. This pecu- 
 liarity, however, is also noticed in true epilepsy. In syphilitic epilepsy, 
 as in the ordinary form, there occur the half attacks, as well as the full 
 attacks ; but the former are not so much confined to the head as in true 
 
 1 Syphilis of the Nervous System : N. Y. Med. Journ., Nov., 1870. 
 1 Med. Times and Gaz., April, 1874, p. 389.
 
 212 THE VENEREAL DISEASES. 
 
 epilepsy ; there may be only a partial unilateral spasm, passing away with- 
 out reaching the extent of a full attack. 
 
 The features which are commonly relied upon to diagnosticate syphi- 
 litic epilepsy (besides the history) are: the relatively advanced age of the 
 patient; the existence of persistent, fixed headache before the attack, 
 worse at night; a persistence or aggravation of the intellectual symptoms 
 (hebetude, etc.) between the attacks, instead of a diminution of the same, 
 such as is encountered in ordinary epilepsy; and the peculiar character of 
 the attack, commencing perhaps habitually in a thumb or finger, and be- 
 coming first unilateral, then general. 
 
 Special paralysis of the cerebral nerves is less often observed with 
 syphilitic epilepsy than with some of the other forms of nervous syphilis. 
 Fatal cases generally terminate with profound coma, more or less pro- 
 longed. 
 
 OTHEK POEMS OF HERVOT7S SYPHILIS AFFECTING THE MUSCLES. 
 
 Generalized paralysis, closely simulating the generalized paralysis of 
 the insane, is not a very infrequent symptom of brain syphilis. There is 
 no constant lesion found in this condition. The patient is more apt to be 
 depressed and to suffer from hebetude than to entertain ideas of grandeur, 
 as in non-specific general paralysis. Catalepsy of syphilitic origin has 
 been encountered, and even chorea; but these affections are not well de- 
 fined, and are very rare. All of these maladies, when due to syphilis, re- 
 spond to a well-directed, vigorous treatment. A cure may not be possi- 
 ble in all of them, but much improvement can generally be attained. 
 
 SYPHILITIC APHASIA. 
 
 This affection is by no means uncommon as a result of syphilis of the 
 brain. It may come on quite early in the disease, but, like the other 
 nervous affections, is generally quite late. All the forms exist, due to syphi- 
 lis the loss of articulate speech with ability to write, loss of speech as 
 well as of the power of writing, the use of words inappropriately, the loss 
 of one language while another is remembered when the patient could talk 
 in two tongues. The prognosis is better in syphilitic aphasia than in any 
 other form, but there is nothing in the affection itself which stamps its 
 syphilitic nature upon it. History and concomitant signs must be relied 
 upon for a diagnosis. Treatment commenced promptly is often very 
 effective. 
 
 SYPHILITIC INSANITY. 
 
 Mania, acute and chronic, hebetude, dementia, and general paralysis are 
 certainly in some cases due to syphilis. History, accompanying phenom- 
 ena, and other symptoms affecting the nervous system due to syphilis, 
 have to be relied upon for a diagnosis. The whole matter is clothed in 
 considerable uncertainty; but, where there can be any certainty of the ex- 
 istence of syphilis, no consideration should deter the physician from giving 
 the patient the benefit of the doubt. The effect of treatment is often very 
 prompt in these cases, and lifts the cloud from the patient's brain, an 
 effect as apparent to the sufferer and his friends as it is to his physician. 
 1 have known a case of profound coma where there was no positive
 
 SYPHILIS OF THE NERVOUS SYSTEM. 213 
 
 history of previous disease, and where the patient could give no account 
 of himself, yet where a diagnosis of brain syphilis was made and acted 
 upon, to the prompt relief of the patient. In such cases it is well to search 
 the whole body of the patient. Look for circular white scars with a pig- 
 mented margin, examine the pupils for mydriasis. Search the retina with 
 the ophthalmoscope for optic neuritis. Pinch the shins, even if no nodes 
 are found, and see if the patient shrinks. Press upon all the different 
 parts of the skull, and notice whether the patient moves, as if he disliked 
 pressure upon any particular spot. Finally, examine the throat for cica- 
 trices of past syphilitic lesions, and frequently, without asking a question, 
 a diagnosis of nervous syphilis can be made, and a treatment instituted 
 which will restore the patient promptly to the exercise of his functions. 
 
 BEAIK SYPHILIS SIMULATING SUNSTROKE. 
 
 Desire to sleep is often a marked symptom in the case of patients 
 with brain syphilis. It may be connected with the most varied symp- 
 toms, or occur independently of other symptoms of a nervous order. It 
 is most apt to come on after an attack of supposed sunstroke. 
 
 Patients in late syphilis not infrequently first show nervous trouble in 
 the following way: on a hot day, while under exertion, or, sometimes, 
 when doing nothing, such a patient will be overpowered with the heat, 
 as it is called. There will be faintness, vertigo, pain in the head, perhaps 
 loss of consciousness. These symptoms are apt to be followed by loss of 
 strength, inability to undergo physical exertion, positive incapacity for 
 any mental effort, and with this, often a languid condition of general 
 incapacity and inability to do anything, which is very distressing to the 
 patient. With this, sometimes, there comes an intense desire to sleep. 
 The sleep does not satisfy. With much sleep, the patient is no better; 
 and with little sleep, not materially worse. Such patients often eat very 
 well exceptionally well. They grow fat, but cannot seem to get any 
 good out of their food in the way of strength. Heat, especially the heat 
 of the sun, makes them worse. They feel better in winter, but the sum- 
 mer wilts them down, makes them good for nothing. 
 
 These patients do not generally associate their symptoms in any way 
 with their antecedent syphilis perhaps long forgotten but consider 
 that they have been " touched by the sun," as they often put it, and they 
 seek for comfort through years of tonics and electricity, but do not find 
 it. A mixed treatment of mercury and the iodides is the best tonic for 
 these cases; but they often drag along very slowly, and in the end re- 
 main more or less intellectually and physically broken, and emotionally 
 weak for the remainder of their lives. Zittman's decoction sometimes 
 freshens up such cases amazingly, or a course at a water-cure, or at the 
 dry cure in Lindeweisse. 
 
 SYPHILIS OF THE CORD. 
 
 The lesions of syphilis affecting the cord are much the same as those 
 which have already been detailed in connection with syphilis of the 
 brain. The bones of the spinal column suffer from exostoses and necro- 
 sis, its fibrous and vascular membranes become involved in pachymenin- 
 gitis, or the seat of gummatous deposits, in a diffused or circumscribed
 
 214 THE VENEREAL DISEASES. 
 
 form. The cord itself may become soft in spots, or, more often, sclerosed, 
 in connection with diffuse, hyperplastic, connective-tissue proliferation, 
 or gummatous deposits, or arterial changes. 
 
 The symptoms attending all these lesions vary with the locality and 
 extent of the latter. The diagnosis is generally obscure, and depends 
 much upon the history of the concomitance of other symptoms nervous 
 or otherwise of syphilis. The treatment is often so effective as to un- 
 expectedly bring about a cure in the most seemingly desperate cases a 
 fact which makes the prognosis of syphilitic affections of the cord rela- 
 tively very good. 
 
 The symptoms of syphilis of the cord are, loss of motion or sensation 
 in the arm, leg, or body, along the course of certain nerves, the roots of 
 which may be involved in the lesions, neuralgias sometimes very in- 
 tense, and worse at night paraplegia, and a spurious form of locomotor 
 ataxia. 
 
 SYPHILITIC PARAPLEGIA. 
 
 Paraplegia due to syphilis is rarely complete. Occasionally coming 
 on within the first year after chancre, it is usually one of the very latest 
 of the nervous manifestations of syphilis. It has been encountered in in- 
 herited disease. It often comes on insidiously. The patient notices that 
 his legs are heavier than usual. He stumbles more often and on less oc- 
 casion than is his wont. He gets tired without due cause. He drags his 
 feet more than usual. The bladder always suffers along with the muscles 
 of the thighs, and legs, and the rectum, usually, as well. The patient can- 
 not throw a good stream of urine, and cannot extrude his fasces with any 
 satisfaction to himself. 
 
 At this stage most cases are diagnosticated to be reflex urinary paral- 
 ysis, and the bladder is often treated, the urethra slit, the prepuce cut off, 
 in the hope that, the supposed cause of reflex paralysis being removed, the 
 patient will get well a vain hope in these cases. 
 
 The legs are generally unequally paralyzed, and one of them much 
 more than the other. Certain groups of muscles in the different legs suf- 
 fer, perhaps symmetrically on the two sides, sometimes not so. Generally 
 sensibility remains intact, occasionally it is abolished. 
 
 There is rarely any numbness in the extremities, or pain in the back, 
 or convulsive twitchings; and there are no pains in the legs unless the le- 
 sion is confined to the meninges of the cord. The sensation of constric- 
 tion around the body is not usually complained of. Indeed, there is no 
 pathognomonic sign by which the syphilitic nature of a given paraplegia 
 can be even surmised. The history, the absence of any cause other than 
 syphilis, the presence of other evidences of syphilis of the nervous system, 
 or of any of the tissues, are important aids in the differential diagnosis. 
 The good effect of an energetic treatment is often quite prompt and very 
 obvious from the first. Mercury is of more value, relatively, in treating 
 syphilitic lesions of the cord, than in connection with similar lesions In the 
 brain. Inunction, carried to the extent of touching the mouth, is to be 
 tried, if an ordinary mixed treatment with preponderance of the iodides, 
 has been pushed without success. 
 
 Old cases of paraplegia, due to syphilis, do not generally get entirely 
 well under any treatment. They improve to a certain extent, and then 
 stop. The emotional and other accompanying intelligential phenomena 
 may cease, and the patient become absolutely well, while his bladder, rec-
 
 SYPHILIS OF THE NERVOUS SYSTEM. 215 
 
 turn, and certain muscles or groups of muscles in the lower extremity, re- 
 main permanently weakened. 
 
 la one such case, seen with Dr. Van Buren, it was necessary to apply 
 an apparatus, with an arrangement of rubber straps to represent the ham- 
 string muscles, all of which on both sides were much atrophied, in order 
 to allow the patient to walk erect. The bladder calls for attention so long 
 as its function is interfered with by the lesion causing syphilitic paraple- 
 gia, and sometimes for the rest of the patient's life. Care must be taken 
 to see that the bladder empties itself properly; and should it not do so, 
 the catheter must be gently used and the bladder washed out at stated 
 intervals. It must be remembered that the power of the bladder to resist 
 the impressions produced upon it by local violence is diminished, on ac- 
 count of the damage to its nerves by the syphilitic lesion. Consequently, 
 much more care and gentleness than usual is necessary in the use of the 
 catheter, to escape lighting up cystitis of the vesical neck, a complication 
 which causes much pain and the loss of time, and perhaps may lead to an 
 inflammation so profound as to permanently thicken the lining membrane 
 of the bladder and leave it in a state of mild chronic cystitis, from which 
 it never recovers. It is wiser to use enemata for the rectum than to depend 
 upon cathartics. 
 
 SYPHILITIC LOCOMOTOE ATAXIA. 
 
 Syphilis can certainly produce ataxic symptoms in the lower extremi- 
 ties. Fournier ' has collected a number of cases of his own, of Fereol, and 
 others. Whether the ataxic symptoms, however, can be called true loco- 
 motor ataxia, is the question. Certainly, the symptoms of true locomotor 
 ataxia may be so closely simulated that it is impossible to say, clinically, 
 that the disease produced by syphilis is not locomotor ataxia, and certainly, 
 also, treatment greatly improves these cases. I have observed several 
 cases in which the violent pains in the muscles were present, the strength 
 of the muscles preserved, and yet inco-ordination of movement so marked 
 that the patient could not walk without difficulty, and not run at all. 
 Such patients walk in a very stiff, clumsy way, bringing their heels down 
 solidly on the floor, but yet very unsteadily. They cannot stand on one 
 leg, cannot run, cannot stand firmly with the eyes shut, can hardly walk 
 at all or turn around with the eyes shut, cannot feel the grourfd plainly 
 under their feet, or touch a given object promptly with the end of the 
 foot, when asked to do so. I have not investigated the tendon reflex in 
 syphilitic locomotor ataxia. 
 
 The legs, in these cases, remain firm and strong muscularly, although 
 the patient thinks they are weak, until the contrary is proved by an at- 
 tempt on the part of his physician to flex or extend the leg in opposition 
 to the patient's will. The bladder in these cases is always involved in the 
 lack of power of co-ordination between the muscles which control its 
 function. Generally there is no atony, the expulsive power is good, but 
 there is more or less persistent spasmodic stricture, the cut-off muscles of 
 the deep urethra failing to relax in response to the patient's will. Such 
 cases are apt to become annoying and to call for the use of the catheter. 
 The bladder itself does not generally require washing or other treatment. 
 The rectum is not generally interfered with, in its function, to any marked 
 extent. 
 
 1 Gaz. med. de Paris, December 30, 1876.
 
 216 THE VENEREAL DISEASES. 
 
 I have seen one case where paraplegia with wasting of the muscles 
 and great loss of power in the lower extremities came on, produced by 
 syphilis of the cord. The patient could not get about without crutches. 
 Under treatment he got well of his paraplegia, but the sclerosed patches 
 left in his cord by the antecedent syphilitic lesions produced ataxia. His 
 muscles increased in strength, his legs and thighs grew visibly in size, 
 he discarded his crutches; but presently he got a sensation of constric- 
 tion about the body, and found that he could not control his legs. He 
 had to resume a cane, and finally crutches again, although his legs and 
 thighs were now large and firm, and no effort on my part could flex or ex- 
 tend his leg against his will. Bladder symptoms, which had come on in 
 this case with the paraplegia, persisted during the ataxia. 
 
 The treatment of ataxia due to syphilis is that of tertiary syphilis 
 mixed treatment, with an excess of iodides. I believe, however, that mer- 
 cury used freely has more effect in these cases than the iodides, and have 
 seen good effects follow a vigorous course of inunction. 
 
 The effect of treatment is slow and often unsatisfactory ; I think 
 more so in ataxic syphilis than in any other. It may be that the sclerosis 
 causing ataxia is secondary to previous syphilitic deposits, and, being 
 pseudo-cicatricial, is of course permanent and not influenced by treatment. 
 These cases are so rare that it is hard to make deductions about them. I 
 have not met more than half a dozen cases in all. I cannot recall more 
 than one reasonably perfect cure; but all the cases were improved by 
 treatment. 
 
 SYPHILIS OF SPECIAL NERVES. 
 
 The gummatous, bony and pachymeningeal changes, so common at the 
 circumference of the great nervous centres, often bring about symptoms 
 referable to implication of the different nerves dependent on pressure at 
 their points of exit through the foramina, or implication along their course 
 (e. ff. f in the cavernous sinus) in gummatous changes. Hence, the disor- 
 derly grouping of nervous symptoms has been considered to be sugges- 
 tive of syphilis as a cause of all the various phenomena, since the lesions 
 of syphilis are apt to be multiple and scattered, without any particular 
 order in their distribution, and it is natural for the symptoms to partake 
 of the same character. 
 
 Again, the special nerves themselves, any of them, may occasionally 
 suffer from congestive, hvperplastic or gummatous changes in their con- 
 nective tissue, or sheaths at any part of their course, or be involved in 
 neighboring gummatous processes or other tissue-changes. In this way 
 disorderly symptoms of different nerves may come on, due to syphilis as 
 a cause. 
 
 Finally, the essential influence of the syphilitic poison, without physi- 
 cal lesion, doubtless occasions some nervous symptoms, especially early 
 in the disease, such as neuralgias, inordinate appetite, sciatica, local areas 
 of analgesia and anaesthesia at the backs of the hands and elsewhere. 
 
 Heubner ' states that it is unusual for any of the special nerves to be 
 involved when the nervous symptoms are due to lesions of the cerebral 
 arteries (syphilitic endo-arteritis). 
 
 No nerve in the body is free from the possibility of being attacked by 
 syphilis, but certain ones are much more often involved than others; the 
 
 'Op. cit, p. 228.
 
 SYPHILIS OF THE NERVOUS SYSTEM. 217 
 
 motors of the eye, the seventh pair, the fifth pair, and the spinal nerves 
 take the lead. Among the nerves of special sense, the optic suffers most 
 often, optic neuritis being very common in connection with syphilis of the 
 brain, the portio mollis of the seventh pair coming next in frequency, 
 the olfactory third. The sense of smell is not often injured except in 
 connection with ulcerative or necrotic changes within the nose, and the 
 sense of taste very rarely forsakes a patient except in connection with 
 destructive changes in the mucous membrane of the pharynx and nose, 
 or extensive gumma of the tongue. 
 
 The nerves running to the muscles of the eye lose their power very 
 often through syphilis, the third most commonly of all. When the func- 
 tion of the third nerve is interrupted, or of portions of it, the result is ptosis 
 (quite common), mydriasis (very common), divergent squint (least com- 
 mon). Mydriasis is so common as to be almost constant in brain syphilis. 
 It may be due to optic neuritis in an advanced state; anything which 
 blunts the sensitiveness of the retina to light will make the pupil dilate. 
 When mydriasis occurs alone, as it often does, without any evidence of 
 retinal cause or loss of function of the third nerve, the short ciliary 
 branches coming from the lenticular ganglion are the only ones which func- 
 tionate imperfectly. The lenticular ganglion presides over the dilatation 
 and contraction of the pupil as well as over accommodation, and, as Hutch- 
 inson ' has pointed out, when there is cycloplegia (paralysis of the cil- 
 iary muscle) and a motionless pupil, the orbital muscles acting well, there 
 must be disease of the lenticular ganglion, and this condition of things 
 does sometimes occur in connection with syphilis. It is far more common, 
 however, to find mydriasis occurring alone, all the other muscular condi- 
 tions in and about the eye being normal. Tait and Tuke have reported 
 cases of long-persistent myosis due to syphilis. 
 
 About the ptosis and the squint there is nothing special to record. 
 These symptoms, as well as the mydriasis and the myosis, yield to treat- 
 ment of the stage of syphilis in which they occur. The mydriasis is per- 
 haps, of all, the most persistent. 
 
 The patheticus nerve (fourth pair) has been reported paralyzed by 
 syphilis (Graefe), and the sixth pair also occasionally suffers. 
 
 Facial neuralgia, or, more rarely, anaesthesia due to syphilis of the fifth 
 nerve, is sometimes encountered, yielding to mercury early in syphilis, and 
 more slowly to the iodides later. 
 
 Facial paralysis is quite common in syphilis. Early in the disease 
 this symptom has been noted. It is mild in character, and yields to mer- 
 cury. Late in syphilis it may come on alone or in connection with other 
 symptoms, and not infrequently it is the forerunner of some serious out- 
 burst; it may precede a general attack of hemiplegia by several days. 
 It yields, sometimes slowly, to mixed treatment, and especially to the 
 iodides in large doses. 
 
 The other pairs of nerves are very seldom involved by 'syphilis, but they 
 are not exempt. 
 
 The spinal nerves rarely suffer in a neuralgic way, but paralyses, an- 
 aesthetic and neuralgic troubles, may involve any of them occasionally. 
 Pleurodynia is common in the anaemia of early syphilis and in the cachexia 
 of the tertiary stage. Sciatica of syphilitic origin is not common or 
 well known, but undoubtedly occurs. N. B. Emerson,' of New York, in 
 
 1 Lancet, Feb. 10, 1877, p. 199 (London Path. Society). 
 8 Trans. Am. Neurological Association, N. Y. , 1877.
 
 218 THE VENEREAL DISEASES. 
 
 an excellent paper on the subject, has given cases occurring early arid late 
 in the disease. 
 
 SYPHILIS OF THE SYMPATHETIC. 
 
 The sympathetic ganglia are not left unmolested by syphilis. Petrow, 
 in 1873, called attention to changes produced in the sympathetic ganglia 
 by syphilis, pigmentation, and colloid degeneration of nerve-cells; inter- 
 stitial connective-tissue hyperplasia causing atrophy of nerve cells and 
 fibres; enlargement and proliferation of the endothelium surrounding the 
 nerve-cells, followed by fatty degeneration. 
 
 Hutchinson believes that the dyspepsia of syphilis is due to some ob- 
 scure disease of the sympathetic ganglia. Disease of the lenticular gan- 
 glion has already been referred to. 
 
 In cases of repeated cerebral congestion due to syphilis, Althaus ' pre- 
 mises that the superior cervical ganglion of the sympathetic is the seat of 
 organic change. 
 
 As may be observed from what is written above, the effect of syphilis 
 upon the sympathetic system are mainly conjectural. Very little is known 
 about it, much is left to discover. 
 
 Since attention of late years has been especially directed toward the 
 nervous symptoms of syphilis, many discoveries have been made. Four- 
 nier's recent book (La syphilis du cerveau. Paris, Masson, 1879), gives 
 perhaps as complete a showing of the subject as any that has been written, 
 and will repay perusal. 
 
 1 Med. Times and Gaz., Nov. 10, 1877.
 
 CHAPTER XIII. 
 
 SYPHILIS OF THE GENITOURINARY SYSTEM IN BOTH 
 
 SEXES. 
 
 Syphilis of the Kidney. Syphilitic Albuminuria. Syphilis of the Penis. Syphilis of 
 the Testicle ; Epididymitis, Orchitis (Diffuse, Gummatous). Diagnostic Table of 
 Syphilitic, Tubercular, Cancerous, and Sarcomatous Enlargement of the Testicle. 
 Treatment of Syphilis of the Testicle. Impotence due to Syphilis. Syphilis 
 of the Genital System in the Female. Functional Derangements of Menstruation 
 due to Syphilis. The Effect of Syphilis upon Pregnancy. Cause of Abortion in 
 Syphilis. Syphilis of the Mammary Gland, Diffuse, Parenchymatous, Gumma- 
 tous. 
 
 SYPHILIS OF THE KIDNEY. 
 
 SYPHILIS affects the kidneys in three forms: as interstitial, diffuse, con- 
 nective-tissue cell hyperplasia, as gummy tumor, and as amyloid degener- 
 ation. 
 
 The diffuse chronic syphilitic nephritis is similar to other parenchyma- 
 tous forms of interstitial nephritis, except that it is more apt to occur in 
 patches, and that upon section small clusters and collections of cells (gum- 
 mata), are often found scattered through it. The patches of circum- 
 scribed disease become contracted and condensed with the progress of the 
 affection, and the capsule adheres to them. 
 
 Gummata are not often met with in the kidney. They rarely get 
 larger than peas. In structure they resemble gummata of other organs. 
 They are always associated with more or less diffuse, parenchymatous 
 nephritis, each gumma being situated in a condensed band of connective 
 tissue. Gummata of the kidney do not seem to exist alone. If they are 
 found, the same lesions may be looked for in the liver and spleen with 
 confidence that they will be discovered there. 
 
 Amyloid degeneration of the kidney has in it nothing which is speci- 
 fic. It may be associated with other lesions due to syphilis, or exist 
 alone. In the latter case it is the rule to find the liver also and the spleen 
 to be amyloid; but this degeneration may exist in all these organs, and 
 yet the patient have no syphilis. Nevertheless, amyloid degeneration of 
 the viscera is common enough in connection with late syphilitic cachexia 
 to have attracted general attention; and although the change is not in it- 
 self specific, it is undoubtedly in some way often due to syphilis as a cause. 
 
 SYPHILITIC ALBUMINURIA. 
 
 The only way in which the existence of syphilitic lesions of the kid- 
 neys can be even surmised during life is by the presence of albumen in 
 the urine, with or without casts, for the ordinary tissue-changes in the
 
 220 THE VENEREAL DISEASES. 
 
 organ are not attended by local pain or general fever. There may be 
 symptoms of uraemia (but very seldom) and general anasarca (equally rare), 
 but I am not aware that albuminous retinitis occurs; and often there are 
 no symptoms at all, excepting the presence of albumen in the urine, to 
 declare that the kidneys are not sound. 
 
 Such a case was observed by me, in connection with Dr. Van Buren, 
 in the person of a patient seen in consultation with Dr. Dubois. The 
 urine was loaded with albumen, so as sometimes to boil into a solid white 
 mass, and it never contained any blood or pus. No casts were found, the 
 specific gravity ranged high, the general health remained perfect in all 
 respects (except that the patient grew thin), there was not the least urae- 
 mia or swelling of the face or legs, and occasionally the quantity of the 
 albumen in the urine would change materially without cause. 
 
 This patient eventually recovered entirely, every trace of albumen dis- 
 appearing from the urine, which became as light, clear, and bright as 
 sherry, and remained so after boiling and adding nitric acid. 
 
 I have seen several other cases of albuminuria, which came on during 
 the course of syphilis. They are generally unimportant, and get well 
 under treatment. I am certain that in some cases slight transient albu- 
 minuria is produced by the prolonged use of iodide of potassium in large 
 doses. This ceases on leaving off the drug. 
 
 Hans Hebra 1 reports a case of syphilitic paraplegia cured by treat- 
 ment. A month later the patient came back with swollen legs and intense 
 albuminnria, which got quickly well under large doses of the iodide of 
 potassium. M. Bradley" has reported general anasarca in a child with 
 inherited syphilis, four months old, who had a papulo-squamous eruption 
 and aibuminuria. Mercury with chalk cured the child of its skin disease 
 and its albuminuria in a few weeks. This child, says Bradley, had not 
 had scarlatina. Bradley also remarks that he found albumen in the urine 
 of two out of twenty patients with inherited syphilis whom he had exam- 
 ined, and it is well known by autopsical evidence, that syphilis of the kid- 
 ney is much more common in inherited than in acquired syphilis. The 
 diffuse parenchymatous form is most often met with in inherited disease. 
 
 Syphilis of the ureter does not seem to occur. Syphilis appears 
 also to spare the bladder, except in connection with disease of the spinal 
 cord. 
 
 SYPHILIS OF THE GEXITAL SYSTEM IX THE MALE. 
 
 The penis most often bears the brunt of the attack in primary syphi- 
 lis in being the seat of chancre and lymphangitis. Later in secondary 
 disease, cutaneous eruptions occur upon it, and mucous patches and ulcers 
 within the cavity of the prepuce and (very rarely) within the urethra. In 
 tertiary disease, ulcerated subpreputial gumma is by no means rare; a 
 papular eruption may occur within the urethra, giving rise to a gleet. I 
 have observed once such a case. The lumpiness in the urethra could be 
 felt, and it, with the gleet, disappeared promptly under antisyphilitic 
 medication by the mouth. 
 
 Finally, in tertiary disease, gummata occasionally occur in the corpora 
 cavernosa, usually in the anterior third of the organ; they are very rare, 
 and must be distinguished from chronic circumscribed inflammation of 
 
 VVierteljahresschrift f. Derm. u. Syph., No. II., p. 35. 
 1 British Medical Journal. 1871, Vol. I., p. 117.
 
 SYPHILIS OF THE GEXITO-URINAKY SYSTEM. 221 
 
 the sheaths of the corpora cavernosa ' and from calcification of the 
 penis. 
 
 Gumma of the corpus cavernosum is a hard, painless, semi-elastic 
 swelling at first. It causes deflection of the penis when erect, toward 
 the side upon which it is situated, and to an extent proportionate to the 
 size of the growth. In structure it is like other gummata. It goes 
 on to reach a certain size, and then may soften and shrivel away, or be- 
 come fibrous, or possibly calcify. I do not know of any case personally 
 where a gumma of the corpus cavernosum has softened and discharged 
 externally. General calcification of the penis occurs in plates upon the 
 sheath of the corpus cavernosum. It is apt to be general, and is not of 
 syphilitic nature. 
 
 Chronic circumscribed inflammation of the corpora cavernosa is also 
 mainly superficial, confined to the sheath and underlying tissue, painful 
 (somewhat) to pressure, often advancing in one direction as it gets well 
 in the other, never by any chance suppurating, occurring spontaneously 
 or as a result of injury, never due to syphilis. 
 
 The last two affections are not in the least degree helped by anti- 
 syphilitic treatment, either mercurial or by the iodides ; but gummy 
 tumor promptly disappears when the latter remedy is boldly pushed in 
 large doses. 
 
 The prostate does not appear to suffer directly from syphilis. Gum- 
 ma in this region is possible, but very rare. 
 
 The spermatic cord is sometimes the seat of gummy tumor, and 
 the scrotum a favorite locality for condylomata and scaly patches of the 
 circinate sort. 
 
 SYPHILIS OF THE TESTICLE. 
 
 Four different affections attest the action of syphilis upon the testicle: 
 
 1. Epididymitis. 
 
 2. Diffuse orchitis. 
 
 3. Gummy tumor. 
 
 4. Functional impotence. 
 
 They may all be arrested and cured by appropriate treatment. 
 
 SYPHILITIC EPIDIDYMITIS. 
 
 During secondary syphilis, in the earlier months three or four after 
 chancre (Dron) there may appear in the epididymis, usually at its head, 
 on one or both sides of the body, a round, hard tumor, standing distinct 
 from the testicle, and not capped over it as in ordinary chronic epididy- 
 mitis. The lump varies in size, but generally gets to be as large as a 
 good-sized marble. It is attended by a slight amount of spontaneous pain, 
 increased by manipulation; occasionally the swelling is perfectly indolent, 
 and the pain is never so great as that experienced in ordinary epididymitis. 
 
 Nothing more is known of the affection than this. I have encountered 
 it only two or three times. It is quite rare. It always gets well, never 
 has been known to soften, and no autopsy has been reported. It is quite 
 constant in its appearance at the globus major, and does not extend to 
 
 1 Van Buren and Keyes : Gen. Urinary Diseases and Syphilis. N. Y. , 1874, p. 24.
 
 222 THE VENEREAL DISEASES. 
 
 the body of the epididymis, or to the globus minor. It never involves 
 the testicle. Rollet places the outside limit of its existence at two 
 months from its first appearance. 
 
 Treatment is mercurial. No variation is required from that in use 
 for the stage of syphilis in which the affection occurs. Local measures 
 are unnecessary. The patient need not alarm himself about the lump. 
 Unlike the chronic thickenings left in the body and tail of the epididymis 
 after gonorrhoeal epididymitis, the syphilitic form does not occupy the 
 calibre of the tubes, or occlude them by pressure, as proved by Dron, who 
 found spermatozoa in the semen of a patient, both of whose testicles 
 were the seat of this affection. 
 
 SYPHILITIC OKCHITIS. 
 
 In the tunica albuginea, and in the fibrous septa running between the 
 clusters of seminal tubules, usually commencing at the circumference, 
 perhaps generalized through the whole parenchyma, sometimes confined 
 to a limited area, a cellular overgrowth of the connective-tissue elements 
 may arise due to syphilis, constituting diffuse sj^philitic orchids. 
 
 This new tissue develops until it has reached a certain limit, and then 
 contracts upon itself, squeezing the secreting elements of the testicle, and 
 finally reducing the whole gland to a fibrous cicatricial nodule of small 
 size, or producing depressions and seams which mark the limited areas of 
 disease and distort the gland more or less. Along with the other changes 
 in the organ the tunica vaginalis becomes thickened, and its cavitv oblit- 
 erated by cohesion of its two surfaces, or cut up into partitions by partial 
 adhesions. 
 
 The result of the anatomical changes is a gradual, general enlargement 
 of the organ or a localized patch of induration, usually the former. After 
 a time the organ atrophies, with or without treatment, and gets to be a 
 mere fibrous knot, or, in any case, smaller than it originally was. Suppu- 
 ration never occurs. 
 
 Syphilitic orchitis is a late symptom, rarely appearing during the first 
 year of the disease, and sometimes coming on long after all symptoms 
 have ceased. It is occasionally found in inherited syphilis. 
 
 The symptoms are an insidious swelling of one or both testicles with- 
 out pain. Generally the patient finds out by accident that one of his tes- 
 ticles is unnaturally large and hard. Squeezing such a testicle in the hand 
 causes the patient little or no pain, and the organ feels to the hand as hard 
 as wood. It preserves its oval shape the epididymis is indistinguishable 
 from the body of the testicle the cord is not involved, the tunica vaginalis, 
 instead of being obliterated, may be full of fluid. 
 
 GUMMY TUMOR OF THE TESTICLE. 
 
 Gumma of the testis is less common than diffuse orchitis. With gumma 
 there is generally, also, more or less fibrous thickening. Small gummata 
 are generally scattered through the morbid fibrous tissues of the organ 
 large ones surrounded by condensed fibrous tissue, like a capsule. The 
 gumma is at first purely cellular; finally it is found as a fine, fibrous felt- 
 ing, the seat of amorphous granulo-fatty degeneration. In the cheesy 
 centre, plates of cholesterine are sometimes found (Virchow).
 
 SYPHILIS OF THE GENITO-URINAKY SYSTEM. 223 
 
 The gumma is recognized as a distinct tumor perhaps accompanying 
 the physical changes indicative of diffuse orchitis. It is painless. The 
 nodule grows to a certain size, then softens centrally and undergoes cheesy 
 degeneration, or, infiltrating the tunica albuginea, the two surfaces of the 
 tunica vaginalis adhere, and the skin becomes attached over the swelling 
 mass. Finally the skin softens, ulcerates, and lets out the gumma, which 
 bears with it the contents of the testicle, the whole mass protruding out- 
 side and constituting one form of benign fungus of the testicle. This fun- 
 gus grows larger on account of an increased formation of gummy material 
 within the tunica albuginea, the surface of the protruded portion becomes 
 covered with granulations and bathed in a scanty pus. The yellow, de- 
 generated, gummatous matter is found lying between clusters and coils 
 of seminal tubules, which may be carelessly pulled out by the unwary 
 practitioner under the idea that they are dead, sloughy, and of no service. 
 The tissues of the scrotum contract around the base of the fungus, mak- 
 ing it pedunculated. The whole mass is hard, insensitive, not bleeding 
 easily. 
 
 If the affection be not arrested by treatment, its natural termination 
 is to go on until the whole of the contents of the tunica albuginea have 
 been extruded, after which the mass dries down and puckers, leaving the 
 wasted stump of the testicle attached to the cicatrix in the scrotum. 
 
 The epididymis is sometimes the seat of gummy tumor, but rarely; and 
 the cord (Verneuil) also occasionally. 
 
 The symptoms of syphilitic testicle, besides the changes of form 
 already described for the diffuse and gummatous form, are: diminution 
 or absence of sexual desire, and often entire absence of erections. 
 
 The diagnosis of syphilitic testicle is often difficult. There is no possi- 
 ble danger of mistaking it for gonorrhoaal epididymitis, or any other acute 
 inflammatory affection of the epididymis or testicle; the intense pain in 
 these maladies, both spontaneously and upon handling the organ, excludes 
 syphilitic testis from diagnostic consideration when it is in question. 
 Nor is there any considerable chance of the error of mistaking chronic epi- 
 didymitis, the pseudo-tubercular testis, for syphilitic disease of the organ. 
 The lumpy condition of the epididymis capping the soft testicle above, or 
 hanging down as a cheesy nodule below the tail of the epididymis, perhaps 
 softening into abscess and becoming fistulous, but leaving the soft, elastic 
 testicle intact in its peculiar natural sensibility; this chronic malady has 
 nothing in common with syphilitic testicle, and, although it may occasion- 
 ally suggest the syphilitic epididymitis of Dron, yet its chronic course and 
 peculiar pathological physiognomy will readily distinguish it from the 
 more innocent syphilitic affection. 
 
 It is still insisted upon by Curling and others that there is a simple 
 inflammatory orchitis, a sarcocele, which is neither tubercular nor syphi- 
 litic. This is possible, but exceptionally rare. I have occasionally en- 
 countered a case clinically where no other diagnosis but this seemed pos- 
 sible, yet it is a good rule to adopt Sir Astley Cooper's method and never 
 to cut out an inflamed testicle until mercury has had a full chance; and, 
 it may be added, the iodide of potassium as well. A benign fungus has 
 also been described, but it is much more uncommon than syphilitic fungus. 
 
 The main difficulties in diagnosis of syphilitic testicle, however, are 
 hydrocele, tubercle, cancer, and sarcoma of the testicle. Hydrocele is not 
 important. Many syphilitic testicles are so surrounded by the fluid of a 
 hydrocele that their physical characters are entirely obscured. In no case 
 is it safe to decide that a hydrocele is a simple matter until it has been
 
 224 
 
 THE VENEREAL DISEASES. 
 
 tapped and the testicle examined. If, after tapping, the physical signs 
 are those of syphilis of the testicle, no radical treatment of the effusion in 
 the tunica vaginalis should be undertaken; both because it is likely to 
 fail, and because it is unnecessary, since antisyphilitic treatment will re- 
 move the effusion together with the lesion of the testicle. 
 
 Tubercular testis, however, is often painless; and certain stages of 
 cancer of the testicle and of sarcoma are suggestive of syphilis. The 
 salient points of clinical difference between these affections can be best 
 presented in the form of a short diagnostic table. 
 
 Diagnostic Table. 
 
 YPHILITIO TESTICLE. 
 
 TUBERCULAR TESTICLE. 
 
 CANCEROUS TESTICLE. 
 
 SABCOMATOUS TESTICLE. 
 
 1. Date of appearance 
 
 Adolescence. 
 
 Youth. 
 
 Youth. 
 
 generally. Middle age. 
 
 
 
 
 2. Size. Karely larger 
 
 Often larger than a 
 
 Sometimes enormous, 
 
 Often very large, but 
 
 than a goose-egg. 
 
 goo&e-egg. 
 
 weighing several pounds. 
 
 generally becoming can- 
 
 
 
 
 cerous when it attains 
 
 
 
 
 great size. 
 
 3. Commencement. 
 
 Generally in the testi- 
 
 Always in the testicle. 
 
 Always in the testicle. 
 
 Generally in the epididy- 
 
 cle. 
 
 
 
 mis. 
 
 
 
 
 4. Growth. Insidious, 
 
 Slow; of ten lasts many 
 
 Rapid; average about 
 
 Slow at first, often rapid 
 
 often unnoticed, may last 
 
 years. 
 
 two years. 
 
 later on ; total duration 
 
 several years. 
 
 
 
 many years. 
 
 6. Physiognomy. 
 
 Nodular, occupying the 
 
 Unevenly lobulated in 
 
 Generally even, or 
 
 Smooth andeven through- 
 
 epididymis ; scrotum of- 
 
 various directions ; veins 
 
 slightly lobulated ; scro- 
 
 out, or containing one or 
 
 ten reddened and hot. 
 
 of scrotum often enlarged, 
 
 tum unchanged. 
 
 more nodules in the tes- 
 
 
 integument unchanged. 
 
 
 ticle; scrotum unchanged. 
 
 
 
 
 6. Induration. Very 
 
 Not marked, the feel is 
 
 The lobules present dif- 
 
 Solid, meaty feel, not 
 
 strongly marked, woody. 
 
 elastic. 
 
 ferent degrees of hard- 
 
 very hard ; thi re may 
 
 
 
 ness ; some of them seem 
 
 be a cyst which fluctu- 
 
 
 
 to fluctuate. 
 
 ates. 
 
 7. Spontaneous pain. 
 
 Insignificant, as a rule. 
 
 Present in paroxysms, 
 
 Absent. 
 
 Absent. 
 
 
 often very sharp. 
 
 
 8. Pain on handling. 
 
 Generally absent ; nor- 
 
 Pain increased by hand- 
 
 Absent ; normal sensi- 
 
 Generally absent; normal 
 
 mal sensibility gone. 
 
 ling ; no natural testicular 
 
 bility gone. 
 
 sensibility gone. 
 
 
 sensation. 
 
 
 9. Fluid in tunica va- 
 
 Not unusual. 
 
 In small amount. 
 
 Usually absent. 
 
 ginalis. Common. 
 
 
 
 
 10. Softening and dis- 
 
 Softening and abscess 
 
 Rather common, leav- 
 
 Does not occur. 
 
 charge. Rather excep- 
 
 the rule, leaving fistula. 
 
 ing malignant fungus. 
 
 
 tional : sometimes occurs, 
 
 
 
 
 leaving fungus. 
 
 
 
 
 11. Often bilateral, 
 
 Often bilateral consecu- 
 
 Very rarely bilateral. 
 
 Hardly ever bilateral. 
 
 simultaneously or con- 
 
 tively. 
 
 
 
 secutively. 
 
 
 
 
 12. Sexual power. 
 
 Sometimes diminished, 
 
 Not impaired, except 
 
 Not impaired. 
 
 Diminished or absent. 
 
 often not impaired. 
 
 by size and i>ain. 
 
 
 18. Fungus found 
 
 Abscess and fistula 
 
 Fungus found some- 
 
 No fungus. 
 
 sometimes, of small 
 
 found, but not fungus. 
 
 times growing rapidly. 
 
 
 growth, pale, not bleeding 
 
 except in the shape of 
 
 livid in color, bleeding 
 
 
 easily. 
 
 simple granulations. 
 
 very easily. 
 
 
 13. Inguina andpelvic 
 
 Normal or tender from 
 
 Enlarged cancerous. 
 
 Not involved while the 
 
 glands. Normal. 
 
 simple inflammation. 
 
 
 tumor remains benign. 
 
 14. Spermatic cord. 
 
 Generally involved 
 
 Often implicated to- 
 
 Always normal. 
 
 Rarely implicated. 
 
 after a time. 
 
 ward the end. 
 
 
 15. Seminal vesicles. 
 
 Frequently diseased. 
 
 Normal. 
 
 Normal. 
 
 Normal. 
 
 
 
 
 16. Treatment. 
 
 Quite unsatisfactory ; 
 
 Prompt castration is Prompt castration de- 
 
 Promptly satisfactory in ! cure possible, but very 
 
 necessary, and affords the sirable to prevent the tes- 
 
 case of gummy tumor ; \ slow, if accomplished at 
 
 only hope of saving the tide from becoming can- 
 
 often very slow in its ef- ' all ; general tubercnliza- 
 
 patient's life. 
 
 cerous, since sarcoma m 
 
 fects, if the malady has , tion quite apt to come on 
 
 
 this region often runi 
 
 already existed for some ! and terminate the case ; 
 
 
 into cancer. 
 
 time in the diffuse form ; 1 castration is often justi- 
 
 
 
 treatment necessary to i liable. 
 
 
 
 save testicle from atrophy, 
 
 
 
 
 which can always be ac- 
 
 
 
 
 complished when treat- 
 
 
 
 
 ment is commenced in 
 
 
 
 
 time. 
 
 
 
 \
 
 SYPHILIS OP THE GENTTO-UKINAKY SYSTEM. 225 
 
 Treatment. Syphilitic testicle in the diffuse form calls for mercury 
 as well as the iodide of potassium. Local treatment is of little or no 
 value, but a suspensory bandage should be used to protect the enlarged 
 organs from injury. Mercury may be employed by general inunction. 
 Local inunction of the scrotum, or the wearing of plasters upon it, is 
 dirty, and possesses no superior merit. The effect of treatment is slow, 
 but it should be persisted in to save whatever of the glandular structure 
 is possible from atrophy. The iodide should be pushed up to large 
 doses (twenty grains or thereabouts), and the effect watched. If a re- 
 turn of sexual appetite and a reduction in the size of the gland are not 
 quite noticeable within a month, it is better, for the stomach's sake, to 
 reduce the dose of the iodide to five, or, at most, ten grains, and push 
 the mercurial by inunction until the mouth is mildly touched. After 
 this the dose of the mercurial may be also diminished, and pressure of 
 the testicle (by strapping) combined with a moderate internal mixed 
 treatment. 
 
 For gummy tumor, the iodides alone are needed, in doses as large as 
 the stomach can conveniently manage. A prompt effect is to be ex- 
 pected. 
 
 Fungus of the testicle should on no account be molested by local 
 treatment. If it becomes strangulated and threatened with gangrene, 
 it is proper to liberate the neck of the fungus from its pressure by suit- 
 able incisions through the skin, dartos, and albuginea. Otherwise the 
 fungus must be left alone, covered by a piece of lint smeared with vase- 
 line, to protect it from friction and injury. The iodide of potassium, 
 given in sufficient doses, will soon cause the gummatous deposit within 
 the tunica albuginea to be absorbed, and all the seminal tubules within 
 the fungus, which have escaped destruction by pressure, will be naturally 
 drawn back within the cavity of the testicle. Toward the end, a little 
 pressure may hasten the disappearance of the fungus and the cicatriza- 
 tion of the wound. 
 
 FUNCTIONAL, IMPOTENCE. 
 
 Syphilis may cause functional impotence, not due to any physical 
 lesion of the testicles. In the tertiary stage, impotence may come on 
 independently of any cachexia, the testicles appearing normal in size, and 
 possessed of their peculiar sensibility, but perhaps feeling a little flabby, 
 as if less full of blood than usual; under these circumstances, the patient 
 may lose all sexual desire, and absolutely all power of erection. 
 
 This condition is certainly due to some impression upon the nervous 
 system. There is a very positive bloodlessness of the penis, and testicles. 
 Treatment often restores power, and then the organs regain their plump- 
 ness. The affection is not due, as has been claimed, to the use of the 
 iodides, or to any wasting influence their prolonged use exercises upon 
 glandular structure. Patients have this form of impotence, who have 
 never taken the iodides patients whose symptoms have all been con- 
 trolled by mercurials. Moreover, the iodides, internally, constitute the 
 best treatment for the malady. 
 
 One reason why the iodides have been accused of causing atrophy of 
 the testicles is, doubtless, because, in many cases of advanced gummatous 
 orchitis, the iodides produce at first a diminution of the enlarged testicle, 
 and, during the continuance of the medicine, the gland atrophies away 
 to a stump. The iodides are now accused of this catastrophe, whereas the 
 15
 
 226 THE VENEREAL DISEASES. 
 
 truth is that all the secreting structure of the testis was already de- 
 stroyed, and replaced by newly formed tissue before treatment was com- 
 menced. The atrophy was inevitable. Truly, its appearance was has- 
 tened by the iodides, but not caused by them; and the trouble was that 
 treatment was commenced too late to save an organ already pathologi- 
 cally doomed to destruction. 
 
 There is no special diagnostic feature which distinguishes functional 
 impotence, due to syphilis, from the same affection dependent upon other 
 causes (generally, moral; sometimes, gouty); but, when a patient, having 
 formerly had syphilis, complains of failing sexual appetite and power, it 
 is always allowable to suspect that the influence of the old disease upon 
 the nerves regulating the sexual sense is the cause of the trouble, and 
 the prognosis at once becomes proportionately less severe than it would 
 have been had no former syphilis existed. 
 
 Treatment. The best treatment for functional syphilitic impotence 
 is mixed internal medication in reasonably mild form, persistently pushed. 
 The effect of treatment is slow, but often very manifest. A perfect cure 
 is possible. Other measures, such as tonics, change of air, general fric- 
 tions to the whole surface of the body, shower-baths, etc., may be used, 
 but they hold a place second to that occupied by antisyphilitic treatment. 
 
 I have encountered a number of these cases, totally disconnected with 
 pathological tissue-changes in the testicles, and am confident that the af- 
 fection exists as a special malady, and that it is curable by antisyphilitic 
 treatment. 
 
 SYPHILIS OF THE GENITAL SYSTEM IT* THE FEMALE. 
 
 The female genitals are the common seat of chancre, erosions, and 
 mucous patches. Tertiary tubercular patches are found within the vagina, 
 and tertiary brawny infiltrations, leading to ulcers which are very chronic 
 in their course. Gummata in this region may perforate one or the other 
 of the vaginal septa. Excepting from possible mucous patches in its 
 cavity, the unimpregnated uterus does not appear to suffer from syphilis. 
 Lancereaux describes a case of gummy tumor of the ovary similar to the 
 same lesion in the testicle, and both he and Hutchinson have encountered 
 some cases of imperfect sexual development in the female, in connection 
 with congenital syphilis, making it seem probable that parenchymatous 
 ovaritis is possible in hereditary syphilis, as parenchymatous orchitis and 
 gumma of the testicle in the male are known to be. 
 
 Gummata have been found in the Fallopian tubes. 
 
 Functional derangements of menstruation are very common in 
 women with syphilis. In the secondary stage, anaemia leads to scanty 
 menstruation, the relaxed ligaments allow the organ to become easily dis- 
 placed. Hence arise all sorts of malpositions with catarrhal states of the 
 uterine cavity, painful menstruation, sterility, hysteria, etc., due to gen- 
 eral causes rather than the specific action of syphilis. Metrorrhagia may 
 also come on by what mechanism does not seem evident. 
 
 The cachectic stage of tertiary syphilis also leads to uterine derange- 
 ments and induces a premature change of life. 
 
 Treatment of these uterine derangements is that of the stage of syph- 
 ilis in which they occur, together with such local measures as each indi- 
 vidual case may call for.
 
 SYPHILIS OF THE GENITO-UKINAEY SYSTEM. 227 
 
 THE EFFECT OF SYPHILIS UPON PBEGNANCY. 
 
 When a woman is in active syphilis, she rarely carries a child to term. 
 At first it is customary for such a woman to abort at or about the third 
 month of utero-gestation. Such a woman may have been poisoned by 
 her husband, and had a chancre without knowing it. Her sore throat 
 may have been transient, her first eruption so light as not to have at- 
 tracted attention; but she finds her color fading, her hair growing dry 
 and falling out, her scalp getting scurfy, her face wearing a pinched and 
 wearied expression. She is evidently anaemic; she feels languid, listless, 
 incapable of undertaking anything, and at the present day, since the 
 fashion so goes, she generally passes for being malarial. 
 
 Such a woman, without any obvious ;signs of syphilis about her, does 
 not thrive upon any regimen, or tonic course, or quinine, or change of air, 
 so well as she does upon a combination of blue mass and dried sulphate of 
 iron, or a mild dose of corrosive chloride of mercury in compound tinc- 
 ture of bark. Such a tonic suits her. The mercurial element always 
 brightens her up, and sends the blood again to her faded cheeks. 
 
 A woman under these circumstances will usually abort. Should she 
 become pregnant again, she will again abort, but probably at a later 
 month of utero-gestation. Again pregnant, she again aborts; on this 
 occasion, perhaps, miscarrying at the seventh month. The next attempt 
 may produce a dead-born child, with its skin commencing to come off. 
 Finally a child will be born at term alive, perhaps plump and clean-skinned, 
 but in from two to four weeks it begins to fall away in flesh, gets snuffles, 
 sore mouth, eruptions, jaundice, and dies; another child appears and dies 
 in a convulsion after a few months of life, or perishes by marasmus in its 
 second summer. At last a fat child is born seemingly healthy, but, as it 
 grows, its fontanelles close too rapidly, it is microcephalic, looks like an 
 old man, is perhaps very precocious, but it has a harsh cry, contracted 
 jaws, bad teeth; the second set are syphilitic teeth. It has a syphilitic 
 countenance, and grows up, perhaps, dwarfed or deformed in its bones, to 
 fall a victim, possibly, to gummatous lesions of the bones, the brain, the 
 eye, or the viscera during development into manhood. 
 
 After this the mother will produce a perfectly healthy child, if her 
 own health be good. Her subsequent offspring will not probably be de- 
 formed. They will not be strumous. There is no change of type by 
 transmitted inheritance. A child may be weakly, if the mother or father, 
 or both, be in poor health, or from -a variety -of causes ; but if the parent 
 is syphilitic, the child is either syphilitic or healthy, so far as the syphilis 
 essentially has anything to do with the matter. 
 
 Now, during all this time above detailed, a mercurial treatment given 
 to the mother, by inunction, or internally, during the whole course, or the 
 greater part of her pregnancy, will generally cause her to produce a 
 healthy child a child who not only is healthy at birth, but remains 
 healthy, and does not require treatment. Treatment rarely has so good 
 an effect if used in the first pregnancy. Then the syphilitic poison is too 
 strong. A live child may be born reasonably healthy, but its health is 
 not assured, and it may demand treatment to preserve it from injury by 
 the development of hereditary syphilis. 
 
 Again, if a mother has produced a healthy child under treatment, she 
 must go on, and at her next pregnancy again take a full mercurial course, 
 although she may have had no symptoms of syphilis during a number of
 
 228 THE VENEREAL DISEASES. 
 
 years, or she will run the risk of again producing a diseased child. 
 During how many pregnancies this must be kept up is not known, but 
 cases are on record where the successful production, under mercury, of two 
 healthy children successively (the eighth and ninth, all the previous chil- 
 dren having died syphilitic), did not succeed in rendering the mother ca- 
 pable of bringing a non-syphilitic child into the world. 1 In cases of this 
 sort, therefore, it will be wiser to medicate the mother at least through 
 three successive pregnancies before allowing her to try the experiment of 
 passing through a term of utero-gestation unaided by drugs. 
 
 CAUSE OF ABORTION IN SYPHILIS. 
 
 Exactly what it is that causes abortion and premature delivery so 
 often when the parents are syphilitic, is not certainly known. Disease 
 and death of the foetus does not necessarily bring on premature delivery, 
 for a dead child is often carried to term. If the germ is so blighted that 
 its development into a foetus is impossible, abortion, perhaps, is natural ; 
 but the main trouble seems often to lie in the placenta. The question 
 whether syphilitic uterine disease is a prime factor in causing the placen- 
 tal changes, or whether the latter owe their origin to a blighted ovum, 
 does not appear to have been clearly decided. Finally, whether the pla- 
 cental changes have in them anything which can be called specific, or whe- 
 ther they are such as may occur in other morbid states, not syphilitic, is 
 also undecided. 
 
 The syphilitic placenta, as described by Fraenkel, of Breslau," under 
 the name of disfiguring granulation-cell disease, consists in a multiplica- 
 tion of the cellular elements of the villi and of their epithelial coating, 
 together with an increase of thickness in the vessel-walls. By this pro- 
 cess, which Fraenkel thinks goes on centrifugally from the vessel, the 
 villi increase in size, then the vessels become occluded, and, finally, the villi 
 atrophy. The unaffected villi become congested, extravasations of blood 
 take place, and the foetus suffocates, because its blood cannot be aerated 
 in the diseased placenta. 
 
 This occurs, Fraenkel thinks, when the origin of the disease in the 
 foetus is syphilis of the father. When the mother is the source of the 
 transmitted syphilis, the maternal placenta is diseased, there is an in- 
 creased growth of connective tissue in the framework of the placental de- 
 cidua, hypertrophy of the cells of the decidua, and atrophy of the villi by 
 compression. 
 
 The syphilitic nature of the foregoing changes is denied by Lawson 
 Tait,' who believes that the same lesions may be due to causes other than 
 syphilis. 
 
 Fatty and amyloid degeneration of the placenta has been considered 
 to be dependent upon syphilis, and a cause of miscarriage, and tumors re- 
 sembling gummata have been observed in the placenta; but the truth is, 
 that this field is not yet thoroughly worked out, and we simply know, 
 clinically, that the placenta is often abnormal histologically, and that the 
 
 1 Thurman's case : Journ. de med. et de chir. Toulouse. Oct., 1851. 
 
 * Ueber Placentarsyphilis : Archiv f. Gynaekologie, Vol. V., 1873, p. 45. These 
 riews, given by Angus Macdonald. may be found in the American reprinb of Obstetrical 
 Journal of Great Britain and Ireland/October, 1875, p. 472. 
 
 1 Transactions London Obstetrical Society. London, 1876, p. 326.
 
 SYPHILIS OF THE GENITOURINARY SYSTEM. 229 
 
 product of conception, itself more or less diseased, is often thrown off be- 
 fore term. 
 
 Treatment. The condition of affairs described above may certainly 
 be averted by treatment. Mercurial treatment is of the most value. The 
 iodides have little or no power in averting the tendency of syphilitic 
 women to miscarry. Mercury will generally do this, and when it accom- 
 plishes the result, it does so without injury to either the child or to the 
 mother. 
 
 The manner of giving mercury, under these circumstance, is unimpor- 
 tant, provided enough is given. Inunction is highly praised by some au- 
 thorities. The objection to inunction is, that it is dirty, not suitable to 
 the sex, and that it is difficult to grade the dose accurately, according to 
 the necessities of the patient. A given amount of mercury does not af- 
 fect all people in a similar way. Some patients have a boundless toler- 
 ance of it, while others become salivated with great facility. In the preg- 
 nant state there are no symptoms to be guided by, and the value of the 
 mercurial course can only be decided at the end of pregnancy, when it is 
 too late to increase the do'se if it has not proved efficient. 
 
 Consequently it is best to have some rule for guidance. The method 
 I have adopted is the following: I use an unirritating form of mercury 
 combined with a tonic such as 
 
 3 Pil- hydrargy ri gr. c. 
 
 Ferri sulph. exsiccat gr. 1. 
 
 M. Ft. pil. L 
 Or 
 
 $ . Pil. hydrarg gr. c. 
 
 Quinine bisulph gr. 1. 
 
 M. Ft. pil. 1. 
 
 Commencing at the beginning of pregnancy, one of these pills is to be 
 used after each meal (three a day) for a week. Then four pills a day afre 
 used for a week, then five pills a day for a week, and so on until the med- 
 icine begins to disagree. When the mouth becomes a little touched, all 
 medication is suspended for a week, and then a dose, two-thirds of what 
 was found necessary to touch the mouth, is commenced with and given 
 regularly. It may be alternated, from time to time, with a mild dose of 
 corrosive sublimate in compound tincture of bark. It may be intermitted 
 entirely for a time, and replaced by inunctions of the oleate of mercury 
 or of mercurial ointment, to let the stomach rest a drachm being used 
 of the oleate (ten per cent, squibb) daily, or less, and after a short time 
 the internal medication being resumed. 
 
 If the stomach becomes irritated by the prolonged use of mercury, in- 
 unctions must be relied upon in quantity regulated by the tolerance of 
 the patient. If the prolonged use of a mild dose internally keeps the 
 mouth tender, the hygiene of the mouth must be attended to, alkaline 
 mouth washes used, and the tartar carefully removed from the teeth. If 
 the bowels show irritability, bismuth and catechu, with an unirritating 
 diet, must be combined with the mercurial. 
 
 Such a course will save most mothers from miscarrying. The chances 
 of averting the mishap are greater the farther removed the conception is 
 from the chancre. Success or failure in one pregnancy must modify the 
 treatment of the next, and the result is certain to be finally satisfactory 
 to all concerned.
 
 230 THE VENEREAL DISEASES. 
 
 Parents who have lost one or two children by miscarriage through 
 syphilis become very despondent, and the mother often needs considera- 
 ble encouragement to induce her to do anything for a given pregnancy, if 
 former trials have failed. 
 
 There is no objection to continuing the mercurial treatment up to the 
 date of delivery, diminishing the dose during the last month, since, presu- 
 mably, if the child has gone well so far it will take less to hold it. Sig- 
 mund thinks the mercury should be stopped with the seventh month, but 
 there does not appear to be any good reason for such a course. Milk diet, 
 combined with the mercurial, is very advantageous in pregnancy, and in 
 any case a mild diuretic should be occasionally used. 
 
 SYPHILIS OF THE MAMMARY GLAND.. 
 
 Mention has been made of the possible chancres about the nipples, and 
 the mucous patches, and ulcers, and lesions upon the skin covering the 
 female breast. The gland itself is attacked sometimes by syphilis. Two 
 forms of the affection have been observed a diffuse mastitis, and a gum- 
 matous infiltration. 
 
 Diffuse syphilitic mastitis is very rare. It has only been observed 
 apparently in the secondary period of the disease, and is encountered in 
 the male as well as in the female (Ambrosoli). The gland simply gets 
 swollen and tense, slightly painful. There is no change in the integu- 
 ment, which does not adhere to the underlying tissues. No special treat- 
 ment is necessary. The swelling always goes down without leaving any 
 trace behind. 
 
 The gumma of the breast is a very hard swelling occurring on one 
 or both sides without pain. It goes on to involve the skin, softens and 
 discharges. It is very often mistaken for cancer. History and concomi- 
 tant lesions make the diagnosis, and the iodides in large doses effect a 
 cure. Gumma of the breast has, been observed in connection with in- 
 herited syphilis.
 
 CHAPTER XIV. 
 
 SYPHILIS OF THE EYE AND EAR. 
 
 Syphilis of the Eyelids and Conjunctiva. Syphilis of the Cornea, the Iris (Plastic and 
 Gummatous Iritis). Syphilis of the Vitreous, of the Ciliary Body, of the Choroid, 
 of the Retina (Atrophy of the Retina, Retinitis Pigtnentosa). Syphilitic Optic 
 Neuritis. Syphilis of the Ear. Syphilis of the Outer Ear and Auditory Canal. 
 Plastic Myringitis. Syphilis of the Auditory Nerve. Syphilis of the Middle Ear. 
 Ear Affections found in Inherited Syphilis. Catarrhal Inflammation of the 
 Middle Ear, Deaf -mutism. 
 
 THE skin of the eyelids is occasionally the seat of chancre; patches 
 of various kinds of eruption may come upon it, and mucous, flat papules 
 are not uncommon. The tarsal borders may be uniformly thickened in 
 late syphilis, and little circumscribed gummata, looking 1 like styes, but 
 more livid and painless, are quite common in this region during the course 
 of the malady. 
 
 Upon the conjunctiva, chancre and mucous patches have been ob- 
 served. I have seen a case of indurated chancre of the caruncle in a 
 female, which had been excised on account of a diagnosis of epithelioma, 
 but induration recurred in the cicatrix, and general syphilis followed. 
 Gummy tumors of this region (the lachrymal caruncle) is quite a serious 
 affection in appearance. Dr. R. W. Taylor, of this city, has reported * 
 two excellent cases, one of which had been excised for cancer, but, return- 
 ing, was cured by iodide of potassium. 
 
 The lachrymal sac, and the skin over it, may be the seat of gummatous 
 deposit, and if this be allowed to ulcerate, lachrymal fistula may result. 
 The nasal duct is frequently occluded by reason of ulcerative gumma- 
 tous changes of mucous membrane and bone within the nasal cavity, es- 
 pecially if the lachrymal bone be involved in necrosis. 
 
 Changes in the cornea are very uncommon in connection with 
 acquired syphilis. With inherited disease chronic interstitial keratitis 
 (Hutchinson) is quite common. It will be described, along with the other 
 lesions of inherited syphilis, in Chapter XV. I have seen one well-marked 
 case of chronic interstitial keratitis due to acquired syphilis in an adult. 
 This patient got slowly but perfectly well under a mixed treatment. 
 
 The iris suffers very often in acquired syphilis. Mydriasis and 
 myosis have been described in connection with the affections of special 
 nerves due to syphilis. 
 
 Iritis. It is probable that, at least, half of all the cases of iritis 
 which occur are syphilitic in origin. Iritis most often comes on in severe 
 cases of syphilis with one of the early eruptions; particularly is it apt to 
 coincide with a pustular eruption. The symptoms are exactly the same 
 as those of acute iritis due to any cause; slight dulness and change in 
 the color of the iris, more or less injection of the peri-corneal conjunctiva 
 
 1 New York Medical Record, March, 1875.
 
 232 THE VENEREAL DISEASES. 
 
 (possibly chemosis), lachrymation, supra-orbital pain, generally worse at 
 night, and intense photophobia. The pupil is hazy, and will not dilate in 
 the dark. When forced to dilate by the use of atropia or duboisia, its 
 margin is often festooned, it does not dilate regularly. Plastic exudation 
 of lymph is quite common, effused from the borders and posterior surface 
 of the iris by means of which adhesions are effected with the anterior 
 capsule of the lens, and the dilatability of the pupil permanently compro- 
 mised. Its opening may be entirely occluded. A thin, diffused plastic 
 exudation sometimes tills the anterior chamber. It may seem to be ab- 
 sorbed and to melt away under treatment. 
 
 Gumma of the iris is less common, but may be observed as a small, 
 yellowish red papule growing from the iris. This may reach a consider- 
 able size, fill up the pupil, and distend the anterior chamber. It may be 
 seen to disappear under the internal use of the iodide of potassium. In- 
 stead of growing out as one distinct tumor, there may be several small 
 gummata upon the iris, or the whole muscle may be diffusely infiltrated, 
 and contract strong adhesions with the capsule of the lens. 
 
 The ciliary body and the choroid may be involved in inflammatory 
 and gummatous complications in connection with syphilitic iritis. 
 
 Relapse of plastic iritis, especially if there be many adhesions, is quite 
 common, and these relapses may continue on for a number of years, a 
 slight cause, such as over use of the eye, the influence of cold, a very 
 bright light, being sufficient to kindle up an attack. Plastic iritis is often 
 double, simultaneously or consecutively. Gummatous iritis is generally 
 confined to one side. 
 
 Treatment. Iritis generally yields a very prompt obedience to the 
 influence of mercury. The drug may be given in any shape, but it should 
 be pushed until its effects are quite obvious. If the patient is anfemic 
 and debilitated, cod-liver oil, tonics, change of air, good food, etc., are all 
 of the highest value. No care should be spared to put the patient under 
 the best possible dietetic and hygienic surroundings, for an important 
 function is threatened. The mercury should be pushed until the gums 
 show its influence slightly. 
 
 The great danger in iritis is adhesion of the pupillary margin to the 
 anterior capsule of the lens. If this occurs, it is vastly better that it 
 should do so with the pupil widely dilated; hence it is always advisable 
 to use instillations of solutions of atropia or duboisia into the eye. A 
 solution of gr. i. iv. to the 3 i. of distilled water may be used; a few 
 drops being placed beneath the lid once a day, or oftener, if it is found 
 necessary, in order to hold the pupil dilated to its greatest extent, and 
 this should be continued until all photophobia has passed, and all conges- 
 tion ceased. If atropine irritates, a solution of duboisia, the new mydria- 
 tic, may be used. The eye should be kept closely shaded from light, 
 but it is not wise to keep the patient in the house, much less to confine 
 him to a dark room. Oleate of morphia, or the oleate of morphia with 
 oleate of mercury, may be rubbed over the brow in case of pain alone, or 
 combined with belladonna ointment. 
 
 The gummatous form of iritis comes most readily under the influence 
 of the iodides, but the use of atropia is desirable in these cases as well as 
 in the plastic form. For old cases where the pupil is adherent, and re- 
 lapses occur, iridectomy is the remedy. 
 
 The vitreous body, from degeneration of its cells and proliferative 
 changes, may show opacities caused by syphilis, and capable of removal 
 by treatment.
 
 SYPHILIS OF THE EYE AND EAE. 2JJ 
 
 Cataract may ensue as an indirect result of syphilis due to disease 
 in the choroid, the ciliary body, the iris, and dependent upon opacities 
 in the lens, or its capsule. Anti-syphilitic treatment will not relieve 
 these opacities, and the result of operation for cataract is not always 
 satisfactory, owing to possible damage occasioned by syphilis in the 
 deeper structures of the eye. 
 
 Cyclitis has been observed as a result of syphilis and gummata, in- 
 volving the ciliary body, in severe cases implicating the iris, attended by 
 great pain and calling for extirpation of the globe of the eye. 
 
 The choroid may be affected by syphilis alone, or in connection, 
 with disease in other structures within the globe ; it often participates 
 in inflammatory disturbances which primarily involve the iris. Syphilis 
 does not seem to produce changes in the choroid which are pathogno- 
 monic. Choroiditis disseminata, described by Graefe, is a common form of 
 the disease as produced by syphilis. 'In this condition the ophthalmo- 
 scope reveals, through a clouded vitreous humor, small scattered spots of 
 a pale color, perhaps with reddened borders scattered over the posterior 
 surface of the chamber of the eye. The retinal vessels may be occasion- 
 ally seen unchanged, passing over these spots, which are of varied size, 
 but never large, and are evidently elevated exudations. The optic nerve 
 is congested. 
 
 These elevated exudations may disappear entirely under treatment, 
 leaving but little trace, or they may be succeeded by small white atrophic 
 spots, without pigment, except at their borders, where there is an intensi- 
 fication of pigmentation in the shape of a dark line. The vitreous is 
 more or less clouded with opacities. 
 
 This disease is very chronic in character, not attended by any impor- 
 tant symptoms, so far as the general health is concerned. The amount 
 of influence upon vision is proportionate to the position and extent of 
 the exudative patches, and the degree of atrophy following them. The 
 course of the malady is very chronic; it occurs in late secondary disease, 
 and well along in the tertiary period. Mercurial treatment is appropriate, 
 and, unquestionably, is often slowly effective of much good. In old 
 cases, where atrophy is an accomplished fact, or far advanced, treatment 
 is of little or no value. Local treatment is useless. The eyes should 
 be kept protected from strong light. 
 
 The retina also suffers from syphilis. Both eyes may be attacked 
 simultaneously or (most often) successively. The duration of retinitis is 
 variable; sometimes it lasts but a few weeks, but, more often, is chronic, 
 lasting several months. There is no outside redness upon the conjunc- 
 tiva, no lachrymation, no pain, moderate photophobia. The only subjec- 
 tive symptoms are, in the beginning, flashes of light; later, failure of 
 sight. The affection may get well, and leave little or no trace, or may 
 lead to permanent impairment of vision. 
 
 The ophthalmoscope reveals a cloudy vitreous, and a retina apparently 
 obscured. Its outlines are less distinct than usual, the retina is oedema- 
 tous, the retinal vessels are hyperaemic, as well as the optic nerve; the 
 outline of the papilla is not clearly marked. The veins are full, and 
 there may be haemorrhages. 
 
 There is a form of syphilitic retinitis, which Virchow has called re- 
 curring central retinitis, due to syphilis, in which the changes are pretty 
 closely confined to the neighborhood of the yellow spot. The malady 
 passes off, and returns, perhaps, several times. 
 
 In connection with atrophy of the optic nerve, attending syphilitic
 
 234 THE VENEREAL DISEASES. 
 
 lesions within the calvarium, the retina may also atrophy. Central vision 
 then gradually disappears, and defects of vision become evident in other 
 parts of the field. Hughlings Jackson has pointed out that there may be 
 evidence of considerable engorgement of the papilla, by the ophthalmo- 
 scope, for some time before vision begins to fail in these cases. 
 
 Retinitis pigmentosa has been ranked, by Hutchinson and a num- 
 ber of authors, among the changes of the eye prevailing in inherited 
 syphilis. As described, it appears that the pigment spots are scattered 
 irregularly over the fundus of the eye; the choroid is involved, amaurosis 
 .comes on early, and the progress of the affection is rapid (Swanzy). 1 
 
 The treatment of syphilitic retinitis is by mercurials in moderate 
 amount. No great energy of treatment is called for, and a cure may be 
 expected, if treatment is applied during the early stages of the malady. 
 Locally, the eyes should be shaded by colored glasses. The abstraction 
 of blood, by occasional leeching df the temple, has been recommended. 
 
 Optic neuritis is an affection very common in syphilis, in connection 
 with a variety of lesions of the brain. It may also originate primarily 
 within the globe of the eye, independently of external causes. It is very 
 often found in connection with convulsive and paralytic changes, due to 
 syphilis, and is looked upon as a corroborative symptom of great value 
 in many cases. 
 
 The symptoms are: diminution of the field of vision, in one direction 
 or another, often irregularly a portion, perhaps an irregular half or a 
 quarter of the field, being lost. J. Hughlings Jackson s has published a 
 case of intra-cranial syphilis, where double optic neuritis, due to cerebral 
 gumma, was not attended by any evidence of impairment of vision. 
 He therefore insists upon a routine examination of the eyes, with the 
 ophthalmoscope, in all cases of nervous disease due to syphilis, especially 
 if there be pain in the head, in order that impending optic neuritis may 
 be detected early, and loss of sight warded off. 
 
 In simple, light cases of optic neuritis, the ophthalmoscope shows 
 only a little indistinct blurring of the papilla, a congestion of the nerve, 
 and distention of the central vessels. In severer cases, the disk is greatly 
 swollen, with irregular, obscured borders. The disk seems infiltrated, 
 and is of a cloudy white, or grayish red color, the vessels distended, ir- 
 regular, tortuous. This appearance is known as "choked disk." It in- 
 dicates intra-cranial pressure, as by a tumor, and is only a syphilitic 
 symptom by coincidence. It occurs equally well in connection with tu- 
 mors of the brain due to other causes. Optic neuritis is oftener double 
 than single. , 
 
 The treatment of optic neuritis is the mixed treatment of tertiary 
 syphilis with preponderance of the iodides. Local measures are unneces- 
 sary. The effect of treatment often depends upon the promptness with 
 which it is commenced, and its power to remove the intra-cranial lesion, 
 which has given rise to the trouble in the eye. The eye-symptoms are 
 often of only secondary importance; but improvement in the size of the 
 field of vision, and an arrest in the progress of the affection may be often 
 attained by suitable treatment persisted in for a considerable time. 
 
 1 Dublin Quarterly Journal, Vol. LI, 1861, p. 294. 
 1 Journal of Mental Sciences, July, 1874.
 
 SYPHILIS OF THE EYE AND EAK. 235 
 
 SYPHILIS OF THE EAE. 
 
 The ear suffers in various ways by syphilis. TJlcerative and bony le- 
 sions within the cavity of the nose and the pharynx lead to thickening 
 and inflammatory changes in the Eustachian tube and its mucous lining. 
 These may terminate in catarrhal troubles of the middle ear, and conse- 
 quent impairment of hearing. 
 
 The external ear is the seat of many cutaneous lesions and ulcers in 
 syphilis; mucous patches appear sometimes in the external auditory canal, 
 and a peculiar dry scaliness of this canal, with tendency to impaction of 
 cerumen, is quite commonly encountered in syphilitic patients. This af- 
 fection calls for constant care and frequent syringing of the ear to keep 
 the passage in good order and the drum-head clear until the tendency to 
 dry exfoliation passes away. Improving health, when the depressing in- 
 fluence of syphilis has been removed, restores the integument of the audi- 
 tory canal to its normal condition. 
 
 There is an inflammatory condition of the middle ear due to syphilis 
 which is not a catarrh. No suppuration occurs, but a thickening of the 
 drum-head and of the tissues within the middle ear leading to a restraint 
 in the movements of the ossicula. It is a sort of plastic myringitis. 
 Schwartze and Roosa believe that this condition originates in a periosti- 
 tis of the middle ear. There may or may not be pain as a subjective con- 
 dition in this affection. The hearing is always more or less impaired. 
 
 The treatment of this affection consists in the employment of warm 
 syringing, the application of leeches behind the ear, inflation of the tym- 
 panic cavity, and the use of laxatives and diuretics. The mercurials in- 
 ternally are generally more effective than the iodides; but the possibility 
 of implication of bone calls for the use of the last-mentioned remedy, al- 
 though not in very large doses. 
 
 The auditory nerve, the second branch of the seventh pair, is some- 
 times the seat of special disease in syphilis, aside from any loss of function 
 due to disease of the bones of the internal ear or gummy tumor involving 
 the nerve. Such essential loss of function in the nerve has been observed 
 in secondary syphilis by Roosa, who found it could be greatly improved 
 by internal treatment. In tertiary disease it sometimes comes on suddenly 
 without warning, not attended by pain, without any especial symptoms 
 except that the patient becomes deaf often very rapidly so. 
 
 If the cochlea is involved, the high notes of the musical scale are lost 
 first (Roosa), or are heard double, and the tuning-fork on the forehead is' 
 heard best in the sound ear. Some ringing of the ear is complained of, 
 and vertigo, with staggering, are apt to usher in the disease. 
 
 The diagnosis of syphilis, in cases of deafness coming on in this way, 
 must be based upon the history and concomitant symptoms. 
 
 The treatment must be energetic. No time is to be lost. The dis- 
 ease should be taken, if possible, at its very beginning, and opposed vig- 
 orously with specific remedies from the start. Both mercury and the io- 
 dide of potassium should be used, and both should be pushed rapidly. If 
 J possible, the mercurial bath should be employed. Two drachms of the 
 i black oxide daily in a vapor-bath is not too much for these cases, and the 
 iodide of potassium should be commenced in ten-grain doses, largely di- 
 luted in water, after each meal. The quantity should be slightly increased 
 at each dose daily, until the point of tolerance has been reached. Every- 
 thing in these cases must be made subservient to the treatment. The pa-
 
 236 THE VENEREAL DISEASES. 
 
 tient should give up business; he should have his mind put at rest and be 
 amused as much as possible. He should be confined to an unirritating 
 diet, rice, milk, etc., with bismuth, if necessary, that he may bear his 
 medicine well, and the medicine should be pushed to the point of toler- 
 ance; for with this disease certainty in the conviction of a correct diag- 
 nosis and vigorous boldness in treatment is half the victory. 
 
 In inherited syphilis the ear suffers in two ways. There may arise, 
 in a child with inherited syphilis, a.catarrhal condition of the middle ear, 
 which is very obstinate, and likely to result in inflammatory adhesions of 
 the ossicula and permanent impairment of hearing. 
 
 Internal mercurial treatment, with cod-liver oil, and plenty of suitable 
 food, constitute the best measures to be employed against this affection, 
 in combination with change of air, syringing of the external and inflation 
 of the internal ear. 
 
 Deaf-mutism sometimes occurs in children with inherited syphilis 
 who have been born with perfect capacity for hearing. Jonathan Hutch- 
 inson has called attention to a loss of hearing which may come on very 
 suddenly, sometimes quite slowly, in children with inherited disease, after 
 they have begun to talk, but before the age of puberty. This affection is 
 apparently an essentially nervous malady, not attended by any pain. There 
 is no evidence to prove that the lesion is inflammatory. Treatment is of 
 little or no value in these cases, and their pathology is not understood.
 
 CHAPTER XV. 
 
 INHERITED SYPHILIS. 
 
 Syphilis does not change in Type during Transmission by Inheritance. The Syphilitic 
 Fretus. Bone Syphilis in Inherited Disease. Inherited Syphilis in the Infant. 
 Date of Appearance of Symptoms in Inherited Disease. Pemphigus of Inherited 
 Syphilis. The Syphilitic Countenance. Syphilitic and Mercurial Teeth. Inter- 
 stitial Keratitis. General Treatment of Inherited Syphilis. 
 
 SYPHILIS may be transmitted by inheritance. The vexed question as 
 to whether the child can derive its disease solely from the father, the 
 mother being sound, has already been discussed (p. 70), as well as the possi- 
 bility of inheritance in the third generation. There can be no possible 
 doubt that active early syphilis in the mother necessitates disease in 
 the child, if haply the latter come to term at all; while active early syph- 
 ilis in the father is not incompatible with a healthy child, if the mother 
 be not poisoned. This has been attested by numerous well-observed in- 
 stances, from a variety of sources. I have witnessed it on two occasions, 
 which do not admit of any doubt in my mind. After syphilis becomes 
 latent in the parents, when they both appear to be healthy, the child may 
 still be syphilitic, and repeated successive conceptions may all yield a dis- 
 eased product for a number of years, the limit of which cannot be defi- 
 nitely stated for any given case. This much, however, seems certain, that 
 the rule is for syphilis, eventually, to wear itself out, and for syphilitic 
 parents, no matter how protracted their disease, eventually to produce 
 healthy offspring, provided their own health has not been seriously and 
 permanently undermined by syphilitic cachexia or visceral lesions. In 
 other words, syphilis is transmitted only as syphilis. Scrofula is not syph- 
 ilis. Debility and nervous disease in children is not syphilis. A syph- 
 ilitic parent may produce a weakly child, because she has had her own 
 health broken by syphilis; but she would have produced exactly the same 
 child, had her health been broken by want and privation, by cancer, by 
 malaria, by alcohol, or any other cause. Syphilis does not change in type 
 by transmission. It does vary greatly, as seen in the child, but it varies 
 in activity, in intensity, not in type. A child born to parents in active 
 syphilis is not apt to live unless its own vitality has been sheltered by 
 the treatment of the mother while it was in the foetal state. A child 
 born to parents whose disease is on the wane, perhaps nearly exhausted, 
 shows but few evidences of disease, and those perhaps only during ado- 
 lescence; but what symptoms it does show bear the brand of syphilis, and 
 are relievable, if at all, mainly by antisyphilitic treatment. 
 
 Syphilis of the uterus, ovaries, and placenta, has been already consid- 
 ered (p. 226).
 
 238 THE VENEREAL DISEASES. 
 
 THE SYPHILITIC FfETUS. 
 
 When the intensity of syphilis is great enough, the germ is incapable 
 of development to maturity, and the foetus dies. This death of the pro- 
 duct of conception may be attended by and due to alterations in the 
 placenta, or it may have no connection with such changes. The ovum 
 may be blasted to such an extent that abortion of a misshapen organized 
 mass occurs within a few months after conception. The sj'philis of the 
 parents, under these circumstances, is too apparent to need confirmation 
 by any fresh proof drawn from any condition of the ovum, and the latter 
 is hopelessly damaged from the start, so that even very active treatment 
 of the mother is powerless often to save it from ruin. Attempts at sav- 
 ing the fcetus must, however, be made at each subsequent pregnancy, and 
 the chances of success will improve very materially with each attempt. 
 
 When the child has been fully formed, and then dies in utero, it is 
 very uncommon for the uterus to carry it to full term. The movements 
 of the child cease, and the mother may feel debilitated without being 
 positively sick, or she may retain her usual health. Under these circum- 
 stances, even if the death of the fcetus can be proved by a cessation of 
 the heart-sounds, it is best not to interfere with nature. Nothing is to 
 be gained by bringing on premature labor, and no damage likely to ensue 
 by leaving the dead child where it is. The labor is not likely to be un- 
 natural in any respect. The mother should be prepared beforehand for 
 the announcement of the death of her child, and measures be instituted 
 early to suppress the flow of milk. 
 
 When a fcetus has been dead in the uterus for some time, it becomes 
 macerated. The epidermis raises into large bullse over portions of the 
 body, or sheds off entirely in large patches. The amniotic liquid is more 
 or less cloudy, discolored, sometimes putrid. In such children are found 
 invariably certain pathological tissue-changes in the viscera and in the 
 bones, particularly the epiphyseal ends of the long bones. These changes 
 are the same as those which are found (although less marked) in the vis- 
 cera and bones in children who die of inherited syphilis at varying periods 
 after birth. The visceral changes are much the same as those which occur 
 in connection with some cases of acquired syphilis, the difference being 
 that, with inherited disease, visceral lesions are much more common than 
 in acquired syphilis, and that they are more often of the diffuse intersti- 
 tial type than gummatous, as distinct tumors. Interstitial hyperplastic 
 thickening of the parenchyma of the liver and lungs is very common in 
 inherited syphilis so common as to be the rule in all cases dying early. 
 The thymus is quite constantly involved, and the spleen and kidneys very 
 often. The changes in these organs produced by inherited disease have al- 
 ready been considered in connection with the visceral changes produced by 
 acquired syphilis. It is unnecessary, therefore, to repeat them here. The 
 changes in the bones in inherited syphilis, however, have in them enough of 
 special interest to demand a separate description. The ordinary necrotic 
 and carious changes, the subperiosteal gummata, and the ulcers involving 
 the bone, already described for acquired syphilis (p. 183), occur also some- 
 times in children with inherited disease who survive ; but the lesions now 
 about to be studied are found only in inherited syphilis, and are peculiar 
 to it. They are very constant also, and it is said may always be found 
 upon any dead-born foetus, if the cause of its death has been syphilis. 
 All children "with inherited syphilis do not necessarily suffer with these
 
 INHERITED SYPHILIS. 239 
 
 bony changes, or at least, if they do, they grow up without bearing any 
 evidence in their bones that they have so suffered ; but, if the syphilis in 
 the inherited state be intense enough to blight the ovum and cause the 
 death of the foetus, then these bony changes, more or less marked, are 
 constantly found. Parrot states that the changes are constant, and begin 
 in utero, or shortly after birth. 
 
 BONE SYPHILIS IN INHERITED DISEASE. 
 
 Much has been written of late years upon this all-important subject. 
 Only a sketch of the actual conclusions already reached can be given here 
 for lack of space. 1 
 
 The symptoms of bone syphilis in inherited disease are a thickening 
 at the ends of the long bones, sometimes involving the skin in inflamma- 
 tory adhesion, sometimes attended by local softening and suppuration, 
 sometimes having gone on to a separation of the epiphysis from the shaft 
 of the bone, and given rise to an inability to use the limb (pseudo-paraly- 
 sis, Parrot). The bones most often diseased in the order of their relative 
 frequency are the long bones of the extremities, the ribs, the scapula, 
 ilium, cranium, the clavicles, the metacarpal and metatarsal bones, lastly, 
 the vertebrae. The lesions are nearly always symmetrical. 
 
 The changes in the bones take place at the line of cartilaginous junc- 
 tion between different centres of ossification, and are most marked at the 
 epiphyseal line of junction at the ends of the shafts of the long bones. 
 Here may be found fusiform swellings thickening the bones and osteo- 
 phytes, bony overgrowths, which may be felt through the skin. If the 
 degenerative changes have advanced far enough, an epiphysis may be 
 separated from its diaphysis, without any perforation of the skin or dis- 
 charge of gummatous material ; or, finally, there may be multiple fractures 
 of the bones (rarely), or the skin may become adherent and perforated, 
 allowing the debris of bony and cartilaginous tissue with gummatous ma- 
 terial to be discharged externally. 
 
 All of these conditions (except the last) may be found in children dead- 
 born, and, any of them, during infantile life, with or without other evi- 
 dences or of syphilitic disease. They should be sought for in the foetus 
 dead-born and prematurely delivered, if there be any reason to suspect 
 syphilis in the parents. 
 
 Another morbid condition, due to syphilis and described by Parrot, is 
 
 1 Full information may be obtained by consulting : 
 
 Valleix : Bull, de la Soc. Anatom. Paris, 1834, p. 169. 
 
 Bargione : Lo Sperimentale, July, 1864. 
 
 Wegner : Virchow's Archiv, Vol. L. , p. 305. 
 
 Waldeyer and Koebner : Virchow's Archiv, Vol. LV., p. 367. 
 
 O. Haab: Virchow's Archiv, Vol. LXV., p. 366. 
 
 Parrot : Archiv. de physiol. norm, etpath., 1872, Nos. 3, 4, and 5 ; and same journal, 
 1876, No. 2, p. 133 ; also Gaz. des hop., Sept. 25, 1877, p. 881, and Gaz. med. de 
 Paris, No. 44, 1873. 
 
 Taylor : Bone Syphilis in Children. N. Y., 1875. 
 
 Porak: Bull, de la soc. de chir., Dec. 5, 1877, p. 608. 
 
 Polaillon : La France med., Nov. 4, 1877, p. 701. 
 
 Editorial in Brit. Med. Journ. , Oct. 13, 1877, p. 530 ; on Communication by P.arrot 
 to Association for Advancement of Science at Havre.
 
 240 THE VENEREAL DISEASES. 
 
 the formation of osteophytes in the anterior fontanelle of the growing 
 child, by means of which the sutures sometimes become ossified and the 
 development of the cranium and of the brain interfered with, or even ar- 
 rested. 
 
 These syphilitic changes in the ends of the long bones may require the 
 microscope for their detection. Often, however, the changes are manifest 
 to the unaided eye. The thickening at the end of the bone may be felt 
 and seen. The paralytic symptoms are most obvious, the child will not 
 and cannot move an extremity. The perforation of the skin and gumma- 
 tous discharge can be seen and touched. 
 
 On cutting into the bone, the morbid line between the epiphysis and 
 diaphysis may be distinguished as a reddened or grayish yellow band, and 
 the prolongations of calcined cartilage can be seen and felt. 
 
 It is possible to divide the minute changes into three degrees: 
 
 In the first degree a layer of osteophytic growth may envelop the 
 bone, sometimes making it so thick as to double its diameter. The epi- 
 physeal cartilage is also thickened. The cartilage-cells become hypertro- 
 phied. Increased proliferation takes place within them, and the cartilage 
 becomes prematurely infiltrated with earthy salts. 
 
 In the second degree there is premature calcification of the intercellu- 
 lar substance, and arrest of true bony formation. 
 
 In the third degree there is softening, and inflammatory changes take 
 place. 
 
 The exact histological nature of the morbid process does not seem to 
 be invariably the same, although the changes always take place in a line 
 between the proliferating and the hypertrophic zone of the cartilage, as 
 shown by Haab. This author, however, believes that the degeneration is 
 a molecular degeneration of the cartilage along a line parallel to the line 
 of ossification, the cartilage-cells falling into the molecular change and 
 becoming disintegrated, after previous active proliferation. 
 
 Wegner looks upon the process as an osteo-chondritis beginning in the 
 cartilage. He believes that the vascular supply through the vessels be- 
 comes deficient, through a too rapid deposit of bone-salts on the one hand, 
 while the proliferating cartilage-cells, on the other hand, make a stagna- 
 ting zone between the proliferating cartilage and the medullary spaces of 
 the diaphysis. 
 
 Waldeyer and Koebner believe the process to be the formation of a 
 syphilitic granulation tissue, growing out from the medullary prolonga- 
 tions of the diaphysis into the cartilage, and there falling into softening 
 which leads to a shedding of the epiphysis. 
 
 In summing up it may be said that the changes produced in the ends 
 of the long bones by inherited syphilis take place through the ossifying 
 zone of the cartilage and the sub-periosteal tissue. They consist in hy- 
 perostosis and calcification, which may lead to permanent thickening of 
 the bone without softening, or may be active enough to terminate by 
 softening and cellular disintegration, as is the case in other gummatous 
 formations. 
 
 The pathognomonic value of these changes in the ends of the long 
 bones is very great, since no one has yet claimed to have found them pro- 
 duced by a cause other than syphilis, and they may, therefore, be largely 
 instructive as to the cause of death in obscure cases, where repeated mis- 
 carriages take place, and the existence of syphilis in the parents is not on 
 any other account suspected. 
 
 The treatment of syphilitic children upon whom these lesions exist
 
 INHERITED SYPHILIS. 241 
 
 is very effective. It should be a mixed treatment, mercury being used 
 by inunction, and the iodide of potassium given internally in repeated 
 doses well diluted, commencing with a very small dose (half a grain or less 
 for an infant) and increasing it steadily but slowly, as it is tolerated, until 
 a dose producing an obvious effect is reached. A dose somewhat smaller 
 than this maximum dose may be continued for some months after the 
 child has recovered from all local evidences of progressive disease. 
 
 SYPHILIS IN THE INFANT. 
 
 A child born alive with inherited syphilis l may have its lungs so stiff- 
 ened with interstitial, syphilitic, cellular changes that it cannot breathe 
 sufficiently to support life. Its liver may be solid with parenchymatous 
 changes, and it may grow visibly yellow and expire in a few days or weeks, 
 without any especial symptoms on the skin or mucous membranes. 
 
 Digestion may be interfered with by the induration of the pancreas, 
 which Birch-Hirschfeld 2 found to be so common in his autopsies of chil- 
 dren dead with inherited syphilis. Occasionally a child dies in convul- 
 sions without any surface signs of syphilis. 
 
 Ordinarily, however, when a syphilitic child is born alive, even if it 
 happens to be plump and fresh-looking for the first few days, very char- 
 acteristic changes soon begin to show themselves. The face grows thin 
 and old-looking. If there have been any eruptive phenomena at birth 
 (excoriated, papular, scaly patches), these increase in number and extent. 
 If the skin was intact at birth, it begins to show livid patches, which run 
 on to become papular or pustular; or excoriations of livid color, and cracks 
 and fissures appear, with pimples, boils, abscesses, and other lesions. Con- 
 dylomata and ulcers at the anus are very common. The skin comes off 
 from the fingers and is shed from the palms and soles in large patches ; 
 sometimes the nails come off. Mucous patches, fissures, and ulcers appear 
 about the mouth. Catarrh involves the nostrils and the child gets the 
 snuffles, the nostril caking-up to the point of complete obstruction, so that 
 the child finds it difficult or impossible to nurse. 
 
 Meantime, the voice grows husky, hoarse. The child cries in a fright- 
 ened, explosive way, or moans its life out in croaking sobs. Dry, tearless, 
 pitiful crying is sometimes the method the poor little sufferer takes to 
 announce his distress; but he soon becomes marasmic, and death cures 
 him of his pains. 
 
 If, by careful nursing and active treatment, he pulls through, the child 
 may become marasmic later, or be stunted in his growth, perhaps weakly 
 in constitution, possibly hydrocephalic. During his early life he may have 
 disease in his bones, ulcers, gummata in different positions, ocular trou- 
 bles; indeed, he is exposed to a long series of disorders, which, if not con- 
 trolled by antisyphilitic treatment, make life a burden and lead to de- 
 struction of tissue, to deformity, to loss of function in various important 
 organs. 
 
 On the other hand, a child may entirely recover, and, after a reason- 
 ably prolonged treatment, grow up to good health and become as vigor- 
 
 I Acquired syphilis (for example, vaccinal syphilis) is very serious, and often rapidly 
 fatal in the infant ; but it is similar to acquired syphilis in the adult, in that the vis- 
 ceral lesions only come on after a longer or shorter period of secondary eruptions. 
 
 II Archiv f. Heilkund., Feb., 1875. 
 
 1G
 
 242 THE VENEREAL DISEASES. 
 
 ous as any one else. Such children, nevertheless, may have syphilitic 
 teeth (p. 244), and be stamped with the syphilitic countenance for life. 
 
 The date of appearance of syphilitic symptoms upon children 
 with inherited disease, who are born apparently in perfect health (as often 
 happens), is very variable. Statistics taken in lying-in hospitals make the 
 most common period about the second three weeks of life. Occasionally 
 children grow up to be several months old before symptoms show them- 
 selves, and these symptoms may be quite light and be overlooked. In 
 such cases, when tertiary symptoms come on quite late in adolescence or 
 early in adult life, as they sometimes do, they almost invariably receive 
 the cod-liver oil, iron, etc., believed to be of value in scrofulous complaints, 
 and much important time is lost and tissue often sacrificed by failure to 
 adopt antisyphilitic measures in time. Fournier has a case where inherited 
 syphilis appeared at the age of 25; Zaulbaco has one at 26; Bulkley one 
 at 23, and another at 24; Dron one at 20. I have now under observa- 
 tion a woman of 22, with gummata of the nose, due to inherited disease. 
 Atkinson, of Baltimore, has called attention to this subject in an excellent 
 paper upon " Late Hereditary Syphilis," in the American Journal of Medi- 
 cal Sciences, January, 1879. 
 
 This possibility of the appearance of lesions due to hereditary syphi- 
 lis late in life must be constantly kept in mind, or mistakes are quite 
 certain to be made, to the grave detriment of the patient. 
 
 SYPHILITIC PEMPHIGUS. 
 
 Flattened bullae, varying in size from that of a small split-pea to that 
 of a penny, situated upon a red base with a red areola and containing a 
 thin sero-pus, are sometimes found scattered over the surface of syphili- 
 tic children at their birth, or coming out in crops shortly after birth. 
 This is the pemphigus of the new-born ; it is nearly always syphilitic 
 in nature. It is said of the infantile pemphigus not syphilitic, that it 
 always first attacks other parts of the body, appearing later upon the 
 palms and soles, while true syphilitic pemphigus starts always in the last- 
 mentioned localities, and may indeed remain confined to them. The bul- 
 ke burst and show excoriated, livid surfaces beneath, or dry up into green- 
 ish yellow crust. 
 
 Children so intensely syphilitic as to have this eruption, very rarely 
 recover under any treatment. Mercury by inunction is most suitable. 
 
 THE SYPHILITIC COUNTENANCE. 
 
 Certain physical traits of countenance, marked more or less strongly 
 in different cases, are commonly enough encountered, upon growing chil- 
 dren with inherited syphilis, to be considered pathognomonic of the dis- 
 ease. They constitute what Mr. Hutchinson calls the syphilitic counte- 
 nance, and are striking enough to attract attention and to put an observ- 
 ant physician upon the track of syphilis in many cases before he has asked 
 the patient a single question. A child with inherited syphilis does not 
 necessarily have the syphilitic countenance. Many children, unmistakably 
 syphilitic by inheritance, bear no marks that distinguish them from 
 healthy children. One child in a family may be marked, and all born 
 later may escape.
 
 INHEEITED SYPHILIS. 
 
 243 
 
 In a child somewhat stunted in growth, perhaps looking pinched in 
 all its physical contour, or squared and dwarfed in stature, generally 
 with an abnormal intelligence running 
 to precocity which delights its parents, 
 or to a stolid stupidity suggestive of 
 idiocy such a patient, a growing boy 
 or girl, without any positive ulcers, 
 or nodes, or other lesions indicative of 
 syphilis, will be found often to have a 
 coarse skin, with the pores more marked 
 than usual. His color will not be ruddy, 
 but sallow, dead-looking, dry, or perhaps 
 greasy. His face will look flattened out, 
 rather devoid of expression, prematurely 
 old, grave, perhaps anxious. His fore- 
 head is rounded and prominent, like that 
 of a hydrocephalic child. The eyes are 
 often small, the nose undeveloped, par- 
 ticularly at the bridge, which remains 
 broad and sunken as it was in baby- 
 hood. The corners of the mouth are 
 often puckered with cicatrices, repre- 
 senting old ulcers at the angles ; other 
 scars may mark the mucous membrane 
 lining the cheeks, and the throat may 
 exhibit the ravages of past ulceration. 
 Such a child is apt to have constant 
 chronic nasal and pharyngeal catarrh. 
 With this physiognomy the syphilitic 
 teeth are apt to be found, and marks 
 of old iritis, choroiditis, or interstitial 
 keratitis, and more or less deafness, is 
 rather the rule than the exception. 
 
 Fig. 22 (from Maury's Photograph- 
 ic Journal) represents very fairly the syphilitic countenance, together with 
 scars of ulcers, nodes, overgrown and irregular bones, and the general 
 unlovely shape, of a girl who has suffered severely from inherited syphilis. 
 
 SYPHILITIC AND MERCURIAL TEETH. 
 
 Hutchinson, in his Illustrations of Clinical Surgery, London, 1876 l has 
 described and figured, with copious illustrations, the effects of syphilis in 
 modifying the shape of the central incisors of the upper jaw, as well as 
 the changes in the teeth produced by the use of mercury during their 
 forming stage. Mercurial teeth are very often found in the mouth along 
 with syphilitic teeth, and the mercurial teeth were generally considered 
 to be also syphilitic until Hutchinson clearly pointed out the distinction 
 between them. 
 
 The true syphilitic "test teeth," as Hutchinson calls them, are the 
 two central incisors in the upper jaw, the teeth of the permanent set. 
 The milk teeth do not show this typical peculiarity of structure, and no 
 
 Fasciculus III. , Plate xi.
 
 244 THE VENEREAL DISEASES. 
 
 other teeth can be relied upon to indicate the presence of hereditary syph- 
 ilis, excepting the two above mentioned. The first set of teeth may 
 be chalky, and fall into rapid caries ; the second set may also be very de- 
 fective, falling rapidly into caries, some of them stunted in growth, some 
 of them placed crosswise or altogether out of place in the mouth ; but 
 none of these peculiarities are essentially syphilitic. On the other hand, 
 a child may be markedly syphilitic by inheritance, and yet its teeth be 
 perfectly sound. 
 
 The " test teeth " are only found in connection with inherited syphilis. 
 The two central incisors are smaller than natural, and usually converge 
 somewhat (Fig. 23, from a cast of a personal case), or diverge a little. 
 
 The cutting border is narrower than 
 the base of the tooth, making them 
 peg-shaped, and along the lower edge 
 they are uniformly notched with a 
 single broad notch, as shown in the 
 plate. 
 
 These single broad notches are the 
 features of the teeth which stamp 
 
 Flo 23 them as syphilitic. The serrations 
 
 at the cutting border of the incisor 
 teeth, produced by a number of shallow notches, mean nothing so far as 
 syphilis is concerned. They are seen not infrequently upon all the inci- 
 sors, of the lower jaw particularly. Irregular notches, even in the centre of 
 the upper central permanent incisors, are not pathognomonic; and peg- 
 shaped teeth, or teeth uneven in any respect, or badly placed or seamed or 
 discolored, have no value as indicating antecedent syphilis. The " test 
 teeth," as above described, are caused by syphilis, and are not caused by 
 anything else so far as has yet been discovered. The cause of the pecu- 
 liar deformity of the teeth is not accurately known. 1 It is believed to be 
 due to stomatitis occurring while the teeth are forming, the notch being 
 generally due to a chipping away of the edge of the teeth, which edge at 
 first is very thin. 
 
 This mechanism of the formation of the notch, however, is not uni- 
 form, I believe, on account of a case which I watched from an early age. 
 The notch was blunt and uniformly smoothed off, covered by enamel. 
 The teeth were polished white and perfect, but typical in their general 
 physiognomy. Both the parents of the child had syphilis, and she her- 
 self had lost her soft palate at an early age, had a number of eruptions, 
 and, finally, syphilitic mania and gummata, while under observation. 
 This child came under my observation at the age of fourteen years. She 
 is now twenty-two, married, and the mother of a healthy child. Most of 
 her teeth, including the test teeth, are smooth, clean, and reasonably white, 
 and the notches of the test teeth are now as broad and smooth, and typi- 
 cal as they were when first observed. 
 
 Generally, when the edge of the notched tooth is thin, it chips off, 
 
 1 At a recent meeting of the London Path. Soc., Mr. Hutchinson showed (Lancet, 
 Dec. 6, 1879, p. 837) the crown of a milk tooth from a child with inherited syphilis. 
 Two small abscesses formed in the middle line of the gum in this case, over the cen- 
 tral incisors, from which, when opened, the crowns of the two incisors escaped. Mr. 
 Hutchinson thought that this case helped to show why the contra) incisors are espe- 
 cially affected by inherited syphilis, and sustained his view that the sacs of the teeth 
 are inflamed more or less in these cases this accounting for the defect. He had 
 Been a case similar to the one under discussion, once before, in a syphilitic child.
 
 INHERITED SYPHILIS. 245 
 
 and wears down with advancing life, and finally loses its characteristic 
 appearance. 
 
 Mercurial teeth (Figs. 24 and 25), according to Hutchinson, illus- 
 trate the effect of the excessive use of mercury of mercurial stomatitis 
 upon the permanent teeth. The teeth most plainly marked by mercurial 
 stomatitis are the first (the anterior) molars. The incisors, all of them, 
 and the canine teeth suffer. The bicuspids escape. The mercurial tooth 
 is deficient in enamel, covered with ridges and spines of exposed dentine, 
 dirty-looking, and apt to become promptly carious. Quite often only the 
 half of the tooth farthest removed from the gum is unhealthy, the half 
 nearest the gum preserving its enamel in a smooth and reasonably white 
 
 FIG. 24. FIG. 25. 
 
 condition. The grinding surface of the molars is involved in the affec- 
 tion. Very naturally the influence of mercury is also often shown upon 
 the typical syphilitic teeth, but this is accidental, and by no means essen- 
 tial. 
 
 Hutchinson states that other forms of stomatitis may also produce this 
 change upon the permanent teeth, but it is more marked and more com- 
 mon after mercurial stomatitis. 
 
 INTERSTITIAL, KEKATITIS. 
 
 The cornea is frequently the seat of a chronic interstitial inflammation 
 in cases of inherited syphilis. The affection is most common between the 
 ages of six months and three years, most common of all during second 
 dentition, but may be observed during adolescence. Occasionally it is 
 encountered in acquired syphilis. 
 
 The affection comes on insidiously, with slight peripheral cloudiness of 
 the cornea advancing toward its centre, attended by moderate photopho- 
 bia and more or less of a peri-corneal zone of subconjunctival hyperasmia. 
 Sometimes the symptoms become quite intense. The cornea gradually 
 grows quite white, and sight may become so reduced that only the differ- 
 ence between light and darkness can be perceived. The cornea may be- 
 come soft and fluctuating in spots by diffuse infiltration of pus. Ulcera- 
 tion is uncommon, or very superficial if it occurs. 
 
 Gradually, as the malady gets well, the whiteness disappears from the 
 periphery toward the centre, leaving sometimes clouded spots behind. 
 The iris, the choroid, and the ciliary body may be involved in inflamma- 
 tion during the course of the disease. 
 
 Both eyes may be involved consecutively. The affection in each eye 
 lasts from a few months to more than a year. Relapse is possible.
 
 246 THE VENEKEAL DISEASES. 
 
 Treatment. Hygiene and dietetics form an essential part of the 
 treatment in these cases. Cod-liver oil, tonics, and change of air are of 
 great service. Treatment by mercurial inunction is of the most value, or 
 mild internal mercurial preparation may be used, due attention being paid 
 to the digestion. The course must be persevered in persistently, with 
 confidence of ultimate success in preserving vision, if the general health 
 remains good. 
 
 Local treatment is of some assistance, but not so valuable as the gen- 
 eral measures. Warm fomentations in the beginning of the affection are 
 strongly recommended by Noyes, and instillations of a solution of atro- 
 pine are of considerable advantage, especially in those cases in which the 
 iris is threatened or involved in inflammation. 
 
 TREATMENT OF INHERITED SYPHILIS. 
 
 In the chapter upon the general treatment of syphilis, great stress was 
 laid upon the fact that mercury was a natural antidote to syphilis, more 
 or less useful in all its stages, most valuable in its power of keeping the 
 disease in check, and very certainly possessed of ability to gradually elim- 
 inate the disease, and retard relapses of symptoms. In tertiary forms of 
 syphilis, however, mercury was accorded only a second rank among reme- 
 dies, the preparations of iodine, notably the different iodides, taking the 
 lead. 
 
 In inherited syphilis all the stages of the disease come together, as it 
 were. The child is born already permeated through and through with 
 syphilis, and possessing at the same time visceral and bony changes due 
 to tertiary alterations of tissue and secondary phenomena, in the shape of 
 excoriations, papules, pustules. The discharges from many of these lesions 
 are essentially and actively contagious. 
 
 In inherited disease, notwithstanding these pathological facts, the 
 iodides can usually be dispensed with, except when dealing with the late 
 lesions of adolescence and bone lesions occurring during childhood. Com- 
 monly, all the good that can be obtained from treatment may be derived 
 from a persistent use of mercury, not pushed to the extent of producing 
 salivation. 
 
 Salivation is very difficult to produce in young infants. Excess of 
 mercury given to them generally runs itself off by the bowels. Just be- 
 fore, and during the period of second dentition, especial care is necessary 
 in the use of mercury, in order to avoid causing enough stomatitis to give 
 rise to mercurial teeth. 
 
 Mercury is introduced into the circulation of syphilitic children pre- 
 ferably through the skin. The only obstacle to this is extensive ulceration 
 of the surface (and even this does not preclude the possibility of dusting 
 the skin with calomel), or the existence of so great an irritability of the 
 integument, that the local use of mercury cannot be borne. This, how- 
 ever, is exceptionally uncommon. The advantage of administering mer- 
 cury by the skin is that it spares the child's stomach for food. At no 
 period of life is it so essential that the stomach should be unhindered in 
 the performance of its function as during babyhood. Another excellent 
 reason for employing inunction upon babies is, that it is often impossible 
 to say whether they get enough mercury if the stomach is relied upon, 
 and valuable iime may be lost in this uncertainty. Some babies vomit 
 more or less after each feeding, and are constantly regurgitating between
 
 INHERITED SYPHILIS. 247 
 
 their repasts, and whether all of a powder or potion given internally stays 
 down or not, is sometimes a matter of great uncertainty. 
 
 If inunction is decided upon, from five to twenty grains of the ten or 
 twenty per cent, oleate of mercury may be rubbed daily into a different 
 part of the child's integument, the dose being regulated by the intensity 
 of the symptoms and the age and vigor of the child. A better plan than 
 this, and one the infants seem to prefer, although it is dirtier, is to spread 
 upon the flannel belly-band of the child a thick patch of blue mercurial 
 ointment, and bind it against the integument, removing it daily, and 
 washing the skin well with warm water and soap. 
 
 If any eruption or mercurial erythema appears at the site of the mer- 
 curial application, a new spot should be selected, and the irritated skin 
 washed with a delicate toilet soap and abundantly powdered, while a piece 
 of old linen should be worn under the binder, between it and the im- 
 pending mercurial eruption. While the belly is recovering, the legs, 
 thighs, feet, and arms may be used for inunction or for the continued ap- 
 plication of ointment upon bandages. 
 
 By this too much mercury can hardly be used. As soon as the snuffles, 
 the eruptive lesions, and the restlessness of the child begin to mend per- 
 ceptibly, the quantity of inunction or of the ointment bound upon the sur- 
 face may be diminished; but the treatment must be kept up steadily in a 
 mild way in some form or other, certainly as long as through the period 
 of the second dentition. 
 
 If for any other reason it is deemed advisable to use mercury internally 
 instead of by inunction, the gray powder, mercury with chalk, is a prepa- 
 ration sanctioned by long usage. This may be administered in powder, 
 commencing with a sixth to a quarter of a grain two or three times a day, 
 and working up the dose rapidly or slowly according to the intensity of 
 the symptoms, until the latter show signs of yielding or the bowels are 
 irritated by the drug. 
 
 In the latter case it is better to diminish the dose or to substitute in- 
 unction, or, in some cases, where a continuance of a large dose is very de- 
 sirable, the bowels may be quieted by the internal use of mild doses of 
 opium. This, however, will very rarely be called for. 
 
 A good way of producing a rapid effect of mercury upon a child is to 
 dissolve a half grain of corrosive sublimate in six ounces of water, and to 
 give a teaspoonful of this hourly for the first day, then every two hours, 
 finally every three hours or at longer intervals, unless it obviously disa- 
 grees. 
 
 Indeed, I know of no internal preparation which agrees better with an 
 infant than a solution in water of the corrosive chloride of mercury. I 
 have used it in various other disorders as well as in syphilis, and I think 
 the best way to give it is to order a half-grain of corrosive sublimate to 
 be dissolved in six ounces of water. Each teaspoonful of this mixture 
 contains one ninety-sixth of a grain of the drug, and is a fair dose, if it is 
 frequently repeated. 
 
 This watery solution has absolutely no taste. The child who will spit 
 out a powder will take this solution, believing it to be water. The medi- 
 cine will mix with milk without turning it, or with any food in such a way 
 that its presence is unsuspected; and if the whole or a portion of a given 
 dose should be regurgitated by an infant, it is not a very serious matter, 
 since the doses follow each other in such quick succession. 
 
 I have not yet found this preparation to disagree with the youngest 
 infant. The average interval between the doses has been three to four
 
 248 THE VENEREAL DISEASES. 
 
 hours for prolonged treatment, the intervals being shortened when a 
 prompt or vigorous mercurial influence was desired. Mercurial stomatitis 
 I have not seen accompany the use of this remedy in this way, and in- 
 testinal disturbance is equally uncommon plenty of warning being given 
 by premonitory symptoms before any explosion comes on, so that there 
 is time to avert the latter. 
 
 Dr. M. A. Wilson experimented with this treatment, at my request, upon 
 a number of infants with inherited disease, at the Out-Door Department 
 of the New York Foundling Asylum; while Dr. E. R. Chadbourne, house 
 physician in the same institution, kindly conducted another series of ex- 
 periments for me in the same direction, upon infants, during the summer 
 of 1879. 
 
 Both of these gentlemen have reported favorable results, so far as tol- 
 erance of small doses of the bichloride by young infants is concerned, the 
 absence of any irritating or evil effect of any kind, and the prompt influ- 
 ence of the course upon the cutaneous lesions of inherited disease. 
 
 Many cases died, as they do under all treatment; but even in most of 
 these the visible symptoms seemed to be favorably modified by the drug. 
 
 The cases treated by Drs. Wilson and Chadbourne ranged from birth 
 to two years of age, the . doses of mercury from the y^ to the -fa of a 
 grain. The intervals between the doses were never shorter than two or 
 longer than four hours average three. In only one case out of a dozen 
 experimented on did any gastric or intestinal disturbance come on, and 
 this was promptly allayed by lengthening the interval between the doses. 
 
 Iodide of potassium may be administered through the milk of the 
 mother, or in mild doses by the mouth of the infant, provided the dose 
 be given with the food and be itself considerably diluted with water. 
 
 In no case should a child born of syphilitic parents, whether it shows evi- 
 dences of inherited disease or not, be allowed to suckle a healthy wet-nurse. 
 The risk of infecting the latter is too great to be overlooked. A syphi- 
 litic child may, however, suckle its mother with advantage, and can never 
 infect her (Colles's law), even although s"he be considered healthy and 
 has never shown any symptom of syphilis. The same rule applies to a 
 wet-nurse. A syphilitic woman may have recovered and may secrete good 
 milk, and such milk is perfectly suitable for the child, while the latter 
 cannot poison the nurse.
 
 PART III. 
 GONORRHCEA AND ITS COMPLICATIONS, 
 
 CHAPTEK I. 
 
 GONORRHCEA IN THE MALE. 
 
 Definition. True Gonorrhoea is not acquired by Contact of the Urethra with Pus not 
 in itself Gonorrhoeal. Cases illustrating that Urethral Pus does not always pro- 
 duce Gonorrhoaa in the Female, nor Vaginal Pus in the Female always Gonor- 
 rhea in the Male. The Causes of Urethral Inflammation. Symptoms of Urethri- 
 tis in an Unhealthy Urethra not due to the Contact of a Virulent Pus. Symptoms 
 of Inflammation in a healthy Urethra, due to Contact of Gonorrhoeal Pus or other 
 Irritating Substance, under Circumstances capable of generating Urethritis. 
 Chordee. Lymphangitis of the Prepuce. Spasmodic Stricture. Breaking the 
 Chordee. Gleet. 
 
 
 
 GONORRHCEA in the male is an intense urethral inflammation, charac- 
 terized by a period of incubation, and by a profuse discharge of pus 
 which possesses virulent qualities. 
 
 This definition at once places gonorrhoea in the rank of virulent dis- 
 eases, a position not accorded to it by some writers in high authority. 
 Yet it is impossible to see why gonorrhoea should not be called virulent. 
 It has a period of incubation, runs a course of varied length, possesses 
 its virulence to the very end, and is in the highest degree contagious. 
 These are the qualities to which syphilis and chancroid owe their claim 
 to virulence, and why should the title be denied to gonorrhcea ? 
 *- *Ihe reason for taking gonorrhcea from the list of virulent, and pla- 
 cing it among simple diseases, is that intense urethritis resembles it so 
 closely in all its symptoms that, clinically, a diagnosis between them 
 often cannot by any possibility be made.) This, however, is simply due to 
 the fact that the symptoms of inflammation of the urethra, when they 
 run high (as they always do in gonorrhoea), are alike, whether their 
 cause is a simple or a virulent one. Theoretically, a distinction must be 
 recognized between urethritis and gonorrhcea, although practically such a 
 difference oftentimes cannot be demonstrated, and clinically the symp- 
 toms of inflammation of the urethra have to be treated symptomatically 
 in accordance with the grade of their intensity, without regard to the 
 cause, since medicine as yet knows of no specific for gonorrhoea. 
 
 There are many reasons for maintaining this ground. The intensely 
 contagious quality of gonorrhoeal pus has been too long and too well
 
 250 THE VENEKEAL DISEASES. 
 
 known to require more than a mention. It has been amply demonstrated 
 by direct experiment (largely by French investigators) from urethra to 
 urethra. Rollet refers to it at some length. It has been demonstrated 
 with equal certainty by oculists, by inoculation of the conjunctiva for 
 clinical purposes. In course of nature it is often disastrously demon- 
 strated upon the victim who has exposed himself to it in sexual inter- 
 course; and the eyes of a patient with gonorrhoea may also attest the 
 powerful contagiousness of the disease. 
 
 No one can possibly dispute the fact that, if pus taken from a case of 
 true gonorrhoea be placed upon the orifice of the urethra of the male, or 
 the vagina of the female, an inflammatory disturbance of considerable 
 intensity will be lighted up. 
 
 On the other hand, it cannot be denied that pus of the most varied 
 character (not gonorrhoeal) may be placed upon the meatus of the male 
 urethra, or poured along its course, without inflaming the canal. In 
 cases of intense balanitis beneath a very tight prepuce, the cavity of the 
 foreskin is constantly filled with dense creamy pus; yet in such a case, if 
 the foreskin be slit up, it is customary to find the glans penis excoriated 
 in patches, and the meatus of the urethra raw perhaps, but no urethritis. 
 Chancroid sometimes is situated within the very lips of the meatus, and 
 extends a certain way down the canal, but it does not give rise to gon- 
 orrhoea. Pus from pyelitis may be voided as thick as cream through 
 the urethra, but it does not occasion inflammation of the canal. 
 
 In the female, pus from the kidney or bladder, passing through the 
 urethra, pus in vast quantities coming from the uterus, pus from chancres, 
 and chancroids, and mucous patches none of these kinds of pus produce 
 gonorrhoea in the female. 
 
 Finally, the male may often, usually in fact does, cohabit with a 
 female whose vagina contains more or less pus from the uterus, and re- 
 main well; while in many ctees a man with a more or less purulent dis- 
 charge may lie with a woman, and she will remain sound. Not so in 
 either case, however, if there be even a very little of the poison of gonor- 
 rhoea in the case. A gleet after a gonorrhoea which is nearly well may 
 give a gonorrhoea to a woman, and a small amount of lurking gonorrhoea 
 in the vagina may easily poison the male. 
 
 Just at this point comes in all the difficulty of the problem. We hear 
 very little of it from the female side. A large percentage of men in cities 
 have a small amount of gleet from one cause or another, mostly in con- 
 nection with stricture; yet gonorrhoea in the females (their wives), with 
 whom they cohabit, is far from being common it is, indeed, very excep- 
 tional. In France, a gleet is considered a natural thing with a soldier, so 
 much so that it is called the "military drop;" but the women with whom 
 they live are not phenomenal in having any analogous disorder. Indeed, 
 there are certain forms of urethral discharge which seem to call for the 
 married state for their cure, which get well during regular sexual hygiene, 
 and do so without involving the wife in any disorder. I have repeatedly 
 sanctioned marriage while a patient had still a slight amount of urethritis, 
 which would not get well because he was engaged to be married and was 
 therefore, perhaps, constantly suffering from ungratified sexual desire, 
 due to stimulation without relief: and I have seen the happiest result fol- 
 low such a marriage. I know that this course is a very unsafe one. I do 
 not recommend it as a rule for general use. 1 distinctly condemn it. It 
 is assuming an enormous responsibility to tell a man with a urethral dis- 
 charge to marry an innocent, virtuous woman; yet it must be done some-
 
 GONOKKHCEA IN THE MALE. 251 
 
 times after deliberation, and, if there be no gonorrhoea in the male, the 
 woman is perfectly safe. If there is a considerable amount of pus, a 
 great creaminess in the urethral discharge, it is wise to postpone marriage 
 until this has been reduced; but an urethral discharge, not very freely pu- 
 rulent and not dependent upon true gonorrhosa, does not disqualify a man 
 from marriage, any more than a leucorrhoea disqualifies a woman. 
 
 This point is such a delicate one that I am constrained to dwell upon 
 it, and to illustrate it by the recital of several cases. 
 
 A gentleman came to me with the following story. He had been 
 married several years and remained true to his wife. He went abroad. 
 Shortly before returning, while in England, he fell from grace on one oc- 
 casion, several days before going aboard ship. He felt uneasy during the 
 return trip, and when nearly home noticed a slight mucous moisture in 
 the orifice of the urethra, upon rising in the morning. After returning 
 home he feared to have intercourse with his wife, and his discharge be- 
 came worse. He consulted me. I found that his discharge was mainly 
 mucus, although quite palpable and only purulent in the morning. He 
 had had a former gonorrhoea in youth. I concluded that gonorrhoea was 
 impossible, since more than two weeks had passed since the time of his 
 exposure, and his discharge did not indicate virulence. I therefore told 
 him that he was keeping up a mild urethritis by sexual stimulation with- 
 out relief, and advised immediate renewal of relations with his wife. This 
 prescription was faithfully carried out, with the effect of prompt relief to 
 the urethral discharge, without other treatment. 
 
 This same gentleman came to see me after another European trip; but 
 this time he had not exposed himself. He arrived home while his wife 
 was menstruating, and soon found that he had a slight urethral discharge 
 something like what had troubled him so much before. For this he con- 
 sulted me. I ordered the same prescription, and cure followed at once. 
 
 Another patient, living quietly and regularly, performing his marital 
 duties without exposure, after hard work in a cold winter, found that he 
 had an urethral discharge which was quite positively purulent. During the 
 treatment of this he ran down in health, became rheumatic, and had a 
 perineal abscess. After the abscess was nearly well, while the urethral 
 discharge was still clearly purulent, although getting decidedly thinner, 
 he resumed his sexual relations with good effect and without damaging 
 his partner. This man had an unhealthy urethra damaged by a former 
 gonorrhoea, but ordinarily he was perfectly well. . 
 
 I have repeatedly been consulted by men with an urethritis which 
 yielded some pus, who were married and in constant sexual relations, 
 which they stated had a good effect upon the discharge, the wife remain- 
 ing well. 
 
 A very striking case .is the following: a patient of mine had persistent 
 purulent gleet of several years' duration, due to stricture and following 
 gonorrhoea. Under hygienic and tonic influences, assisted by cutting the 
 meatus and using a very large steel sound, he got entirely well. He con- 
 tinued well a couple of years, and then became engaged to marry. 
 
 While waiting for his wife to get ready he became overstimulated 
 sexually, and visited an old partner on one or more occasions. As a re- 
 sult, apparently, his purulent gleet returned. 
 
 For this I treated him in every way known to me without success. I 
 could reduce the discharge to a rather profuse mucous gleet, without much 
 creaminess in its quality, but no further. I cut him internally, according 
 to the modern doctrine, as an experiment, to which he consented, until his
 
 252 THE VENEREAL DISEASES. 
 
 urethra was very unnecessarily large, the so-called full size being reached. 
 The effect of this cutting was not to cure the gleet, but to give the patient, 
 at the site of the incision, a hard, fibrous lump in the roof of the urethra, 
 which caused his penis to bend painfully upward during erection for 
 many months. Meantime the discharge continued unabated, and the 
 patient put off his marriage from month to month. 
 
 I finally became convinced that there was no poisonous (gonorrhosal) 
 quality in the discharge, if there ever had been any, and I urged the pa- 
 tient to marry, since the hard lump in the roof of his urethra had now sub- 
 sided, so as to allow an erection to occur without pain. But marry the 
 patient would not, being afraid of poisoning his wife. 
 
 I therefore took him to see in consultation a well-known specialist in 
 urethral disease in this city. The latter, as I had anticipated, advised that 
 the urethra be again cut internally. This I declined to do, and asked my 
 patient to put himself under the charge of the physician whom I had re- 
 quested him to see with me. The patient, however, would not do this 
 unless I would guarantee a cure; and this I could not conscientiously do. 
 His discharge of pus, therefore, continued thin and watery, but quite 
 abundant; and his future wife commenced to talk of discarding him. 
 
 I now absolutely forced this man to marry. I took all the responsibil- 
 ity. Offered to do everything for himself and for his wife in case of acci- 
 dent, and to protect him from her censure. Thus I finally succeeded in 
 bullying him to the altar, convinced as I was that treatment was useless, 
 and that the man's urethritis was kept up by ungratified sexual desire. 
 
 He married on a certain day, informing me the day before that he 
 would not leave town after his marriage, since he expected both that he 
 would immediately suffer from an increase in his discharge and that his 
 wife would become poisoned. 
 
 It was three weeks when I next saw him. He looked fat and healthy, 
 but disturbed. I asked him how he had been, and how his wife was. .She 
 was in good health, and his urethral discharge had ceased shortly after his 
 marriage. But, he said, it is all coming back again. I am beginning to 
 have a discharge, and to feel the old sensations in the urethra yesterday 
 and to-day. I asked him when his wife had begun to menstruate. He 
 replied, " The day before yesterday." 
 
 What can be more strikingly illustrative of the effect of sexual hy- 
 giene upon an urethral discharge than this case? I told the man to do 
 nothing, and that he would again recover shortly after his wife had ceased 
 menstruating, and that when he became sexually calmer he would not 
 suffer during the monthly sickness of his partner. He went away contented, 
 and has never been a patient of mine since. I met him upon the street 
 about two years afterward. He looked well, and, in response to my ques- 
 tion, said that he was perfectly well, and that his wife had presented him 
 with a fine boy. 
 
 It is possible to multiply instances of this sort without limit, but enough 
 has been said to show that an urethral discharge in the male does not neces- 
 sarily produce gonorrhoea in the female. If the discharge in the male be 
 the tail end of a gonorrhoea, however, then the woman is fortunate, in- 
 deed, if she escapes contagion. 
 
 Finally, as to the power of pus in the vagina to give gonorrhoea to 
 the male. Doubtless the male often, and most often, indeed, gets his 
 urethritis from contact with such irritating discharges, but he does not 
 necessarily become irritated by them at all. Indeed, he usually escapes, 
 unless his o\vn urethra has been damaged by previous gonorrhoea, and he
 
 GONOREHCEA IN THE MALE. 253 
 
 happens to be himself either debilitated, overtired, or full of liquor, or 
 suffering coincidently from very acid urine, or unless he overstimulates 
 himself sexually. All of these causes are capable alone of producing 
 urethritis; each of them separately may do it, as recorded cases attest; 
 even intense sexual excitement, much prolonged, without any sexual 
 contact at all, and, a fortiori, if the local influence of irritating discharges 
 lends a helping hand. 
 
 When a patient, however, offers himself, in sexual exposure, to the 
 poison of true gonorrhoea, he is certain to become poisoned without the 
 cooperation of any of the adjuvants mentioned above. A simple expos- 
 ure is enough. The result is quite certain, and very evident. 
 
 The theoretical distinction, therefore, between gonorrhoaa and ure- 
 thritis is clear; the clinical distinction is often equally so. Yet, without 
 doubt, an intense urethritis is one and the same in its symptoms, whether 
 its cause be gonorrhoeal virus or any other irritating internal or external 
 cause; and the treatment of intense urethritis is the same, whether its 
 cause be virulent or otherwise. 
 
 Cause. From what has already been written, it may be inferred \ 
 that the causes of urethral inflammation are quite varied. The cause of 
 true virulent gonorrhoea is single, namely, contact of the affected person 
 with gonorrhoeal pus from another person. Urethritis, however, may be 
 produced in a variety of ways almost infinite, and it cannot be distin- 
 guished in its symptoms, when intense, from a gonorrhoea. This fact 
 cannot be too often repeated. That surgeon is bold indeed, who, in face 
 of a certain urethral discharge of given intensity, will pronounce upon its 
 origin with any confidence. No one can be accused of impure relations 
 because he has a profuse urethral discharge. It cannot even be said that 
 such a person has had sexual intercourse at all; for it is possible for a 
 man, virgin of all venery, to have an intense urethral inflammation, and 
 much injustice may be done by accusing him, on the one hand, or, on the 
 other, of accusing his partner if he has had one of having given him 
 a disease. 
 
 The moral is, that the physician is not a judge. His function, if he 
 has any of the judicial sort, is to shield the innocent. He should accuse 
 no one, but confine himself to his own proper duties, and treat the symp- 
 toms of the patient. 
 
 If the urethra is healthy, it does not easily become inflamed, except- 
 ing by contact with gonorrhoeal pus. Yet, a healthy urethra does some- 
 times suppurate after mechanical violence, such as the rough introduction 
 of instruments through it; after chemical violence the injection of irri- 
 tating substances for experiment, or under the idea of employing a pro- 
 phylactic against supposed infection. A healthy urethra may also be- 
 come inflamed by the combined influence of venereal excitement espe- 
 cially if intense or prolonged and contact of an irritating discharge, leu- 
 corrhoeal pus, menstrual blood, etc. 
 
 An unhealthy urethra is always ripe and ready for inflammation. In 
 strumous, strongly lymphatic, gouty, and rheumatic subjects, the urethra 
 seems prone to take on inflammation easily, especially if the person be 
 cachectic, overworked, or at all reduced in general health from any 
 cause. In such cases the mucous membranes generally are apt to be in 
 an irritable condition, and to take on subacute inflammation from trivial 
 causes. 
 
 When the urethra is actually diseased, on account of the previous ex- 
 istence in it of acute inflammation when it contains a thickened, hyper-
 
 254 THE VENEREAL DISEASES. 
 
 jemic patch, constituting a slight stricture then it is in a prime condi- 
 tion to be irritated into suppuration often a suppuration of formidable 
 proportions by causes which, in a healthy urethra, would fail of pro- 
 ducing any obvious result. This is especially true when the urethra, 
 besides being the seat of a chronic patch of congestion left behind by an 
 old gonorrhoea, is, at the same time, diathetically unhealthy, owing to 
 the broken health, the bad hygienic surroundings, the cachectic condi- 
 tion, the nervous prostration, or the scrofulous or gouty constitution of 
 the patient. 
 
 When the urethra is unhealthy, the introduction of a sound will some- 
 times produce quite a sharp attack of urethritis. The passage of very 
 acid urine through the canal may bring about the same result, whether the 
 uric acid crystals be due to indigestion, an attack of gout, or over-stimu- 
 lation by alcohol (particularly beer or champagne). Mere excess of sexual 
 excitement will sometimes produce a flow of pus, and prolonged sexual 
 intercourse may do the same, particularly and this is one of the most 
 active causes if there be any irritating discharge in the vagina. In early 
 married life the male is not unlikely to get a little urethritis from his 
 wife ; but after his approaches become less amorous, he has no further 
 trouble. 
 
 In connection with many morbid states of the prostate (cancerous, 
 tubercular, inflammatory), and of the urethra (herpetic, chancrous in 
 deep urethra, tubercular, syphilitic) a more or less purulent flow from the 
 urethra may be encountered, and a purulent discharge dependent upon, 
 organic stricture is of every-day occurrence. 
 
 Symptoms. In studying the symptoms of inflammation of the ure- 
 thra, it will be convenient and practical to make two classes of cases, and 
 briefly to review the symptoms in each. 
 
 Symptoms of urethritis of an unhealthy urethra, not due to 
 the contact of a virulent pus. This is by far the commonest form of 
 urethritis. This is the form which those people have who say they have 
 had a dozen cases of gonorrhoea, and of those boasters, who claim that 
 they get the gonorrhoea constantly, but that they do not mind it, as they 
 have a little injection which cures it up in three or four days. In this 
 form the patient gives himself the disease much more than his partner 
 gives it to him. He has a damaged patch of mucous membrane within his 
 urethra, and any one of a number of exciting causes is sufficient to kin- 
 dle the slumbering congestion into an active discharging inflammation. 
 
 In these cases the discharge originates at a certain distance within 
 the urethra from the very start. It does not commence at the meatus. 
 The patient has intercourse perhaps with a woman who has no gonorrhoaa 
 who at most has a purulent leucorrhcea. In twenty-four to forty-eight 
 hours he presents himself to the physician for inspection, stating that he 
 has an attack of gonorrhoea. 
 
 Inspection now shows that the lips of the meatus urinarius are not in 
 the least swollen. The attack manifestly has not begun at the meatus. 
 The lips of the urethral orifice still show the livid line so often seen when 
 there is stricture in the course of the canal. The discharge is thick and 
 purulent from its very start. There is little or no itching, or tingling, 
 along the course of the urethra. There is some heat and smarting in the 
 urethra during the urinary act, but very little discomfort between times. 
 
 A discharge starting in this way is not a gonorrhoea ; but it may go on 
 and assume all the quality of the most intense urethral inflammation, ac- 
 companied by any of the complications of ii; >JK in'iu-a. and absolutely in-
 
 GONOKRHCEA IN THE MALE. ZOO 
 
 XV 
 
 distinguishable from it clinically ; or it may subside in a few days, or, at 
 most, weeks, under moderate symptomatic treatment, and give very little 
 discomfort. The latter termination is by far the more common. 
 
 Symptoms of inflammation in a healthy urethra due to con- 
 tact of gonorrhceal pus, or other irritating substance, under cir- 
 cumstances capable of generating urethritis. Urethritis, under 
 these circumstances, always commences at the meatus. If the cause has 
 been inoculation with gonorrhoeal pus, there is always a period of incuba- 
 tion between the moment of exposure and the outbreak of the first symp- 
 tom. This incubation period is usually from five to eight days. When, 
 however, the cause is some irritating discharge, not gonorrhoeal, com- 
 monly the evidences of commencing irritation at the meatus appear on the 
 second day ; sometimes they are delayed up to the fourth, or even sixth, 
 but rarely any longer. .- 
 
 The first symptom in these cases is an osdema of the meatus, which 
 makes the lips of the urethral orifice pout. This swelling may be insigni- 
 ficant in urethritis; it is invariable in gonorrhoea. The color of the orifice 
 of the urethra is pink rather than blue. The patient feels a sensation as 
 though a hair had been caught in the meatus and was being drawn through 
 it. There is a sensation, varying between a tickling and an itching, which 
 is quite apt to be complained of, either at the very meatus or at a point 
 about three-quarters of an inch within the urethra, upon its under side. 
 These sensations keep the patient's mind fixed upon his genitals, and call 
 upon him to empty his bladder rather more frequently than usual. The 
 passage of urine over the tender ends of the urethra causes a hot, stinging 
 pain, an ardor urinag, more or less intense, in different patients. 
 
 Between the lips of the pouting meatus, perhaps faintly sealed with 
 dried mucus, a drop of watery pus is seen at all times during the first 
 twenty-four hours. On the second day this drop becomes more creamy, 
 and all the disagreeable sensations increase, while from day to day the 
 discharge becomes more copious and more purulent. 
 
 During the second week the pus from the urethra assumes a green 
 tint, due to slight admixture with blood, and all the symptoms intensify, 
 unless the discharge turns out to be a mild urethritis, in which case it 
 sometimes reaches its height during the first week, and commences to de- 
 cline during the second. This it never does if it is true gonorrhoea. 
 
 Chordee. If the inflammation runs high at the end of the second and 
 during the third week, erections become painful. The inflammation does 
 not remain confined to the surface of the urethral membrane, but works 
 down through the minute ducts into the mucous glands of the urethra, 
 and spreads from thence to the delicate meshes of the spongy tissue of 
 which the corpus spongiosum is composed. These meshes of tissue, be- 
 coming stiffened and agglutinated together by the inflammatory process 
 over a given (usually limited) area, no longer allow themselves to become 
 distended by the influx of blood which occurs during erection. As a con- 
 sequence, when the rest of the penis is distended with blood, and only a 
 limited portion remains empty, the empty part, being relatively too 
 short, draws together the distended parts, acting like a cord to a bow, and 
 the penis becomes curved, its point of greatest concavity corresponding 
 to the inflamed area of corpus spongiosum. The inflammation often does 
 not run so high as to obliterate the meshes of the corpus spongiosum, but 
 renders them sensitive when dragged upon. In such a case there will 
 be a painful, perhaps hard spot in the urethra upon erection, but no bend- 
 ing of the penis.
 
 256 THE VENEREAL DISEASES. 
 
 This bending of the penis is called chordee. Painful erections are 
 very common during the third week of a gonorrhoea, and from that date 
 onward until the discharge has ceased. Sometimes erections still continue 
 to be somewhat painful after the flow of pus has entirely disappeared. 
 
 During the second or third week, in some cases, the prepuce becomes 
 implicated in inflammation. This is due to a lymphangitis, generally of 
 the smaller lymphatic vessels. As a result the foreskin may swell enor- 
 mously, and become white with oedema, and this oedema may go on to 
 involve the whole penis. It frequently leads to paraphymosis, when the 
 prepuce is short. If the very finest lymphatics are the seat of the inflam- 
 mation, the prepuce swells, but is red, hot, erysipelatous, there is com- 
 paratively little oedema, the tissues of the prepuce are inflamed and stiffened 
 with inflammatory exudation. If the prepuce be long, phymosis is apt to 
 occur, and occasionally the inflammation runs on to the extent of produ- 
 cing abscess between the layers of the prepuce. 
 
 When the prepuce is tight, although it may not become inflamed in 
 its own texture, yet if the gonorrhceal discharge is not kept carefully 
 washed out of its cavity, the pus is apt to be retained in the furrow be- 
 hind the glans penis, and there becoming decomposed, to give rise to bal- 
 anitis and posthitis, and to lead to the formation of innumerable warts, 
 the so-called venereal warts, which are always apt to be produced by un- 
 cleanness beneath the prepuce. 
 
 As the inflammation extends backward within the canal of the ure- 
 thra, the deep urethral muscles are apt to be thrown into spasm, which 
 leads to dribbling of urine and difficulty in voiding the contents of the 
 bladder. Sometimes actual retention comes on, usually only in connec- 
 tion with active inflammatory congestion of the prostate and cystitis of 
 the neck of the bladder. Abscess of the prostate, peri-urethral abscess, 
 perineal suppuration, inguinal glandular abscess, are among the possible 
 complications of intense inflammation of the urethra, while swelled testicle 
 is a sequence so common as to be often considered a complication rather 
 to be expected than not in severe cases. Inflammatory complications of 
 the fundus of the bladder, and of the kidneys, are possible, but rare in 
 connection with gonorrhoea. 
 
 When the urethral inflammation runs high, haemorrhage from the ure- 
 thra may occur, either spontaneously during erection or as a result of 
 straightening the curved penis during erection. When the penis is so 
 straightened the inflamed spot of corpus spongiosum may be ruptured 
 through the mucous membrane of the urethra, and violent haemorrhage 
 may follow, to say nothing of the traumatic stricture which is sure to ap- 
 pear subsequently at the point of rupture. 
 
 In those rare cases where upward chordee appears on account of in- 
 flammation of the corpus cavernosum, violent straightening may cause ef- 
 fusion of blood within the sheaths of the corpora cavernosa, but rarely 
 produces free bleeding from the urethral surface. 
 
 After the urethral flow has continued at its height for a period vary- 
 ing from one to a number of weeks, all the inflammatory symptoms grad- 
 ually subside, chordee becomes less frequent and less intense at night, 
 the discharge lessens, and finally ceases entirely. It may relapse, leading 
 to a new discharge lasting for several weeks, or prolong itself indefinitely 
 in the shape of a gleet, which is more or less puriform in different cases, 
 and subject to exacerbation and improvement, from time to time, from 
 varied trivial causes.
 
 GONORRHOEA IN THE MALE. 257 
 
 GLEET. 
 
 Gleet is chronic urethritis. A severe and protracted gonorrhoea may 
 run on into a gleet after passing through the acute stage, and remain as a 
 gleet indefinitely. The discharge from the urethral orifice in gleet is a 
 blue, thick, mucoid material, more or less purulent and creamy in different 
 cases. Generally, in gleet, the lips of the meatus are found sticking to- 
 gether when the patient wakes in the morning, a small amount of the 
 discharge having scabbed over the meatus. Behind the scab there may 
 be a drop of pus, or there may be none. 
 
 Some cases of urethritis are so mild that they are gleety from the 
 start, and never become freely purulent. 
 
 Gleet may exist as a symptom of stricture of the urethra, and of the 
 most varied, prostatic, inflammatory, and degenerative troubles, not in the 
 least degree venereal in origin. The only real interest which attaches to 
 gleet in a venereal way is the question of the contagiousness of gleet. 
 
 The gleet following a gonorrhoea is poisonous. How long it retains 
 its virulent quality is not known. Gleet from stricture and prostatic le- 
 sions does not possess contagious qualities. It is often impossible to pro- 
 nounce positively upon a gleet, and to say whether it is contagious or not; 
 but there is a very safe rule to go by, namely: when a gleet is frankly and 
 freely purulent it is apt to possess contagious properties ; gleet which is 
 mucoid, blue in color, sticky in consistence, is incapable of lighting up in- 
 ilammatory trouble in another. 
 
 17
 
 CHAPTER II. 
 
 TREATMENT OF URETHRAL INFLAMMATION IN THE MALE. 
 
 The Relation of the Physician to his Patient during the Treatment of Urethritis. The 
 Abortive Treatment of Gonorrhoea. Hygienic Treatment ; Medical Treatment by 
 Alkaline Diuretics, by Sandal- Wood Oil, by Copaiba (Copaibal Erythema), by Cu- 
 bebs. by Turpentine, by Iron, by Tincture of Cantharides. The Internal Treat- 
 ment of Gleet. The Use of Injections in Urethritis. How to Inject the Urethra. 
 Dressings for the Penis during Urethritis. Treatment of Chordee. Treatment 
 of Painful Urination. Treatment of Retention of Urine in Gonorrhoea. Treat- 
 ment of Venereal Warts. Treatment of Inflammatory Phimosis. Paraphimosis 
 and its Treatment. 
 
 THE treatment of Urethritis is accompanied by moral difficulties not 
 experienced to the same extent in connection with any other malady. 
 When a man gets urethritis he rarely feels willing to acknowledge that it 
 is largely, perhaps wholly, his own fault; and it is not customary to see 
 him stand up and take his punishment like a man. He generally accuses 
 his partner of all the blame for his misfortune, although she, indeed, may 
 have no contagious disease; he feels ashamed of himself, tries to sneak 
 out of his troubles, and demands of his physician anything and everything, 
 asserting that he positively must be cured in a few days. He will nearly 
 always demand, with impatience, how long it will be before he will be 
 well, and he calls for violent measures in order that the course of the dis- 
 ease may be cut short. If he is not satisfied on these points, and prom- 
 ised a speedy cure, he refers to some friend, or perhaps to a number of 
 friends, who laugh at gonorrhoea, and tell him that they constantly get 
 it and cure it for themselves in a few days with some favorite prescription; 
 and it is by the standard of this misinformation from friends that the result 
 of the physician's efforts is often judged. 
 
 In syphilis the patient is far more frightened than when he has gonor- 
 rhoea, but he never disturbs the physician by asking for a cure within a 
 few days. The popular idea about syphilis is that it lasts forever, and 
 the patient with this disease asks his physician not to cure him promptly, 
 but whether he ever can get the poison thoroughly out of his " system," 
 as he puts it. 
 
 If, therefore, the surgeon allows himself to be browbeaten* by the ig- 
 norance of his patient, he has to commence the treatment of urethritis a 
 very obstinate disease under most disadvantageous auspices; and the 
 patient is apt in the end to be dissatisfied with the result, no matter how 
 creditable that result may really be. To be just to himself, the surgeon 
 must start as master of the field, if he hopes for any comfort; and the only 
 way to do this with a foolish young man suffering from his first attack, or 
 with an anxious husband who expects his wife to return home in ten 
 days, is to have a perfect understanding at the very commencement of 
 treatment. 
 
 The patient should be informed that gonorrhoea, badly managed, is as
 
 TREATMENT OF URETHRAL INFLAMMATION IN THE MALE. 259 
 
 serious a matter, in many cases, as syphilis; that gonorrhoea probably kills 
 more patients than syphilis does, through its ultimate effect, by means of 
 stricture of the urethra, upon the bladder and the kidneys. If the patient's 
 associates find gonorrhoea to be so light a matter, it is well to refer him 
 back to them for treatment. The surgeon should absolutely refuse in any 
 case to give a promise of cure in any given time. He cannot give such 
 an assurance honestly, and if he happens to hit right with his guess in the ' 
 case of one patient, that patient will injure his reputation greatly; for he 
 will boast among his companions of a prompt cure within a certain prom- 
 ised number of days, and his friends will come with their gonorrhoeas and 
 demand a like promise and a like speedy cure, and failing to get it, will 
 denounce the physician as incompetent. No man can positively assert at 
 the start whether a given urethral inflammation just commencing at the 
 pouting orifice of a healthy urethra is to be a severe case or not, or whether 
 it will yield a prompt response to remedies. 
 
 If a man has already had several attacks of gonorrhoea, and his present 
 attack comes on without any oedematous swelling of the meatus urinarius, 
 the chances are that the attack will be a mild one. If the case is one of 
 first attack, and there has been not more than forty-eight hours' incuba- 
 tion, the chances also are that the inflammation will not be violent. If 
 there has been no sexual intercourse at all to occasion the new outbreak, 
 then, although the course of the malady may be slow and its duration 
 protracted, the symptoms are not apt to run high. 
 
 In any case, so far as making a prognosis is concerned, it is proper to 
 say to the patient that he has a disorder which is perfectly curable by 
 gentle treatment, but which often fails to get well if harsh measures are 
 used; that the symptoms require intelligent management, according to 
 their intensity; that it is safer and surer in the end to make haste slowly, 
 and that all will be done by treatment that can be effected by drugs. 
 
 Under such an understanding, the surgeon's hands are free, and the 
 patient's mind at rest, because he (the patient), under the circumstances, 
 will either seek treatment elsewhere, or he will yield himself up to his 
 physician, and follow his instructions with willing confidence. Then, if 
 the case turns out to be a mild one, and gets well in a fortnight, the pa- 
 tient is delighted and appreciative. If it drags itself along for two or 
 three months, he is regretful, but satisfied. 
 
 The abortive treatment of gonorrhrea should not be attempted. 
 It is accompanied by considerable danger, and is absolutely uncertain. 
 Those cases which get well under its use are cases of urethritis which 
 doubtless would have recovered promptly under mild treatment. When 
 it does not cure, it greatly increases the grade of intensity of the inflam- 
 mation, and leads with much certainty to stricture ultimately, and imme- 
 diately in many cases to complications on the side of the bladder and tes- 
 ticle, not devoid of danger to important functions. As a general rule, it 
 will be found that those who have most faith in the value of the abortive 
 treatment are those who have not tried it at all, or medical men and 
 young practitioners who have not had much experience with the disease. 
 After a few disastrous failures, the practice is generally abandoned. The 
 few authorities in high position who advocate the abortive treatment are 
 becoming yearly more oracular in their utterances, more reserved in prom- 
 ising any certain effect from the use of harsh injections very early in the 
 course of a gonorrhoea. I do not assert that abortive treatment does not 
 sometimes seem to cut short an attack of urethral inflammation, but I cer- 
 tainly maintain that no man can assert that it will always do so, no mat-
 
 260 THE VENEREAL DISEASES. 
 
 ter how it is used; and I believe that the damage it does in the cases in 
 which it fails far outbalances the alleged good it accomplishes in cases 
 of apparent success. I doubt greatly whether a true virulent gonorrhoea 
 can be aborted by the use of strong or astringent injections at the start. 
 
 The treatment of urethritis which aims at an intelligent management 
 of the symptoms according to their intensity, once adopted, is not likely 
 to be given up for any other plan, because the results are in the main so 
 satisfactory. This treatment is hygienic and medicinal. 
 
 Hygienic treatment of urethritis. Absolute regularity of life 
 should be enjoined in all cases from the start; anything like irregularity 
 is detrimental. The patient should rest as much as possible, lying clown 
 rather than sitting or walking. He should indeed avoid exercise at first, 
 and keep as far as possible in a uniform temperature. Regularity should 
 be practised in sleeping and in eating, and particular attention should 
 be bestowed upon the function of the intestine. 
 
 The amount of food taken at the beginning of an attack should be 
 moderate, its quality bland and unstimulating, its nature light and varied. 
 If the patient be debilitated, on the other hand, plenty of meat should be 
 allowed, the full ordinary amount of food should be taken, and in some 
 cases even a little red wine from the very beginning. Milk is an excellent 
 article of diet in all cases. Where it cannot be promptly digested, the 
 work of the stomach may be made easier by adding salt to the milk; and 
 a laxative, such as a dinner-pill, may be given at night, or a little com- 
 pound liquorice powder, or, if the patient prefers, some bitter sulphate of 
 soda-water in the morning. 
 
 Among the articles of food to be avoided in all acute cases (excepting 
 those coming on in decidedly debilitated subjects, when intelligent excep- 
 tions must be made), are pastry, gravies, fried fats, and greasy articles of 
 food, all rich made-dishes and indigestible substances, all condiments of 
 every description, excepting in the mildest form. Salt, however, is not 
 objectionable; pickles and acids usually are. Asparagus is harmful to 
 some patients. 
 
 Among the drinks to be avoided are strong coffee and tea; chocolate 
 in any form, since this beverage stimulates the sexual appetite; all wines 
 and liquors of any description, particularly the fermented wines and malt 
 liquors. 
 
 Soda-water, root- beer, and Vichy water, may be used as beverages 
 with decided advantage, and the more water that can be taken between 
 meals the better, particularly rain-water, which is very bland to the stom- 
 ach and a mild diuretic. It is always well for patients to take a full 
 glass of water upon retiring, so that the morning urine may be less dense 
 than would otherwise be the case. 
 
 Smoking is not objectionable. 
 
 The mind should be kept absolutely free from impure thoughts during 
 the whole of the attack, and no sexual excitement permitted for a moment. 
 The penis should be handled as little as possible. 
 
 This latter precaution must be strictly enforced for two reasons. In 
 the first place, the constant pulling at the urethra, in order to see how 
 much pus it contains and what its quality may be, is very irritating to the 
 inflamed mucous membrane of the canal. In the second place, fingering 
 the urethra exposes the eyes of the patient to inadvertent inoculation. 
 The caution of extreme cleanliness and avoidance of the contact of any 
 pus from the urethra with the conjunctiva should be very forcibly given 
 to each patient, and frequently repeated and insisted upon.
 
 TEEATMENT OP URETHKAL INFLAMMATION IN THE MALE. 261 
 
 As a final hygienic precaution it is well for the patient to carry his 
 testicles in a suspensory bandage, since the tendency to epididymitis is 
 in this way decidedly lessened. 
 
 All the hygienic precautions alluded to should be held in force during 
 the whole course of an urethral discharge, and for a considerable period 
 after its apparent cessation (a week to ten days), through fear of a relapse. 
 
 The medical treatment of urethral inflammation is regulated 
 by the stage of the disease and the intensity of the symptoms. The first 
 thing to be done in all cases is to see that the urine be made abundant 
 and alkaline, so that it may be bland and unirritating in its passage over 
 the inflamed surface of the urethral mucous membrane. To accomplish 
 this dilution of the urine it may be enough to take an extra tumbler of 
 water several times a day between meals, or of Bathesda water or of Vichy 
 water. Should the dilution of the urine not materially reduce its acidity, 
 some alkaline drug may be given well diluted with water, and adminis- 
 tered during the third hour after each meal. If an alkali is given on an 
 empty stomach before eating, the flow of acid during the next meal is 
 pretty certain to be greater, and the result upon the blood of the alkali 
 as a medicine to be proportionately diminished. If an alkali is given 
 during a meal, its effect upon the blood is largely counteracted by the 
 acidity of the digestive juices. Given during the third hour after a meal, 
 the greatest amount of therapeutical effect is obtained from the least 
 amount of the drug; consequently, when practicable, this hour should be 
 chosen for the administration of the remedy. 
 
 The best alkaline drug, in cases of irritation of the bladder or urethra, 
 is the citrate of potash. This salt, however, is unstable. In solution, 
 after being kept for a time, it becomes changed to the carbonate of pot- 
 ash; and even in the dry state, if exposed to the air, it undergoes a simi- 
 lar alteration in part. The carbonate of potash, although a fair alkali, is 
 not so good a diuretic as the citrate, and does not, as a rule, agree so well 
 with the stomach. Finally, it may be well to state that the apothecary 
 generally buys his citrate of potash in a bottle holding a pound of the 
 powder; from this bottle he dispenses, and the pound may last him many 
 months. In such a case all those served after the first few customers must 
 necessarily get an inferior article. 
 
 Therefore, when citrate of potash is prescribed for a patient, it is well 
 to order him, if possible, to procure his supply from a freshly-opened bot- 
 tle, and to whatever quantity may be necessary, dry in the powder, in wide- 
 mouthed ounce-bottles tightly corked. Along with his bottles, in a small 
 drachm-bottle, he should receive a single dose, be it five, ten, twenty, or 
 thirty grains, so that from his wide-mouthed bottle he may take out a por- 
 tion equal to the sample for each dose, and may make a fresh solution in 
 a claret-glass of water each time that he takes the medicine. In this way 
 'he will always have a fresh article, since by taking three doses a day he 
 will use up an ounce before any of it has had time to spoil, if he keeps 
 the bottle corked. 
 
 Occasionally the citrate of potash disagrees with the stomach, even 
 when taken with all possible precautions. Under such circumstances it 
 produces a sense of discomfort in the region of the stomach, perhaps nau- 
 sea, possibly diarrhoea, and sometimes a pain in the head across the fore- 
 head. In these cases the remedy must be discontinued, and some other 
 alkali tried, or Vichy water substituted. 
 
 The dose of the citrate of potash vaires from five to thirty grains. 
 Just enough should be given to keep the urine constantly neutral or
 
 262 THE VENEREAL DISEASES. 
 
 slightly alkaline. If the citrate of potash cannot be obtained or disagrees, 
 the bicarbonate of soda or of potash may be used, or liquor potassae in 
 sufficient quantities to produce the desired effect. 
 
 The means already detailed are of service in all cases; but, in selecting 
 further remedies, some discrimination is desirable. 
 
 If the case is one in which there is reason to suspect that the discharge 
 comes from a patch of damaged urethra, strictured or not, which has been 
 excited to suppuration where, for instance, a drop of pus appears at the 
 beginning of the attack in a meatus which is not oedematous or swollen, 
 in such a case there is generally no occasion for any further internal medi- 
 cation than the alkaline diuretics already alluded to. A very mild injec- 
 tion may be used at once, increased in strength every few days; and very 
 often in a short time the supposed gonorrhoea subsides, and the patient 
 rejoices in an escape from a prolonged sickness whfch he had perhaps 
 looked upon as inevitable. The qualities of the different substances used 
 for injection into the urethra will receive consideration presently. 
 
 In case the orifice of the urethra is pouting, indicating the probability 
 of a commencing acute attack, the best substance to use in most cases in 
 connection with the alkali is the oil of sandal-wood. The pure oil is very 
 expensive, and what is sold is apt to be much adulterated, especially if 
 bought at cheap drug-stores. Consequently, it is not advisable to order 
 this remedy to poor people. The value of the drug is not therapeutically 
 great enough to justify a poor man in preferring it to copaiba. The pa- 
 tient in good circumstances may take it in the form of capsules, or dropped 
 upon a lump of sugar in increasing doses, commencing at ten drops at a 
 dose, and working up to perhaps as much as thirty drops. One capsule 
 is enough to commence with, and three generally as many as the stomach 
 can bear. 
 
 Sometimes it may be desirable to give the oil and the alkali combined 
 in a single prescription, such as the following, which is not unpalatable: 
 
 3 Ol. santali ss. i. 
 
 Liq. potassas 3 ij. iv. 
 
 Syr. acacife 3 i. 
 
 Aquae foeniculi q. s. ad iij. 
 
 M. 
 S. Teaspoonful, well diluted, in the third hour after eating. 
 
 Sandal-oil agrees with most stomachs much better than copaiba. It 
 produces no trouble upon the skin, and is not apt to excite diarrhoea. 
 When it disagrees, it generally does so by causing intense pain in the 
 back, over the region of the kidneys. In pushing the drug to obtain its 
 full effect, it is well to continue increasing the dose until some uneasi- 
 ness is complained of in this region, and then to interrupt it for a day or 
 more, waiting for the pain to subside, as it does quite promptly. After 
 this the drug may be resumed at an appropriate dose. 
 
 The effect of sandal-oil in full doses is usually soothing to the patient's 
 sensations. In cases of ordinary urethritis it often promptly modifies the 
 intensity of the discharge. In true gonorrhoea it is less effective, and 
 sometimes seems to exert no influence whatsoever. 
 
 If the patient be poor, sandal-oil should not be thought of, but the 
 balsam of copaiba should be used at once. If he be well-to-do, and the 
 sandal-oil has helped him but little or not at all, then also recourse may 
 be had to copaiba, which, although difficult to take and hard to digest, is
 
 TREATMENT OF URETHRAL INFLAMMATION IN THE MALE. 263 
 
 more efficacious in many cases. The balsam is inexpensive and therefore 
 generally quite pure, no matter where obtained. It is put up in capsules 
 by a number of manufacturers, and these capsules may be taken with the 
 alkaline diuretic, commencing at a dose of one, and increasing until three 
 or even four are taken at a time. The balsam may be given in combina- 
 tion with the alkali, in a prescription similar to the one already advised 
 for sandal-wood oil, or in one of the following mixtures: 
 
 R. Bals. copaibas f ss. i. 
 
 Liq. potassas 3 ij- iv. 
 
 Syr. tolu | iss. 
 
 Extr. glycyrrhizse 3 ij. 
 
 Aquae menth. pip q. s. ad f iij. 
 
 M. Shake. 
 S. One to two teaspoonfuls at a dose. 
 
 R. Bals. copaibas 3 iv. 
 
 Syr. tolu, 
 Syr. acacias, 
 
 Aquae menth. pip aa 3 viss. 
 
 M. Shake. 
 S. Teaspoonful. 
 
 The balsam may be administered in an endless variety of combinations, 
 mixed with sandal-oil, with cubebs, solidified into pills with magnesia, 
 and in countless mixtures. In general, the method by capsules is most 
 convenient and palatable, since the drug is only tasted during the regur- 
 gitations in the throat, which are so constant and offensive in some peo- 
 ple when they take copaiba. The odor of the balsam also remains on the 
 breath, and is quite strong in the urine of the patient in all cases. 
 
 Copaiba disagrees with many patients. It causes acute indigestion 
 in some, and more moderate dyspepsia in others. Sometimes it will 
 not stay down at all, but is rejected by the stomach. Occasionally it 
 produces headache and great depression of spirits. Sometimes it causes 
 diarrhoea. The urine, when full of copaiba, may coagulate under heat in a 
 manner suggestive of the presence of albumen. 
 
 Copaiba! erythema. One of the specific effects of copaiba is to 
 produce an acute eruptive disorder, known as copaibal roseola or ery- 
 thema. Its advent is frequently announced by a chill, with headache and 
 nausea, sometimes by diarrhoea and considerable fever. The eruption is 
 general, and consists of red raised blotches which itch intensely. 
 
 When the eruption appears, the urethral discharge becomes greatly 
 modified, or ceases entirely, but it generally returns as the eruption fades. 
 
 The treatment of copaibal erythema is to give plenty of fluids by the 
 mouth, and bland diuretics, to assist the kidneys in eliminating the 
 offending substance from the blood. Warm baths are comforting, espe- 
 cially if they contain a little baking-soda about one ounce to thirty 
 gallons or some of the infusion of bran, as in the ordinary bran-bath. 
 Dusting the skin with starch-powder is cooling, and a few days generally 
 suffices to so moderate the eruption that the itching is no longer distress- 
 ing. On the first appearance of this eruption the copaiba must be 
 stopped; but it may be resumed again, if it be desired, in smaller doses, 
 after the eruption is well on the decline. 
 
 Copaiba is undoubtedly a very useful drug in the treatment of gonor-
 
 264 T1IE VEXEKEAL DISEASES. 
 
 rhoea. The very fact that it still continues to be used, in spite of its 
 nauseousness, is sufficient proof of this. Yet it is not well to expect too 
 much of it. It sometimes acts admirably in cases of urethritis, and is 
 evidently comforting in many cases of gonorrhoea, but it does not, and it 
 should not be expected to, jugulate the disease. By its effects it must be 
 judged. It is valuable in the increasing and in the stationary period of 
 the malady. If it gives a little comfort and checks the discharge some- 
 what, it should be continued, provided the stomach is not too much dis- 
 turbed by- its use. As soon as the stationary period draws to its close, 
 and the discharge is fairly checked and positively on the decline, copaiba 
 generally ceases to be very useful, and has to give place to cubebs. 
 
 Gurjun balsam, in drachm doses, twice a day, has been of late re- 
 commended in place of copaiba. It is said to be more agreeable to the 
 stomach. It may be prescribed in mixtures similar to those in which 
 copaiba forms the chief ingredient. 
 
 When the discharge commences to decline, cubebs, turpentine, iron 
 and cantharides are the best remedies, of relative efficacy in the order 
 given. 
 
 Cubebs may be administered as a powder, or in drachm-doses of the 
 fluid extract. The oleo-resin is the most useful preparation, in my opin- 
 ion, and that made by Merck, of Darmstadt, the best of its kind. Plan- 
 ten has put up this oleo-resin in capsular form. The dose is from ten to 
 thirty minims, and it may be administered in various ways. Small quan- 
 tities are easily taken upon a lump of sugar, larger doses best in capsules. 
 One capsule at a dose is enough to begin with, to be gradually increased. 
 Patients generally halt at three capsules at a dose, but sometimes they 
 take four. 
 
 The effect of cubebs in moderate doses is rather to stimulate diges- 
 tion and act as a tonic. The breath smells of it, and the urine is full of 
 its odor. Large doses are distinctly irritating to the stomachs of most 
 patients, and cause diarrhoea, with griping pain. If the neck of the bladder 
 happens to be at all congested, or if the organ tends to be irritable, cubebs 
 is generally harmful, since it aggravates such conditions, and, if pushed, 
 may go so far as to bring on inflammation of the neck of the bladder. 
 
 Turpentine is sometimes useful in the declining stage of gonorrhoea, 
 and may be given in those cases in which cubebs does not agree. The oil 
 of turpentine may be taken upon a lump of sugar, in five- to twenty-drop 
 doses, three or four times a day. If preferred, it may be given very con- 
 veniently in the form of the pearls of turpentine, as they are called 
 prepared by Clertan. The dose of these is from one to three. 
 
 Sometimes turpentine acts as an irritant, just as cubebs does, and in- 
 duces frequent urination. In such case, the remedy must be changed or 
 the dose lessened. 
 
 Iron, in the form of the tincture of the sesquichloride, is a time-hon- 
 ored remedy in the treatment of the subsiding stage of gonorrhoea, espe- 
 cially when it tends to become gleety. Besides the tonic properties of 
 iron, this tincture is believed to exercise an especial influence over the 
 genito-urinary system. The dose is from ten to thirty drops in water, 
 three times a day, taken through a glass tube upon a full stomach. It is 
 certainly very beneficial at times. 
 
 If iron makes the head ache or produces positive constipation, it is not 
 likely to do much good to the urethral discharge. The constipating in- 
 fluence may be counteracted, however, by combining with each dose from 
 ten to thirty minims of the fluid extract of buckthorn.
 
 TREATMENT OF URETHRAL INFLAMMATION IN THE MALE. 265 
 
 Tincture ofcantharid.es enjoyed considerable reputation at one time 
 as a stimulus in the last stage of a declining gonorrhoea. It is but little 
 used at the present day, but yet there is virtue in it, and in obstinate cases 
 it may be tried, taken pretty well diluted with water upon a full stomach, 
 in from five- to twenty-drop doses. 
 
 When used in large doses this remedy also has a decided tendency 
 to produce irritation at the neck of the bladder. Indeed, if taken in over- 
 doses, it causes inflammation of the vesical neck quite certainly "with 
 strangury, bloody urine, etc. 
 
 The internal treatment of gleet is the same as that suitable for the 
 declining stage of gonorrhoea, that is, if the gleet follows close upon a gon- 
 orrhoea and is its prolonged winding up. Generally, however, when a gleet 
 prolongs itself after a gonorrhoea, it is either because the patient is too 
 much medicated and cannot employ his stomach satisfactorily for its 
 proper function, the conversion of food into a pulp ready for intestinal 
 digestion, or it is because there is some local lesion in the urethra (stric- 
 ture, prostatitis), or constitutional defect (debility, tubercle, gout). 
 
 Under these circumstances iron and turpentine are about the only in- 
 ternal remedies likely to do good. Wine should be given, a generous diet 
 ordered, change of air and relaxation from work. Cod-liver oil sometimes 
 has an excellent effect in these cases. 
 
 Local treatment is of the utmost value in these cases. The intelligent 
 use of injections takes first rank where there is no stricture, and if the lat- 
 ter exist, even of very large calibre, its treatment should be undertaken 
 at once as a proper treatment for the gleet. 
 
 THE USE OF INJECTIONS IN URETHBITIS. 
 
 Injections of the urethra are capable of rendering invaluable service in 
 urethritis, but when inappropriately used they may occasion much mis- 
 chief. The only safe rule for guidance in grading the strength of an ure- 
 thral injection is to determine to get all the good that seems possible out 
 of a given weak injection before resorting to a stronger one, and not to 
 start with the idea that the urethra must be made to stand a strong injec- 
 tion in order that it may be forced into a rapid recovery from its lesions. 
 No injection should be used in the urethra which produces any uncom- 
 fortable sensation lasting more than four or five minutes at the most. It 
 is desirable in most cases to produce a warm, pricking sensation, which 
 may become uncomfortable for a moment or two; but a positive pain 
 generally means that some chemical violence has been done to the surface 
 of the urethra, and such violence may be the starting-point of stricture. 
 
 It must also be remembered, in regard to a given injection, that if it 
 does not do the good required of it, a different strength of the same in- 
 gredient in solution may have the desired effect. There is little, if any- 
 thing, specific about injections. The reputation which hangs about cer- 
 tain proprietary injections is simply the glamour of mystery. When the 
 composition of such an injection becomes known, it loses its great renown 
 and takes its place among good injections, if it happens to be good, and 
 there are a great many very good injections. A practitioner will learn 
 all about a given substance if he uses it frequently, and it is advisable for 
 him to stick to one or two substances and use them intelligently, rather 
 than to employ a great variety of injections in the hope that, by skipping 
 from one to another, he may hit upon some*peculiar quality which his
 
 266 THE VENEREAL DISEASES. 
 
 patient really needs, but which he has not the wit to reason out before- 
 hand. 
 
 It is well also to remember that, when a discharge ceases under a 
 given injection, it may return promptly if the injection be abruptly discon- 
 tinued. A discharge, indeed, cannot ever certainly be pronounced to have 
 ultimately ceased until it has remained well for a week ; and during this 
 week of expectation the same injection should be continued which has been 
 successfully employed, with this difference, theft it should be diminished 
 in strength from day to day, and used at longer intervals than during the 
 cure. 
 
 A final precaution concerning injections is this : occasionally an in- 
 jec^ion produces and keeps up a discharge on account of being inappro- 
 priately strong. This is most apt to be the case with young men who 
 often frighten themselves into a belief that they have a gonorrhoea when 
 they have nothing of the sort, and commence a fierce onset upon the urethra 
 with injections a treatment which promptly excites a flow of pus and 
 confirms their fears. On the other hand, at the close of a gonorrhoea, 
 when an injection of considerable strength has been employed to arrest 
 the purulent discharge, an oozing of gleety mucus may keep on, main- 
 tained by a strong injection the use of which has been persisted in. 
 
 In either of these sets of cases rapid improvement follows a cessation 
 of the injection. 
 
 The method by which the urethra may be most conveniently inject- 
 ed requires a short description. Syringes with long nozzles are little 
 used of late years, and several varieties of short-nozzled or conical-ended 
 instruments are in the market, made of glass, hard rubber, and other sub- 
 stances. Any of these will do, but the hard rubber urethral syringe, 
 known by the trade name of No. 1 A, is probably the best. Long-nozzled 
 syringes have the disadvantage of scratching the urethra with their tips, 
 against which the tender mucous membrane is forced by the pressure of 
 the fingers clasping the urethra upon the outside. 
 
 Fig. 26 represents the No. 1 A syringe. Its bulbous tip only should 
 
 be introduced into the urethra, in 
 order to make an injection properly. 
 It is a mistake to crowd the conical 
 tip deeply into the meatus. This 
 
 bruises the canal perhaps as posi- 
 
 p IO _ 2g. tively as does the long nozzle of the 
 
 old-fashioned syringe, the only dif- 
 erence being that the injury is done at a different part of the canal. 
 
 In using an injection, the latter should be slightly warmed, or at least 
 the bottle should be kept in a warm place, so that its temperature may be 
 but little lower than that of the body. Warming the syringe by hold- 
 ing it a moment in hot water will sometimes answer all purposes. In 
 this way the urethra receives no shock from cold, and does not contract 
 painfully upon the stimulating fluid which is thrown into it. 
 
 The syringe is filled with the warmed injection, and all air carefully 
 expelled. The patient now urinates, washing the pus in this way from 
 the inflamed surfaces. After the canal is fairly free from urine, the noz- 
 zle of the syringe is to be gently introduced just beyond the bulbous tip 
 into the inferior angle of the meatus, and the two lips of the orifice are 
 to be pressed against each other with the thumb and finger of the disen- 
 gaged hand. The lips of the meatus are not to be pressed upon or 
 against the instrument, but against each other. Now the canal of the
 
 TREATMENT OF URETHRAL INFLAMMATION IN THE MALE. 267 
 
 urethra must be very gently distended, by pushing the piston slowly home; 
 the syringe may be at once removed, the injection retained about thirty 
 seconds, and then allowed to escape. 
 
 These motions constitute the whole act in many cases. The quantity 
 of fluid held by the syringe is not enough to penetrate into the canal 
 farther than the bulb, and, in a capacious urethra, not as far. There is 
 little chance of doing harm, therefore, by throwing the injection too deep- 
 ly down the canal. After injections have been used for a time, it is al- 
 lowable to manipulate the fluid in the canal, by holding the meatus shut 
 with the finger and thumb of one hand, while with the fingers of the 
 other hand, the fluid is pressed forward in the urethra so as to distend it, 
 and backward, so as to make it penetrate more deeply. In so pressing 
 back a fluid, the finger should never be carried beyond the penoscrotal 
 angle, or the fluid may be driven back into the prostatic sinus and light 
 up cystitis, or occasion epididymitis. A light injection used twice a day 
 generally does more good than a strong injection used only once. 
 
 The time to use injections with most success is, when a discharge is 
 upon the decline, after the height of the inflammatory stage has passed. 
 In cases which commence deep in the urethra, where the meatus does not 
 pout, injections may be used from the very beginning of the attack ; in 
 other cases it is better to wait and not to use them at all until the flow 
 has begun to yield to internal medication. 
 
 A good injection to begin with is simple dilute lead- water. This is 
 not apt to do any harm, and its effect is soothing. 
 
 Sulphate of zinc makes a standard injection of great value. 
 
 5 Zinci sulph gr. ss. iv. 
 
 Aquae rosae f i. 
 
 M. 
 
 or the same strength of zinc may be used in combination with dilute lead- 
 water. Such a mixture contains the white sediment of the sulphate of 
 lead, which should be shaken through the mixture before the latter is 
 used. This is a very old injection, and has given great satisfaction. 
 
 IJ . Zinci sulphocarbolatis gr. i. iv. 
 
 Aquae f i. 
 
 M. 
 
 is another injection possessing about the same qualities as the sulphate 
 of zinc injections, but preferred by some patients. 
 
 IJ Quiniae bisulph gr. ij. 
 
 Acid sulph. dil nivi. 
 
 Aquae i. 
 
 M. 
 
 makes an excellent stimulating injection. 
 
 3 Pulv. aluminis gr. v. x. 
 
 Aquae 3 i. 
 
 M. 
 
 is a fair astringent injection; a better one is a solution of tannin, at 
 about the same strength. The tannin solution, however, has the great
 
 268 
 
 THE VENEKEAL DISEASES. 
 
 disadvantage of staining the linen a brownish color, which will not wash 
 out, and its use, therefore, calls for much care. 
 
 M. 
 
 Zinci permanganatis .......................... gr. ^ ij. 
 
 Aquae ................................... 
 
 1 1. 
 
 is an excellent injection at the end of the gleety stage of a gonorrhoea. 
 
 This injection is of a beautiful purple color and stains the linen, but the 
 
 stain washes out. 
 
 Injections of iron are sometimes highly praised; the subsulphate, half 
 
 a drachm in six ounces of water, is well spoken of by Bumstead, as a 
 strong astringent at the end of the gleety stage. This 
 also stains the linen. 
 
 Ricord's red wine injection must not be overlooked. 
 Some patients use it with great apparent good effect. It 
 is supposed to be tonic as well as astringent to the urethra. 
 It is simply a mixture of ordinary claret with rose-water 
 (or common water), commencing in the proportion of two 
 parts of the latter to one of the former, and gradually in- 
 creasing the relative strength of the wine, using of course, 
 the same brand of red wine constantly. Finally, pure wine 
 can be used. 
 
 Another pleasant tonic and gently astringent injec- 
 tion is tea. Tea infusion may be used just as it is brought 
 on the table, undiluted, black or green tea. It is suitable 
 in chronic cases of thin gleet, and is clean, always at hand, 
 and much praised by some patients. It is actually a tan- 
 nin injection, but more efficacious by far than a solution 
 of tannin of similar strength. 
 
 Urethral suppositories made with cacao butter or gela- 
 tin are dirtier, and not so useful as injections. 
 
 When ordinary injections fail, deep urethral injections 
 very rarely are of any service. Nitrate of silver and strong 
 injections of tannin are sometimes used by the surgeon 
 through a deep urethral syringe, a few drops of the fluid 
 being deposited at that portion of the canal whence the 
 discharge is presumed to flow. This plan cannot be gen- 
 erally recommended. The physician has to administer 
 the injections, and as a rule very little assistance is derived 
 from them. If deep applications are to be made, they 
 can be used with much precision through the tube of the 
 endoscope, or by means of the cupped sound. 
 
 The cupped sound (Fig. 26) explains itself. It is a 
 simple conical steel sound, with hollow cups in its sides, 
 into which may be placed any stimulating paste or oint- 
 ment desired, and the cups then may be held against the 
 area of inflammation at longer or shorter intervals, for a 
 FIG. 27. ^ ew minutes at a time, and the effect watched. 
 
 Generally, however, all cases calling for deep injections 
 
 are either cases of stricture, or of prostatic surface inflammation. In the 
 
 former case the stricture should be treated; for the latter, time, hygiene, 
 
 change of air, and marriage are the appropriate remedies, and far more 
 
 serviceable than deep injections.
 
 TREATMENT OF TJRETHRAL INFLAMMATION IN THE MALE. 269 
 
 One appliance of modern introduction calls for notice. It sometimes 
 yields very good results. I refer to the instrument called the cold sound, 
 and described by Winternitz, 1 of Vienna. Fig. 27 represents the instru- 
 ment, which is simply a silver catheter with no eye and two orifices. The 
 instrument is divided down the middle internally by a partition, which 
 does not extend quite to the break, and the two 
 canals therefore communicate freely at the tip 
 of the instrument. To use the instrument it is 
 only necessary to attach a fountain syringe 
 containing water at the desired temperature 
 to one nozzle, and a piece of rubber-tubing to 
 the other. The catheter is then introduced 
 past the seat of the urethral irritation, and 
 the fountain syringe elevated so that there may 
 be a continuous flow of water from the syringe 
 down one side of the silver catheter and up the 
 other through the rubber tube, and into a re- 
 ceptacle placed conveniently to receive it. 
 
 This instrument has been used in cases of 
 neuralgia of the urethra, nocturnal pollution, 
 and gleet. I have not thus far derived much 
 benefit from it, excepting in the last-named 
 condition. In gleet due to a flabby, atonic 
 state of the urethra, and not dependent upon 
 stricture, I believe this instrument to possess 
 value. Winternitz uses it with a certain graded 
 diminution of the temperature of the water 
 employed. I have not found any advantage in 
 this plan, but have adopted the simpler ex- 
 pedient of using water at the temperature of 
 melting ice, and letting it flow slowly through 
 the canal during five minutes on an average. 
 On several occasions I have obtained an ex- 
 cellent result, but this method of treatment, 
 as may be said of all the others advised for 
 gleet, will not cure every case. 
 
 Finally, in cases of a gleety termination to 
 a gonorrhoeal flow, where the discharge will not 
 cease under the means employed and there is no 
 stricture, pressure exercised by the passage very gently, twice a week, 
 of a full-sized steel sound, will often promptly terminate the case. 
 
 The dressing's of the penis, when the urethral discharge is abundant, 
 become a matter of importance. Some patients prefer to wrap the penis 
 up in old muslin, retaining the latter with a light elastic band; but this is 
 apt to slip off if the elastic be loose, or to cause erection if it be tight, and 
 to soak through sometimes if the discharge becomes profuse. Some pa- 
 tients like a towel folded once or twice, and tied by a broad tape about 
 the waist, so as to hang like an apron over the penis. This they tuck 
 about the organ, and let the discharge soak up as it flows. 
 
 Bumstead thinks well of drawers cut like swimming-drawers, but this 
 will not be enough protection when the flow is quite free. 
 
 One of the nicest dressings is what is known as a penis suspensory. 
 
 Fio. 28. 
 
 Berliner klin. Wochenschrift, July 9, 1877.
 
 270 
 
 THE VENEREAL DISEASES. 
 
 Fig. 28. It is simply a waist-band holding a stiff little hoop, large enough 
 for the penis to pass through, from the circumference of which hoop hangs 
 
 a fine rubber bag. The bag is loose 
 enough not to sweat the penis, and a piece 
 of absorbent cotton is placed in the bottom 
 of the bag to soak up all discharges. The 
 only objection to these bandages is that 
 they are flimsy and perishable. 
 
 Twisting a couple of sheets of thin 
 water-closet paper about the penis is an 
 efficient protection when the discharge is 
 light. The paper stays in place much 
 better than linen or muslin. 
 
 Finally, when the discharge is quite 
 scanty, it may, without damage, be re- 
 tained within the urethra, between the 
 different acts of urination. This may be 
 readily accomplished, when the prepuce 
 is long, by putting some lint or cotton 
 over the meatus, and retaining it in place 
 by drawing the foreskin forward over it; 
 and when the prepuce is short, by cutting 
 in a piece of old muslin about three inches 
 
 square a hole suitable in size, to allow the passage of the corona glandis 
 through it. The foreskin is drawn back, the glans penis inserted through 
 the hole in the muslin, and then the foreskin is again drawn forward, 
 retaining the muslin, and so puckering it up around the meatus that the 
 patient's linen is certain to be preserved from spot. 
 
 TREATMENT OF CHOBDEE. 
 
 A certain amount of chordee is unavoidable in severe cases, and it is 
 better for the patient to endure it with good grace, sparing his stomach 
 any extra medication. He must keep up his alkaline diluents, and have 
 some cold water near his bedside, or a piece of cold metal, which he may 
 use locally upon awaking with a painful erection. Generally the simple 
 emptying of the accumulated urine in the bladder is enough to cause the 
 erection to cease, and with it the pain. The erection may come on again 
 at once, however, as soon as the patient gets warm in bed, and it may be 
 active enough to prevent sleep. In such case, medicine is called for. 
 Sometimes, however, drugs may still be avoided by soaking the penis in 
 intensely hot water just before retiring, and tying a towel around the 
 waist with a knot in the back, for cases in which lying upon the back 
 brings on the erection. 
 
 When chordee is violent enough to prevent sleep, it is best to com- 
 mence with lupulin as follows: 
 
 IJ . Lupulin 3 jss. 
 
 Ft. pil. no. xx. 
 
 S. Take eight pills the first night. If this does not suffice, take twelve 
 the second night. If this does not succeed, fifteen pills may be taken at 
 a dose.
 
 TREATMENT OF URETHRAL INFLAMMATION IN THE MALE. 271 
 
 The objection to lupulin is that it is very bulky, and many patients 
 will not take so many pills. The fluid extract is difficult to administer. 
 The tincture is objectionable on account of the alcohol it contains. More- 
 over, lupulin sometimes causes diarrhoea, and makes the patient's mouth 
 and stomach uncomfortable on the following day. Sometimes it causes a 
 dull headache. 
 
 Bromide of potassium acts admirably upon some patients, but the dose 
 given must be a large one. Dr. E. A. Banks, of this city, first brought 
 this treatment to my notice. A drachm dose in solution of the *bromide 
 should be given on retiring, and this must be followed by another drachm 
 if the first fails to attain the desired result. 
 
 The objection to bromide in continued use, from night to night, is 
 that it often upsets the stomach, if the latter be delicate. It sometimes 
 produces diarrhoea when used in large doses, and it sometimes brings out 
 a red, scaly eruption upon the face, to which patients decidedly object. 
 Hydrobromic acid may be used in some cases, but the dose is double 
 that of bromide of potassium, and the effect upon the urine seems to be to 
 acidify it, which is objectionable. 
 
 In bad case, final recourse has to be had to opium in some form. It is 
 needless to add that the sooner this can be dispensed with the better. 
 
 Suppositories of a grain or more of the watery extract of opium may 
 be used, made up with cacao butter or with wax, and introduced into the 
 rectum on retiring. Codeine, or the meconate of morphia in camphor- 
 water, may be given at night, in doses sufficient to counteract the pain 
 when the latter is very intense. A laxative should accompany the opiate. 
 
 Dr. R. F. Weir, of this city, discovered, while treating a case of pre- 
 scrotal urethral fistula by operation, that an elastic tube passed beneath 
 the scrotum and penis prevented erection in the patient upon whom he 
 employed it; the doctor's object being to keep urine from entering the 
 portion of the urethra which had been operated upon for the patient had 
 an opening in the perineum also. I have tried this expedient upon pa- 
 tients in several cases of chordee, but I find them rarely willing to submit 
 to sufficient pressure from an elastic tube to attain the desired result. 
 One patient stood the pressure well and derived advantage from it. 
 
 TBEATMENT OF PAI^FIEL URISTATION. 
 
 Often the alkaline diluents and the sandal-oil or copaiba make the pain 
 on urination tolerable; but sometimes it is. so intense that the patient de- 
 mands relief. This he may sometimes obtain by taking the bromide of 
 potassium in moderate quantities, and if the drug does not disagree he 
 may continue it during several weeks. The possible bad effects of a pro- 
 longed use of the bromide may be counteracted by combining it with the 
 syrup of the bromide of iron, and the possible acidifying influence upon 
 the urine may be neutralized by the addition of an alkali to the mixture 
 as follows: 
 
 $ . Potass, bicarb 3 iij. 
 
 Potass, bromid 3 i j- iv. 
 
 Syr. ferri bromid ss. 
 
 Syr. aurantii corticis 3 iss. 
 
 Aquae q. s. ad 3 iij. 
 
 M. 
 S. Teaspoonful in water, three or four times a day.
 
 272 THE VENEREAL DISEASES. 
 
 Hyoscyamus is a substance of great value in overcoming ardor urinae. 
 It may be given in the form of solid extract in pill, two or three grains 
 three or four times a day, or in the shape of tincture, preferably combined 
 with liquor potassae, as follows: 
 
 I . Liq. potassse f ss. 
 
 Tr. hyoscyami ij. iij. 
 
 Syr. zingiberis f iss. 
 
 Aquae cinnamomi q. s. ad vi. 
 
 S. Dessertspoonful, two or three times a day, in water. 
 
 TREATMENT OF RETENTION OF URINE IN GONORRHCEA. 
 
 A perfectly healthy urethra may become so much inflamed by gonor- 
 rhoea, that, from swelling of the prostate and (chiefly) deep urethral 
 spasm, retention of urine comes on. This result is much more apt to follow 
 if the urethra was the seat of stricture, more or less tight, before the at- 
 tack. Generally, when retention comes on during the acute stage of a 
 gonorrhoea, the prostate may be felt through the rectum to be hot and 
 throbbing, and the possibility of abscess of the prostate must be kept in 
 view. 
 
 Not uncommonly retention complicating gonorrhoea may be promptly 
 overcome by giving the patient a su*bcutaneous injection of ten to fifteen 
 minims of Magendie's solution of morphine, and a hip-bath of water at a 
 temperature ranging between 105 and 115 Fahrenheit. 
 
 Pieces of ice may be put into the rectum, and allowed to melt there, 
 according to Cazenave's ingenious suggestion. 
 
 If other means fail, a soft catheter will generally reach the bladder 
 without difficulty or danger If there be abscess of the prostate, a long, 
 curved silver catheter will have to be used, and this will sometimes punc- 
 ture the abscess and evacuate the pus, after which the urine will flow 
 away without assistance. 
 
 TREATMENT OF VEGETATIONS. 
 
 Venereal warts, as they are commonly called, spring up readily in both 
 sexes about the genitals, if any acrid and irritating discharges are re- 
 tained until they have had time to decompose. These warts are common 
 under a tight prepuce in connection with gonorrhoea, as well as with 
 chancroid and syphilitic lesions, and are often found complicating bala- 
 nitis when there has been no venereal exciting cause whatsoever. The 
 warts are not the flat, pedunculated tubercles of syphilis, but are like seed- 
 warts of the hand, composed of pointed, papillary prominences, either 
 crowing up into a raspberry-like mass, varying from the size of a pin's 
 head to that of the end of the thumb, or spread out in a dry, velvety way 
 over a large, flat surface. That the surface is composed of acuminated 
 papillae is as obvious in one form of the malady as in the other. 
 
 Treatment of these warts, wherever found and however caused, is quite 
 simple. Cleanliness is a great prophylactic, and an essential to radical 
 cure. When the general health is low, cod-liver oil and tonics are of value 
 in obstinate cases. 
 
 Generally, local treatment is sufficient, especially if the warts be few
 
 TEEATMENT OF UEETHEAL INFLAMMATION IN THE MALE. 273 
 
 in number. In such case each separate wart may be touched with pure 
 nitric acid. This turns the top of the wart yellow, and the yellow layer 
 may then be picked off. The stump must be again touched, and the acid 
 allowed to dry in. Another and another yellow layer may have to be 
 taken away, according to the size of the wart. Finally, when the wart 
 has been burned down even with the surrounding mucous membrane, 
 one final drop of acid, to destroy the hypertrophied papillae at their very 
 foundation, will generally insure the patient against any further return 
 of the malady upon that particular site. 
 
 When there are a number of warts surrounded by a moist discharge, 
 no local treatment is so good as a plentiful and repeated dusting with dry 
 calomel and washing the surface daily with diluted Labarraque's solution. 
 
 When the clusters are quite numerous, perhaps, more or less dry, 
 an excellent local application is the saturated solution of muriate of am- 
 monia. 
 
 Under the same circumstances, the local application, plentifully, of 
 the saturated solution of thuja occidentalis, with ten- to sixty-minim doses 
 of the same tincture internally, three times a day, will often affect the 
 warts quite promptly, and cause their entire disappearance. 
 
 TREATMENT OF INFLAMMATORY PHYMOSIS DUE TO GONORRHOEA AND TO 
 BALANITIS AND POSTHITIS. 
 
 Balanitis and posthitis are best prevented as complications of gonor- 
 rhoea by great cleanliness. When they come on, frequent washings be- 
 come imperative ; and when the foreskin is too tight to be drawn back, its 
 cavity must be thoroughly syringed out several times a day, with a one- 
 half of one per cent, watery solution of carbolic acid, or with some other 
 cleansing fluid. If the foreskin can be retracted, the excoriated surfaces 
 may be dusted with calomel and oxide of zinc, in equal parts by weight, 
 and dressed with a piece of prepared lint soaked in diluted lead-water or 
 some astringent solution, one of the best of which is the following : 
 
 3 . Vin aromatic 3 iss. iv. 
 
 Aquas q. s. ad | i. 
 
 M. 
 
 If the prepuce be congenitally narrow at its orifice, it is well to take 
 advantage of the opportunity to insist upon the propriety of slitting it up 
 along the dorsum if it is short, of performing circumcision if it is redun- 
 dant. In the latter case care must always be taken in the adult that the 
 cutaneous margin of the circumcised prepuce be amply loose. If it is not 
 so, the cutaneous raw circle must be made larger by a cut along the dorsum 
 of the penis, half an inch long or thereabouts, in order to change the small 
 circle into a larger oval before the mucous membrane is stitched to the 
 skin. A more elegant, but a little more troublesome method, is to leave 
 the integument on the dorsum circular at the cut edge, and to make the 
 half-inch incision along the raphe beneath the penis. Into the angle thus 
 opened, a triangular piece of the semi-mucous membrane of the penis, in- 
 cluding the frenum, and shaped with scissors to fit the gaping cut, may be 
 inserted and stitched. The result in cases operated on in this way is par- 
 ticularly satisfactory. 
 
 If the prepuce is inflamed and not in a fit state for operation, but yet 
 18
 
 274 THE VENEREAL DISEASES. 
 
 phymosed, mild injections of lead and sulphocarbolate of zinc are appro- 
 priate. They should be used warm. 
 
 Inflammation of the prepuce involving its whole thickness is treated 
 by putting the patient to bed, elevating the penis upon a compress placed 
 on the thigh or abdomen (the penis should never hang down in these cases), 
 and dressing at first with some soothing lotion, like 
 
 $ . Liq. plumbi subacetat. dil i. 
 
 Spts. rect 3 i. ij. 
 
 which should be kept constantly applied, to be followed by an astringent, 
 such as a solution of the glycerole of tannin in water, from one to three or 
 four drachms to the ounce of water. The hard oedema of the prepuce 
 sometimes following lymphangitis must be left to time to cure. 
 
 Paraphimosis complicating gonorrhoea is generally caused by oedema. 
 The deeper parts are not strangulated and not likely to be, and there is 
 rarely any occasion to attempt to reduce the prepuce. If it is considered 
 desirable to replace the prepuce, this may be effected by wrapping up the 
 swollen member in a rubber bandage long enough to squeeze out the 
 oedema, after which reduction becomes quite easy. Sometimes a few 
 coats of contractile collodion will keep down excessive oedema and com- 
 fort the patient, and sometimes a rapid disappearance of the oedema may 
 be brought about by the constant application of a strong solution of tan- 
 nin. Should the accident of positive strangulation of the penis occur, the 
 strictured point must be divided with the knife.
 
 CHAPTER III. 
 
 COMPLICATIONS OF GONORRHOEA IN THE -MALE. 
 
 Inflammation of the Follicles of the Urethra. Follicular and Peri-Urethral Abscesses. 
 Gowperit^s. Inflammation of the Lacuna Magna. Death due to Gonorrhoea. 
 Gonorrhoea! Cystitis. Gonorrhoea! Epididymitis. Sterility following Gonorrhceal 
 Epididymitis. Treatment of Gonorrhoea! Epididymitis, Prophylactic and Curative. 
 The Tobacco Poultice. Strapping the Testicle. Chronic Epididymitis. 
 
 BESIDES the common complications, chordee, balanitis, phymosis, etc., 
 already detailed in the preceding chapter, there remain to be considered 
 inflammation affecting the glands of the urethra, peri-urethritis, gonorrhceal 
 cystitis, and epididymitis. 
 
 Inflammation of urethra! follicles. The follicles of the urethra 
 always participate more or less in all acute inflammations of the canal. 
 In chordee the follicles at the affected spot are certainly involved, and are 
 probably the route by which the inflammation reaches the deeper tissues. 
 These mild inflammations get well spontaneously, as a rule, when the sur- 
 face congestion goes down. 
 
 In the prostate, however, this is not always the case. Here the irritation 
 seems to love to linger in some cases after gonorrhoea, attended by an 
 oozing of a gleety material from the prostate, perhaps a certain amount 
 of irritability of the bladder, possibly pain during the ejaculation of the 
 spermatic fluid, sometimes pain on crossing the legs, on sitting, on jolting. 
 The symptoms may, indeed, much resemble those of stone in severe cases, 
 when there is a certain amount of surface thickening of the mucous mem- 
 brane of the prostate, as well as implication of its follicles. 
 
 These cases generally occur in broken-down phthisical subjects, or in 
 those who inherit gouty tendencies. 
 
 Treatment is very ineffective. Bland alkaline drinks, tonics, regu- 
 larity of life, change of air, and marriage, are the best means through 
 which a final cure can be reached. These patients often imagine they 
 have spermatorrhoea. 
 
 The same treatment applies when the symptoms show that one of the 
 seminal vesicles has become the seat of inflammation, propagated from an 
 inflamed urethra. 
 
 There are three other forms of follicular disease of the male urethra, 
 all quite rare, but occasionally occurring as complications to urethral in- 
 flammation. One of these is the cystic abscess of small size, sometimes 
 encountered near the fossa of the frenum in connection with gonorrhoea. 
 The tumor is round, hard, painful, feeling like a shot or a pea as it moves 
 under the skin beneath the fingers, and connected to the mucous mem- 
 brane of the urethra by a long, thin peduncle, the obliterated duct of the 
 gland. 
 
 These are little follicular abscesses. They should be cut out entire, 
 or at least half of their circumference should be cut away while the 
 wound is left open to granulate.
 
 276 THE VENEREAL DISEASES. 
 
 Inflammation of Cowper's glands, usually only one at a time, is 
 another follicular inflammation of the urethra, but so rare in connection 
 with urethritis as hardly to deserve mention. The symptoms are, at first, 
 the appearance of a distinct hard swelling on one side of the raphe, mak- 
 ing it painful for the patient to sit down. This soon changes into a dif- 
 fuse inflammatory swelling involving the perineum and scrotum, more 
 prominent on that side of the raphe upon which the inflammation began. 
 
 The treatment consists in poulticing and an early free incision, al- 
 though resolution of this form of inflammation has been occasionally noted. 
 
 A third form of follicular inflammation said to be not uncommon, 
 although I have never been certain that I could decide when it existed, 
 is inflammation of the lacuna magna upon the roof of the urethra. 
 Phillips is generally quoted in connection with this malady, and his 
 advice that the pouch of the lacuna be slit up upon a fine director, when 
 the malady can be located at this point, is generally endorsed. 
 
 Finally, peri-urethral abcesses are often the result of the spread of 
 inflammation from inflamed follicles going on to suppuration. 
 
 Peri-urethral abscess is very rare with gonorrhoea. It is much 
 more common in connection with stricture. With the acute malady it 
 occasionally occurs at any point along the urethra, but preferably at the 
 forward end near the frenum, or far back near the bulb. Free opening of 
 these hard masses, well down to the urethral mucous membrane, before 
 suppuration has occurred, is the best treatment. In the perineum fluctu- 
 ation occurs promptly, and it is safe to wait for it, since there is no fear 
 that the urethra will be extensively denuded in this region. If the abscess 
 occurs witHin the capsule of the prostate, it generally opens into the ure- 
 thra, or is opened during catheterism undertaken to relieve retention. 
 
 Fistula may be left behind by peri-urethral abscess, and a prolonged 
 gleet by prostatic abscess, unless the latter has been detected through 
 the rectum, and opened through the walls of the gut an excellent treat- 
 ment whenever a point of fluctuation can be felt in this region. 
 
 As an exceptionally rare complication of gonorrhoea may be men- 
 tioned suppurative adenitis in the groin. A certain amount of tender- 
 ness in the groin is very common in severe gonorrhoea, with more or less 
 turgescence of the ganglia; but suppuration, although possible, is quite 
 uncommon. 
 
 Death occurring during the course of an acute gonorrhoea may be 
 due to pyelitis, Murchison reports two cases, 1 or to peritonitis starting 
 from abscess in the seminal vesicles, or to some suppurative inflammation 
 deep among the tissues of the pelvis, and due to gonorrhoea. Hunter 
 alluded to this subject, and a number of cases have been reported, espe- 
 cially in the French journals. Faucon 2 has written an excellent article 
 upon the subject recently. 
 
 GONOBEHtEAL CYSTITIS. 
 
 An inflammation of the neck of the bladder is apt to come on in con- 
 nection with urethritis under a variety of circumstances. It very rarely oc- 
 curs spontaneously during gonorrhoea. Generally some immediate exciting 
 
 1 Transactions of the Clinical Society, London, 1876, p. 25. 
 
 * De la pt-ritonite et du masculine phlegmon sous-peritoneal d'origine blennorrha- 
 gique. Archives gen., 1877, Oct., p. 385, and Nov., p. 549.
 
 COMPLICATIONS OF GONORRHOEA IN THE MALE. 277 
 
 cause produces it. Among the most common of these are the use of 
 strong injections, especially if thrown too deeply into the canal; strong 
 and continued sexual excitement, or attempts at intercourse during a 
 gonorrhoea; excess in physical exertion of any sort; abuse of liquor; ex- 
 cess in the use of cubebs, turpentine, or cantharides for the cure of the 
 gleety stage of gonorrhoea; the use of instruments in the urethra at too 
 early a date in the course of the attack, especially if there be any lack of 
 perfect gentleness in manipulation during such instrumentation. 
 
 All of these, and certain other analogous causes, are sufficient to ex- 
 cite gonorrhoeal cystitis in a patient having anurethral discharge, although 
 the discharge itself may have become very mild and gleety, and much 
 the more so when the discharge is intense. The same exciting causes are 
 also sometimes productive of cystitis when the gleety urethral discharge 
 is due to stricture, and not very infrequently an attack of mild cystitis 
 comes on in a patient with a diseased urethra, the exact immediate cause 
 of which cannot be determined. 
 
 Gonorrhceal cystitis is not commonly encountered until the urethral 
 discharge has been active for several weeks. 
 
 Symptoms. As the cystitis comes on, the patient at first makes 
 water a little more often than usual by day (sleeping perhaps through 
 the whole night), and the urethral discharge lessens, so that he congratu- 
 lates himself that he is getting well. Soon, however, he finds that the 
 calls to urinate become more imperative. On the call he must find 
 speedy relief, or his bladder will contract partially in spite of his efforts 
 to restrain it, and he may wet himself. Then follows pain on urination, 
 and a sharp, grinding, bearing-down pain following each act of urination, 
 due to the fact that the empty bladder continues to contract, and 
 squeezes its own tender neck. 
 
 From this time on there is a constant sense of weight, a dull pain over 
 the pubic symphysis, more or less heat and discomfort in the perineum, 
 a constant sensation of fulness of the bladder, calling for repeated and 
 unavailing straining to pass water, the best efforts culminating in a spurt 
 of only a few drops of turbid urine full of pus and often tinged with 
 blood. 
 
 Before this state has been reached the patient has become quite fever- 
 ish, with dry tongue, parched lips, and constipated bowels. One peculiar 
 quality of the fever attending inflammation of the bladder, rarely lacking 
 in a well-marked case, is very serious depression of spirits. Patients with 
 this malady are often more depressed, more anxious, less manageable than 
 if they had a far more serious disease, although the fever itself very rarely 
 runs high. The only consolation that they find is in the fact that their 
 discharge has ceased, a comfort to which they have no valid claim, since 
 a return of the show of pus at the meatus is generally one of the first 
 and most certain signs that the cystitis has begun to get well. 
 
 Gonorrhosal cystitis generally gets perfectly well in a period varying 
 from a few days in mild cases, up to a couple of weeks, or even several 
 months, in bad cases. Sometimes permanent irritability is left behind, a 
 circumstance which lends a respectability to the malady it would not oth- 
 erwise possess. 
 
 Treatment. When a patient with an urethral discharge commences 
 to make water too often, the first thing to do is to search for the exciting 
 cause and stop its action if possible. Give up injections and make the pa- 
 tient keep as quiet as possible in all physical respects. One precaution 
 is this: the bladder should not be entirely emptied at any act of urina-
 
 278 THE VENEREAL DISEASES. 
 
 tion. Many patients cannot arrest the stream at will when the neck of 
 the bladder is inflamed; but the attempt should always be made, and 
 when it can be accomplished considerable benefit may be expected from 
 this simple precaution. Much of the distressing pain after urinating can 
 be averted if half an ounce of urine is left in the bladder; and in any case, 
 if the patient must go on urinating until the bladder is empty, he should 
 be told on no account to repeat the spasmodic voluntary effort of expell- 
 ing the last few drops from the urethra which his malady inclines him to 
 do. Once this "coup de piston" may be made, but it should not be re- 
 peated. 
 
 In mild cases, rest upon the back may be all that is required in the 
 way of treatment, except the use of hot water, preferably in a rubber 
 bottle, which affords considerable comfort when placed (partly filled, so as 
 not to be too heavy) over the bladder or against the perineum, especially 
 if the hips be kept raised slightly above the level of the shoulders. 
 
 Any stimulating balsam or tincture which is being given for the 
 gonorrhoea should be stopped at once. The alkaline diluent should be 
 continued, and bland drinks, like flaxseed tea, elm-bark decoction, infu- 
 sions of triticum repens, buchu, arenaria rubra, etc., to afford the patient 
 a little mental comfort, for certainly they do not do much good physi- 
 cally, excepting in so far as they are mildly diuretic. 
 
 Bathesda mineral water drunk freely is unquestionably of value in 
 these cases, and an exclusive milk diet has a peculiar merit. The latter 
 must be accompanied by enough of some mild vegetable laxative to 
 overcome its constipating tendency. If it purges, as is sometimes the 
 case, skimmed milk may be substituted for whole milk. A gallon a day 
 is full diet for a healthy man. If so much can be managed by the stom- 
 ach, nothing else whatever need be given either to eat or to drink. 
 
 All those articles of food and drink which were condemned in the diet- 
 etic section on the treatment of gonorrhoea must be equally avoided here 
 (page 260). 
 
 Hot hip-baths are of considerable service in this affection. The heat 
 of the bath should range in the region of 110 Fahrenheit, the pelvis should 
 be covered by the water-line, and the bath be not longer than three or 
 four minutes in duration. Such baths may be repeatedly taken every 
 few hours during the day when they afford relief. 
 
 As for medicines, anodynes hold the first rank. The frequency of 
 urination must be stopped, whatever happens. The old combination: 
 
 IJ Liq- potassae 3 ss. 
 
 Tr. hyoscyami iss. 
 
 Syr. aurantii cort 3 i. 
 
 M. ' 
 S. Teaspoonful in water every four hours. 
 
 will give relief in mild cases. The strength of the alkali in this prescrip- 
 tion may be decreased, and that of the hyoscyamus perhaps increased 
 with advantage. Hyoscyamus may be used alone, as tincture, in drachm 
 doses several times a day, with the happiest effect in the cases in which 
 it agrees. It must be remembered that hyoscyamus sometimes causes de- 
 lirium. 
 
 When mild measures of this sort fail to control the frequency of uri- 
 nation, a positive anodyne must be employed. Half-grain or whole grain 
 suppositories of the watery extract of opium, with a third to the half of
 
 COMPLICATIONS OF GONOERHCEA IN THE MALE. 279 
 
 a grain of the extract of belladonna, may be used and repeated often 
 enough to keep the intervals of urination two hours long. The belladonna 
 sometimes disagrees. 
 
 Powders of morphine, like the following: 
 
 ]J . Morph. bimeconatis gr. vij. xiv. 
 
 Gum camphor 3 i. 
 
 Resinae jalapae gr. vj. x. 
 
 Pulv sacch. alb 3 ss. 
 
 M. Ft. chart, no. xx. 
 Put into waxed paper. 
 
 S. One, as required. 
 
 
 
 may be used for the same purpose, to keep the intervals of urination two 
 hours long by daylight, or an analogous liquid preparation: 
 
 IjL Elix. opii (McMunn) 3 vi. xij. 
 
 Elix. rhamni frangulae ss. iss. 
 
 Syr. aurantii q. s. ad | iij. 
 
 M. 
 S. Teaspoonful, as required. 
 
 By persistence in these means, the pain, the tenesmus, and the fre- 
 quency of urination will gradually subside, and the discharge begin to 
 reappear at the meatus. For this return, some mixture of copaiba (p. 263) 
 should be used internally, since the effect of this drug upon the bladder 
 is often also quite beneficial. 
 
 The patient must resume his habits of life slowly, and conduct the 
 subsequent treatment of his gonorrhoea with great circumspection. 
 
 GONOEBH(EAL EPIDIDYMITIS. 
 
 Epididymitis occurs quite frequently as a complication of gonorrhoea. 
 Fournier places its frequency as high as twelve per cent., and Sigmund at 
 between six and eight, believing that the left testicle is more often at- 
 tacked than its fellow. Like gonorrhoeal cystitis, it may come on in re- 
 gular sequence as a result of the gradual spread downward of the urethral 
 inflammation to the mouths of the ejaculatory ducts. Its most common 
 date of appearance, during the course of a gonorrhoea, is the end of the 
 third week. 
 
 The date of appearance of epididymitis, however, is by no means fixed. 
 I have seen it come on during the first few days, as a result of irritating 
 injections used to abort a gonorrhoea, and it may be encountered at any 
 period later, or even at any time afterward during life, if stricture be left 
 behind by the gonorrhoea. Stricture of the urethra, or rather the irritation 
 so constantly existing behind it, is a fertile source of epididymitis. 
 
 Generally, epididymitis is due to some direct exciting cause over and 
 above the general inflammation of the urethra. Among such immediate 
 causes may be enumerated most of those irritants, general and local, which 
 have been enumerated already as being capable of lighting up cystitis in 
 a patient with gonorrhoea, such as injections too irritating in quality or 
 thrown too deeply into the canal ; the passage of a sound or other instru- 
 ment, for exploratory or other purposes, down a urethra which is the seat
 
 280 THE VENEREAL DISEASES. 
 
 of surface inflammation; sexual irritation of any sort; drinking; violent 
 exercise, which is generally believed to act by directly damaging the tes- 
 ticle mechanically, and thus, as it were, calling down the inflammation 
 from the urethra. Hence the prophylactic importance of a snug suspen- 
 sory bandage. 
 
 Symptoms. When acute epididymitis is about to attack a healthy 
 testicle, it generally takes at least twenty -four hours to get fairly under 
 way. Sometimes signs of warning may be appreciated by the well-in- 
 formed observer, even earlier than twenty-four hours before the testicle 
 begins to swell. The first sign is generally an uneasiness referred to the 
 depths of the groin, upon the side about to become affected, with a 
 sense of weight and uneasiness in the testicle of that side, which is usually 
 already somewhat over-sensitive to handling. With these symptoms there 
 may be some general malaise, a little constipation, slight headache, a tri- 
 fling fever. 
 
 These symptoms are quite apt to come on in the afternoon after a day 
 of ordinary exercise. I cannot recall a case in which the first signs of 
 epididymitis appeared early in the day, when that epididymitis appeared 
 in due course as a complication of gonorrhoea. 
 
 The patient naturally keeps still with the pain in his groin or testicle, 
 and the rest of an evening, or a night, or both, often makes him so com- 
 fortable that, upon awaking the next morning, he may not be con- 
 scious that he has any unusual pain until he is upon his feet possibly 
 not then for there is no disease more apt than this one to stop unexpect- 
 edly at any point in its course, and thus to justify the most varied 
 means of treatment. Indeed, after quite a marked prodromal stage, a 
 night's rest sometimes dissipates the pains, and the patient becomes and 
 remains well. 
 
 This fortunate result is rare. Generally, as the day goes on, the pain 
 in the groin becomes more intense, the testicle rapidly or gradually grows 
 heavy, hot, and painful, the enlargement commencing at the lower in 
 the back part. There may be a sharp chill, followed by intense fever, 
 nausea, headache, and vomiting. Constipation is uniform, and sometimes 
 there is a tendency to frequency in urination, with more or less pain in 
 the act. 
 
 Now the malady is fairly under way, and the testicle continues rapidly 
 to swell. The flow of pus from the urethra becomes diminished, or stops 
 entirely, to the delight of the patient, who indulges in the vain hope that 
 that part, at least, of his misfortunes, at last is over. It is a kindness to 
 undeceive him, and let him know that his relief from urethral trouble is 
 only transitory, and that his discharge will surely return as the inflamma- 
 tion in the testicle subsides. 
 
 The fever increases, at first, as the testicle swells, and to the intense 
 and increasing pain in the groin is added, often, an intolerable splitting 
 pain in the back, low down. Meantime the testicle has increased in all 
 its dimensions. A little fluid generally collects in the tunica vaginalis, 
 keeping the testicle oval in shape as it increases in size. The scrotum 
 gets red and hot, and is sometimes the seat of a very considerable cedem- 
 atous effusion. 
 
 The intensity of the symptoms, and the height to which the inflam- 
 mation is to run, vary greatly in different cases. There may be nothing 
 more than a little tension of the testicle, most marked posteriorly, lasting 
 only a few days, and totally relieved by the recumbent posture, if the tes- 
 ticle be at the same time elevated and supported. On the other hand,
 
 COMPLICATIONS OF GONOEEHCEA IN THE MALE. 281 
 
 the suffering may be intense, the scrotum hot, red, and shining, the pain 
 in the groin and back excruciating, the tunica vaginalis tense and full of 
 fluid, the substance of the whole testicle seemingly in a state of most 
 active inflammation, and this condition is not relieved either by position 
 or by support to the testicle. 
 
 First attacks of epididymitis, like first attacks of gonorrhrea, are 
 usually much more formidable in their symptoms than subsequent visita- 
 tions of the same malady. In the subacute form of epididymitis, espe- 
 cially in a testicle which has been the seat of former attacks, the whole 
 malady may consist in a hard lump, which appears at the globus minor 
 or major, attended by more or less pain, dragging, and constitutional 
 symptoms. This lumpiness usually remains long present, perhaps for 
 months, or even years, becoming, finally, almost or quite insensitive, 
 and not responding at all to medication. 
 
 In the acute cases it generally takes from two days to a week for the 
 increase in size of the testicle to reach its height, after which the swelling 
 goes down at first slowly, then quite promptly, so that in ten days or 
 two weeks, under treatment, it may be counted upon with reasonable 
 certainty that the most desperate case will be practically well that is, 
 free from pain to such an extent that it may be supported in a suspen- 
 sory bandage, or at least strapped, and thus the patient be allowed to 
 get about in comfort. 
 
 Sometimes, after an acute attack, a chronic induration of the epididy- 
 mis remains behind for an indefinite period. Such testicles are rather 
 prone to relapse. The cord may become involved, and the testicle itself 
 become pseudo-tubercular, or even tubercular. 
 
 Sterility due to ordinary inflammatory epididymitis calls for 
 a few words of notice here. An acute attack of the affection, if it passes 
 over within a reasonable time, leaves no injury to the epididymis behind 
 it; but the subacute attacks those characterized by localized large nodu- 
 lar developments in the tail or head of the epididymis are apt to fail 
 to get entirely well, and as a consequence the convoluted tube consti- 
 tuting the epididymis becomes obliterated at the point occupied by the 
 nodule, and the passage of spermatozoa through it becomes mechanically 
 impossible. 
 
 The quality of the inflammation in epididymis seems to be plastic 
 rather than catarrhal, although it commences in the lining membrane of 
 the tube of the epididymis. The calibre of the tube becomes filled up 
 as the morbid process advances, and the atmosphere of connective tissue 
 in which the tubes lie becomes the seat of a similar plastic inflammation. 
 This process thickens the whole epididymis by new connective-tissue de- 
 posits, and fuses together into a solid mass the convolutions of the canal 
 of the epididymis. The canal shows irregular dilatations and contractions 
 at the seat of the lesion ; granulo-fatty degeneration may subsequently 
 attack the whole mass, reducing it to a cheesy condition, in which even 
 the contour of the tube of the epididymis cannot be made out. The 
 name of Gosselin is generally coupled with this subject, since his investi- 
 gations went far to clear up the pathology of chronic gonorrhreal epi- 
 didymitis and to demonstrate the mechanical cause of the sterility which 
 was known to exist in some of these cases after both testicles had been 
 the seat of the disease. Gosselin pointed out that localized epididymitis 
 of the tail of the testicle was more apt to produce sterility than when 
 the head of the epididymis alone was involved in the disease, the reason 
 being that many tubes unite to form the globus major, while fhe globus
 
 282 THE VENEREAL DISEASES. 
 
 minor is composed of the convolutions of a single tube and unfortu- 
 nately the globus minor is the peculiar seat of election of this malady. 
 
 The sterility encountered after gonorrhceal epididymitis is only present 
 when both testicles have been diseased, and not necessarily then. This 
 sterility has no connection with impotence. The patient's virile powers 
 are as strong as ever, his sexual act perfect, his ejaculation satisfactory 
 and full, and the testicle does not remain painfully swollen after sexual 
 contact. Yet the fluid ejaculated is not healthy sperm. It has the sper- 
 matic odor, but is watery in quality, and apparently composed entirely 
 of fluids from the seminal vesicles and from the prostatic follicles, for the 
 most careful microscopic examination has failed to detect any spermatozoa 
 in it. Consequently, such a patient is necessarily sterile, although he is 
 not at ill impotent. 
 
 The treatment of this condition is unsatisfactory. It is believed 
 that iodide of potassium, mild mercurials, and cod-liver oil internally, 
 hasten absorption; but it is not well to place much faith in the curative 
 action of these drugs. Time will effect a cure in some cases; it will fail 
 in others. Possibly long-continued pressure might assist absorption and 
 help to clear the tubes. 
 
 The most important medical bearing which a knowledge of this gon- 
 orrhceal sterility possesses is in its relation to the question of marriage. 
 Many patients know that prolonged chronic epididymitis on both sides is 
 liable to entail the loss of the power of procreation, and before marriage 
 such a man may come to demand an opinion as to his capacity to beget 
 a child. The only grounds upon which such an opinion can be honestly 
 rendered are (presumptive) the existence of a lumpy indurated condition 
 of the epididymis on both sides, and (positive) the entire and continued 
 absence of spermatozoa from the spermatic fluid. 
 
 TREATMENT OF EPIDIDYMITIS. 
 
 The prophylactic treatment of epididymitis is very simple. A 
 snug suspensory bandage should be worn, and all such exercise as might 
 jolt or bruise the testicle must be strictly enjoined. The patient should 
 be kept particularly quiet during the acuter periods of the urethral dis- 
 charge, and cautioned against the least approach to sexual excitement. 
 All those articles of food or drink which are known to increase the inten- 
 sity of the urethral inflammation also tend to produce epididymitis, and 
 must be avoided; and much care is necessary in the selection of proper in- 
 jections, as well as in the manner of administering the latter. Finally, 
 and above all, great circumspection must be exercised in using a bougie 
 or sound for the cure of a retiring gonorrhosa. The patient should be 
 prepared for the first introduction of such an instrument by taking an al- 
 kaline diuretic for at least twenty-four hours beforehand, and it is better, 
 on the first introduction of an instrument, not to pass it entirely into the 
 bladder, but only into the membranous urethra. The time selected for 
 the passage of an instrument for the first time should be late in the after- 
 noon or in the evening, and the patient should remain quietly at home 
 during the evening and night. By the exercise of these precautions, it 
 will rarely, if ever, be possible for the patient to accuse his surgeon of be- 
 ing the immediate exciting cause of his swelled testicle. 
 
 The curative treatment of epididymitis varies somewhat with the 
 grade of intensity of the inflammation. During the premonitory twenty-
 
 COMPLICATIONS OF GONORKHCEA IN THE MALE. 283 
 
 four hours, when the only complaint is of a slight weight or dragging at 
 the cord in the groin, with perhaps some discomfort in the testicle and a 
 pain in the back, it is proper to put the patient immediately to bed upon 
 his back, to administer a brisk laxative, and to sling the testicle well up 
 so that the cord may be entirely relieved from its weight, while the return 
 circulation from the testicle is favored by gravity. 
 
 This slinging-up of the testicle is a most important matter during 
 all stages of the treatment of the malady under consideration. It can- 
 not be effected by means of the suspensory bandage. Such a bandage 
 lets the testicle drop between the thighs, and, although it is very use- 
 ful in the erect posture, it loses its value entirely when the patient lies 
 down. 
 
 An excellent means of suspending the testicles is that employed in 
 most hospitals. It is quite effective, but is unfortunately dirty, and con- 
 fines the thighs to such an extent that most private patients will not en- 
 dure it. In some cases, however, the method is very applicable. It con- 
 sists simply in cutting a strip of ordinary adhesive plaster, four or five 
 inches broad, and long enough to stretch from one side to the other over 
 the tops of the two thighs, just beneath the scrotum, as the patient is lying 
 down. It is applied by being fastened securely in place, the adhesive 
 side sticking to the skin on the outer aspect of both thighs as they lie 
 close together, the scrotum and inflamed testicle meantime having been 
 drawn well up out of the way, to be afterward gently deposited upon the 
 tense, smooth, dry table, formed between the thighs by the non-adhesive 
 side of the plaster. 
 
 The plaster is dirty, the legs are constrained, the top of the plaster 
 sometimes cuts into the root of the scrotum; but the bandage does not 
 slip, and the support is quite efficient. 
 
 The best method of making support, and one which applies to all cases, 
 whether or not poultices or other dressings are to be used, is the follow- 
 ing: a large handkerchief is obtained preferably of silk. This is to be 
 folded into a triangle. At the centre of the long side of this double tri- 
 angle, exactly opposite the right angle, a piece of tape about three feet 
 long is to be sewed. An ordinary stiff roller-bandage, long enough to en- 
 circle the waist, completes the apparatus, which is to be arranged as fol- 
 lows: the roller-bandage is drawn quite snugly around the waist above 
 the flare of the pelvic bones, and secured by safety-pins or by needle and 
 thread. Then the patient is instructed to hold the testicles and scrotum 
 well up above and over the symphysis pubis. The centre of the long side 
 of the triangular silk handkerchief, marked by the tapes, is now placed in 
 the perineum, well up against the root of the scrotum, and one end of it 
 is carried up on either side along the fold of the groin, under the roller- 
 bandage and over the same, after which both these ends are drawn upon, 
 so as to make the long side of the triangle sufficiently tense under the 
 scrotum, and then the ends are fastened into place with large safety-pins. 
 Finally, the patient rolls on his side, and one of the tapes carried between 
 the nates and under the roller-bandage, at the middle of the back, is 
 knotted to its fellow in such a way as to keep the perineal portion of the 
 handkerchief a fixed point. The right angle of the triangular handker- 
 chief is to be loosely pinned up against the roller-bandage in front, to re- 
 tain in place any dressing which may be put upon the testicle. 
 
 A bandage well arranged as above directed cannot slip, and gives 
 more comfort than any other appliance with which I am familiar. All 
 applications to the testicle may be made by its aid, excepting ice, and my
 
 284 THE VENEREAL DISEASES. 
 
 experience has caused me to condemn ice as a local application in all con- 
 ditions of impending or actual epididymitis. 
 
 Certain authorities advise ice, and its application is very simple. It 
 is only necessary to separate the thighs and place the inflamed testicle 
 upon a suitable cushion, after which broken ice, floating in its own water, 
 contained in a bladder, or a rubber or oil-silk bag of ample size, is placed 
 upon the testicle and cushion. Ice is useful in intense neuralgia of the 
 testicle; harmful, I believe, in most inflammatory conditions. 
 
 Numerous internal remedies have been at various times advocated in 
 the treatment of epididymitis. None of them have held place. The con- 
 tinued nauseant influence of frequently repeated small doses of tartar 
 emetic has proved of no value in my hands. Pulsatilla has been loudly 
 vaunted of late, splendid effects being stoutly claimed for it in doses 
 of one-tenth of a minim often repeated, up to one drop three times a 
 day. It has failed in my hands, employed in both ways, either to check 
 the pain or modify the course of the malady. I think well of correcting 
 the strong tendency to constipation, which always exists in the disease, 
 by the daily use of gentle laxatives; and on the few occasions where the 
 pains demand it, I see no objection to the administration of a small amount 
 of codeia or other gentle anodyne. Beyond this I cannot recognize any 
 value in internal medication. 
 
 As for the local heroic measures, but three require mention: bleeding, 
 puncture of the tunica vaginalis, and puncture of the tunica albuginea. 
 
 Leeches upon the scrotum do not afford any considerable relief, accord- 
 ing to my experience, and are attended by obvious disadvantages. Where 
 the testicle seems to be strangulated by the intensity of the inflammation. 
 a large number of leeches ten to twenty placed over the upper part of 
 the scrotum and along the course of the cord, will sometimes afford relief 
 from the immediate and excruciating pain; but puncture of the tunica 
 vaginalis, or of the albuginea, will afford similar relief at a less cost of 
 blood, and consequently of vitality. 
 
 Puncture of the tunica vaginalis. In all acute cases of epididy- 
 mitis there is more or less effusion of serum into the cavity of the tunica 
 vaginalis, making an acute hydrocele, the size of which is sometimes con- 
 siderable, generally unimportant. When the tension within the testicle 
 is great, and the effusion considerable, relief may sometimes be promptly 
 afforded the patient by resorting to puncture of the tunica vaginalis. A 
 number of punctures may be made subcutaneously with a fine, sharp- 
 pointed knife, so that the fluid may escape into the meshes of the connec- 
 tive tissue of the scrotum, or the serum may be drawn off by the modern 
 process of puncture and pneumatic aspiration. After aspiration the cav- 
 ity may refill, but often the acuteness of the pain subsides after a single 
 puncture, and the subsequent collection of fluid may be disregarded. 
 W r hen the tunic is not distended, its puncture does not afford relief as 
 might be inferred. 
 
 This operation is entirely devoid of any risk or danger, and is justifi- 
 able under all circumstances of distention of the tunica vaginalis in con- 
 nection with acute inflammatory disease. 
 
 Puncture of the tunica albuginea. In connection with epididy- 
 mitis, the secreting structures of the testicle within the tunica albuginea 
 may become congested and distended to such an extent as to produce the 
 intolerable pain of acute orchitis, a pain felt intensely in the testicle and 
 radiating thence up the cord, along the groin, and into the small of the 
 back. This pain may often be relieved at once by a single subcutaneous
 
 COMPLICATIONS OF GONOREH(EA IN THE MALE. 285 
 
 section of the tense tunica albuginea to the extent of about one-third of 
 an inch, or even less. The operation is a simple one. A sharp-pointed 
 tenotome is introduced obliquely under the skin of the scrotum, and the 
 tunica vaginalis entered; then the blade is made to advance flatwise with- 
 in the cavity of the tunica vaginalis for a short distance, after which it is 
 turned so as to present its cutting edge to the tense tunica albuginea, the 
 testicle being steadied by the operator's free hand. Finally, by a deliber- 
 ate puncture upward followed by a slight incision on withdrawing the 
 knife, the incision to lie at about the centre of the forward part of the 
 tunica albuginea, a slight cut is made in the tense tunic, and the little 
 operation concluded. 
 
 It is doubtful whether any harm can follow this surgical manoeuvre. 
 In a recent spirited contest upon the subject, between the English sur- 
 geons, it was claimed, on the one hand, that this method of cure was won- 
 derfully rapid and absolutely harmless ; while, on the other hand, it was 
 maintained that the damage inflicted upon the testicle sometimes caused 
 its ultimate atrophy, and that the incision did not always either cure 
 the pain or shorten the natural duration of the malady. 
 
 It is hard to conceive how such a puncture as has been described can 
 really injure a testicle, and it seems probable that those cases in which 
 atrophy of the testicle followed puncture were instances of true orchitis, 
 which, as is well known, frequently goes on to atrophy of the testicle 
 when no puncture at all has been resorted to. Still, in face of the possi- 
 bility of any ultimate blame attaching to the surgeon, in case of any dam- 
 age to the testicle, if puncture has been employed, it is well to resort to 
 this procedure only after mature consideration, and after ordinary means 
 of stilling the pain have failed. 
 
 Multiple minute punctures of the tunica albuginea, made with a large 
 surgical needle or the point of a fine, straight bistoury, answer often as 
 well as section of the tense membrane, and are probably attended by less 
 risk of doing harm. 
 
 The sheet-anchor of treatment in epididymitis, however, is position of 
 the testicle, and, next to this, the local use of hot fomentations of the nar- 
 cotic sort. Belladonna and opium in different forms, as hot decoctions 
 and infusions, have been employed largely, but they are not devoid of 
 danger, and possess little advantage over tobacco. Tobacco is undoubt- 
 edly a filthy substance, but, with care, it may be so managed that the pa- 
 tient is little, if at all, soiled by it. As to danger, there is practically 
 none. Thin-skinned persons, who have never smoked, may absorb 
 enough of the poison to become faint, pale, nauseated, and dreadfully 
 depressed ; but, if they are informed of the possibility of these occurrences 
 beforehand, and remove the tobacco when the objectionable symptoms first 
 begin to appear, the inconvenience soon passes off, and there is no possible 
 danger, either to life or to subsequent health. Excoriations oflarge size upon 
 the skin of the scrotum contraindicate the use of any narcotic or anodyne 
 in the poultices, which must then be composed of some simple material. 
 
 To make a tobacco poultice, which shall be at once efficient and clean, 
 the following course may be followed : one ounce (a paper, as ordinarily 
 sold for chewing) of fine-cut tobacco is to be finely shredded into a tin or 
 earthen vessel, containing from eight to ten ounces of boiling water. 
 Into this is put a tablespoonful of glycerine or of sweet oil, and into the 
 whole, while being rapidly stirred, is mixed a powder of equal parts of 
 ground elm-bark and ground flaxseed, in sufficient quantity to bring the 
 whole mass to the proper consistence for a soft poultice.
 
 286 THE VENEREAL DISEASES. 
 
 A square piece of oil-silk, or of thin rubber-sheeting, two or three 
 times the size of the proposed poultice, and containing a hole at a suita- 
 ble place, through which the penis is to protrude, is now to be laid upon 
 a flat surface. Upon this a doubled piece of cotton cloth, considerably 
 larger than the proposed poultice, is to be placed. Upon this cotton cloth 
 the tobacco mixture is poured, so as to make a poultice not less than one- 
 quarter nor more than half an inch thick. The mass should be about as 
 consistent as mush, and the liquid parts not in such excess as to be visi- 
 ble. Upon the top of this mass, after it has been rapidly smoothed down 
 and squared off, should be placed a single thickness of some gauzy mate- 
 rial, a little larger in all directions than the tobacco mass, and, finally, the 
 four edges of the doubled cotton cloth should be turned in twice upon 
 themselves, in such a way as to enclose the poultice and the gauze upon 
 it all around, in a frame, as it were. The attachment of a few points by 
 needle and thread complete the poultice. 
 
 The poultice when made should be perfectly moist, soft, and smooth, 
 but should never drip. It should be large enough to cover the entire tes- 
 ticle indeed, the whole scrotum. Both testicles may be taken in with 
 advantage. The poultice must be applied as hot as it can be borne, with 
 the rubber cloth or oiled skin outside of it, the whole to be sustained by 
 the handkerchief -sling, described on page 283. 
 
 Such a poultice, so made and applied, will keep hot and moist for a long 
 time, and in the hands of a careful person is not at all dirty. If a little 
 moisture should drip away, it can be easily caught in a couple of folded 
 towels or a sheet beneath the buttocks. Two such poultices in the twenty- 
 four hours are generally sufficient. A tobacco poultice may be sprinkled 
 with powdered opium or with laudanum, or mixed with oleate of morphia, on 
 the start, if an extra amount of local stupefying influence over the pain is 
 desired. 
 
 I think it well in all cases bad enough to confine the patient to bed, 
 that such a poultice as the one above described should be applied at once 
 as soon as the testicle is suspended. It often succeeds in stupefying the 
 testicle within a few hours and entirely overcoming the pain. In all very 
 acute or intense cases, however, this effect cannot be expected before the 
 lapse of two or three days, possibly longer. 
 
 The vast majority of cases of epididymitis call for no further treat- 
 ment than the simple means already enumerated: mild laxatives, an ele- 
 vated position of the testicle with the patient upon his back, and a well- 
 made tobacco poultice. Under these means the acute symptoms pass off 
 in a period varying from a few hours in mild cases, to a few days, all pain 
 disappearing at the very outside in two weeks, in the worst cases. Generally 
 the patient who lies down at once, even with a very severe first attack of 
 the disease (which is the worst he can have), may be promised that he will be 
 out and attending to his business in ten days, and this period under good 
 management may often be shortened to a week, while cases which last 
 only from twenty-four hours to three days are by no means uncommon. 
 
 When the acute symptoms are over, however, the patient is not well. 
 The pain usually subsides entirely in from one to three, or possibly five or 
 six days; but, long after the patient ceases to feel pain, any handling of 
 the still swollen organ makes him wince, and an attempt to remain long 
 in the erect position brings on acute pain. Therefore, if the patient 
 wishes to avoid relapse, he must not presume to go about his business un- 
 til he can stand with the tesicle unsupported for at least fifteen minutes 
 without experiencing any pain. When he can do this, he may go with
 
 COMPLICATIONS OF GONORRHCEA IN THE MALE. 287 
 
 his testicle well supported in a snug suspensory, inside of which is a piece 
 of thin rubber and a piece of prepared lint, smeared, perhaps more for 
 form's sake than anything else, with some indifferent ointment. 
 
 STRAPPING. 
 
 
 
 Should a patient find it necessary to leave his bed before completing 
 his week or ten days, and not be able to wait until he can stand erect for 
 fifteen minutes without pain, he may do so by the aid of strapping. Just as 
 soon as the acute symptoms are fairly on the decline and the testicle can 
 be handled, even although it be with pain, the patient may get up and 
 go about with safety, so far as relapse is concerned, if the testicle be prop- 
 erly strapped. Strapping should be first done at night, and the first 
 straps should be put on with great gentleness and not too tightly. The 
 patient must be directed to stay in bed all night, and to remove the straps 
 or to cut them down the front, if the testicle be not quite comfortable in 
 half an hour after the straps have been applied. 
 
 An effectual method of applying straps is the following: a number of 
 strips are cut from a roll of fresh adhesive plaster, ranging about ten 
 inches long by three-quarters of an inch wide. If the plaster be not very 
 fresh, an assistant is necessary to warm the strips of plaster one after an- 
 other, and hand them to the operator. The patient sits upon the edge of 
 the bed, with his thighs stretched wide apart. The operator, upon a low 
 chair, sits directly in front of him, seizes the enlarged testicle gently with 
 his left hand above the globus major, and, by a motion at once rotary and 
 constricting, under gentle traction he pulls the testicle down until he can 
 easily encircle the cord above with his thumb and index finger. 
 
 The sound testicle meantime slips up upon the opposite side, and the 
 whole scrotum is pinched in about the neck of the swollen testicle, and 
 held there for a moment with the finger and thumb of the operator's left 
 hand, until the parts become used to the traction and the tension. Now a 
 piece of prepared lint, previously cut long enough to surround the top of 
 the testicle and about one and one-half inch broad, is placed under the in- 
 dex finger and thumb posteriorly and brought forward so as to surround 
 the neck of the testicle, while its free ends cross in front and lie below 
 upon the body of the tumor. 
 
 The object of this lint is to prevent the cutting to which the tight top 
 strap subjects the tender integument of the scrotum. After it has been 
 satisfactorily adjusted, the first adhesive strap is to be placed. This is 
 done by holding the two free ends of the lint with the underlying scrotum 
 tightly about the neck of the tumor, while the centre of the adhesive strip 
 is placed posteriorly upon the centre of the strip of lint. One end of the 
 adhesive strip is now brought around, following the centre of the strip of 
 lint, and attached to the integument of the scrotum beyond the lint. 
 Finally, the other end of the adhesive strip, also following the centre of its 
 half of the lint strip, is brought around under considerable pressure and 
 attached either upon the half of the adhesive strip already placed, or cross- 
 ing the latter upon the integument over the tumor below. 
 
 Upon the successful laying of the top strap depends the success or the 
 failure of the whole strapping. If it does not lie smoothly and retain the 
 testicle tightly, it is well to remove it and put on another. How tight it 
 must be is of course a matter of judgment; but the tendency certainly is 
 to make it too loose, and it always seems to be tighter than it is on account
 
 288 THE VENEREAL DISEASES. 
 
 of the shining 1 , tense, purple look of the scrotum beneath, if it be allowed 
 to remain a moment, due to the arrest of the return circulation in the 
 veins. 
 
 To place the other straps is now an easy matter. Each one is to be 
 started posteriorly, and to overlap the one above by half or even two-thirds 
 its breadth, and each half of each strap is to be brought around under con- 
 siderable tension, preserving its relation to the upper strap, attached, and 
 cut off at a suitable length. 
 
 Going down the testicle, the straps are made to lie more and more in 
 a circular direction, until finally a strap is placed which leaves the egg- 
 shaped end of the livid scrotum projecting beneath it, not covered, but yet 
 incapable of receiving any more circular straps. If any of the circular 
 straps now prove so tight as to push the testicle up through the constrict- 
 ing ring formed by the top strap, the dressing is worthless, and must be 
 reapplied. If, however, the testicle is tightly held, its remaining livid ex- 
 tremity may be bound in by a number of short, broad straps very tightly 
 applied from behind forward, and laterally, until the whole of the testicle 
 has been covered in. 
 
 These last straps are quite important. They cannot be put on too 
 tightly, and, to place them at all properly, the testicle has to be squeezed 
 enough to give the patient a great deal of pain. Outside of these final 
 straps another circular one may or may not be placed, according to taste, 
 and the strapping is complete. 
 
 When a testicle, after acute inflammation, is snugly strapped for the 
 first time, it is apt to throb and grow painful for a time. If, at the end 
 of half an hour, the patient lying down, the pain has gone or is subsiding, 
 the strapping is efficient and may be left in place. Long before morning 
 the testicle will have become perfectly comfortable, and the patient may 
 go around at will through the day, wearing an ordinary suspensory band- 
 age or continuing his handkerchief-sling, without fear of relapse and without 
 feeling pain. If, on the contrary, half an hour after the straps have been 
 applied, the pain is on the increase, the straps must be removed or cut down 
 the front, or the pain will continue, will grow insufferable, and probably 
 prolong the whole attack of epididymitis many days by reason of a fresh 
 onset of inflammation. In any case, if the pain be intense after half an 
 hour, the straps have been improperly applied, and have done harm instead 
 of good. 
 
 The first strapping, if a good one, should last forty-eight hours. It 
 may be most conveniently removed by the patient in a hot bath. After 
 the straps become thoroughly soaked in the water, they come off readily, 
 and then a little soap and water does all that need be done toward remov- 
 ing the adherent plaster. 
 
 New straps should be applied at once as tightly as the first, or even 
 more tightly, to overcome the oedema which is sure to be found at the bot- 
 tom of the scrotum, replacing within the strapping whatever bulk has 
 been lost by the testicle. These second straps may remain on for three 
 days, when, usually, none further will be needed. 
 
 CHRONIC EPIDIDYMITIS. 
 
 In successive gonorrhoeas, or in connection with stricture or other 
 urethral inflammatory affection, partial epididymitis often comes on, es- 
 pecially in a testicle which has once been the seat of acute inflammation.
 
 COMPLICATIONS OF GONORRIICEA IN THE MALE. 289 
 
 In these attacks the symptoms are usually quite moderate. The hard 
 lump at the tail (usually), or in the head of the epididymis, sufficiently 
 discloses the nature of the disorder and the cause of the pain. 
 
 These cases are generally easy to manage. A few days' rest, even 
 without poulticing, often makes the pain so tolerable that a little warm 
 swathing in a suspensory bandage allows the patient to get about. 
 
 Mercurial ointments and iodine are of little value in these states. The 
 main reliance is to be placed upon curing the cause and getting the ure- 
 thra into good condition. Instrumentation within the urethra, and injec- 
 tions, are to be avoided until tenderness has left the testicle. As good a 
 local application as any in these cases is the oleate of morphia rubbed up 
 with fresh stramonium ointment, one part to two.- It makes a soft, oily 
 mass, which may be applied on lint inside of the thin rubber which the 
 suspensory bandage surrounds. 
 
 The treatment of the sterility following epididymitis has already been 
 considered. 
 
 The question of abscess following localized epididymitis, and of pseudo- 
 tubercular disease of the testicle, is out of place in a work of this character. 
 
 19
 
 CHAPTER IV. 
 STRICTURE OF LARGE CALIBRE. 
 
 Stricture of the Male Urethra. Spasmodic Stricture. Examples of this Form of Stric- 
 ture. Stricture of Large Calibre : Symptoms, Diagnosis, Treatment. Resiliary 
 Strictures of Large Calibre. Internal Urethrotomy in the Pendulous Urethra, the 
 Limit of the Cut, the Result, and the After-treatment. 
 
 A VERY common result of gonorrhoea in the male is the formation of 
 stricture of the urethra. Stricture may be due to many other causes, 
 such as trumatic violence of any sort, mechanical or chemical, especially 
 any kind of bruising of the canal transversely; or to congenital imperfec- 
 tion of the urethra, particularly common at the meatus; or to spasmodic 
 action of the muscles of the deep urethra, sometimes reflex; yet all these 
 causes combined only yield a small proportion of the cases of real stricture 
 stricture producing symptoms as encountered in ordinary practice. Many 
 cases of gonorrhoea get well and leave the urethra sound, even although 
 the urethral inflammation has been intense and prolonged. On the other 
 hand, many cases of mild urethritis, which are not due to gonorrhoeal poi- 
 soning and have never run high in the suppurative stage, prolong them- 
 selves indefinitely in the shape of a gleet, and exploration of the urethra 
 demonstrates that there is a tight place in the canal yielding a tinge of 
 blood to the exploring instrument, manifestly excoriated upon its surface, 
 and clearly the lesion whence proceeds the oozing which constitutes the 
 gleet. 
 
 The question of spasmodic stricture is so interwoven with that of 
 organic stricture, that neither of them can well be considered apart from 
 the other; and although, accurately speaking, stricture of the urethra 
 is no more a venereal disease than uraemia is scarlet fever, yet it is so 
 closely related in many ways to gonorrhoea that its description naturally 
 falls into place here, and the various forms of stricture call equally for a 
 certain amount of detail. 
 
 I shall describe the three forms of stricture inversely as to their im- 
 portance, taking up first the spasmodic stricture, next the stricture of 
 large calibre, and, finally, the stricture of small calibre. 
 
 SPASMODIC STRICTURE OF THE URETHRA. 
 
 The existence of spasmodic stricture of the urethra has been doubted, 
 but it plainly is a reality, as may be easily demonstrated. It is indeed 
 the least venereal of all strictures, and may depend upon a multitude of 
 causes, general as well as local, moral as well as physical. Moreover, it 
 may complicate either of the other forms of stricture and give to them an 
 importance which they would not otherwise possess. In this way spas- 
 modic stricture earns for itself a right to respectful consideration; its ex- 
 istence cannot be ignored.
 
 STRICTURE OF LARGE CALIBRE. 291 
 
 Spasmodic stricture is generally capable of very easy demonstration. 
 A personal case will well illustrate this. 
 
 A young man, under twenty years of age, and perfectly healthy so 
 far as urethral or antecedent venereal disease of any kind was concerned, 
 finding some pediculi upon his pubis, was kindly supplied with a lotion by 
 an obliging friend, with which to kill them. This he applied faithfully in 
 the morning. The lotion, which proved to be simple tincture of staves- 
 acre, proved quite irritating, and presently occasioned much tingling and 
 burning of the skin where it had been applied, and brought on a desire 
 to urinate; but the patient to his surprise found that he could not void a 
 drop of urine, the bladder being only slightly distended. 
 
 He continued up and about all day, making repeated but absolutely 
 futile efforts to empty his bladder, and finally was brought to my office 
 for relief late in the afternoon. I at once passed a full-sized olivary 
 soft catheter into the bladder, encountering no obstacle, and a clear, 
 bright stream of urine gushed out in torrents through the instrument to 
 the amount of more than a pint. 
 
 The patient passed water voluntarily in the evening before retiring, 
 and has had no further trouble. 
 
 This case was certainly one of spasmodic stricture of the muscles of 
 the deep urethra, due to irritation reflected from the skin. There was no 
 present or past malady of the bladder or urethra, and has been none 
 since. Efforts were made in vain by the patient to empty his bladder 
 during all stages of fulness. There was not a particle of atony in the 
 case, for, as soon as the urine found a hole from which to escape, it 
 gushed forth under the powerful contraction of the detrusor, and did hot 
 dribble away sluggishly from the end of the catheter, as it is wont to do 
 in cases of atony, unless aided by the efforts of the abdominal muscles. 
 The stream in this case continued with equal force and vigor up to the 
 last few drops. Here then is a case of pure reflex spasm of the urethra. 
 
 In the autumn of 1877 an old man applied to me for relief on account 
 of frequent, painful, and imperfect urination in a small stream, his symp- 
 toms being particularly troublesome at night. He squeezed out a few 
 drops of urine in my presence, in a small stream and with great pain. 
 The urine was clear and sparkling, of normal reaction. 
 
 The patient was very thin, and percussion and palpation over his abdo- 
 men quickly made it apparent that the bladder was fully distended. The 
 natural inference in the case of this old man was that he was suffering 
 from prostatic overgrowth and atony. I told him that I should endeavor 
 to introduce a catheter, and should draw off a portion only of the con- 
 tents of his bladder. I introduced a soft rubber English catheter of full 
 size. It halted sensibly for a moment at the membranous urethra, and 
 then slipped rapidly into the bladder; but before its eye had reached the 
 cavity of the bladder, urine began to pour tumultuously out, both through 
 the catheter and along the outside of it. So violently did the urine flov,-, 
 that it was with difficulty the catheter could be retained in the bladder 
 to allow part of the flow to escape through it, and even this was finally 
 abandoned, and the rushing stream of urine swept the catheter out of the 
 urethra, and followed in a continuous stream of full size and force until 
 every drop had escaped from the bladder. Of this I satisfied myself by 
 reintroducing the instrument. The urine was of the best quality, per- 
 fectly bright and clear. Surely there was no valve here, no prostatio 
 lobule, no atony nothing but spasm of the deep urethral muscles. 
 
 The old man's urethra was perfectly healthy as to any present or past
 
 292 THE VENEREAL DISEASES. 
 
 inflammatory disturbance, and in seeking a cause for the retention, I 
 found that his rectum was in trouble. He stated that he had had haemor- 
 rhoids for several years, but he begged me not to examine them, saying 
 that he was using an ointment as a suppository which gave him relief, 
 and that he did not desire to do anything else, and would not be exam- 
 ined. I could not overcome his scruples, and had to wait for develop- 
 ments. 
 
 Meantime the old man got a soft catheter, and used it when he had 
 retention. It was only necessary to start the urine by introducing the 
 catheter up to the neck of the bladder, after which, on each occasion, the 
 urethra performed its function perfectly. For many days at a time he 
 would pass his water as well as any one, and then suddenly, without 
 obvious cause, retention would again overtake him, and perhaps persist 
 for a day or more or pass off, if the catheter was promptly used. 
 
 I soon got access to this patient's rectum, and found it to be the seat 
 of epithelial cancer just beginning to ulcerate. The prostate was not 
 enlarged. Here then was an explanation of the spasmodic stricture. 
 
 The case was not a fit one for operation upon the rectum. I watched 
 the patient for about a year, when he died from progress of his cancer, 
 which involved the sphincter and the neighborhood of the anus, but never 
 touched the bladder or urethra. Urinary symptoms continued in an in- 
 termittent way until the end. 
 
 In 1868, Dr. Van Buren snipped off one small tab of skin the result 
 of an external hasmorrhoid not at the time at all inflamed, but simply 
 annoying by its presence. The patient was an old gentleman in the best 
 of surroundings. He took no ether for the little operation, and the 
 sphincter was not stretched. His urinary organs were in perfect condi- 
 tion. For five days after this trifling operation he could not urinate, 
 and a soft catheter had to be introduced three or four times a day. After 
 this he got well, and did not use a catheter again until his death, which 
 occurred some years later. 
 
 In 1876, I stretched the sphincter, under ether, and tied off some 
 internal haemorrhoids in a man under middle age. From the moment of 
 the operation until the eleventh day, not one drop of urine could this 
 patient void spontaneously. A catheter was in constant demand. His 
 urethra was sound, and he became and continued well, after the soreness 
 left his rectum. 
 
 Dr. Emmet has seen a case where necrosis of the coccyx produced 
 spasmodic stricture of the urethra; and Verneuil a similar condition, due 
 to abscess in one of the seminal vesicles. I have two personal cases 
 where stricture of this sort was due to reflected irritation from a chroni- 
 cally inflamed seminal vesicle, and notes of a number of other cases due 
 to the most varied causes. 
 
 Tuffnell's case is well known, where a patient had a stricture deemed 
 impassable (doubtless because fine bougies only were used in attempts 
 to pass it). This patient suffered so much, that a day was appointed 
 upon which perineal section should be performed; but, before the date ar- 
 rived, he passed some links of tape-worm, unsuspected before, and, as a 
 part of the preparation for his operation, a medicine was given to dis- 
 lodge the worm. This proved successful. The worm was passed, and 
 with it the impassable stricture disappeared, and the patient urinated 
 freely at will. 
 
 It has occurred several times, in my experience, for a surgeon to 
 make a diagnosis of tight stricture in a given case, and to find his filiform
 
 STKICTUEE OF LARGE CALIBRE. 293 
 
 bougie which he has passed with difficulty grasped, as he attempted to 
 withdraw it, when there has been nothing more in the case than spasmo- 
 dic stricture of the deep urethra, as proved by the fact that a well- 
 warmed, large, blunt steel sound, held gently against the face of the 
 obstacle, has, after a short delay, slipped, by its own weight, smoothly 
 into the bladder. 
 
 The medical journals, and surgical books and theses of the past as 
 well as the present day, contain plentiful examples of spasmodic stric- 
 ture. Dartigues, in his Thesis (Paris, 1873), quoting Hippocrates, Mal- 
 gaigne, Cooper, and others, as authority, refers to many cases of reten- 
 tion from spasm of the urethra following various surgical injuries, such 
 as luxation of the hip forward, amputation of the thigh (five cases), ab- 
 lation of the breast, breaking up of anchylosis of the knee. The influ- 
 ence of a tight meatus upon the deep urethra, of phymosis, of irritations 
 in the kidney, and of other more distant lesions, have claimed attention 
 from time to time. Reflex phenomena, as affecting the urinary organs 
 and caused by them, have received a certain share of attention. (Civiale 
 and others have called it sympathy). Prof. Sands has collected, from the 
 older writers before the time of Civiale, a number of interesting in- 
 stances of lesions involving the urinary organs as cause of distant trou- 
 bles (Home's case of sciatica, due to stricture, being perhaps the most 
 striking), and a few of urinary troubles due to perinea! irritation, one of 
 these being strangury induced by teething, in a boy, and relieved by 
 cutting the gums. (Hospital Gazette, May 3, 1879, p. 132.) Verneuil, 
 in France, in 1866, before the Anatomical Society of Paris, pushed the 
 spasmodic theory so far as to claim that most strictures were to be found 
 in the forepart of the urethra, and not deeper, as had been taught many 
 of the supposed deep organic strictures being only spasmodic strictures 
 due to irritation in the forepart of the canal. Folet l followed his master 
 in establishing the new doctrine. 
 
 Otis, 2 in this country, has generalized, from his own experience, laws 
 still more positive than Verneuil, claiming that organic stricture is very 
 common forward, and quite infrequently occurs in the deep urethra, 
 spasm being at the bottom of most of the so-called tight organic stric- 
 tures in this region. Dr. Otis's first publication on the subject was in 
 1873. 
 
 These gentlemen have, however, as yet failed to convince a majority 
 of the sober-minded men in the profession, either by their cases or their 
 arguments, that spasmodic stricture of the deep urethra is so common, or 
 organic stricture so rare. As stated by Sebeaux, 3 Verneuil's law is the 
 following: all spasmodic strictures due to irritation of the urethra are 
 situated in the membranous portion of the canal; if due to irritation 
 above the vesical neck, on the other hand, the stricture lies in the poste- 
 rior vesical sphincter, which is composed of unstriped muscular fibre. 
 Robin and Cadiat state 4 it as their belief that the spasm lies always in 
 the unstriped, never in striped muscular fibre; but they do not appear to 
 me at all to demonstrate their position. The fact that females have re- 
 
 1 fitudes sur les retrecissements peniens de 1'urethre. Archiv. gen., 1867, Vol. I., 
 p. 424. 
 
 2 Radical Cure of Stricture of the Male Urethra. New York, 1878. 
 
 3 Contracture du col de la vessie. Paris, 1876, p. 32. 
 
 4 Sur la structure intime de la muqueuse et des glandes urotbrales de rhomme et 
 de la femme. Journ. d'aiiatomie etde la physiologic, 1874, p. 531.
 
 294 THE VENEREAL DISEASES. 
 
 tention of urine, apparently due to spasmodic stricture, seems to justify 
 the assertions of Robin and Cadiat. 
 
 Spasmodic stricture certainly exists. There is more of it than some 
 of the best authorities allow, but far less of it than a few enthusiastic 
 writers would lead one to suppose. The last word has not been spoken 
 upon the subject, and probably will not be until the unfortunate personal 
 feeling, which is at present obvious in all discussions on the subject, shall 
 have passed away. 
 
 Who is unfamiliar with the effect of shame, haste, anxiety, anger, ner- 
 vous excitability, and other emotions, in making it absolutely impossible 
 for a perfectly healthy patient, sometimes, to make water at all for a con- 
 siderable time ? Such retention is due to a spasm of the urethra. The so- 
 called inflammatory stricture is usually only a secondary spasm, induced 
 by the irritated state of the urethra; for the swelling of the urethra alone 
 could hardly successfully oppose the detrusor. The grasping of a sound 
 by an organic stricture, through which the instrument has been passed, is 
 due to spasm. The lack of co-ordination between the detruscr and the cut- 
 off muscles, often leading to retention in cases of locomotor ataxia and 
 partial paraplegia (especially syphilitic), acts apparently by causing spasm 
 of the deep urethral muscles. The different conditions in which deep or- 
 ganic stricture habitually finds itself sometimes allowing a reasonably 
 free stream of urine to pass, again so nearly closed up that only a few 
 drops can be painfully voided with great effort this difference is undoubt- 
 edly due more to spasm than it is to any purely inflammatory change in 
 the stricture itself. That form of partial or complete retention sometimes 
 seen in connection with a very slight stricture of large calibre, either in 
 the deep or in the pendulous urethra, is certainly due to spasm, as proved 
 by the ease with which many of these cases allow the passage of a large- 
 sized steel instrument without the employment of any force. Of this 
 form of stricture 1 have seen several instances. Some of the numerous 
 cases reported by Dr. Otis are excellent examples of spasmodic stricture. 
 In some of the cases his diagnosis has been questioned, but most of them 
 are striking examples of the malady in question. 
 
 Treatment. The surgeon's tact and ability are often largely taxed 
 to discover the cause of deep urethral irritability and spasm. To be suc- 
 cessful in his treatment he must find the cause; when that is removed the 
 stricture will get well. The cause may lie in a tight meatus, or in an ir- 
 ritable anterior or posterior stricture of large or small calibre; but the 
 spasm is not, by any means, always- due to such a cause. I have knowl- 
 edge of a number of cases in which the urethra has been extensively cut 
 in its forward parts, in accordance with the views of the most modern 
 school in urethral pathology and therapeutics, without the slightest ad- 
 vantage to the patient, although the moral effect of a surgical operation 
 is sometimes sufficient to cause a patient to declare himself better during 
 a long enough time for his case to get into print. 
 
 Some deaths have followed the use of the dilating urethrotome. I lost 
 one patient in March, 1873, and showed the diseased kidneys to the Path- 
 ological Society during the same month. In this case a deep stricture 
 was divided, and the same result would have followed the use of any other 
 instrument, the kidneys being at fault. Dr. Sands, in one of his contro- 
 versial papers, reports three fatal cases of urethrotomj', in which the di- 
 lating urethrotome was used. Dr. Otis, in his reply in the Hospital 
 Gazette of June 28, 1879, endeavors to relieve the instrument from any 
 blame in these cases. But the citation of cases is of no value in this
 
 STRICTURE OF LARGE CALIBRE. 295 
 
 connection. No one can doubt the mechanical excellence of Dr. Otis's 
 instrument; nor can one doubt that, where any cutting operation will kill, 
 death will follow the cut, no matter by what instrument the cut is made. 
 The reason why the operations made with the dilating urethrotome show 
 such a light mortality is, that these operations are performed almost ex- 
 clusively upon the pendulous urethra, and urethrotomy in this region is a 
 most trivial matter when compared with the same operation performed 
 upon the deeper portions of the canal. Death very rarely follows ure- 
 throtomy in the pendulous urethra. The nearer the meatus, the less the 
 risk; but this fact does not make promiscuous and unnecessary cutting 
 any the more surgical. 
 
 The pendulous urethra should be respected when possible, and left as 
 nature made it. That it may generally be cut with little or no risk to life 
 by no means justifies an operation not imperatively demanded by the 
 symptoms in a given case. 
 
 I have tested the new method quite extensively, and find myself in- 
 clined, by experience, to be more and more conservative, and to cut less 
 and less within the urethra anywhere beyond the first three-quarters of 
 an inch from the meatus except in desperate cases believing that such 
 cutting, on the whole, does more harm than good in a majority of instan- 
 ces. This conclusion is a growing one, and has been deliberately reached. 
 It is based not only upon my own cases which I have cut, but also upon 
 a considerable number of patients whom I have cared for on account of the 
 same malady, for which they had been unsuccessfully cut, in some cases 
 a number of times, by the foremost advocates of our day for extensive 
 anterior internal urethrotomy. I do not by any means condemn this oper- 
 ation, which I think an excellent one and indispensable to the cure of some 
 cases; but what I do feel called upon to condemn, is the extensive in- 
 discriminate cutting of the anterior urethra, now commonly indulged 
 in, especially by young surgeons, for any and all possible morbid condi- 
 tions of the urethra, simply because the canal is smaller in some parts 
 than it is in others, as the Almighty evidently intended that it should be. 
 This will be again referred to at p. 296. 
 
 The treatment of spasmodic stricture, then, is to find and remove the 
 cause. If that cause seems to be an organic stricture of the urethra any- 
 where situated, that stricture must be appropriately dealt with. 
 
 The treatment of organic stricture will be discussed after a descrip- 
 tion of the stricture itself. 
 
 STEICTUEE OF LABGE CALIBRE. 
 
 Stricture of large calibre may be encountered anywhere along the 
 urethra from the meatus up to the apex of the prostate. Stricture of the 
 prostate does not exist. One or two instances of it only have been en- 
 countered, or at least recorded. Obstruction, both to the passage of urine 
 and to the introduction of instruments, undoubtedly occurs in the pros- 
 tate; but such obstruction is due to hypertrophic, congestive, or degen- 
 erative causes, involving the prostatic body, and not to any stricture situ- 
 ated in the sinus itself. 
 
 The distinction between a stricture of large calibre and one of small 
 calibre is, of course, an arbitrary one. In a general way it may be stated 
 that any stricture, which may be safely treated by dilatation with solid 
 steel conical instruments, is a stricture of large calibre, while one which
 
 296 THE VENEREAL DISEASES. 
 
 may not be so treated must be ranked of small calibre. Such a rule 
 places the boundary between large and small calibration at 10 of the 
 American scale, an instrument five millimetres in diameter (15 French). 
 Below this a conical steel instrument should not, as a rule, be employed 
 in the urethra for dilating purposes. 
 
 Stricture of large calibre is frequently congenital at the meatus that 
 is, the meatus is not developed to the extent to which nature intended 
 that it should be. The meatus is often found sealed up to the size of a 
 pin-head, livid in color, conical in shape, pouting, manifestly unnatural. 
 From this upward it is found of all sizes, sometimes altogether dispro- 
 portionately large as compared with the rest of the canal. 
 
 Now, the meatus should be the smallest place in the urethra, just as the 
 nozzle of any hose-pipe is smaller than the tube itself; and this is neces- 
 sary for the vigorous delivery of a full, smooth stream. How then shall one 
 decide whether the meatus is too small or not ? Simply by ascertaining 
 whether there is any cul-de-sac, any pouch behind either angle of the meatus, 
 on the roof or on the floor of the canal. If a probe passed into the orifice 
 can make such a pouch, then the meatus is too small. This smallness is 
 generally a congenital deformity and not a pathological condition, and 
 its existence never calls for any interference on the part of the surgeon, 
 unless it be presumed to be the probable cause of symptoms, or unless it 
 interferes by its smallness of size with the proper treatment by instru- 
 ments of morbid conditions of the urethra more deeply seated, or of the 
 bladder. Interference with the meatus for any other cause than these is 
 meddlesome and unsurgical. 
 
 The same general line of argument applies to another portion of the ure- 
 thra the region lying, in round figures, at about two to three inches from 
 the meatus. Ninety-nine people out of a hundred have stricture of large 
 calibre in this region, if the fact that this portion of the canal is smaller 
 than some portion of the canal anterior to it be looked upon as constitut- 
 ing stricture, as many men of the present day seem prone to believe. 
 All the diagrammatic charts of the urethra which I have ever seen repre- 
 sent the canal as naturally narrowing down in this region to expand again 
 into a sinus before the final narrowing of the meatus. This condition 
 exists normally, and it is as irrational to alter it theoretically, and as 
 Quixotic to attempt to improve upon it practically, as it would be to try 
 to give every one a Roman nose because that type seems the most noble. 
 
 These contractions of the urethra at the meatus and lower down, as 
 they are ordinarily encountered, are not pathological. They vary much, 
 as a man's mouth, and nose, and ears vary in size from that of the same 
 organs in another. The contracted meatus is not due to a tight prepuce 
 in early life, or to lack of hygienic care. 1 have tested a number of 
 Israelites who have had no foreskin since the eighth day of life, and I 
 find these points of contraction as marked in them as in the Christian. 
 Time and again, in examining a patient for one thing or another, not 
 urinary in any sense (cases of chancre, hernia, skin disease, and for 
 morbid conditions of the testicle not inflammatory), I find a very small 
 meatus. I naturally ask for symptoms, but, finding none, I see no occa- 
 sion to interfere. In examining for stone or enlarged prostate, the sec- 
 ond point of narrowing, at two inches or more, may usually be detected; 
 but if it occasions no symptoms, since it certainly does not cause either 
 the stone or the enlarged prostate, there is no occasion to direct any 
 treatment against it. 
 
 There is no just measure of size for the urethra, so far as I am aware.
 
 STRICTURE OF LARGE CALIBRE. 297 
 
 The arbitrary decision that because the penis, in repose, measures three 
 inches in circumference, the circumference of the whole course of the 
 urethra must be thirty millimetres, has a foundation only in the theoreti- 
 cal accuracy of its enthusiastic originator. The circumference of a man's 
 penis in repose varies greatly after and before a prolonged sea-bath, for 
 instance, and under other circumstances, as I have verified by measure- 
 ment. The exhaustive paper of Prof. Sands, 1 read before the County 
 Medical Society, and ably seconded by the remarks of Prof. Weir," bring- 
 ing the literature of the subject up to date, and showing casts of the ure- 
 thra skilfully executed upon the bodies of four seemingly healthy people 
 of different ages, proved conclusively that there is no uniformity in size 
 to the urethra, and no regularity about it. The casts in Prof. Sands's pa- 
 per show numbers of constricted points which might be readily demon- 
 strated to be strictures by the urethrameter in a willing hand. 
 
 The demonstration of the existence of these bands along the urethra 
 is very easy during life. They may uniformly be found. The larger the 
 exploring instrument, the more bands does it discover. I have not yet 
 found a person upon whom I could not demonstrate points of uneven dil- 
 .atability along the urethra: whether such person were healthy or the sub- 
 ject of real stricture; whether he suffered from no symptoms or had a 
 gleet; whether his urethra had been cut internally or not; whether the 
 symptoms for which the urethra had been cut had yielded to the treat- 
 ment or not. I do not know that this experience is universal, but I think 
 it must be. I remember one poor fellow, whose urethra I cut again and 
 again when testing this method, urged on by the patient himself and for- 
 tified by the advice and consent of experienced men in consultation. He 
 did not get well, but his urethra finally reached a size which allowed a 27 
 American (42 French) conical steel sound to pass easily down the urethra 
 into the bladder; and immediately afterward, a No. 39 bulb passed up and 
 down the canal detected a number of inequalities and linear points where 
 the canal was smaller than at other points. One of these bands was sit- 
 uated internally, at a point corresponding to nearly the middle of the fre- 
 num externally (for the insertion of the frenum into the glans penis had 
 been utilized in order to enlarge the meatus), and the poor fellow put his 
 index finger into his urethra up to this point, and, asserting that he could 
 feel another stricture there, begged me to cut it. This I respectfully de- 
 clined to do, and the patient shortly disappeared from view, doubtless to 
 seek other advice. 
 
 Therefore I contend that all urethral canals, healthy or unhealthy, 
 will yield bands of irregular constriction to any one exploring with a large 
 enough instrument; and that, too, irrespective of the cure of any stricture 
 which may have been cut, or of the symptom (gleet usually) for which it 
 may have been cut. Consequently, the existence of these bands in the 
 anterior portions of the urethra does not constitute stricture, and stricture 
 may be cured while they still remain behind. 
 
 Finally, and most positive evidence of all, I have the anatomical proof 
 that these bands do not constitute stricture. Some years ago I had the 
 good fortune to be present at a post-mortem examination upon the body 
 of a patient who died at a certain short interval I think it was about two 
 weeks after perineal section for impermeable stricture, and after having 
 had a number of strictures in his pendulous urethra divided by Dr. Otis, 
 
 1 New York Medical Journal, March, 1876, p. 225. 
 
 2 Ibid., April, 1876, p. 377.
 
 298 THE VENEREAL DISEASES. 
 
 with his dilating urethrotome. Dr. George Peters had verified the pres- 
 ence of these numerous strictures before the operation; Dr. McBurney 
 made the autopsy. I did not learn clearly of what the patient died, but 
 I believe death was ascribed to the kidney. Dr. Bumstead and myself, in 
 the evening, went to the house of Dr. Otis to examine the patient's ure- 
 thra. The line of the cut could be seen, but the mucous membrane along 
 the whole course of the cut on either side seemed absolutely sound to the 
 eye and to the finger. No hardness, 110 bands could be detected. Dr. 
 Otis reserved the specimen for careful examination by the microscope. 
 The result of that examination I have not seen reported. 
 
 In one of the cases of death alluded to by Dr. Sands, the floor of the 
 urethra at the autopsy was found divided anteriorly to the extent of three 
 and a half inches; the mucous membrane was not thickened, and " showed 
 no appearance of disease to the naked .eye." "A tight organic stricture, 
 undivided, was noticeable at the bulbo-membranous junction." 1 In this 
 case death occurred on the sixteenth day, from uraemia. 
 
 At this point it seems desirable to inquire what it is, then, that consti- 
 tutes stricture of large calibre in the anterior urethra, and when it is ne- 
 cessary for the surgeon to interfere. In answer it may be said: stricture 
 of large calibre of the anterior urethra does exist when an exploring in- 
 strument passed gently through a physiologically contracted area draws 
 blood (on account of an erosion or a granular condition of the membrane 
 at this point), or when the physiological condition is carried to an excess, 
 as, for instance, when the ineatus is only as large as a knitting-needle. 
 How small the second or other contracted points of the urethra must be 
 to constitute stricture, I do not know; and I consider it as unimportant as 
 I do the size of the rectum at one of its natural points of constriction the 
 sphincter tertius, the point of reflection of the peritoneum. Stricture 
 may also certainly be said to exist when it may be felt as a fibrous band 
 from the outside, after a full dilating solid instrument has been passed 
 through it. None of the physiological bands can be so felt, while the 
 inodular deposits can always be felt. 
 
 Finally comes the really practical question : When should a surgeon in- 
 terfere with instruments in the treatment of stricture of large calibre of 
 the anterior urethra? The proper answer I believe to be, never until the 
 occurrence of symptoms calls for interference. This rule, like all others, 
 has its exceptions. I believe, however, that it holds absolutely for all 
 congenital strictures of the meatus, unless they are very tight, and for 
 some strictures in this region the result of cicatrices. It holds also for 
 that (we may call it) physiological band of constriction often found just 
 within the meatus, at about one-fourth of an inch or thereabouts, and cer- 
 tainly for the deeper bands in the pendulous urethra. It is exceedingly 
 rare for any stricture of large calibre of the anterior urethra to close so 
 tightly as to give rise to serious urinary complications (leaving spasmodic 
 stricture from reflex action out of the question), except the variety known 
 as inodular stricture, and stricture resulting from a cicatrix of the meatus. 
 Both of these forms of stricture, then, may be appropriately attacked before 
 they have given rise to any symptoms stricture of the meatus, and inod- 
 ular stricture of the pendulous urethra such a stricture as may be felt 
 like a ferule, or a lumpy band around a solid instrument which has been 
 introduced through it. 
 
 Symptoms of stricture of large calibre. These strictures may 
 
 1 L. c., p. 135.
 
 STRICTURE OF LARGE CALIBRE. 299 
 
 give rise to spasmodic and irritable troubles in the deep urethra, symptoms 
 of cystitis, sciatica, and of the most varied nervous functional troubles in 
 different parts of the body. When they do so act, however, they are 
 themselves generally more or less sensitive, sometimes inflamed and gran- 
 ulating upon their surface. Sometimes, on the other hand, especially at 
 the meatus, such strictures are neither inflamed nor sensitive, and it often 
 becomes a very nice question to decide whether they have anything to do 
 with troubles deeper in the canal or not. 
 
 The vast majority of these strictures, according to my experience, pro- 
 duce no symptoms whatsoever, excepting a slight gleet, and very many 
 of them not even that. Before deciding that a given tight spot in the 
 urethra is the cause of other trouble deeper in the canal, it is wise to elim- 
 inate all other sources of such trouble, and not to jump at the conclusion 
 that because there are bands in the urethra, and spasmodic or inflamma- 
 tory trouble farther down, the latter necessarily depends upon the former, 
 and will be relieved by a cutting operation. Such a doctrine must cer- 
 tainly sooner or later lead a young man to the border-line of quackery, if 
 not into its domain. 
 
 In cases of grave doubt the surgeon is certainly justified in operating 
 upon strictures with the knife, and if no good comes of it he cannot be 
 blamed; but he should only decide to act after due deliberation and a 
 careful study of his case. The meatus and first inch of the canal may be 
 cut with far more impunity, and to a greater extent, if necessary, than 
 any other portion of the canal. 
 
 The most common symptom of strictures of large calibre in the pendu- 
 lous, or in the deep urethra, is a gleet, more or less purulent. 
 
 Diagnosis. When a stricture of large calibre is important enough 
 to yield any symptom besides the possible (but improbable) spasmodic 
 and reflex irritative phenomena referred to and the gleet, there are cer- 
 tain physical means of diagnosis which yield quite accurate results. One 
 quite constant symptom, really analogous to gleet, is the occurrence of 
 little thread-like bodies, snaky rolls of white material which float around 
 in the freshly voided urine, gradually sinking to the bottom of 
 the vessel. These are clusters of pus-corpuscles which have 
 gathered upon the excoriated and granular surface of the ure- 
 thra at and behind the stricture, like soft scabs, and are washed 
 off by the stream of urine in its passage. They can be easily 
 caught in a pipette and examined with the microscope. These 
 shreds of pus-cells are not pathognomonic, since they occasionally 
 come from the prostatic urethra; but they seldom do so, and gen- 
 erally indicate stricture of the urethra. 
 
 The clinical diagnosis of stricture of large calibre is easy and 
 satisfactory. A bulbous bougie (Fig. 30), preferably of metal, 
 as large as the meatus will take, may be warmed and anointed 
 with vaseline, and gently passed through the urethra. When it 
 comes to a tight spot the surgeon can feel it as well as the pa- 
 tient. If this spot is the seat of the gleety discharge, the bulb 
 of the instrument is very apt to be faintly tinged with blood at its tip upon 
 withdrawal. Points of stricture are often sensitive; their length may be 
 measured by the aid of this bulbous instrument and their number ascer- 
 tained, if more than one exist. This exploration refers only to the pen- 
 dulous urethra. 
 
 If, on attempting this exploration, congenital or pathological narrow- 
 ing of the orifice of the urethra be found to exist, the canal ma}' still be
 
 300 
 
 THE VENEREAL DISEASES. 
 
 explored without cutting the meatus, by the use of the very ingenious ex% 
 panding urethrameter (Fig. 31) devised by Dr. Otis. This instrument A 
 is introduced closed B, capped with a piece of thin rubber C, down to the 
 sinus of the bulb. It is there to be expanded until the patient feels a 
 slight distention, and then to be slowly withdrawn toward the meatus. 
 Upon encountering resistance the handle is turned so as to make the size 
 of the bulb smaller, all changes in the bulb being marked upon an index- 
 plate at the handle. The shaft of the instrument is marked 
 in inches, and by its aid all constrictions in the canal may be 
 accurately located, measured, and calibrated. 
 
 In short, exploration by this instrument leaves nothing to 
 desire, excepting a point of departure. Here, unfortunately, 
 it fails, for it has to assume either that the size of some por- 
 tion of the canal is the natural size of the whole course of the 
 urethra (which is manifestly inaccurate, as has been shown), 
 or the surgeon has to assume some arbitary dimension as 
 being the proper size of the urethral canal, and in this he is 
 as apt to be wrong as to be right, the danger being that he 
 will overestimate the size of the canal, because he starts in 
 one of its widest natural pouches. 
 
 Moreover, with this instrument, damage is apt to be in- 
 flicted upon a sensitive urethra, which may and often does 
 lead (as I have witnessed) to an aggravation of all the symp- 
 toms for which the exploration was made, and to the lighting 
 up of new ones (cystitis, epididymitis). This instrument dose 
 excellent service at times, mainly in the way of accurately 
 locating strictures in the pendulous urethra, which the sur- 
 geon has decided should be cut. 
 
 When, therefore, the meatus is small and the urethra 
 has to be explored, the stricture of the meatus, and any 
 tight spot within the first three-quarters of an inch from the 
 meatus, may be cut at once as a part of the examination. If 
 the meatus alone is involved, it may be cut down to the 
 bottom of any pouch lying behind either of its angles, and 
 fully two sizes (American scale) larger, for in healing it will 
 contract somewhat, and it should be left so that when well 
 it may be at least physiologically large. Any band smaller 
 than the new cut meatus and lying near it should also be cut 
 at the same sitting, as part of the examination. 
 
 This course is advised for several reasons. First, the ure- 
 thra cannot be properly explored from before backward with 
 a bulbous bougie, unless the orifice of the urethra will admit 
 the passage of a fair-sized bulb. 
 
 Secondly, no organic stricture deeper-seated can be treated 
 with sufficiently large instruments unless the meatus is pre- 
 pared for their reception. 
 
 Thirdly, no treatment will cure a stricture at or near the 
 meatus, except the knife, so far as I know. 
 
 Fourthly, the operation itself is trivial in importance, pains but little, 
 never calls for the use of an anesthetic, and never, in my experience, when 
 performed upon an urethra which would tolerate any interference what- 
 ever or was fit for any examination, has given rise to any complication 
 or subsequent discomfort. When practised alone I never have seen it 
 cause urethral chill, or irritation of the canal, or epididymitis, or cystitis. 
 
 FIQ. 31.
 
 STRICTUKE OF LAKGE CALIBKE. 301 
 
 The simultaneous use of the sound upon the deep urethra, however, may 
 cause any of these complications. 
 
 The meatus then should be cut a little larger than full size, and the 
 bulb, then introduced as through a natural meatus, will detect strictures 
 in the pendulous uretha, if there be any. 
 
 Stricture of large calibre of the deep urethra may be sought for with a 
 blunt (not a conical), well-warmed steel sound of a size as large as the an- 
 terior urethra will admit. If there be spasmodic stricture of the deep ure- 
 thra, such an instrument, in my experience, will always go in if properly 
 handled. It is written on good authority that this will not always occur, 
 and I must therefore believe it ; but personally, after considerable experience 
 I can say that I have never met a case which I believed to be spasmodic 
 stricture in which I could not pass a blunt sound in the way I shall de- 
 scribe, and certainly I have never cut a case of spasmodic stricture by the 
 perineal section; for, in all my cases of this operation some done with and 
 some without a guide I have invariably been able to see and to feel the mor- 
 bid tissue constituting the stricture in the bttom of the perineal wound. 
 
 I believe also that a spasmodic stricture of the urethra must necessarily 
 yield under ether and allow the passage of a full-sized blunt sound, not- 
 withstanding a recent case reported to the contrary by Dr. Otis. 
 
 The blunt sound, well warmed and oiled, should be gently carried down 
 the urethra and its beak presented accurately at the hole in the triangu- 
 lar ligament. Here it should be held under even pressure rather firm, 
 but not violent a perfectly uniform pressure and with a very steady hand, 
 for several minutes, perhaps five, or possibly more. The patient, mean- 
 time, should be entertained and diverted, pleasantly if possible the scro- 
 tum being held well up by the unemployed hand, which at the same time 
 steadies the beak and the curve of the instrument through the perineum. 
 If under such a manoeuvre the sound does not presently slip along and 
 glide smoothly and rather swiftly into the bladder, it is, I believe, always 
 either because the stricture is not spasmodic, or because the beak of the 
 instrument has not been properly brought to bear upon the cramped muscles. 
 
 Treatment. Stricture far forward in the urethra must be cut to be 
 cured. This is most conveniently done with a straight, blunt bistoury. 
 The prepuce should be retracted, the previously dried head of the penis 
 seized between the thumb and index finger of the left hand, and the blade 
 of the knife, well oiled, introduced to the proper depth in the urethra. It 
 is generally best often Accessary on account of the pocket to cut the 
 meatus along the floor of the urethra; but in some peculiar shapes of the 
 glans penis it may be better to cut the roof of the urethra. 
 
 When all is ready the surgeon squeezes the glans penis tightly with 
 the thumb and finger which hold it, since this diminishes the patient's 
 perception of the pain of the cut, and at the same moment slowly and 
 steadily draws the well-oiled sharp blade along the floor of the urethra, 
 appreciating with his surgical sense of touch the resistance offered to the 
 knife by the encircling band of stricture. When this yields and is thor- 
 oughly cut through, he can appreciate it at once by a cessation of the 
 feeling of resistance which the band has given, and he has cut enough. If 
 it is only a pouched meatus which the surgeon has to transform into a slit, 
 he regulates his incision accordingly. Civiale's or any other meatotome 
 may be used, if the surgeon prefers. Dr. Otis advises the operator to 
 place the index finger of his left hand along the integument beneath the 
 urethra, so that the stricture band may be felt between the finger and the 
 knife. In this position he cuts directly upon the finger until he can feel
 
 302 
 
 THE VENEREAL DISEASES. 
 
 the point of the knife against the soft tissues and appreciate the absence 
 of the band between the finger and the knife. This is an excellent 
 method better in many cases than any other. 
 
 The cut meatus sometimes bleeds profusely, sometimes hardly at all. 
 The expedients for stopping blood are: pressure for a time, followed by 
 collodion applied in several coats to the well-dried meatus while it is held 
 together under pressure, to keep the blood from oozing while the collodion 
 is drying on; or a small roll of absorbent cotton soaked in pure subsul- 
 
 phate of iron, which may be introduced 
 into the bottom of the cut with a probe. 
 There is never any danger from possible 
 excess of bleeding, for the patient can al- 
 ways stop the haemorrhage until the sur- 
 geon arrives, by digital pressure, and the 
 surgeon can always finally arrest it by in- 
 jecting the urethra with the liquid subsul- 
 phate of iron diluted about one-half. It 
 is better not to put subsulphate of iron into 
 the urethra,, if it can be avoided, since this 
 substance is apt to leave the walls of the 
 canal inflamed, hardened, and ready to 
 suppurate. Much time in the treatment 
 may be lost on account of the use of this 
 haemostatic. 
 
 When there is little or no bleeding, 
 some cotton or lint, so arranged as to be 
 retained beneath the prepuce, is all that is 
 required. 
 
 A cut orifice will heal up immediately 
 if left to itself. My usual plan to prevent 
 this is to furnish the patient with a hair- 
 pin, with the curved portion rebent and 
 the angle much increased in size, so as to 
 be large enough when oiled, and passed 
 down the urethra, to lie with one leg of 
 the pin against the roof of the urethra, the 
 other leg at the bottom of the whole length 
 of the wound, while the two points are 
 oxitside. I tell the patient to pass this on 
 the night after being cut, and on the fol- 
 lowing two nights ; then to skip a night 
 
 for two passages ; then to skip two nights for three passages of the pin. 
 By the end of this time (a full fortnight) the meatus has often healed 
 entirely, or so nearly that it may be left to itself, and, if thoroughly cut 
 and healed open, it never recontracts. 
 
 The treatment most appropriate for all other organic strictures of 
 large as well as small calibre, is by dilatation at first. Should this fail, 
 other means are at hand. Steel instruments, nickelled, conical in shape, 
 are most serviceable, arid do the most accurate as well as the most effec- 
 tive work in dilating the canal, either pendulous or deep, provided the 
 size of the instrument is as large as No. 10 American (15 French). Should 
 the stricture be smaller than this size, soft instruments are best to com- 
 mence with. 
 
 The conical instrument (Fig. 32) tapers for two and three-quarter 
 
 Fio. 32.
 
 STRICTURE OF LARGE CALIBRE. 303 
 
 inches, and should be made upon what is called the short curve, with an 
 extra shortness of the curve at the last half-inch near the beak, since this 
 extra curve greatly facilitates introduction, especially at the hole in the 
 triangular ligament, by keeping the point of the instrument against the 
 roof of the canal. Such an instrument, as large as the stricture will admit, 
 well oiled and warmed, should be passed with great gentleness well into 
 the bladder. The power of the instrument is great, being, as it is, a com- 
 pound of wedge and lever, and the surgeon should exercise considerable 
 self-control, so as not to abuse that power. The passage of one such in- 
 strument as this is equivalent to the passage of seven sounds of the old 
 blunt pattern, since the conicity in the larger instruments extends through 
 seven sizes. 
 
 The instrument is to be introduced, and then, very gently, immediately 
 withdrawn. At the first sitting only one sound should be passed a sound 
 of moderate size. 
 
 The time most appropriate for a reintroduction of the steel sound in 
 a case of stricture of large calibre must be determined by the effect pro- 
 duced by the instrument upon its trial trip. The immediate effect is 
 often only an increase in the amount of pain experienced during urina- 
 tion. After a day or two the discharge from the urethra often visibly in- 
 creases; but this subsides spontaneously, or by the aid of a very mild in- 
 jection, and at the end of four or five days the symptoms for which the 
 sound was introduced have reached the same grade as that at which they 
 existed at the moment of the first introduction of the sound. . Twenty- 
 four hours should now be allowed to pass, or even forty-eight, and 
 then a sound of one or two sizes larger may be gently passed into the 
 urethra. 
 
 The result of this second instrumentation is that the symptoms are less 
 aggravated by it than they were by the first, improvement arrives a little 
 sooner, is more marked, and remains longer. In this way, increasing the 
 sizes, and using on each occasion a conical sound as large as will pass, the 
 symptoms generally yield entirely, and the patient is well. The most 
 effective treatment by large instruments is that which leaves an interval 
 of one week between the passages of the sound. 
 
 After the symptoms have disappeared the treatment should be discon- 
 tinued gradually. In some mild cases of stricture, not resilient and not 
 traumatic, treatment may be suspended entirely after a few weeks, and 
 the patient is and remains well for the rest of his life, excepting that he 
 is capable of getting a new gleet from a lighter cause than if he had never 
 had stricture. If he does not expose himself, however, to the causes of 
 urethritis, he may marry and remain well for the rest of his days, in most 
 instances, without ever showing any symptoms of lack of health in his 
 urinary or genital apparatus. This is especially true concerning strictures 
 of large calibre of the pendulous urethra, those for which such splendid 
 results in the way of radical cure are claimed by the advocates of the per- 
 petual use of the knife. Truly, in these cases cured by dilatation, the 
 urethrameter, if screwed up to make the bulb large enough, will detect 
 tight places along the pendulous urethra after cure; but so it would have 
 done when the patient was virgin of all disease, and I have already shown 
 that tight places in the pendulous urethra, without symptoms, cannot be 
 regarded as strictures at all.
 
 304 THE VENEREAL DISEASES. 
 
 RESILIENT STRICTURES OF LARGE CALIBRE. 
 
 There is a class of strictures in the pendulous urethra which produce 
 varied symptoms generally gleet and which do not yield entirely to dila- 
 tation, nor do their symptoms disappear under the use of the steel sound. 
 
 These cases belong to one of two groups: either (1) the patient's gen- 
 eral health is such that local means will not (alone) cure him, as is known 
 to be so often the case in catarrhal affections of other mucous membranes 
 attended by thickening; or (2) the stricture is resilient and does not yield 
 to dilatation. 
 
 Regarding the first class, the patient's general condition must be stud- 
 ied, and especially his sexual hygiene. I have known many a case to get 
 well and to stay well, without there being any necessity for a continuation 
 of the use of instruments in the urethra, and this cure has been effected 
 simply by marriage, after all other means, including extreme dilatation 
 and extreme cutting, had failed. 
 
 I have known others to get well promptly by a sea-voyage, change of 
 climate, a prolonged trip to the country, when extreme cutting, by the 
 best-known advocates of this plan, has failed to give relief. 
 
 Then there are cases of gleet associated with tubercle, with prostatic 
 disease, with chronic inflammatory trouble in the seminal vesicles, in which 
 it is folly to attempt a cure, either by dilatation or by cutting any or all 
 of the bands and tight places in the pendulous urethra which the urethra- 
 meter or bulbous sound can be made so easily to detect. 
 
 But, finally, the second group of strictures of large calibre remains. 
 They are resilient, that is, they have in them that tenacious, cicatricial, 
 retractile quality which does not allow dilatation to affect them favorably 
 beyond a certain point. The symptoms yield, but do not entirely disap- 
 pear. A little gleet in the morning continues to mock the efforts of the 
 surgeon and to disgust the patient with his disease, and often with the 
 science of medicine. In these cases, after being certain to locate the 
 symptoms accurately in the stricture, and not to be deceived by ascribing 
 gleet due to diathetic or other cause to a tight spot found in the urethra, 
 the surgeon may employ internal urethrotomy within the pendulous 
 urethra. Under these circumstances, the operation offers a good chance 
 of success in ridding the patient both of the final remains of his symptoms 
 and of the necessity for a continuation in the use of sounds if the sur- 
 geon cuts wide enough at any one point and passes entirely through the 
 unyielding contractile ring of stricture. This ring of modular tissue is 
 white, fibrous-like, cicatricial tissue, and not the yellow elastic fibres which 
 Robin and Cadiat have found so abundantly in the structure of the healthy 
 urethral mucous membrane. 
 
 The treatment by internal urethrotomy, however, is only generally 
 applicable to the pendulous urethra. All organic strictures at or deeper 
 than the bulbo-membranous junction should be treated by dilatation alone 
 by dilatation to the greatest limit to which it can be carried with gentle- 
 ness, and this will cure the symptoms, or so nearly cure them that most 
 sensible men who are made familiar with the dangers of internal urethro- 
 tomy in the curved portion of the urethra will be satisfied with the result. 
 
 Such a cure, or relative cure of stricture in the deep urethra, espe- 
 cially in bad cases of modular stricture, cannot be maintained excepting 
 at the expense of constant dilatation. The patient is condemned to pass 
 an instrument, at such intervals as may be found necessary (from once a
 
 STRICTURE OF LARGE CALIBRE. 305 
 
 week to once a month, after a time at longer intervals), for the remainder 
 of his life, in order to keep down his symptoms and to prevent the recon- 
 traction of his stricture. And this is still the case, no matter by what 
 treatment the urethra has been brought to such a size as to allow the 
 passage of a full-sized instrument into the bladder. Repeatedly does the 
 surgeon find, in hospital and dispensary practice, cases of tight stricture 
 in the curved urethra, which have already been subjected once, twice, or 
 perhaps three times to internal urethrotomy, or even to external urethro- 
 tomy. I have performed perineal section more than once under each of 
 these circumstances, where the patients, from neglect to pass the sound 
 continuously after a former cutting, had allowed the urethra to close at 
 the point of stricture. And I have treated a large number by dilatation, 
 after recontraction had followed the cutting operation. 
 
 Stricture of large calibre in the pendulous urethra may be cured by a 
 variety of means, so that its symptoms may cease forever, without the 
 necessity for any further use of instruments in the canal. 
 
 The same is true regarding the treatment of a mild stricture of the 
 deep urethra cured by dilatation. 
 
 Resilient stricture of large calibre in the pendulous urethra is often 
 incurable except by the knife; and internal urethrotomy, if the cut be 
 large enough, will generally cure the symptoms of such a stricture so that 
 they will not return, although no instruments are used in the urethra 
 after the cut is well. 
 
 Small organic strictures in the pendulous urethra are probably always 
 best managed by internal urethrotomy. 
 
 Strictures of the deep urethra, when organic and situated at or be- 
 yond the bulbo-membranous junction, cannot, all of them, with certainty 
 be radically cured by any operation or by any treatment with which I 
 am familiar. The best treatment in these cases is always dilatation when 
 practicable. Sometimes, after dilatation has been maintained for a long 
 period, the tendency to recontraction ceases, and the patient remains well, 
 so far as symptoms are concerned, without the necessity of any further 
 instrumentation in the urethra. Possibly a like cure may occasionally 
 follow internal urethrotomy I have known it to follow external urethro- 
 tomy in one case; but, in the majority of instances of inodular, organic 
 and traumatic strictures of the deep urethra, a cure is not obtained radi- 
 cally by any operation yet known, and the patient's safety consists in a 
 maintenance of the.calibre of his urethra by the occasional passage of a 
 full-sized instrument through the obstruction for the rest of his life a 
 task not considered at* all difficult by those who do it. 
 
 INTERNAL URETHROTOMY IN THE PENDULOUS URETHRA. 
 
 If, then, internal urethrotomy has become necessary in the treatment 
 of a stricture of large calibre of the pendulous urethra, which of the nu- 
 merous instruments for performing the operation shall be used, and to 
 what limit in size shall the urethra be cut ? 
 
 I have tried nearly all the improved modern urethrotomes, and have 
 found none so good as the dilating urethrotome of Dr. Otis, for dealing 
 with such strictures as have to be cut in the pendulous urethra; and I 
 must repeat that, in my opinion, deeper-seated strictures of large calibre 
 should not be cut internally, for the double reason that: 1. Cutting in this 
 region is a proceeding dangerous to life ; and, 2. Cutting in this region 
 20
 
 306 
 
 THE VENEREAL DISEASES. 
 
 does not produce a radical cure, nor allow the patient to dispense with a 
 continual use of the sound to keep his stricture open; or it does this so 
 seldom that its curative action cannot be relied upon, and the hope of 
 cure does not justify the risk incurred by external cutting. 
 
 Otis's instrument is quite simple and strong. It is a happy modifica- 
 tion of a number of previous types, so combined as to form an instru- 
 ment which performs its functions very accurately. It consists (Fig. 33) 
 of a shaft, the blades of which may be separated by a 
 screw-movement in the handle, and a small knife con- 
 cealed near the distal end of one of the blades, which 
 is drawn up upon a concealed bridge, and brought 
 into action when its handle at the proximal end of the 
 instrument is pulled upon. A dial-plate in the handle 
 registers the degree of separation of the blades. 
 
 To use this instrument, with the urethrameter or bul- 
 bous sound, the location and extent of the stricture to 
 be cut are at first definitely decided upon. Then the 
 urethrotome is introduced (dial-plate and knife upper- 
 most, as a rule) so deeply that the point at which the 
 knife-blade shall emerge shall be at least three-quarters 
 of an inch deeper in the urethra than the deepest limit 
 of the stricture. This I find necessary in all strictures 
 of large calibre; without it the deepest parts of the 
 stricture those most distant from the meatus are not 
 cut. For I find that the lower blade of the instrument, 
 in opening, pushes away the urethra, making it slide 
 back from the upper blade; so that, no matter how ac- 
 curately the meatus may be held against the shaft of the 
 urethrotome, the position of the knife relatively to the 
 stricture slides forward proportionately to the amount 
 of separation of the blades, and therefore, when the 
 knife is brought into action, it may commence the cut 
 entirely in front of the deepest (often the tightest) por- 
 tion of the stricture, unless special care be taken to avoid 
 this mishap. 
 
 When the instrument has been properly placed, the 
 blades are separated until they mark the size to which 
 Jjj it is desired to cut the stricture. In cutting, the handle 
 
 of the knife is withdrawn far enough to make the cut 
 \ in all at least half an inch longer than it was originally 
 
 r j? decided that the stricture measured. Now the blades 
 ^ ^^ are to be rapidly approximated, and the knife returned 
 
 Fio. 33. to its concealment before withdrawing the instrument. 
 
 If other strictures exist farther forward, they may all be 
 included in a single incision along the roof. If a considerable interval of 
 healthy urethra separates them, they may be cut at the same sitting, but by 
 different operations, the deeper one being cut first. The flow of blood forms 
 no material impediment to cutting the second stricture. If the meatus is 
 to be cut, it may be included in the first incision along the roof, or, per- 
 haps better, cut along the floor as the first step in the operation, if this 
 has not already been attended to in the preliminary examination as di- 
 rected at page 301. No ether is necessary in the performance of this 
 operation. It should be done slowly, for accuracy and precision are es- 
 sential factors of success. Stretching the tissues during the separation
 
 STRICTURE OF LARGE CALIBRE. 307 
 
 of the blades generally hurts more than the final cut, according to the 
 assertion of most patients. 
 
 After the cutting has been accomplished, it is well to pass a bulbous 
 sound over the cut region, to decide whether the cutting has been efficient 
 and has thoroughly relieved the constriction. 
 
 If this is found not to be the case, the urethrotome should not be re- 
 introduced. The second cut is likely to pass through the stricture at a 
 different point, and a third cut to take still another route, as has been 
 proved post-mortem (Sands, 1. c., p. 135). Thus the stricture becomes 
 partly cut in a number of places, its outmost circle not being cut through 
 anywhere; and more cutting is done than is justified by the end in view, 
 since each cut increases the possibility of pyzemic complications. The 
 way to avoid the necessity for a second cut is to make the first one de- 
 liberately, to locate it accurately, and to make it deep enough. If this is 
 not done. I believe it to be wiser to postpone the second operation two or 
 three weeks until the first cut has healed, and then to start afresh, as if 
 nothing had previously been done. 
 
 It remains to determine how deeply to cut a given stricture of large 
 calibre in the pendulous urethra. This cannot be absolutely decided by 
 any criterion with which I am familiar. Dr. Otis has fortified his follow- 
 ers with a scale very pleasing in its apparent accuracy, based upon an 
 alleged constancy of relation between the normal size of the urethra and 
 that of the penis in repose; yet this accurate scale (which is certainly 
 only approximate) does not give its followers the satisfaction of doing the 
 whole operation at a single cut. In all the operations which I have seen 
 performed by surgeons, and in most of those recorded in medical journals, 
 the urethrotome is introduced twice or more often at the same sitting; and 
 very frequently it is found, after some days or weeks, that recontraction 
 has occurred, and the stricture has to be cut over again. I have personal 
 knowledge of repetitions in the cutting, to the extent of four times at 
 different sittings, having been done on one and the same individual, by a 
 surgeon than whom none can be more competent in this operation, and 
 that too without resulting in a cure. Consequently it is rather idle to 
 attempt accuracy by measuring so uncertain an organ as the penis, even if 
 the scale possessed the accuracy which its inventor ascribes to it; and the 
 question remains: What rule, if any, have we to go by? 
 
 In answer, it may be stated as a general proposition, that the strict- 
 ured point which will not yield to dilatation must be cut so as to be con- 
 siderably larger than the normal urethra at that point; and that, to insure 
 the best results, a single cut should be made a cut, if possible, to pass 
 beyond all diseased tissues and into the healthy tissue. 
 
 This result is probably often attained by following the measurements 
 of Dr. Otis, since his estimation of the size of the urethra is extreme; but 
 even his measurements will not suffice in some cases where inodular tis- 
 sue has involved the whole substance of the corpus spongiosum, while 
 often they are unnecessarily high. 
 
 The best guide with which I am familiar is the natural size of the 
 healthy meatus a meatus which has no pockets above or below, or out 
 of which such pockets have been cut with the bistoury, so that the meatus 
 may be a flat slit, and not a round point at the apex of a conical glans pe- 
 nis. Furthermore, it must be remembered that the strictured area is not 
 simply to be restored to the normal calibre of the urethra at that point 
 when it was a healthy, elastic canal; but it must be cut considerably be- 
 yond this size, both to insure against the certain amount of contraction
 
 308 THE VENEREAL DISEASES. 
 
 which necessarily takes place at the angle of the cut as it heals, and the 
 more certainly to cut through the outer circle of fibres at the constricted 
 point. 
 
 A fair rule to go by is first to establish the fullest size to which the 
 normal ineatus may be distended the normal meatus not strictured and 
 without pockets and to cut the stricture, after having screwed up the ure- 
 throtome to mark not less than two sizes (American, three or four sizes 
 French) higher than that limit. Should the meatus be strictured congen- 
 itally or by disease, the surgeon's judgment must guide him in the extent 
 of his incision, both of the meatus and of the deeper-seated stricture, re- 
 membering that the normal meatus of the full average-sized penis in the 
 American will range very close upon 20 American scale (30 P'rench). In 
 other words, a conical steel instrument of size 20 will pass, by its own 
 weight, the normal meatus (without pockets) in the average American 
 male taken at random, with fair-sized genitals, or certainly may be passed 
 with a little coaxing, putting the meatus more or less on the stretch, 
 without in the least tearing or injuring it. A penis of less size will have 
 a more moderate urethra, as a rule. 
 
 It has been found by experience, as Dr. Otis has shown, that the 
 breadth of the knife-blade does not count, and that if the blades of the 
 urethrotome be separated to 20 and the cut then made, the strictured 
 point will be found to be cut not above size 20. Therefore, the limits of 
 cutting which I have given are quite moderate, for the meatus is nor- 
 mally the smallest part of the canal, and an incision at least two sizes 
 larger, lower down, is not extravagant, since the cut is quite certain to 
 lose one size while healing. 
 
 If, after healing, it is found that the symptoms persist, and the re- 
 siliency of the stricture remaining shows that the outside fibres have not 
 been cut through, then another operation may be performed, the surgeon 
 being fortified by the knowledge gained during the first operation, and the 
 cut on the second occasion may be made two, or even three (American) 
 sizes larger than before. 
 
 I believe that two operations are safer for the patient than one per- 
 formed at random or extreme on the start. If it must be extreme and 
 possibly some exceptional cases require it the extremity should be pro- 
 portioned to the necessity, and should not be a matter of routine. If 
 after the first cutting the symptoms disappear, no further cutting is justi- 
 fiable, even although the urethrameter or bulbous sound should detect 
 that the point cut is still smaller than the urethra in front of it and be- 
 hind it. The occasion for interference with stricture of large calibre in 
 the pendulous urethra is not its existence, but the symptoms it produces. 
 If there be no symptoms, tight spots in the pendulous urethra of large cali- 
 bre may be safely disregarded. 
 
 The bleeding after internal urethrotomy is very variable. A deep in- 
 cision in one patient may be attended by a moderate flow of blood, while 
 a slight cut in another will bring on profuse haemorrhage. In a given pa- 
 tient, however, the amount of haemorrhage is proportionate to the number 
 and depth of the cuts. Generally, pressure will arrest the bleeding. It 
 is best applied with the fingers placed directly over the urethra. The 
 blood should be allowed to clot, and the clot that forms and protrudes 
 from the meatus should be left in place and not be removed with the fin- 
 gers, for this only allows a continuance of the haemorrhage and necessi- 
 tates the formation of another clot. If the flow of blood persists, contin- 
 uous pressure from without may be tried by placing a piece of split lead-
 
 STEICTUEE OF LAEGE CALIBRE. 309 
 
 pencil along the urethra, with its convexity toward the skin, and securing 
 it in place with adhesive strips and a narrow bandage; or, what is better, 
 if at hand, the instrument especially designed for the purpose by Bates, 
 of Brooklyn, may be employed. It is constructed on the same principle 
 as Trendeleriburg's tracheotomy tube and Guyon's lithotomy tampon. 
 This instrument is simply a thin rubber tube encircling a catheter, and 
 so arranged that the outer rubber may be inflated with air or iced water 
 after the instrument has been secured in place so as to pass lower than 
 the cut point (Fig. 34). The outer tube has two terminal outlets, b and 
 
 FIG. 34. 
 
 c, so that a continuous stream of iced water may be kept passing through 
 it, if desired, while the urine may be drawn through the catheter by 
 taking out the plug, a. 
 
 Another excellent means of arresting haemorrhage is by injecting the 
 urethra full of the liquid subsulphate of iron. The fluid is to be rapidly 
 thrown into the urethra, a drachm is usually enough, and held there by a 
 thumb and finger at the meatus for about half a minute. On liberating the 
 meatus a discolored watery fluid escapes, but no red blood if the injection 
 has been effective, for the urethra is effectually plugged with a solid black 
 clot, generally quite hard enough and adherent enough to stop all haemor- 
 rhage. The only objection to this process is that it tends to induce sup- 
 puration, and sometimes active inflammation of the urethra perhaps of the 
 whole circumference of the canal, and in this way to interfere with the 
 subsequent use of instruments of sufficient size to maintain the cut open 
 until it has healed to the bottom. 
 
 Sometimes little or no blood escapes at the moment of operation, but 
 later, at the time of the next urination or during erection at night, hae- 
 morrhage comes on which sometimes becomes profuse. The same means 
 will arrest it as those alluded to above. 
 
 The after-treatment consists in th use of the conical steel sound at 
 appropriate intervals. Twenty-four hours after the cutting, a full-sized 
 sound large enough to put the meatus fully upon the stretch may be 
 gently introduced. This is followed by haemorrhage, sometimes more pro- 
 fuse and harder to arrest than that which occurred at the moment of the 
 operation; but it yields more promptly, as a rule, and generally becomes 
 arrested spontaneously after a few moments. After another interval of 
 forty-eight hours, the same full-sized sound may be introduced ; or, if the 
 urethra be generally inflamed so that the size causes much pain, one size 
 lower may be employed, but nothing smaller. Again, in forty-eight hours, 
 the process is repeated. The next interval may be three days, and the 
 next four. After this, one or two passages of the sound, at intervals of 
 five days, often terminate the case, although in many instances a much 
 longer time is necessary, and sometimes one, two, or even more sizes in the 
 sound are lost, owing to inflammatory conditions in the urethra excited by 
 the mechanical violence to which it has been subjected. The cut is known 
 to be healed when a full-sized instrument may be passed without being
 
 310 THE VENEREAL DISEASES. 
 
 followed by any blood; but even after this it is wise to keep up the use 
 of a full-sized sound, at longer intervals, for a time. 
 
 If now the symptoms have disappeared, the sound may be laid aside, 
 and the patient is and remains well, although manipulation with the 
 urethrameter may still detect that the point cut is smaller than other 
 parts of the urethra. If the symptoms persist and the stricture recon- 
 tracts, it may be cut again as before, but to a greater extent, as already 
 described above. 
 
 These remarks, I must again repeat, apply to strictures in the pendu- 
 lous urethra. 
 
 The complications attending this operation besides haemorrhage, which 
 can always be arrested in the pendulous urethra, are those inherent to 
 most operations upon the canal, and due often as much to the after-treat- 
 ment by instruments as to the cutting operation. They are urethral fever 
 from shock, epididymitis, cystitis, possibly prostatic or peri-urethral ab- 
 scess, sometimes yielding fistula, occasionally pyaemia and surgical kid- 
 ney. Another complication, not very uncommon where the cut has been 
 deep, is the formation of new modular tissue in the corpus spongiosum, 
 causing painful erection and chordee. Some writers have reported that 
 the latter condition may remain more than a year; painful erections often 
 persist for many months. 
 
 All these complications call for treatment when they arise, and many 
 of them demand a cessation in the employment of instruments to keep 
 the cut open. Thus, the latter is allowed to close, and much of the good 
 which might have been attained by the operation is lost. One of the 
 best means of avoiding complications after urethrotomy is to keep the 
 patient quiet upon his back for several days after he has been cut, giv- 
 ing him plenty of bland diluents to drink, and enough bromide or opium, 
 if need be, to keep down erections. The ingenious device of surround- 
 ing the penis with a coil of rubber-tubing, through which iced water is 
 made to flow continuously, has proved, in my hands, rather a source of 
 erections than a restraint upon them. Injections are not desirable in the 
 after-treatment of urethrotomy, and the balsams are useless. Laxatives 
 are of service while the patient is in bed.
 
 CHAPTER V. 
 
 STRICTURE OF SMALL CALIBRE. 
 
 Symptoms of Tight Organic Stricture ; Diagnosis. Expedients for Threading fine Stric- 
 tures. Treatment of Stricture of Small Calibre. Continuous Dilatation. Inter- 
 nal Urethrotomy of the Deep Urethra. Divulsion. Perineal Section; with a 
 Ghiide ; without a Guide. Urethral Fever and its Treatment. 
 
 ORGANIC stricture of small calibre of any size, from 10, American 
 scale, down to a constriction through which nothing can be passed, is the 
 most important malady of the urethra with which the surgeon has to con- 
 tend. Its causes are gonorrhoea and mechanical or (rarely) chemical 
 violence; its origin may be congenital; at the meatus, the cicatrization 
 of ulcers is a not infrequent cause. 
 
 The seat of election of this stricture, as shown by all the statistics 
 with which I am familiar which have been collected in the dead-house, 
 as well as by the daily experience of the great majority of capable clini- 
 cal observers is in the deep urethra, at the bulbo-membranous junction 
 or thereabouts, when due to gonorrhoea; a little farther back, even well 
 in the membranous urethra, after such common traumatisms as bruising 
 injuries of the crotch. It may be found also congenitally, or as a result 
 of a cicatrix at the meatus, or anywhere along the pendulous urethra, 
 due to injury or to gonorrhoea, when there has been much chordee, espe- 
 cially if the chordee has been broken. In the latter case, the stricture is 
 due to the mechanical rupture of the stiffened and inflamed corpus spon- 
 giosum more than to the gonorrhoea pure and simple. Much that has 
 been said in the last chapter, in a general way, concerning stricture of 
 large calibre, applies equally well here; but some especial points in re- 
 gard to tight organic strictures call for a separate description. 
 
 SYMPTOMS OF TIGHT ORGANIC STRICTURE. 
 
 The most common symptom of tight organic stricture is a diminution 
 in the size of the stream of urine. The flow may be projected in full 
 force, and the stream be as smooth as possible, perhaps bright and clear; 
 but it is a mechanical impossibility that it should be large. The patient 
 may assert, as he often does, that he never in his life passed a larger 
 stream, but such assertions are of no value. Generally the stream is not 
 smooth, but flattened, or variously distorted. One stream may flow away 
 with some force, while another, starting below it without force, dribbles 
 to the ground, or takes a different direction, or perhaps twists itself 
 partly around the other. Again, when the stricture is quite tight, the 
 flow is apt to commence painfully in drops, and only to reach the propor- 
 tions of a continuous stream after the lapse of some time, and after con- 
 siderable effort on the part of the patient. From catching cold, or by
 
 312 THE VENEREAL DISEASES. 
 
 the effect of local spasm from other cause, the constricted point may be- 
 come actually occluded, so that retention comes on. After this has been 
 relieved in one way or another, the patient again urinates with more or 
 . less facility, until he is overtaken by another retention, by cystitis, or by 
 some other symptom, which leads him to seek advice. 
 
 The next symptom in frequency is gleet. Gleet, more or less puru- 
 lent, is found in nearly all cases of tight stricture, but its presence is not 
 necessary. I have known a stricture, traumatic in origin, almost impas- 
 sable to a whalebone bougie, and yet existing for years without the least 
 show of gleet. 
 
 Irritability of the bladder is a very common symptom caused by tight 
 stricture. The cystitis, which comes on gradually, is mainly confined to 
 the neck of the bladder ; it is very mild in character at first, but goes on 
 increasing, so that in many cases of old tight stricture the bladder symp- 
 toms alone are those for which the patient consults a surgeon, and for 
 which he demands relief, perhaps by medicine, ignoring the cause in the 
 urethra. The urine, in these cases, is more or less charged with pus. 
 Partial relapsing chronic epididymitis is another symptom of stricture far 
 from uncommon, and to these may be added perineal fistula following ab- 
 scess, infiltration of urine, and a long list of reflex phenomena, already 
 alluded to in the chapter on stricture of large calibre; urethral neuralgia, 
 sciatica, pains, paralysis, spasm, etc., and certain remote symptoms 
 such as hydrocele, stone in the bladder, sterility, etc. Finally, the 
 natural ultimate result of tight stricture is general chronic inflammation 
 of the bladder, attended by thickening of the walls of the viscus, some- 
 times concentric hypertrophy (thickening of the walls, with permanent 
 diminution of the cavity), dilatation of the ureters, pyelitis, interstitial 
 
 girenchymatous nephritis, uraemia, and death. Many a death ascribed to 
 right's disease is in reality due to kidney changes, brought on by long- 
 standing tight stricture of the deep urethra. 
 
 DIAGNOSIS OF STRICTURE OF SMALL CALIBRE. 
 
 Tight stricture at the meatus may be seen. Along the pendulous 
 urethra it may often be felt from the outside, being usually more or less 
 inodular, composed of a new deposit of fibroid material similar to the tis- 
 sue of the cicatrix after a burn. An accurate diagnosis, however, may be 
 made from within the urethra by the use of instruments for exploring the 
 canal. 
 
 Nothing more need be added to what has already been said in the last 
 chapter concerning the possibility of confounding spasm of the deep urethra 
 with true organic spasm. If the precaution be taken to commence an ure- 
 thral examination with a large-sized blunt (not conical) steel instrument 
 thoroughly warmed, and to proceed as directed in the section on the diag- 
 nosis of spasmodic stricture, I think that an error will become practically 
 impossible. In any doubtful case it is wise to bring the meatus up to its 
 full normal size, as laid down in the last chapter, before commencing the 
 exploration, or it may not be possible to use a large enough blunt steel 
 instrument to decide the question positively. 
 
 Commencing, then, with a large blunt instrument, and working down 
 to smaller sizes, it will sometimes turn out that the tight organic stricture 
 does not exist at all. A surgeon may declare that no instrument will pass 
 because he has used a fine whalebone to commence with, and, having caught
 
 STRICTUEE OF SMALL CALIBRE. 
 
 313 
 
 this in some follicle, has been unable to reach the bladder; or, he may have 
 passed a small instrument into the bladder, and, finding this held somewhat 
 by the urethra on its way out, he decides that there is tight organic stric- 
 ture. 
 
 It has happened to me in my clinique, at Bellevue Hospital, to have 
 a patient brought in under these circumstances a patient whom 
 I had not before seen to be operated on as a case of tight organ- 
 ic stricture. Commencing the examination with a full-sized, blunt 
 steel sound, I have been able to pass the latter readily by its own 
 weight into the bladder. This is by no means uncommon in private 
 practice. I have encountered it frequently; and, in many of these 
 cases, the spasm of the muscles of the deep urethra yields to the 
 blunt instrument without any previous cutting of strictures at the 
 meatus or elsewhere in the pendulous urethra, and the spasm itself 
 is due to a cause other than an irritation in the forward parts of the 
 urethra. 
 
 Passing down, then, after failure of the foregoing manoeuvre, 
 from large to small blunt steel sounds, of course skipping several 
 sizes at a time, an obstacle is encountered invariably at the same 
 depth, at the seat of stricture. Locating it positively in this way, 
 after size 10, American (blunt), has been tried in vain, an effort to 
 reach the bladder may be made with a small, soft, black conical 
 bougie, sharp-pointed, not olivary (Fig. 35). Several of these may 
 be tried, and, at last, a Benas bougie, which is simply a thread of 
 whalebone, covered with a kind of black varnish. 
 
 If any instrument so far tried passes the stricture, the amount of 
 ease with which it glides through the tight spot should be esti- 
 mated, the instrument immediately withdrawn, and, unless there 
 be some special reason to the contrary, the patient should be let 
 alone to see what effect will follow the first instrumentation. If 
 urethral fever follows, and especially if the patient has albumen 
 in his urine, all subsequent explorations must be made with special 
 care, and possibly also with the assistance of certain medical aids 
 for the prevention of chill, which I shall mention shortly. 
 
 If none of the instruments thus far tried will pass, a very valua- 
 ble instrument still remains the filiform whalebone bougie, with 
 the point twisted into spiral, or bent so as to be thrown out of the 
 axis of the shaft of the instrument, as shown in Fig. 36. 
 
 A small syringeful of warmed oil is first thrown into the ure- 
 thra, and then the surgeon feels the anterior face of the stricture 
 with the twisted end of one of these fine whalebones. By advan- 
 cing the instrument during rotation, with the ure- 
 thra made tense by pulling upon the penis, the tip 
 of the filiform bougie is presented at different 
 points upon the face of the stricture, and finally, 
 in a skilled hand, is quite certain to find the orifice 
 of the stricture and to enter it. Once entered, the 
 rigidity of the whalebone comes into play, and the 
 instrument promptly passes on and enters the blad- 
 der. It is rare, indeed, to encounter a stricture into 
 FIG. 36. which one of these slender little instruments can- FIG. 36. 
 
 not be made to pass ; nearly all the so-called im- 
 permeable strictures yield to them. The main difficulty in their employ- 
 ment is the facility with which the point becomes entrapped in the mouths
 
 314 THE VENEREAL DISEASES. 
 
 of dilated follicles, or of a false passage, should one exist. This defect may 
 in a measure be overcome by the well-known device of crowding the ure- 
 thra full of these fine threads of whalebone, and then pushing upon them 
 alternately until the one which presents at the mouth of the stricture 
 passes on into the bladder. 
 
 Another expedient, which I should feel inclined to try in case of failure 
 to pass a tight stricture, is that recommended by Dr. Hadden, in the New 
 York Medical Record of 1877, July 7th, p. 421. I have not tried it, because 
 I have not failed to pass a stricture since I read the article. The expedient 
 is simple and plausible. It consists in carrying iced water through the 
 long nozzle of a syringe, directly against the anterior face of the stricture, 
 for a few moments, after which, Dr. Hadden says that in his hands a 
 stricture became permeable, which was not so previously. Doubtless the 
 cold sound (p. 269) would serve the same purpose, and it would be easier 
 to manage ; and, theoretically, I am not certain that very hot water, car- 
 ried through the cold sound, would not answer the purpose (of relaxing 
 spasm) still better than iced water. 
 
 Finally, if no instrument can be passed, ether may be administered, 
 and the attempt renewed. A filiform bougie, or even a large instru- 
 ment, may pass under ether when all attempts without an anaesthetic have 
 failed. 
 
 By these means a stricture may be located, its permeability ascertained, 
 and its calibre estimated. 
 
 TREATMENT OF STRICTURE OF SMALL CALIBRE. 
 
 As has been already stated, tight strictures at and near the meatus 
 must be cut. Strictures of small calibre are quite rare in the pendulous 
 urethra. When they do occur, it is probably better, as a rule, to cut 
 them, since they are quite certain in the long run to prove resilient, and 
 require cutting, perhaps, after much time has been lost in attempts at 
 dilatation. If they prove too narrow to receive the dilating urethrotome, 
 their calibre may be safely raised in a few days, by what is known as con- 
 tinuous dilatation (described below), and then, as soon as the urethrotome 
 will pass comfortably, they may be cut. 
 
 For all strictures of the deep urethra, dilatation should be the rule, and 
 all operative measures the exception, for the double reason already stated: 
 1. An operation means danger to the patient, and such a risk his physical 
 condition does not usually warrant; 2. After cutting internally or exter- 
 nally, and after divulsion, a radical cure is not attained in most instances 
 only relief as a rule, which is made effective by a continuance of dilata- 
 tion, at more or less prolonged intervals, for an indefinite period. 
 
 Dilatation, therefore, is to be employed whenever practicable. This is 
 done much after the manner advised in the case of stricture of large cali- 
 bre, with the exception that, where soft instruments are used, the inter- 
 vals may be considerably shortened. Practically, however, the rule is the 
 same. When the effect of one dilatation is at its height, another larger 
 instrument should be gently introduced and immediately withdrawn. 
 With very fine instruments, one day is a long enough interval to be al- 
 lowed to pass after the first sitting ; then the interval may be raised to 
 two, then to three and four days, with advantage. As soon as size 10 
 American is reached, soft instruments may be abandoned and the dilata- 
 tion continued with conical steel sounds, as in the case of stricture of 
 large calibre.
 
 STRICTURE OF SMALL CALIBRE. 315 
 
 When, in the case of a very tight stricture, a fine whalebone has been 
 only introduced after many days of patient trial, and especially if there 
 be actual or impending retention, the surgeon's course should depend 
 in a measure upon the character of the stricture, as well as the character 
 of the patient. If the stricture be inodular, complicated with perineal 
 fistula, or very hard and of traumatic origin; or attended by perineal ab- 
 scess; or (above all) by infiltration of urine; or if the patient be hard to 
 manage, having been partly cured before and then allowed himself to 
 relapse; or if he be urgently pressed for time, or subject to repeated and 
 prostrating attacks of urethral fever (his kidneys being presumably sound) 
 under any of these circumstances perineal section upon a guide is called 
 for, and should be performed at once or within twenty-four hours. The 
 guide may be tied in the urethra and left there until the operation. 
 
 If the case be not urgent on any of the above grounds, while it has 
 been quite difficult to pass the stricture with the filiform bougie, the mild 
 and very efficient expedient of continuous dilatation may be used. 
 
 Continuous dilatation is the action exerted upon a stricture by 
 the constant presence of an instrument passed through it. The whale- 
 bone, once inserted, is simply to be retained in place by a piece of heavy 
 silk tied tightly around it near the meatus. The two ends of the silk are 
 then tied together so that the knot shall lie upon the frenum just at the 
 curve of the corona glandis, and then the separate ends are carried around 
 on either side under the corona, and tied with moderate tightness upon the 
 dorsum. 
 
 In this condition the patient is sent home and told to keep quietly 
 about the house. In twenty-four hours the whalebone may be removed 
 and one several sizes larger introduced with ease. This is in its turn tied 
 in. The patient urinates easily alongside of the instrument. The con- 
 tinuous pressure causes, first, muscular action, spasm, and the bougie is 
 grasped, then relaxation of spasm, then inflammatory swelling, then 
 absorption, and usually suppuration. The second instrument may be left 
 in two days or more. In this way, in a week most strictures (if commenced 
 with very small) may be raised a dozen sizes. The larger the calibre of 
 the stricture, the less promptly, as a rule, does continuous dilatation af- 
 fect it. After the stricture has reached a certain size, treatment by ordi- 
 nary dilatation may be commenced; but the intervals must be rather short 
 at first, since a stricture promptly raised to a large size by this method 
 very promptly falls back again if let alone. 
 
 There are some cases of tight stricture in which one may be content 
 with simply passing a filiform instrument and not tying it in, trusting 
 that on the following day a larger size may enter, as in ordinary treat- 
 ment by dilatation. 
 
 Finally, there are cases not quite desperate enough to justify exter- 
 nal urethrotomy, not able to give the time to ordinary dilatation (al- 
 though it does not call for a day in the house, much less in bed), and yet 
 urgent enough to justify prompt measures which shall afford speedy relief. 
 For this class of cases two operations remain internal urethrotomy and 
 divulsion. 
 
 Internal urethrotomy of the deep urethra, in my opinion, is not 
 so good an operation as divulsion. The cases in which I have practised 
 it have given me but little satisfaction. The bleeding is apt to be trouble- 
 some, and much harder to arrest, I have found, than haemorrhage from the 
 pendulous urethra. I have never seen a radical cure effected by internal 
 urethrotomy in the deep urethra; many deaths due to the operation are re-
 
 316 
 
 THE VENEREAL DISEASES. 
 
 corded in the journals, and many more have not been recorded. In any 
 case the operation is only an adjuvant to dilatation; it prepares the way. 
 I do not by any means condemn the operation; but I do not like it, and I 
 think divulsion better. 
 
 If urethrotomy is to be performed internally, probably Maisonneuve's 
 modified instrument is as good as another for the purpose. The grooved 
 staff A (Fig. 37) screws upon a soft conducting bougie, b, d, or is tunnelled 
 at the end to slip over the whalebone guide, and 
 a rather small knife may be used, B, a, prefera- 
 bly with a blunted top to shield the healthy 
 mucous membrane as the knife is thrust along 
 the groove toward the stricture. Without this 
 shield, and sometimes with it, the healthy mu- 
 cous membrane all along the urethra is more or 
 less cut on the roof or floor of the canal, as the 
 case may be, as the knife is passing down to- 
 ward the stricture. 
 
 The after-treatment and means of arresting 
 haemorrhage are much the same in this operation 
 as after internal urethrotomy of the pendulous 
 urethra (page 305). 
 
 DIVULSION. 
 
 This operation is not at the present day held 
 in favor to such an extent as internal urethrot- 
 omy, probably because it seems to be a rougher 
 procedure. It has the great advantage, how- 
 ever, of calling for less after-treatment by instru- 
 ments in the urethra, the haemorrhage is much 
 lighter, and the effect equally lasting. The 
 danger is certainly no greater in this operation 
 than it is in internal urethrotomy, and, for the 
 deep urethra, I consider it the preferable opera- 
 tion. 
 
 The best instrument with which to divulse 
 a stricture I believe to be Thompson's tunnelled 
 divulsor, as made in America, capable of being 
 screwed up to size 21, American scale. Fig. 38, 
 a, represents the instrument. By turning the 
 handle the blades may be separated, b, the 
 amount of separation being registered upon an 
 index in the handle. The instrument is to be 
 used as follows: 
 
 The depth of the front face of the stricture 
 from the meatus is at first accurately ascertained. 
 Then a filiform whalebone bougie, twenty inches 
 long, must be passed through the stricture until 
 its distal extremity reaches the meatus, the 
 other end lying coiled up in the bladder beyond 
 the stricture. The urethra now being injected full of warmed oil and the 
 divulsor being well anointed with vaseline, the tunnel is threaded over the 
 whalebone guide, and, while the tip of the guide and the end of the penis 
 are held tense with one hand, with the other the divulsor is slowly to be 
 
 FIG. 37.
 
 STRICTURE OF SMALL CALIBRE. 
 
 317 
 
 pushed along over the guide, through the stricture and into the bladder, 
 until its point of greatest dilatability lies at the centre of the stricture. 
 The outside of the divulsor is marked in inches to facilitate this step in 
 the operation. 
 
 It is necessary to take every precaution, in guiding the divulsor into 
 the bladder, not to let it double up the guide in front of itself. To guard 
 against this, during the whole time that the point of the divulsor is trav- 
 elling the curved part of the urethra the guide should 
 be pulled upon very gently, so that, as the divulsor 
 slips in, the guide is being steadily pulled out. If 
 too much of the guide is used in this way at any time, 
 the divulsor being left in place, the guide may be again 
 pushed forward through the stricture and the tunnel 
 until all its excess is again coiled up in the bladder, 
 and then, by coaxing and gentle manipulation of the 
 divulsor while the guide is being again withdrawn, 
 the steel instrument is carried safely into the bladder, 
 guided by the whalebone. 
 
 When the divulsor is in place, the guide should be 
 entirely withdrawn and the process of divulsion im- 
 mediately commenced. The handle of the'divulsor 
 may be turned slowly or rapidly. If slowly, it pains, 
 I think, more in the total amount; but some patients 
 prefer it. Occasionally a strong-minded man prefers 
 to screw up the divulsor himself. Generally it is 
 better to screw up the handle rapidly, and save time 
 while the patient's mind is made up to endure the 
 pain, for it is never necessary to use an anaesthetic. 
 
 The handle is to be turned until such a grade of 
 dilatation has been reached as shall have been pre- 
 viously determined upon, or until blood begins to flow 
 rather freely from the meatus, indicating that the mor- 
 bid tissue has been divulsed torn through. The 
 stricture-tissue is brittle, and, although tough, it tears 
 more easily than the sound tissue, the elasticity of 
 which allows it to escape any considerable injury. 
 Thus, the process of divulsion effects about the same result as internal 
 urethrotorny, with the difference that the torn tissue bleeds less than a 
 similar wound made with the knife would, and has very little tendency 
 to heal up immediately; both of which results in my opinion are very 
 desirable, since they do away with the necessity for a considerable amount 
 of after-treatment which might otherwise be required. 
 
 As the divulsor is being unscrewed preparatory to its removal, its 
 handle should be gradually depressed between the thighs, and its point 
 pushed forward into the bladder until the blades meet, when they may be 
 safely withdrawn. Without the exercise of this precaution, it sometimes 
 happens that the closing blades catch a portion of mucous membrane 
 either the ragged, torn edge of the stricture, or a fold of membrane lower 
 down the urethra, and pinch it so tightly that the instrument cannot 
 be disengaged by again screwing it up. The little piece of mucous 
 membrane in such a case must, of necessity, be torn away before the 
 instrument can be extricated. This accident I have seen happen a 
 number of times. I have never observed that any evil effect followed; 
 but it certainly does no good, and makes the urethra much more sore and 
 
 PIG. 38.
 
 318 THE VENEREAL DISEASES. 
 
 unable to receive an instrument again so soon as it would otherwise have 
 done. It is so easy to avoid this accident by the little manoeuvre I have 
 referred to, that it need rarely, if ever, happen. It is certainly 
 better to avoid it. 
 
 After the divulsor has been withdrawn, the bleeding invariably, 
 stops promptly, and no other instrument should be passed into 
 the urethra. The patient is simply put to bed, and told to remain 
 there from twenty-four to thirty-six hours, after which he may get 
 up and go about his business. If he has no chill within this period, 
 the probability is that all danger is over. If he has a chill, he must 
 be kept longer in bed, and his temperature watched to see whether 
 the chill signifies anything more than ordinary urethral fever. 
 
 The question of urethral fever, and of the after-treatment of all 
 operations upon the urethra, will be discussed presently. 
 
 After divulsion no instrument should be passed into the urethra 
 until the lapse of from five to eight days. The torn tissues do not 
 tend to unite, as a cut does. The tear suppurates, and it is better 
 not to attempt to pass an instrument over it until granulations 
 have formed and the inflammatory barrier has been erected by 
 nature under the raw surface. Therefore, first upon the sixth or 
 seventh day, an instrument is to be used. Meantime the patient 
 usually urinates freely, and enough suppuration has come on to 
 occasion quite a purulent gleet. The first instrument passed should 
 be an olivary, conical, soft French black bougie, the olive being 
 upon a slender neck, so that when touched with the finger the neck 
 promptly bends (Fig. 39). Such an olive will slip over the angle at 
 the bottom of the tear in the stricture, while a conical point or a steel 
 instrument might readily catch in it, start a quantity of fresh blood, 
 and make a false passage. The shaft of the olivary bougie should 
 be as large as the calibre of the meatus will readily allow to pass. 
 
 This instrument, then, well anointed with vaseline, is slowly and 
 steadily pushed downward into the urethra, and if the divulsion 
 has been thorough it should go smoothly forward into the bladder, 
 and its extraction should be followed by the appearance of very 
 little blood. No other instrument need be used for forty-eight 
 hours. Then the same soft bougie may be passed, followed by a 
 conical steel sound of larger size, and from this time onward, on 
 every fourth or fifth day, steel instruments of increasing sizes should 
 be introduced, until the largest size the healthy meatus will take 
 passes smoothly into the bladder without being followed by the 
 appearance of blood on its withdrawal. 
 
 Now the stricture may be called cured, so far as any operation 
 will cure it, and the patient should be instructed in the use of a 
 conical steel sound, which he should be ordered to pass for himself 
 once a week, on pain of a return of his stricture. After a time 
 the intervals may be lengthened, and if recontraction does not 
 occur, the sound may be finally abandoned; but there is no cer- 
 tainty how much time must pass before this result is reached, or, 
 indeed, that it ever will be reached. I have known patients, whose inter- 
 vals, after years of use of the sound, had reached three and four months, 
 and in whom no symptoms of stricture existed, and no evidence furnished 
 by the sound they were using, yet who, from motives of ordinary prudence, 
 preferred to pass the sound three or four times during the year, and in- 
 tended to continue doing so during the remainder of their lives.
 
 STEICTUEE OF SMALL CALIBRE. 
 
 319 
 
 The possible complications following divulsion are the same as those 
 liable to be encountered after urethrotomy. Haemorrhage, however, is 
 very rare, and all the other complications less common, because there is 
 less occasion for using instruments in the urethra; and these instruments, 
 acting upon an inflamed canal, are often more at fault in lighting 
 up complications than the operation itself. 
 
 PEEINEAL SECTION. 
 
 This operation is imperatively called for by tight organic 
 stricture deeply situated in the urethra, under certain circum- 
 stances, such as infiltration of urine, perineal abscess, numerous 
 fistulje, and where the stricture is impermeable to an instrument 
 passed from the meatus. 
 
 The latter contingency alone does not necessarily demand 
 external urethrotomy. It is often better in such a case to as- 
 pirate the bladder with a fine, perforated needle above the sym- 
 physis pubis, once or twice if need be, and then to try the urethra 
 again with a whalebone guide. Some traumatic strictures also 
 of the deep urethra are excessively tough and resilient, so that 
 they will not yield to the divulsor, and do not respond to at- 
 tempts at dilatation. These must be cut, and a much more satis- 
 factory result may be obtained from an external than from an 
 internal section. Such a complication of stricture as stone in 
 the bladder naturally calls for perineal section, since two mala- 
 dies may thus be overcome by a single operation. 
 
 PERINEAL SECTION WITH A GUIDE. 
 
 This is as simple an operation as can well be performed. 
 No effort should be spared and no time grudged that may be 
 necessary to effect the passage of a tight stricture with a whale- 
 bone guide; the life of a patient may hang upon so slight a 
 thread. 
 
 The guide having been passed, the patient should be ether- 
 ized and bound in the lithotomy position. The perineum should 
 be cleanly shaved. As instruments besides sponges, artery- 
 forceps, ligatures, a Guyon's tampon (Fig. 40) if deep haemor- 
 rhage be feared, a scalpel, and a straight, narrow bistoury it is 
 well to have two sizes of Gouley's grooved catheter (Fig. 41, a). 
 This instrument is tunnelled, and makes an excellent substitute 
 for Syme's old-fashioned dangerous instrument, with a shoulder of steel 
 and a long, sharp, curved point. A needle-holder is useful with two 
 
 Pia. 41. 
 
 curved needles carrying long, stout, waxed silk ligatures at least three 
 feet long. A blunt steel sound, grooved to its tip, which latter should
 
 320 THE VENEREAL DISEASES. 
 
 be tunnelled for the guide, will answer very well if Gouley's grooved 
 catheter is not at hand. 
 
 The patient being drawn well to the edge of the table, with his knees 
 up and his hips elevated, the operator sits in front of him, passes the tun- 
 nel of the catheter over the whalebone, which lias been previously intro- 
 duced as a guide through the obstruction, and carries it down to the face of 
 the stricture. He then, with the scrotum and testicles drawn well up 
 out of the way, entrusts the instrument to his first assistant, and pro- 
 ceeds to cut down methodically in the middle line, layer after layer, aiming 
 for the tip of the sound, which of course represents the anterior face of 
 the stricture. As soon as the tip of the sound has been exposed, the 
 curved needles are deeply inserted on either side through the skin and 
 deep tissues, and brought out through the urethral mucous membrane, just 
 in front of the anterior face of the stricture, near the tip of the sound. 
 The needles being removed, each ligature is knotted to itself, so as to 
 form a loop on either side. The loops are entrusted to two assistants. 
 They form the best possible means of keeping the wound open without 
 the use of fingers or instruments, which obstruct the light, and allow the 
 whole bottom of the deep wound to be freely inspected, showing the end 
 of the guide disappearing through the stricture, among the tissues which 
 have stopped the tip of the tunnelled catheter. 
 
 It is now but the work of a moment. A little delicate dissection in 
 the middle line, following the black guide, and the operation is over. 
 Care is necessary not to cut off the slender- whalebone in the wound. 
 The catheter may now be easily slid forward into the bladder, a,nd the 
 removal of its stylet allowing the urine to flow freely through it, demon- 
 strates the success of the operation. 
 
 The catheter should now be withdrawn, and the site of the stricture ex- 
 amined. If this has involved the roof as well as the floor of the urethra, 
 a bridge across the roof, generally with a slight pocket above and in front, 
 will be noticed. This should be thoroughly cut through, or it may prove 
 a serious obstacle to the introduction of sounds while the wound is heal- 
 ing. On one occasion I saw this operation performed by an experienced 
 surgeon. He neglected to cut this bridge in the roof of the urethra, and, 
 as a consequence, was unable to pass sounds afterward. The operation 
 had to be repeated under ether before the patient was put in a position to 
 recover. The importance of this little step in the operation becomes ap- 
 parent when it is remembered that, the floor being cut, the roof of the 
 urethra is the only safe guide to the bladder after the operation of peri- 
 neal section. 
 
 Bleeding points next require attention, and finally, the bladder should 
 be thoroughly examined for stone, and the finger should assure the opera- 
 tor that all the hard, fibroid tissue constituting the stricture has been 
 thoroughly cut through at each end of the wound. The pendulous ure- 
 thra should also be examined for stricture, which should be cut if found; 
 and, above all things, the surgeon must convince himself that he can easily 
 pass a full-sized conical steel sound into the bladder through the meatus, 
 and without putting his finger into the wound. If he cannot do this he 
 should find out the reason for his failure, and so study the urethra that 
 he may become familiar with all its peculiarities, and thus become master 
 of the situation; for these things he may not be able to investigate after 
 the patient has aroused from his anaesthetic. 
 
 The application of a tampon is very rarely required. If one is placed, 
 it should be perforated centrally by a catheter; or, if Guyon's rubber tarn-
 
 STEICTUEE OF SMALL CALIBKE. 321 
 
 pon is used, the catheter forms part of the instrument. Under no other 
 circumstances is it allowable to leave any instrument whatsoever in the 
 bladder, either passed through the wound or through the urethra. Such 
 instruments are wholly unnecessary. Their use serves only to give the 
 patient discomfort and fever ; they inflame the urethra, so that it cannot 
 readily take a full-sized instrument while the wound is healing, and thus 
 greatly mar the ultimate success of the operation. They cannot protect 
 the cut surfaces from contact with the urine, and are far more an occa- 
 sion for high urinary fever than a protection against it. In short, any 
 catheter left in the bladder is a source of pain and danger to the patient, 
 and an annoyance to the surgeon. Although its use is still advocated in 
 some quarters, I am unable to discover upon what grounds it is advised, 
 and having seen it occasionally used in hospitals, I cannot refrain from 
 totally condemning it. The wound should be left open for the passage of 
 the urine, and the after-treatment should be conducted upon ordinary 
 surgical principles, so far as attention to the wound, to fever, to diet, 
 etc., is concerned. The scrotum must be strapped up well out of the 
 way of the wound, or it may become excoriated, cedematous, perhaps infil- 
 trated with urine. 
 
 In twenty-four hours, before suppuration has become fairly established, 
 a full-sized conical steel sound should be gently carried into the bladder 
 from the meatus, following the roof of the canal. This serves to over- 
 come the tendency of the cut surfaces to rapid union. After an interval 
 of forty-eight hours, another sound may be passed, generally one or two 
 sizes smaller. Then, at intervals of three or four days, the largest conical 
 steel sound that will go, should be gently carried through the whole 
 course of the urethra into the bladder, and this continued at gradually 
 lengthening intervals until the wound has healed a time generally vary- 
 ing from three to six weeks. 
 
 It is by no means necessary, however, to confine the patient to the 
 house, much less to his bed, during the whole of this period. His peri- 
 neal wound is a matter of little importance. A greased rag, some oakum, 
 and a T-bandage will keep him perfectly clean, and he may get up when 
 he feels inclined, and walk about. I have had an old man past sixty, 
 whom I cut most extensively in the perineum, up, dressed, and walking 
 about upon the eighth day. This would not have been at all possible had 
 any instrument been left in the bladder after the operation. 
 
 Finally, when the patient gets well, he must be taught to use a full- 
 sized conical steel sound for himself, once a week, just as after internal 
 tirethrotomy or divulsion practised upon a tight organic stricture in the 
 deep urethra, or his cure may not be lasting. Many a patient relapses 
 into a condition of impermeable stricture, after having been thoroughly 
 cut in the perineum, either because his surgeon has not impressed him 
 with the necessity of using sounds, or because he himself has been neg- 
 ligent in his duty. I have cut a number of such patients, who had already 
 undergone the operation several years previously. 
 
 What comment more striking than this is necessary to confute the 
 .claims of those who assert that internal urethrotomy, if only the incision 
 be deep enough, will radically cure stricture ? Here all morbid tissue is 
 cut under the eye, -including the healthy tissues and skin, and yet recon- 
 traction follows, unless a sound be continuously used. Stricture of large 
 calibre in the pendulous urethra is one thing; deep organic stricture 
 is another. 
 
 But recontraction is not invariable after perineal section. I cut with- 
 21
 
 322 THE VENEREAL DISEASES. 
 
 out a guide, about nine years ago, a boy with impermeable stricture, re- 
 tention, and overflow, who had already been cut by a surgeon two years 
 previously, in the perineum, for the same stricture. The patient had fallen 
 on the crotch when a child, and crushed his perineum, a part of which, 
 with some of the urethra, had sloughed away. After his first operation, 
 sounds had been passed seven times by his surgeon, on each occasion 
 under an anaesthetic, and then the boy had been told he was well. 
 
 In this case I followed the patient up, and have seen him this year (1879). 
 For a year or more, a sound was passed weekly without ether, then at 
 gradually lengthening intervals, until, six years after his cut, the sound 
 was passed only once a quarter. Then six months went by, and there was 
 no recontraction ; finally, after an interval of a year, the boy, meantime, 
 having grown enormously and developed in every way, I examined his 
 urethra, and found that the strictured point was two sizes larger than it 
 had been the year before, at the last examination. I then considered him 
 cured, and he has remained perfectly well, so far as his urethra is con- 
 cerned. This case is certainly exceptional. I only refer to it as an au- 
 thentic instance of cure of deep organic stricture after perineal section. 
 
 PEBINEAL SECTION WITHOUT A GUIDE. 
 
 This operation is a formidable one on account of the element of un- 
 certainty which it involves. Generally it is finished quite promptly, even 
 under the employment of great care and all known means to insure the 
 safety of the patient; yet the best surgeons have worked hours over a case 
 without reaching the bladder. An excellent surgeon in New York, on 
 one occasion, failing to enter the bladder, when daylight deserted him, 
 at the close of an afternoon's hard work in cautious attempts to find a way 
 into the bladder in such a case, sent his patient back to the wards, and an- 
 nounced to the surgeons standing around that the operation would be 
 resumed at two o'clock on the following day. Generally, I repeat, the op- 
 eration without a guide is easy to a cool-headed surgeon, only a few 
 minutes being required after the front face of the stricture is exposed 
 before a passage into the bladder is obtained; but, in spite of this, no one 
 can afford to laugh at the difficulties of the operation, and no prudent 
 surgeon will undertake it without an abundance of daylight before him. 
 One incident, which I witnessed, may serve to impress the reader, both 
 with the difficulties occasionally encountered in the operation, and with 
 the folly of those who pretend that a guide should be used only by be- 
 ginners. No reputable surgeon can afford to disregard any aid to an oper- 
 ation which gives the patient a greater chance for his life. All operations 
 upon the deep urethra are capital, and involve the issues of life and death. 
 
 The case I have just referred to is the following: a young, but per- 
 fectly competent surgeon, attempted perineal section without a guide, in 
 a case of impermeable stricture. After long and cautious work he failed 
 to reach the bladder, having passed under and to one side of the mem- 
 branous urethra, and reached just beyond the apex of the prostate. The 
 patient had no retention, and the surgeon, after appealing to those around 
 him, determined to postpone any further work for the day, when a sur- 
 geon in high position and with a widespread reputation as a general oper- 
 ator, entered the operating-room. He was told the condition of affairs, 
 called for a silver catheter, passed it through the meatus, put his fingor 
 iitto the wound and manipulated for a moment. Presently he depressed
 
 STRICTUEE OF SMALL CALIBRE. 323 
 
 the handle of the catheter with some force, and called for a bowl. Clear 
 urine flowed through the catheter, and with a smile of satisfaction, amid 
 a spontaneous burst of applause from the assembled doctors, the surgeon 
 withdrew. 
 
 At the autopsy on the following day a round hole was found passing 
 through one lobe of the prostate into the bladder. 
 
 The operation of perineal section without a guide calls for the same 
 preparations as if a guide were to be used. A few fine probes, directors, 
 and a female catheter, are also necessary. A last attempt under ether 
 should always be made to pass a whalebone guide. Failing in this, the 
 grooved sound or catheter is introduced as far as the front face of the 
 stricture, entrusted, with the scrotum, to an assistant, arid central inci- 
 sions are made as before, the point of the sound exposed, the long threads 
 passed, and the loops handed to assistants. 
 
 Now the operator carefully, with fine whalebone or silver probes, 
 searches cautiously on the front face of the stricture for the way through 
 into the bladder. To aid him he may enlarge any existing perineal fis- 
 tula, and try by that route to reach the posterior face of the obstruction 
 within the urethra. Posterior catheterism has been and may again be 
 tried from the bladder through an opening made above the pubes, or 
 puncture of the (perhaps) dilated urethra behind the stricture ; but I 
 think that neither of these processes is advisable for general use. 
 
 Usually the best guide to the bladder is a clear anatomical understand- 
 ing of just where the hole in the triangular ligament is, and in what re- 
 lation that hole stands to the lower edge of the subpubic ligament. 
 This lower edge of the subpubic ligament can always be felt; and be- 
 neath it, exactly in the middle line, about three-quarters of an inch below 
 the symphysis, varying a little in different subjects, lies the hole in the 
 triangular ligament. This hole is generally the operator's objective point. 
 The tendency is to cut too much at first and to probe too little, until the 
 operator loses his bearing in the solid mass of tissues matted together by 
 prolonged inflammation; and once fairly off the track, he rarely recovers 
 his position by any other means than accident. Patient and judicious 
 probing, with a little careful cutting in the anatomical position of the 
 closed urethra, is generally rewarded with prompt success; the probe soon 
 passes on without obstruction for a considerable distance in the direction 
 of the bladder, another probe may be pushed alongside of the first, and 
 a separation of these two allows a little bloody urine to flow out. The 
 tight ring surrounding the probes may now be carefully followed up with 
 the knife for a short distance, the area of the canal widens, a female ca- 
 theter passes readily alongside the probes, and a gush of bloodless urine 
 through it announces that the bladder has been reached. 
 
 One of the most common causes of failure in this operation is the ex- 
 istence of a false passage, starting from the front face of the stricture, 
 the result of some former rude attempt to pass the stricture with a solid 
 instrument. The surgeon may be led on by such a false route far astray, 
 and find his mistake only after he has hopelessly lost his bearings among 
 the diseased tissues. It is well, therefore, not to follow up any inviting 
 sinus without first dilating it a little and learning whether it leads in the 
 proper direction. 
 
 After the bladder has been reached, the operation of perineal section, 
 with and without a guide, are one and the same. No further description 
 of the remaining steps is therefore necessary, since they have been al- 
 ready given. I desire to repeat here, however, that on no account is any
 
 324 THE VENEREAL DISEASES. 
 
 instrument to be left in the bladder after the operation; and on no ac- 
 count is the patient to be discharged as cured until he has been taught to 
 pass a full-sized conical steel instrument for himself, and has been im- 
 pressed with the necessity for doing this with regularity, at weekly inter- 
 vals, until he can demonstrate to the satisfaction of a surgeon that no 
 further recontraction is taking place. 
 
 UBETHRAL FEVEB. 
 
 All operations upon the deep urethra contain an element of danger to 
 life. The simple passage of a catheter, the introduction even of a single 
 smooth sound, has been followed by death within twenty-four hours, the 
 patient dying with a high temperature, following chill more or less severe 
 and prolonged, and the autopsy showing nothing worse, as a lesion, than 
 the remains of a passing congestion of the kidneys. These, of course, 
 are extreme cases. 
 
 Ordinary urethral or urinary fever, however, is very common. It 
 comes on with a chill, sometimes only a cold sensation, and this chill ush- 
 ers in a fever. The chill may occur during the operation or just after it, 
 or anywhere within the twenty-four hours rarely later; perhaps from six 
 to twelve hours after the operation is the time during which chill is most 
 often observed. 
 
 This chill, and the succeeding fever and sweat, commonly mean nothing. 
 They leave the patient prostrated, and feeling weak and miserable for 
 several days, often with a crop of herpes about his mouth. Such attacks 
 of urethral fever occur as well after the simple passage of an instrument 
 which brings no blood, as after the most severe operations. Their cause 
 is unknown. They are far more common in patients with defective kid- 
 neys than in sound men, and more frequent, 1 believe, in nervous, impres- 
 sionable people than in others, especially if fear of the result was felt at 
 the time of the operation. Nervous shock, reflected from the point oper- 
 ated upon to the rest of the body, and especially to the urinary system, 
 seems to be at the bottom of most of the cases. If the kidneys are sound, 
 no evil results beyond temporary depression; if the kidneys are defective, 
 death may rapidly ensue. Hence the necessity of making up one's mind 
 about the probable structural condition of the kidneys before attempting 
 any operation upon, or even exploration of, the urethra. 
 
 And yet diseased kidneys do not necessarily render a patient unfit for 
 an operation. Many a severe operation is done of necessity, upon the 
 urethra and bladder of patients well known to have defective kidneys, 
 and they escape without a chill. 
 
 There seems to be some connection between slight over-distention of 
 a stricture and urethral fever. Thompson mentions the fact, and I have 
 seen cases where a patient will do well enough while using a certain sized 
 sound, but where each attempt to employ a larger size has been followed 
 by a chill. 
 
 In one such case, an old gentleman, finding that dilatation could not 
 be pushed on account of the recurrence of urethral fever, I employed di- 
 vulsion with the effect of curing the stricture by splitting it, and that, too, 
 without giving the old man any chill at all; so that it cannot be the vio- 
 lence of stretching alone which causes chill in these cases, but some per- 
 sistence of irritation in the stretched fibres, for when the fibres are broken 
 by divulsion, no chill, of necessity, follows.
 
 STRICTURE OF SMALL CALIBRE. 325 
 
 It certainly is not urinary absorption, as the French have claimed, 
 which causes urethral fever. The meatus may be widely cut on the floor, 
 at a point where absorption is known to be most active and the lymphat- 
 ics very abundant; yet it is the rarest thing in the world for any urethral 
 fever to follow this operation if no instrument be used farther down the 
 canal, and this, too, in spite of the fact that the urine may be ammoniacal 
 or even putrid. Many old men with diseased bladders, perhaps passing 
 blood in considerable quantities, from raw surfaces kept irritated by the 
 constant use of the catheter, do not have any urethral fever at all for 
 weeks, when on some occasion, perhaps so slight a one as a simple explo- 
 ration of the urethra, often without known cause, a sudden attack of ure- 
 thral fever will come on. 
 
 Consequently, we do not know accurately what urethral fever is, or 
 why it comes at certain times and not at others, or why the same appar- 
 ent combinations of causes will not always produce it. But this much is 
 known quite certainly: that (1) the deeper down the urethra an operation 
 or exploration extends, the more likely is urethral fever to follow; (2) 
 operations near the meatus very seldom cause urethral fever; (3) over- 
 stretching a stricture without rupturing it is more apt to cause the fever 
 than when the fibres are divulsed or cut; (4) one attack by no means pre- 
 supposes another, though the same causes may be brought into play; 
 many a patient has one attack of urethral fever at the beginning of his 
 treatment for stricture by dilatation, and never is troubled again, although 
 the treatment by dilatation is continued; (5) other things being equal, 
 fever and nervous impressionability make urethral fever more apt to occur 
 after interference with the urethra; (6) organic kidney disease makes 
 urethral fever more likely to occur, and more apt to prove fatal, than if 
 that condition did not exist; (7) the occurrence of urethral fever cannot 
 be ascribed to urinary absorption. 
 
 One very serious obstacle to a successful study of urethral fever is that 
 there is no means of knowing whether a given chill following an opera- 
 tion on the urethra or bladder is a chill of urethral fever, or due to some 
 other cause that is, there is no important or essential difference in the chill 
 itself. Thus, an outbreak of malaria following an operation on the urethra 
 is usually mistaken at first for urethral fever; and so also with any chill 
 which may be a starting-point of pyaemia, of epididymitis, cystitis, or of 
 some other malady having nothing to do with the urinary organs. As a 
 general thing it may be said, however, that the chill of urinary fever 
 comes certainly within twenty-four hours of the immediate cause the in- 
 jury to the urethra while chills having some other significance come later, 
 as, for instance, the chill at the beginning of surgical fever following peri- 
 neal section. 
 
 Finally, it may be said of true urethral fever that there is a certain 
 habit about it in some patients. I have known a hospital patient, who 
 persistently through a number of weeks after instrumentation had sharp 
 urethral fever, a temperature reaching 105 Fahrenheit and prostrating 
 him for days, who had his fevers warded off by the treatment which will be 
 given below; and then, after having an instrument passed a few times and 
 escaping chill by these means, it became possible to introduce a sound 
 without taking any precautions, and still no chill followed. 
 
 The study of this malady is curious and instructive, but not very sat- 
 isfactory, because so uncertain. 
 
 Something can be done, however, toward warding off urethral fever 
 and modifying its intensity when it does occur.
 
 326 THE VENEREAL DISEASES. 
 
 Treatment of urethral fever. The most important treatment is 
 such as shall prevent chill, when it is found necessary to operate upon a 
 given urethra. Quinine, formerly much used, is not to be depended upon. 
 I cannot say that it is without value, but long experience with it has 
 made me unwilling to trust to it alone. 
 
 If a patient has casts and albumen in a specimen of urine which 
 does not contain blood, he should be prepared beforehand by treatment 
 for his exploration or operation, as the case may be. He may receive 
 with advantage, for several days before the operation, a mild, thorough 
 diuretic, such as a tablespoonful of the infusion of digitalis containing 
 twenty grains of the citrate or of the acetate of potash, during the third 
 hour after each meal, and he should be encouraged to drink milk and 
 plenty of bland fluids a laxative being added if necessary; this will put 
 him as near as may be on a par with other patients. 
 
 On the night before an operation a laxative should be administered, 
 and ten grains of quinine about two hours before the operation, to get 
 from this drug whatever advantage it may possess, be that advantage lit- 
 tle or great. Fifteen minutes before the operation, ten minims of Magen- 
 die's solution of morphia may be thrown under the skin, and immediately 
 after the operation fifteen to twenty minims of Squibb's fluid extract of 
 jaboraudi may also be inserted under the skin. Among these remedies I 
 estimate as most important the morphine, next the jaborandi. With the 
 jaborandi alone I have succeeded in stopping chill in persons who had 
 chill habitually whenever the urethra was interfered with. My experi- 
 ence with jaborandi, however, is quite recent, and I am unwilling to rank 
 it very high as a preventive of chill, for fear that a more extended trial 
 may disappoint me in my estimate. 
 
 If chill comes on, it is best treated, I believe, by the immediate admin- 
 istration, during the cold stage, of twenty minims of chloroform, to be 
 repeated in fifteen minutes if the chill has not disappeared or is not sen- 
 sibly modified. A small subcutaneous dose of morphia may be adminis- 
 tered at the same time. Chloroform is best given in glycerine and water. 
 If the chloroform be first thoroughly mixed with about four parts of gly- 
 cerine, it may be afterward diluted to any extent with water, without be- 
 coming separated and falling to the bottom of the glass, as chloroform 
 ordinarily does when thrown into water. This mixture is quite sharp to 
 the mouth, and requires plentiful dilution with water. As soon as the 
 chill breaks, a warm drink, preferably without alcohol, aids in starting 
 the perspiration and helps to shorten the attack. By a judicious appli- 
 cation of these means, ordinary urethral fever may be much modified. 
 
 Not so, however, I fear, in malignant cases those which kill in twenty- 
 four hours. I have not encountered such a case for many years, but their 
 character is so desperate that it seems hopeless to do anything. In one 
 case which I had an opportunity of observing closely, the chill a sharp 
 one followed the operation (internal urethrotomy) promptly, and was in- 
 tense in character. High fever came on rapidly, with profuse purging 
 and vomiting, intense headache, and delirium. Death quickly ended the 
 scene. One ureter was found occluded, and both kidneys diseased. The 
 case was one of unavoidable operation, and a record of it was published 
 at the time. 
 
 During the after-treatment of operations, urethral fever is not very 
 apt to come on, whether it has or has not attended the operation. During 
 all such after-treatment, it is desirable to keep the urine bland and unir- 
 ritating, by the use of plenty of watery fluids, abstinence from alcohol in
 
 STRICTURE OF SMALL CALIBRE. 327 
 
 any shape, and the use, if need be, of the citrate of potash in moderate 
 (gr. x.) doses during th'e third hour after eating, three times daily, largely 
 diluted with water. I have sometimes thought that the influence of cold, 
 of indigestion, and possibly even of moral emotions, put a patient into a 
 condition where he was more apt to have urethral chill than when his 
 mind was easy, his stomach content, and his nervous system not depressed.
 
 CHAPTER VI. 
 
 GONORRHCEA IN THE FEMALE. 
 
 Symptoms, Complications. Treatment. Local Treatment. How to wash the Vagina. 
 Medicated Vaginal Injections. Chronic Urethritis and its Treatment. Chronic 
 Cervicitis. Sterility in Women following Gonorrhoea. 
 
 GONORRHCEA in the female is generally an intense vaginitis. A vagi- 
 nitis may occur which is not due to the contact of gonorrhoeal pus, pro- 
 duced perhaps by prolonged and excessive irritation in sexual intercourse, 
 by masturbation, and in various ways; by rape, or by the violence of sex- 
 ual intercourse during the first approaches where there is no rape. Again 
 it may be due, especially in young children, to the presence of thread- 
 worms, which have escaped from the anus and reached the vagina. It 
 may also be found in a more or less acute or chronic state in connection 
 with uterine diseases of various character, Avith pregnancy, or with syphi- 
 lis due to mucous patches, and the acrid discharges therefrom. Indeed, 
 there are a great variety of causes capable of producing vaginitis, which 
 are themselves not at all gonorrhoeal. Yet the same statement may be 
 made regarding these inflammations as was made concerning urethritis in 
 the male, namely, the inflammation is apt to run higher in true gonorrhoea 
 than when the cause is not virulent; but the treatment, under all circum- 
 stances, is to be graded according to the intensity of the inflammatory 
 process, and not according to its cause. 
 
 Gonorrhoea in the female does undoubtedly attack many other struc- 
 tures besides the vagina. Both sets of labia may be included in the in- 
 flammatory process; the vulvo- vaginal gland on either side is frequently 
 attacked; the urethra does not always escape, and the malady may involve 
 the bladder; finally, the uterus and the ovaries may also pay tribute to 
 the general inflammation, and that, too, in a most serious manner. 
 
 Symptoms. The first symptoms of gonorrhoea in the female come 
 on shortly after the application of the cause, if that cause be a combina- 
 tion both of local violence and of virulent pus, as is often the case. When, 
 however, there has been no violence, the period of incubation is of several 
 days' duration, as it is in the male, after which the patient makes complaint 
 of a feeling of heat, weight, and itching about the vulva. This is attended 
 by smarting during urination, not because the urethra is the seat of disease 
 although it may also be involved from the first but because the ostium 
 vaginae, the labia minora, and perhaps the orifice of the urethra are swol- 
 len, inflamed, excoriated, sensitive, and are scalded and irritated by the 
 contact of the acrid urine. 
 
 A secretion of pus soon begins to show itself. This flowing out mats 
 the hairs together, and partly drying into sticky scabs upon the vulva, 
 mixed with sodden epithelium and rancid sebaceous matter, goes into rapid 
 decomposition, and emits a disgustingly offensive odor. The labia become 
 excoriated and swell up with oedema, so that walking or sitting may be- 
 come quite painful.
 
 GONORRHCEA IN THE FEMALE. 329 
 
 Meantime, should the inflammation travel down the ducts, as it may, 
 and take possession of one or both of the vulvo-vaginal glands, a serious 
 complication ensues in the shape of a slow and painful suppuration of the 
 gland, which may so increase the local swelling and pain, as to make 
 walking practically impossible. 
 
 The amount of pus discharged increases rapidly. It becomes thick, 
 green, and offensive, perhaps mingled with blood. In acute cases the in- 
 side of the vagina becomes raw and painful, so that any attempt to intro- 
 duce a distending instrument into the canal occasions great pain. 
 
 This condition of affairs may continue for several weeks, prolonging 
 itself for months, perhaps, in debilitated patients in a subacute or chronic 
 form. The duration of the malady is greatly influenced by treatment. 
 An uncomplicated case, although quite acute, ought to be practically un- 
 der control in from three to five weeks. 
 
 Should the uterine canal take fire, as it may, intra-uterine inflamma- 
 tion, abscess of the Fallopian tubes, ovaritis, and pelvic-peritonitis are 
 among the possible complications. They are not very common, but they 
 do occur, leading sometimes to a fatal result. The symptoms of these 
 various maladies find their description naturally in text-books devoted to 
 the consideration of uterine disease. There is nothing peculiar or special 
 about them to rank them as venereal in any sense, excepting that of coin- 
 cidence, and the nature of the cause does not modify the treatment ordi- 
 narily applicable to the same morbid states due to other causes not vene- 
 real. Consequently, there is no occasion to do more than mention these 
 possible complications here. 
 
 Such other complications, as vulvar abscess, not in the vulvo-vaginal 
 gland, peri-vaginal suppuration and abscess of one or more of the ingui- 
 nal glands, are exceptionally uncommon with vaginitis, although occasion- 
 ally encountered. 
 
 Treatment. Rest and absolute cleanliness are two factors essential 
 to the proper treatment of vaginal inflammation. The patient should be 
 forced to keep her bed. This she will the more willingly do as the grade 
 of the inflammation runs high, since very often the pain on attempting to 
 get about is considerable. 
 
 No collection of pus about the vulva should be allowed. The parts 
 should be constantly washed with mild (half of one per cent.) solutions of 
 carbolic acid, or a little Labarraque solution in water, or with water tinted 
 to a faint purple with permanganate of potash. Thin cloths, moistened 
 in one of these solutions, should be kept constantly upon the vulva. It is 
 well also, for the sake of cleanliness, to cut away the hairs. Frequent 
 warm sitz-baths of short duration, one every two to three hours, are very 
 useful, and are comforting to the patient as well. 
 
 Should abscess form in the vulvo-vaginal gland, no modification in the 
 treatment is called for. A poultice is not necessary, and does not give 
 any more relief than the moist applications and the warm local baths used 
 for the sake of cleanliness. When pus forms it may be let out by a free 
 incision, but the integument should not be incised until the pus has nearly 
 reached the surface, since abscess in this region frequently disappears by 
 absorption. Sometimes the abscess discharges through or alongside the 
 duct. 
 
 After abscess of a vulvo-vaginal gland has discharged spontaneously, or 
 has been opened by the surgeon, the thickening about the gland continues 
 for a long time, and the opening remains fistulous. The discharge from 
 such a fistula may get to be very annoying, and the pus which Hows away
 
 330 THE VENEREAL DISEASES. 
 
 is believed by many long to retain infectious properties. When, there- 
 fore, this condition of things exists, and seems likely to continue, three 
 courses are open to the surgeon: injection by iodine, cauterization, exci- 
 sion. 
 
 Injection by iodine cannot be relied on. In some mild cases, however, 
 in atonic subjects it may so stimulate the sluggish cavity of the abscess 
 as to produce granulations which fill it up if the fistula be dependent, so 
 that the discharges may drain away as soon as formed. 
 
 Incision with cauterization is an effective means of curing these chronic 
 abscesses. The incision should involve the opening (or openings if there 
 be more than one), and lie in the long axis of the labium. It should be 
 very free and largely open up the cavity of the abscess. After arresting 
 the flow of blood, the fistula and abscess should be thoroughly cauterized, 
 either with pure nitric acid, a stick of nitrate of zinc, chloride of zinc, or 
 nitrate of silver, or any efficient caustic, the point being to do it thoroughly. 
 Cauterization may be very efficiently performed in these cases with a 
 Pacquelin's naphtha cautery, or with the electro-cautery. The wound may 
 be packed with carbolized cotton or oakum, and poulticed after forty- 
 eight hours to assist the separation of the slough. As soon as the wound 
 cleans up it may be dressed with pure balsam of Peru, and usually goes 
 on at once to rapid granulation and cicatrization. 
 
 Excision is equally or more effective than the preceding treatment, 
 and quicker in its results. It consists in cutting down in the long axis 
 of the labium upon the inflamed hard tissues, representing the remains 
 of the gland and dissecting them out bodily. The wound is dressed sim- 
 ply and left to granulate. 
 
 But to return to the acute gonorrhoea in the vagina local treatment 
 must be relied upon for its cure. An alkaline diuretic may be adminis- 
 tered by the mouth to make the urine less scalding when it comes into 
 contact with the abraded vulva; but the balsams, so useful in the male, are 
 of little or no value in the female, because the urethra is not the main 
 seat of the disease. Some good may be effected by these remedies in 
 gonorrhoeal conditions of the urethra and bladder, but they do not con- 
 trol the main malady vaginitis. 
 
 The abortive treatment of vaginal gonorrhoea, once much vaunted, 
 does not seem to hold its place in the estimation of authors. Certainly 
 it often fails, and when it fails the patient's condition is worse than if it 
 had never been tried. Its value is so problematical that it cannot be 
 recommended. 
 
 The rational local treatment of gonorrhceal vaginitis is one which 
 regulates the strength of the local application by the stage and intensity 
 of the inflammation, and the effect produced. Cleanliness within the 
 vagina is as necessary as it is outside. The pus must be washed away 
 from the irritated mucous membrane, and the oftener this is done the bet- 
 ter. All instrumentation within the vagina is painful during the acute 
 stage of gonorrhoea, but nevertheless, no washing of the canal can be 
 effective except through an instrument introduced well up to the cervix. 
 Nothing is better for this purpose than the ordinary glass vaginal 'tube 
 of the common fountain syringe. Davidson's syringe has the defect of 
 throwing in the fluid spasmodically and with too much force both for 
 comfort and the safety to the uterus. 
 
 Washing the vagina may be conveniently effected as follows: The 
 patient lies flat upon the back, with the hips raised several inches higher 
 than the shoulders, and the buttocks resting either in a bedpan or upon
 
 GONORRHOEA IN THE FEMALE. 831 
 
 a large rubber sheet in which a crease is made for the purpose of conduct- 
 ing the fluids as they flow out of the vulva over the side of the bed into 
 a vessel suitably placed to receive them. 
 
 A large fountain syringe (or simple rubber bag with rubber tube and 
 long glass nozzle), filled with water as hot as can well be borne by the 
 vagina, varying from 98 to 110 Fahrenheit, or more in some cases, being 
 ready, the glass vaginal nozzle warmed and well oiled is slowly in- 
 troduced carefully along the posterior vaginal wall until its point has 
 been carried well up into the vaginal pouch behind the posterior lip of 
 the uterus. In this pouch secretions are apt to collect and to remain, 
 since ordinary irrigation hardly reaches them. 
 
 As soon as the glass tube is in place, the rubber bag is to be gently 
 raised, and shortly after the pus and water begin to flow away at the 
 vulva, it is again to be raised higher so that the force of the flow of 
 water may be increased. If the end of the tube lies behind the poste- 
 rior lip of the cervix the force of the flow cannot do harm. The posi- 
 tion of the body and the gradually increasing and finally maintained force 
 of the flow of fluid first distends the vagina fully, and then washes it out 
 thoroughly from its deepest part. 
 
 After one bag of water has flowed through the vagina, if the pus 
 has not been all washed out, the bag may be refilled and the process re- 
 peated. This vaginal washing may be renewed several times during the 
 twenty-four hours, more or less frequently according to the rapidity of 
 pus formation. 
 
 Instead of using simple hot water with which to wash the vagina, a 
 little salt may be added, or chlorate of potash or borax, one to three tea- 
 spoonfuls to the pint, not strong enough to produce any effect of which 
 the patient may be made conscious by her sensations. 
 
 From the very commencement of the treatment medicated injections 
 may be employed, after the vaginal wash, for the purpose of restraining 
 the activity of the pus formation, and keeping the inflammation within 
 reasonable bounds. These injections should never be made from without, 
 inward, or into a vagina full of pus, but should be thrown gently into 
 the depths of the vagina after the canal has been washed. The injec- 
 tions are to be made preferably with the same tube through which the 
 washing has been effected. The medicated injection must, therefore, be 
 put either into the fountain syringe after the water has all escaped, or 
 the tube may be uncoupled and fitted by a piece of rubber to whatever 
 syringe it is proposed to employ. It is better not to withdraw the vagi- 
 nal tube for the purpose of introducing another. 
 
 The substances to be employed with advantage in the vagina are sim- 
 ilar to those found useful in the urethra of the male. It is not well to 
 try a great number, one after the other, but to use one or two, varying 
 the strength according to the effect. In watching the effect of an injec- 
 tion, it is always well to commence with a mild solution, and to increase 
 the strength, if it is well borne, until it either modifies the quantity of the 
 pus or commences to produce irritation. If the former result is reached, 
 the injection is doing good; if the latter, it must be abandoned and an- 
 other one tried. Medicated injections should always be heated before be- 
 ing thrown into the vagina, and they should be introduced in a continu- 
 ous stream, flowing without much force. The substances which may be 
 employed in solution, in the acute stage of vaginitis, are dilute lead-water; 
 pure sulphate or chloride of zinc, commencing at half a grain to the ounce 
 of water and increasing; lactic acid, half a minim to the ounce and increas-
 
 332 THE VENEREAL DISEASES. 
 
 ing; bisulphate of quinine, one grain to the ounce and increasing, dissolved 
 in the smallest possible amount of dilute sulphuric acid; or picric acid 
 (Cheron), one grain to four ounces and increasing. 
 
 When some headway has been made in reducing the quantity of the 
 discharge, or making it thinner, other injections may be tried-, such as so- 
 lutions of tannin, alum, red wine, and water, commencing with a weak 
 solution, and running up the strength while the effect is watched. 
 
 As soon as the inflammatory process has so far subsided as to allow 
 the introduction of a speculum, any convenient instrument may be used 
 by the aid of which the walls of the vagina may be thoroughly inspected 
 after the canal has been washed, and the eroded spots of congested 
 membrane may be directly touched with a strong solution of tannin or a 
 moderate solution of nitrate of silver. Such topical applications should 
 be repeated daily, the strength of the solutions being graded according to 
 the effect. At this time, also, advantage may be derived from the use of 
 tampons of absorbent cotton which may be introduced, of small size, 
 through the speculum. Several small packages should be tied up along a 
 string, like a kite-tail, to facilitate withdrawal, for the purpose of absorb- 
 ing the pus as it is formed, and keeping the inflamed surfaces apart. The 
 various forms of absorbent cotton may be used in this way that prepared 
 with carbolic or salicylic acid, with alum, iron, sulphate of zinc, etc. or 
 the physician may apply powders or solutions of any strength, upon one 
 of these small tampons. By these means, without discomfort to the pa- 
 tient, a constant application of any substance desired may be maintained. 
 
 Finally, when the discharge has nearly ceased, the spots from which it 
 exudes must be sought out by the aid of the speculum, and treated by 
 gentle pencilling with nitrate of silver, or by astringents directly applied. 
 Cheron thinks well of the application of pure glycerine to inflamed sur- 
 faces in the vagina. 
 
 The different forms of vaginal suppository, found in the shops, do not 
 yield as satisfactory results as might be expected of them. They seem 
 appropriate, but like the urethral medicated bougies for the male, they do 
 not perform as well as they promise. 
 
 The internal treatment of gonorrhoea in the female is mainly symp- 
 tomatic. Food must be light at first, because the patient is put upon her 
 back and deprived of exercise. Later the food must be strengthened in 
 quality. Laxatives have to be employed, and, finally, perhaps tonics and 
 stimulants. 
 
 A lingering, chronic urethritis, giving no symptoms of which the pa- 
 tient is conscious, but yielding a drop of pus to pressure, upon the ure- 
 thra from behind forward, in the intervals between urination, and tending 
 to prolong itself almost indefinitely as a chronic contagious malady, is 
 spoken of by authors. As treatment, a mild solution of picric acid (one 
 grain to four ounces and increasing) may be injected into the bladder, as 
 advised by Cheron, and afterward slowly voided through the urethra by 
 the voluntary effort of the patient, or, what is better, a solid pointed 
 stick of nitrate of silver may be rapidly passed through the urethra and 
 immediately withdrawn, the process to be repeated once or twice, at in- 
 tervals of about a week. 
 
 The chronic discharges from the canal of the cervix and from the 
 uterus, which are sometimes left behind by a gonorrhoea, belong to the 
 domain of the uterine specialist and yield to the same means that are 
 used successfully to overcome other discharges due to causes not in them- 
 selves virulent/"
 
 GONORRHXEA IN THE FEMALE. 333 
 
 It has been claimed that gonorrhoea in the female is a fertile cause of 
 sterility, that it lingers indefinitely in the uterine neck, so modifying the 
 secretions that the spermatozoa are both mechanically impeded and chem- 
 ically devitalized before they can reach the ovum. It does not seem to 
 me that this point is sufficiently proved to be accepted. Gonorrhoea is 
 certainly very uncommon among respectable women, and particularly 
 common, according to rny experience, among respectable men. Men are 
 certainly sometimes rendered sterile by gonorrhoea, by the mechanism of 
 obliteration of the duct of the testicle as already described. But even in 
 men this result is very exceptionally uncommon, and in women it seems 
 to me that it must be equally uncommon, or even more so. In prostitutes 
 who have gonorrhoea, there are other causes of sterility aside from gon- 
 orrhoea which are capable of explaining the immunity from conception 
 possessed by many of these women.
 
 CHAPTER VII. 
 
 COMPLICATIONS OF GONORRHCEA COMMON TO BOTH 
 
 SEXES. 
 
 Gonorrhoeal Rheumatism. Time of Occurrence, Cause, Parts most often Involved. 
 Chronic Hydarthrosis. The Poly-articular Form. Neuralgia. Bursitis. Nodes. 
 Treatment. Gonorrhreal Rheumatic Iritis, Conjunctivitis, Aquo-capsulitis. 
 Contagious purulent Ophthalmia, its Symptoms, Course, atd Treatment. 
 
 THERE is a form of rheumatism found in connection with gonorrhoea, 
 having peculiar characters, subacute in form, very chronic in duration, 
 and dependent upon the gonorrhoea as a cause. How gonorrhoea causes 
 rheumatism is not known. It is believed to be by a process analogous to 
 a mild pyaemia, but this explanation is hardly sufficient. Women have 
 gonorrhoeal rheumatism with exceptional rarity, and this has been ex- 
 plained on the ground that the vagina and not the urethra is the common 
 seat of gonorrhoea in the female. This is obviously no explanation, but 
 simply the statement of a fact. 
 
 A rheumatism, with certain qualities to be shortly described, attacks 
 certain patients when they have gonorrhoea, and at no other time. It 
 runs a course peculiar to itself, does not yield to the ordinary remedies 
 which are effective against rheumatism, and is not attended by several of 
 the phenomena accompanying ordinary rheumatism. It alternates some- 
 times with troubles in the eye resembling rheumatic affections of that 
 organ, and seems to be due to an idiosyncrasy on the part of the patient 
 rather than any constitutional tendency he may have either to rheuma- 
 tism or to gout. The malady itself, be it sfcid, resembles rheumatic gout 
 more than it resembles either true rheumatism or true gout. 
 
 The time of occurrence of rheumatic symptoms complicating gonor- 
 rhoea is very variable. Fournier places the most common period between 
 the sixth and the fifteenth days of the discharge. It rarely comes earlier 
 than these dates, but may be found very much later, in which case its 
 advent is usually preceded by an increase in the quantity and in the 
 thickness of the discharge. After joint complications have set in, the dis- 
 charge usually abates somewhat, but it does not cease, as it does when 
 certain other complications occur, e.g., an intercurrent attack of epididy- 
 mitis. 
 
 The cause of the malady is the existence of gonorrhoea. Beyond 
 this, nothing is necessary. Cold, a wetting, exposure, diathesis, wrench- 
 ing a joint, privation, bad hygiene, none of these causes need be invoked 
 to explain it. The peculiar idiosyncrasy, whatever that may be, is all 
 that is necessary. Fortunately few possess it. 
 
 The parts most often involved are the joints. Then come the sheaths 
 of tendons, muscles, the structures of the eye, the bursse and the nerves. 
 Cases of gonorrhoeal pericarditis, endocarditis and meningitis are also 
 on record.
 
 COMPLICATIONS OF GONORKIKEA COMMON TO BOTH SEXES. 335 
 
 According to Fournier the sterno-clavicular articulation is a very con- 
 stant seat of gonorrhoeal rheumatism, the knees very often suffer, the 
 ankle comes next, and then the fingers and toes. The bursae, the tendons, 
 and the muscles are involved in an irregular manner in connection usu- 
 ally with troubles in the joints which overshadow them in importance. 
 
 One of the most common forms assumed by this malady is that of a 
 chronic hydarthrosis, most often attacking the knee-joint. This form is 
 generally mono-articular and is apt to relapse in the same individual dur- 
 ing different attacks of urethral inflammation. In a case of bad stricture 
 under my care, the stricture being in the membranous urethra and having 
 been treated by perineal section, the patient during a number of years 
 being careless in his habits and inclined to drink, had repeated attacks of 
 urethral inflammation, not by any means always due to venereal causes. 
 With each attack of suppurative urethritis he suffered simultaneously 
 with some form of gonorrhceal rheumatism, and among these had three 
 or four attacks of hydarthrosis of one or both knees ; he had also, at dif- 
 ferent times, the ocular, bursal, tendinous, arthritic, and muscular symp- 
 toms of gonorrhceal rheumatism, and rarely escaped in less than several 
 months from any attack. My observations embrace a considerable num- 
 ber of cases of gonorrhceal rheumatism, and among them hydarthrosis of 
 the knee has been very common. The ankle and the elbow suffer in the 
 same way, but very much less commonly. 
 
 Taking the knee as type, in a case of hydarthrosis, the serous effu- 
 sion may come on almost without pain; perhaps slowly, sometimes very 
 quickly. The patient finds that he has lost confidence in his knee; it 
 seems unsteady, and perhaps hurts him upon attempting to rise or on 
 going upstairs. With this he is apt to have other unimportant pains in 
 different parts of the body. He now examines the knee to find what is 
 wrong, and is astonished to find the joint distended in an oval way, man- 
 ifestly full of fluid. 
 
 Sometimes the onset of the joint inflammation is attended by consid- 
 erable local pain, but there is no fever, no redness of the skin, no sweat- 
 ing, no excess of urates in the urine; and after the effusion has taken 
 place the pain moderates or disappears entirely, except when the joint is 
 moved or handled. The urethral discharge meantime keeps on unabated. 
 Other joints may now become implicated, but the knee continues swollen 
 instead of getting well, as in ordinary rheumatism. Indeed, the joint 
 first attacked is generally the last to get well, thus earning for the mal- 
 ady the title, mono-articular, even where more than one joint is affected. 
 
 The course of this hydarthrosis is often exceedingly slow. Acute sup- 
 puration, although noted, has been rare. It has been known to prolong it- 
 self for years, and to degenerate in strumous individuals into white swell- 
 ing, and it may go on to an ultimate disorganization of the joint, with 
 final anchylosis. 
 
 The next form of gonorrhceal rheumatism to be considered is the 
 poly-articular variety. This form is nearly as common as the hydarthro- 
 sis, and sometimes coincides with it. The affection closely resembles 
 rheumatic gout, but it is desperately chronic in its course. A patient 
 under my care has had three attacks of this form of gonorrhceal rheuma- 
 tism, each one of which lasted him in the neighborhood of eighteen 
 months. 
 
 The acuteness of the symptoms, in this form of the malady, varies 
 greatly. They may be very mild, simply confined to a little stiffness of 
 the joints upon moving, especially in the morning, or they may go on to
 
 336 THE VENEREAL DISEASES. 
 
 the extent of occasioning very considerable spontaneous pain in the af- 
 fected joints, with redness of the skin at first, and many of the features 
 possessed by joints becoming inflamed in the course of ordinary rheu- 
 matic gout. After some days, however, these acute symptoms become 
 subacute, and the malady assumes its customary march, which is one of 
 tiresome chronicity. In this form of the disease it is customary for sev- 
 eral, perhaps for many joints, to become involved consecutively; but the 
 trouble continues in the old joints, and does not leave them when new 
 joints suffer, as is so apt to be the case in common rheumatism. One 
 or more of the joints implicated in this form of rheumatism may become 
 the seat of secondary hydarthrosis, a phenomenon quite uncommon in 
 ordinary rheumatism. 
 
 The general symptoms are moderate. The fever is absent or not in- 
 tense, and subsides quickly. The urine continues normal, or if charged 
 with urates is so to a degree much less marked than in ordinary rheuma- 
 tism. The sweating, also, is moderate, or absent altogether. 
 
 In this form of gonorrhceal rheumatism, especially when the smaller 
 articulations (fingers and toes) are the seat of the malady, the periosteal 
 and fibrous tissues around the joints seem to share in the inflammation, 
 and the joints become swollen -in a fusiform manner, recalling certain 
 forms of rheumatic gout. These deposits are very slow to disappear. 
 Occasionally they leave distortion of the joint behind them, and, very 
 rarely, anchylosis. 
 
 Finally, in connection with this form of rheumatism, relapsing attacks 
 of erythema nodosum upon the lower extremities have been noted, rheu- 
 matic laryngitis (Libermann) and occasionally pleuritic, endocardial, and 
 pericardial troubles. 
 
 Another form assumed by gonorrhoeal rheumatism is that of pain and 
 inflammation in the muscles, tendons, sheaths of tendons, bursae, and 
 nerves. Such pains are sometimes very acute, they are aggravated by 
 motion and by handling the parts; they are generally worse at night. 
 They are chronic in their course and apt to relapse. A number of 
 weeks, or even months, sometimes pass before they are brought under 
 control. 
 
 The bursae most often implicated are the bursa under the tendo-Achil- 
 lis (the inflammation of which was at one time thought to be pathogno- 
 monic of this form of rheumatism), the bursa under the inferior tuberosity 
 of the os calcis, in front of the patella and behind the olecranon. Other 
 bursae also occasionally suffer, and sometimes in a very acute way. The 
 acute symptoms, however, are rarely of long duration. 
 
 The bursae are very rarely attacked alone. Their inflammation coin- 
 cides most often with the poly-articular form of gonorrhosal rheumatism, and 
 furnishes excellent corroborative evidence as to the nature of the disorder. 
 
 Fournier has called especial attention to a congestive and hyperplastic 
 condition of the periosteum, brought about by gonorrhoeal rheumatism, 
 and found more especially upon those portions of bone which are most 
 prominent, nearest the surface of the body most exposed, in a word. 
 Circumscribed pain, aggravated by pressure, is the symptom which calls 
 attention to these lesions, and examination reveals generally a localized 
 swelling not larger than an inch in diameter, often much smaller. The 
 tissues in such an area are thickened, the skin over them sometimes 
 reddened. Fournier believes that the pain sometimes ascribed to the 
 affection of a bursa or tendon may be due to a deep-seated periostitis 
 the pain under the heel, for example.
 
 COMPLICATIONS OF GONORRIICEA COMMON TO BOTH SEXES. 337 
 
 These periosteal troubles are passing in their nature. In a few days 
 the pain disappears, and resolution takes place. Occasionally the local 
 troubles persist and terminate in a local hard swelling attached to the 
 bone, which takes several months to subside. 
 
 The neuralgias most common in connection with gonorrhceal rheuma- 
 tism attack the lumbar region, or involve the anterior crural or the sciatic 
 nerves. They are neither very common, nor very important. 
 
 Treatment. Gonorrhoea! rheumatism does not yield readily to any 
 treatment. Its peculiarly persistent chronicity is one of the features of 
 the disease. As much rest as possible should be granted to the affected 
 joints, but rest in bed is out of the question for a malady which may 
 (though exceptionally) last eighteen months. 
 
 The hydrarthrosis should be subjected first to the action of multiple 
 vesication. A large number of small blisters, one or two inches in diame- 
 ter, may be consecutively applied, until the whole surface of the joint, ex- 
 cepting the folds and such portions as are put on the stretch during the 
 movements of the joint, has been covered. After this the surface may 
 be kept constantly painted with the strong tincture of iodine and accurate 
 pressure methodically applied, such, for instance, as is obtained for the 
 knee by an elastic knee-cap. 
 
 Alkaline medicines are of little or no value in any of the forms of 
 gonorrhoeal rheumatism, and the same may be said of colchicum, quinine, 
 colocynth, and other remedies used to overcome ordinary rheumatism. 
 There is rarely enough pain to call for opium. Bromide of potassium, in 
 large doses, is often sufficient to meet the indication furnished by pain, ex- 
 cept in connection with some of the acute outbursts of the affection, an 
 acute bursitis, for instance. In such cases a blister will often serve as the 
 swiftest anodyne, and has the advantage not only of controlling the pain, 
 but also of curtailing the malady. 
 
 One remedy, useful in rheumatism, certainly retains some of its power 
 in the gonorrhoaal variety. I refer to salicylate of soda. Doubtless sali- 
 cylic acid or other salicylates would do as well. I have used the salicylate 
 of soda in several cases, pushing it rapidly to the point of producing 
 either some disturbance of the head, the stomach, or the intestines, and 
 then reducing the dose; and I have every reason to be satisfied with the 
 result, which is sometimes unexpectedly prompt. It may fail absolutely. 
 
 The iodide of potassium in moderate, continued doses (gr. v. x. 
 three times a day) seems also to possess virtue in combating some of the 
 more chronic forms of the malady. 
 
 The chronic stages of trouble in the joints, tendons, and bursse are 
 best treated by frictions, massage, and all kinds of manipulation, gentle 
 or severe, according to the intensity of the symptoms, and the effect pro- 
 duced. Sulphur baths, alkaline baths, Turkish, Russian, turpentine, find 
 electric baths, are also quite serviceable in these conditions. Electricity 
 with massage often gives great comfort. The continued current is 
 very useful, although some patients declare that they derive most benefit 
 from the induced current. 
 
 Change of air and sea-bathing will sometimes effect a cure, in a case 
 which drags along hopelessly under all methods. 
 
 GONOEEHCEAL IEITIS. 
 
 During the course of poly-articular gonorrhoeal rheumatism, or alter- 
 natino- with it during different attacks of urethral inflammation, several 
 22
 
 338 THE VENEREAL DISEASES. 
 
 maladies of the eye have been noted, such as are seen, also, sometimes in 
 connection with ordinary chronic rheumatism and rheumatic gout. The 
 iris, the conjunctiva, and the membrane of Descemet are the tissues most 
 apt to be involved. These ocular affections are in no way due to con- 
 tagion. The contact of pus with the conjunctiva produces a very differ- 
 ent malady, one which threatens the existence of the eye, and is very apt 
 to lead to suppuration of the globe. On the other hand, the rheumatic 
 maladies of the eye, dependent upon gonorrhoea as a cause, are never due 
 to contagion, and invariably get well without compromising either the 
 structure of the eye or its function. 
 
 These maladies, therefore, are not clinically of much importance, and 
 their main interest lies in the fact that once a patient suffers from them 
 during the course of a gonorrhoea, he is almost certain, at the time of his 
 next urethral inflammation, to have his eyes involved in a similar manner. 
 
 Symptoms. In this malady the cornea generally becomes somewhat 
 (perhaps considerably) clouded, particularly in its lower portions. The 
 cornea is apt to grow prominent from over-distention with fluid (aquo- 
 capsulitis). The sight becomes imperfect, objects growing misty. The 
 iris, the main seat of the malady, does not show much change in color. 
 The pupil may be slightly dilated and irregular, or normal. The move- 
 ments of the iris are abolished or quite sluggish under the action of light. 
 Adhesions are not common, although plastic exudations do occur. There 
 is generally mild lachrymation, slight photophobia, and uneasiness rather 
 than pain in and about the eye. 
 
 The conjunctiva may be alone the seat of an injection (Fournier) in 
 the course of gonorrhceal rheumatism marked by slight redness and 
 swelling of the conjunctiva, some uneasiness or perhaps no pain at all, 
 and a scanty muco-purulent discharge. 
 
 The course of this iritis is generally rapid, sometimes quite slow. 
 Untreated it may result in adhesions of the iris, but the milder cases get 
 well spontaneously. Both eyes are apt to suffer, more often consecutively 
 than simultaneously. The diagnosis of the affection is easy. It could 
 hardly be possible to confound it with purulent conjunctivitis due to con- 
 tact with gonorrhceal pus on account of the intensity of the symptoms 
 in the latter malady. 
 
 Treatment. If the conjunctiva alone is involved, it is sufficient to 
 wash the eye with warm water containing a little salt, or to use a solu- 
 tion of one grain of sulphate of zinc in the ounce of water, and to shield 
 the eye from light. The patient may go about as usual. 
 
 A certain amount of aquo-capsulitis does not call for any excessive 
 precautions. A little atropine may be used in addition to the means 
 already indicated, and the fluid will generally disappear after a few days. 
 If the tension becomes very great, the anterior chamber may be tapped, 
 and the fluid allowed to escape. 
 
 When the iris is lightly involved instillations of a solution of atropine 
 (gr. ij. to the 3 i.) should be made daily into the eye, or oftener if neces- 
 sary, to keep the pupil dilated, and the eye should be carefully shielded 
 from light. In more severe cases inunctions of belladonna ointment and 
 of oleate of morphia about the eye are called for ; tonics, good diet, change 
 of air in chronic cases, and a leech to the temple or a blister behind the 
 ear. It is questionable whether the internal use of mercury is of any 
 especial value in this malady. Chronic cases demand quinine, tonics, 
 time, and what is perhaps best of all, change of air.
 
 COMPLICATIONS OP GONORRIKEA COMMON TO BOTH SEXES. 339 
 CONTAGIOUS PURULENT OPHTHALMIA. 
 
 This serious malady needs the force of no new illustration to testify 
 to its malignity, yet I may be pardoned for reporting a single case to en- 
 force upon the physician the necessity of instructing the patient at all 
 times in relation to the virulence of his malady, and the danger he runs of 
 losing his sight, should he inadvertently inoculate his conjunctiva with 
 the secretions from his own urethra. 
 
 A young man passing through New York, consulted me for a commen- 
 cing gonorrhoea, his first attack. I saw him but once and gave him proper 
 instructions. Possibly, I was not forcible enough in my warnings about 
 the eyes, but whatever the cause, it turned out that upon the evening be- 
 fore leaving town for the country the patient experienced a feeling as if 
 there were sand in the eye. Arrived at a country town one eye was 
 quite inflamed, and the physician of the place was summoned. This gen- 
 tleman declared the attack to be due to cold, and treated it with mild eye 
 washes, etc. The other eye now took fire. Pain was intense, the dis- 
 charge profuse. The young man was ashamed to acknowledge that he 
 had a gonorrhoea, and he was lulled into security by the assurances of 
 his physician that all would go well. One of the members of the family, 
 however, wrote to me to ask for what the boy had consulted me, and to 
 inquire whether any bad result was to be dreaded from the fierce inflam- 
 mation of both eyes already several days old. 
 
 My instant reply was that sight was threatened, and that the best ocu- 
 list within reach must be summoned. This was done, but almost too late, 
 for after a long and painful illness this patient finally only recovered with 
 the perception of the difference between light and darkness and the power 
 to distinguish large moving objects in a full light. His distorted iris was 
 attached on either side to a misshapen scar constituting the cornea. The 
 beauty had gone out of his eyes and almost their use forever. 
 
 Gonorrhoea, perhaps more than all maladies, throws a responsibility 
 upon the surgeon which he cannot escape. It is his duty, as a part of the 
 treatment of the disease, to dwell again and again upon the danger the 
 patient runs of contaminating himself with his own secretions. If the 
 patient has been thoroughly impressed upon this point, and then by acci- 
 dent infects himself and through shame fails to put any new medical at- 
 tendant upon the right track as to the cause of his malady, he has him- 
 self to blame for the result and cannot accuse his first physician. 
 
 A patient with gonorrhoea should wash his hands each time after 
 handling his penis. All wraps and articles contaminated with the pus 
 should be destroyed. After washing his hands, the water should be in- 
 stantly thrown away, and the towel used to dry his hands upon should 
 not be used for any other purpose. In the same manner, when the sur- 
 geon touches a patient's eyes which are suffering from this virulent in- 
 flammation, he must use all possible precautions not to carry the contagion 
 further, and all dressings, which have been once defiled by contact with 
 the poisoned pus flowing from the eyes, must be immediately destroyed. 
 
 Fortunately, gonorrhceal ophthalmia is rare, doubtless due to the fact 
 that the danger to the eye of contact with gonorrhceal pus is quite gen- 
 erally understood among the people. The disease is not often double at 
 the start, but it is very apt to become double during its course, unless 
 great care be taken to shield the well eye while the other is being treated. 
 
 Symptoms. Within a few hours after contagion the eye feels dry 
 and itching, as if sand were beneath the lids. The eye waters a little from
 
 340 THE VENEREAL DISEASES. 
 
 the start, and the conjunctiva promptly becomes red, the lids slightly 
 oedematous. The preaural lymphatic gland swells and becomes painful 
 to the touch. 
 
 The pain, swelling, and discharge increase with wonderful rapidity. 
 The upper lid swells so much and so rapidly that it soon completely covers 
 the lower lid, and lies out prominently upon the cheek, red and oedema- 
 tous. 
 
 The conjunctiva beneath is the seat of enormous swelling. It becomes 
 highly vascular, looking raw, sometimes livid in color, raised into a thick 
 border around the cornea (chempsis), which lies at the bottom of the cup 
 formed by the swollen conjunctiva, generally drowned in pus. A diph- 
 theritic exudation into the substance of the conjunctiva is quite frequent 
 in these cases. The membrane can be seen but cannot be lifted from the 
 conjunctiva, since the deposit is interstitial and not superficial. 
 
 The pus, green and thick, flows out abundantly upon the cheek, 
 thinned from time to time by a gush of tears, sometimes tinged with blood. 
 The lids partly stick together with the thick incrustations of matter which 
 incessantly flow away. The epithelium upon the cheek becomes sodden, 
 perhaps soaked away by constant contact with the acrid secretions. 
 
 The cornea soon gets into difficulty from strangulation by the chemo- 
 sis. It becomes at first troubled, then softened at the edge at points un- 
 derlying the swollen conjunctiva, and so rapidly do the morbid changes 
 occur, that within twenty-four hours from the commencement of the af- 
 fection the cornea may have ulcerated to the point of perforation. Ab- 
 scess may form in the cornea and discharge externally, followed shortly 
 by a giving way in the posterior wall of the abscess, which allows the 
 fluid to escape from the anterior chamber and the iris to protrude at the 
 opening. Again, the whole cornea may ulcerate peripherally and drop 
 out like a watch-glass, and this may be followed by an escape of the crys- 
 talline lens and suppuration, with destruction of the entire contents of 
 the globe. 
 
 Meantime, pain is often most intense and photophobia extreme. The 
 pain is felt not only in the eye but all around it. There may be little or 
 no fever (unless the globe suppurates), but profound depression of spirits 
 is the rule. A sense of some impending catastrophe seems to overwhelm 
 the sufferer. 
 
 Treatment. When one eye is found to be the seat of contagious 
 purulent ophthalmia, it becomes the physician's duty immediately to pro- 
 tect the other eye. This cannot be done in any better way than by lint 
 (scraped), a piece of bandage, and some collodion. A thin piece of gauzy 
 material, cut round, is first placed over the lid, then enough scraped lint 
 is placed upon it to make a cushion and allow a little pressure to be made 
 by the final seal, which is composed of several superposed layers of coarse 
 cotton cloth, cut round and soaked in collodion. These last layers become 
 attached by the collodion to the integument of the upper lid, the nose, 
 and the cheek, and absolutely shut out the eye from the rest of the world. 
 This bandage may be removed, after twenty-four hours, in order to be 
 certain that the conjunctiva had not been already contaminated before it 
 was applied. If at such inspection the conjunctiva is found sound, the 
 dressing may be reapplied with the absolute certainty that whatever hap- 
 pens to the inflamed eye, the other will certainly be preserved sound for 
 the patient's future use. 
 
 The curative treatment of purulent contagious conjunctivitis rests 
 upon cleanliness, relief of strangulation, and arrest of suppuration.
 
 COMPLICATIONS OF GONORRHOEA COMMON TO BOTH SEXES. 341 
 
 Cleanliness must be maintained through the whole course of the affec- 
 tion. Poulticing is out of the question, since it retains the secretions. 
 Frequent washings with cool water are to be practised, and the edges 
 of the lids left always smeared with vaseline. This prevents their stick- 
 ing together, and the vaseline itself does not become rancid. The wash- 
 ings should be done with a large camel's-hair pencil, or by squeezing water 
 from a soft rag, not with a syringe, for fear of the sputtering which might 
 scatter some of the infectious pus into the eyes of the nurse while per- 
 forming the dressing. Anything that touches any pus from the eye must 
 be thrown away at once or immediately disinfected in a solution of per- 
 manganate of potash, or other equally good disinfectant. These washings 
 may be repeated, with advantage, hourly, or at such intervals as may be 
 called for by the accumulation of pus. 
 
 Next to cleanliness, or perhaps before it, comes the necessity of keep- 
 ing down pus formation. This is to be effected by' local applications, 
 first of cold, second of caustics. Thin compresses, soaked in iced water, 
 and constantly changed, should be applied to the eye. A night nurse, 
 as well as a day nurse, is called for to perform this arduous task. Every 
 few minutes these compresses must be changed, or they heat up and be- 
 come poultices agents of mischief. The colder the eye is kept, the bet- 
 ter, and the means which can effect this most continuously should be em- 
 ployed. Small quantities of pounded ice in a condome have been sug- 
 gested (Grand), and might serve well in some cases, but after the vitality 
 of the cornea is threatened and ulceration has commenced, it is well to be 
 prudent in the use of ice, or to suspend it altogether. 
 
 Among the local applications used with the view of keeping down pus 
 formation, the nitrate of silver in solution holds the first rank. It is of 
 value when the pus begins to be freely formed, and the strength of solu- 
 tion employed, as well as the frequency of the applications, is decided by 
 the violence of the flow of pus and by the effect of the applications upon 
 it. It is best to use the nitrate of silver in solution, on account of the 
 difficulty of touching all parts of the inflamed conjunctiva with the solid 
 stick. It is well to employ two solutions: one quite mild, from gr. iij. to 
 gr. vi. to the i. of water, to be applied every two or three hours; and 
 another, much stronger, from gr. x. up to 3 i- to the 3 i., to apply at in- 
 tervals when the secretion of pus becomes too considerable to be held at 
 all in check by the milder solution. The strength of the caustic solution 
 of course must be regulated by the effect upon the pus-forming process. 
 If a reasonably mild solution will hold it in check, so much the better; if 
 not, recourse may be had at each application, after an interval of eight to 
 twelve hours, or longer, if the solution is quite strong, to a solution of 
 greater strength, until the desired effect has been attained, after which 
 the intervals between the applications may be lengthened, or their strength 
 diminished. 
 
 In making applications of the nitrate of silver to the conjunctiva, the 
 lids should be everted as much as possible, and the application made in 
 the main upon the palpebral conjunctiva; that upon the globe is of less 
 importance, and every effort should be made to avoid getting any of the 
 solution upon the cornea already devitalized by the strangulation of the 
 vessels supplying its nourishment, and especially since it may permanently 
 discolor the cornea. The conjunctival culs-de-sac stand in especial need 
 of the applications, which can hardly be made too thoroughly at these 
 points. After each application of the nitrate of silver the eye should be 
 freely brushed over with a strong solution of common salt in water to
 
 342 THE VENEREAL DISEASES. 
 
 neutralize all excess of the nitrate of silver which may remain in the eye. 
 Cold compresses upon the eye after each application of caustic will help 
 to allay the pain. 
 
 When the conjunctiva and lids swell much, the eye suffers from tension 
 in two ways: by the tightness of the tarsal border which irritates the eye 
 and prevents a free outflow of the discharges, and by the chemosis of the 
 conjunctiva which strangulates the cornea. Both of these strangulations 
 may, and should be relieved, the first but freely cutting the outer canthus, 
 enlarging the palpebral slit, the second by deep and thorough scarifica- 
 tion of the chemosed conjunctiva, or even when the chemosis is more solid, 
 by snipping away portions of the raised rim about the cornea with scissors 
 curved on the flat. A number of strips of conjunctiva, running in rays 
 away from the cornea, may thus be snipped away, with the result often 
 of saving the cornea, and without leading to any ultimate damage when, 
 the eye gets well. Both scarifications and partial excision of the cornea 
 should be practised after, and not before, a cauterization. 
 
 The cornea requires especial attention. The cup at the bottom of 
 which it lies should be washed out, and the edge of the cornea all around 
 under the overhanging chemosed conjunctiva should be frequently in- 
 spected, to detect the commencement of abscess, or of the ulcerative pro- 
 cess. As soon as rupture of the anterior chamber seems imminent, the 
 escape of the fluid should be anticipated by paracentesis of the cornea, 
 and the incision should be kept fistulous, if possible, by the use of a fine 
 probe, until the cornea is out of danger. 
 
 A solution of atropine should be dropped into the eye several times a 
 day from the first. It tends to diminish intra-ocular tension, to reduce 
 pain, and to keep the iris out of harm's way, either from adhesion or from 
 prolapsing into any fortuitous opening in the cornea, due to the perforation 
 of an ulcer. Should such prolapses occur, any portion which projects may 
 be cut away. Adhesion of the iris to the cornea at the point of prolapse 
 is quite certain to take place, calling perhaps for iridectomy when the 
 patient recovers. 
 
 Something may be done toward calming the peri-orbital pains by in- 
 unctions upon the brow and temple of belladonna ointment and oleate 
 of morphine. 
 
 As the eye begins to recover, it must be shaded from the light and 
 tenderly nursed for a long time. The lotions of nitrate of silver may be 
 gradually reduced in strength, and finally substituted by mild solutions of 
 sulphate of zinc, or alum, or by simple salt in hot water. An eye may 
 come out of the contest much damaged, but yet capable of being nursed 
 up to the point of being of considerable use to its possessor. In bad cases 
 vision is totally destroyed. 
 
 The internal treatment should be supporting and tonic throughout, 
 all the energy of the treatment being devoted to the local measures. 
 Mercury, up to the point of producing salivation, has been advised in bad 
 cases where there is a diphtheritic tendency, but the suggestion by no 
 means receives the uniform indorsement of authorities, and is of question- 
 able propriety, certainly so far as regards a majority of the cases seen in 
 cities where the vitality of the individual is not high. The malady itself 
 is unquestionably very debilitating, and tonics and good food are called 
 for more than any other internal remedies. Laxatives are usually re- 
 quired, and a judicious use of anodynes, to insure sleep and control pain.
 
 INDEX.
 
 ABORTION due to syphilis, 228 
 Abortive treatment of gonorrhoea, 259 
 Albuminuria due to syphilis. 219 
 Alopecia due to syphilis, 172 
 Amyloid degeneration due to syphilis, 201 
 Aphasia due to syphilis, 212 
 Ardor urinae, treatment of, 271 
 Arkansas Hot Springs, 107 
 Arthropathy, syphilitic. 182 
 Arteries, syphilis of. 203 
 
 cerebral, syphilis of, 206 
 Auspitz, excision of chancre, 93 
 Auto-inoculat on of chancre, 90 
 
 chancroid, 19 
 
 BALANITIS, treatment of, 273 
 
 Blood, a vehicle of syphilitic contagium, 
 
 05 
 
 Bone syphilis in inherited disease. 239 
 Bone, syphilis of, 183 
 Brain, syphilis of, 20o 
 Bubon d'emblce, 47 
 Bubo, chancroidal. 45 
 
 treatment of, 47 
 indolent, 4(5 
 
 treatment of, 49 
 how to open. 48 
 of syphilis, 95 
 virulent, 50 
 
 treatment of, 52 
 Bursitis, syphilitic, 180 
 
 CANCER antagonistic to syphilis, 63 
 Caries sicca, 185 
 Cauterisatio provocatoria, 78 
 Chancre, auto- and hetero-inoculation of, 
 90 
 
 herpetiform, 87 
 Hunterian, 87 
 mixed, 87 
 phagedaena of, 92 
 nipple, 88 
 lip, 88 
 skin, 88 
 urethra, 89 
 treatment of, 92 
 
 Chancroid, 1 
 
 auto-inoculation of, 18, 28 
 
 value of. 19 
 cicatrix of, 23 
 contagion, methods of, 18 
 communicability to animals, 16 
 complications of, 37 
 course of, 20 
 diagnosis of, 24 
 diagnostic table of, 25, 97 
 duration of, 23 
 ecthymatous, 22 
 follicular. 22 
 form of, 21 
 
 hetero-inoculation of, 22 
 how to cauterize a, 31 
 inflamed, 37 
 
 treatment of, 38 
 inoculation of, 18, 20, 28 
 inoculability, 4 
 
 in generations, 19 
 nature of, 2 
 number of, 21 
 
 not a modified syphilitic sore, 5 
 of anus, 35 
 finger, 36 
 rectum, 35 
 vagina, 36 
 vulva, 36 
 pathology of, 15 
 prognosis of, 28 
 subjective symptoms of, 22 
 eub-preputial, 35 
 treatment, radical, 30 
 palliative, 33 
 preventive, 29 
 Chancroidal bubo, 45 
 lymphangitis, 44 
 phagedrena, serpiginous, 39 
 
 sloughing, 38 
 Choc-en-retour, 73 
 Chordee, 255 
 
 treatment of, 270 
 Colles's law, 89 
 Contagion in syphilis, direct and mediate, 
 
 75 
 Constitution, as influencing syphilis. 81
 
 346 
 
 INDEX. 
 
 Copaibal erythema. 263 
 Cord, spinal, syphilis of, 213 
 Countenance, syphilitic. 243 
 Cystitis, gonorrhoeal, 270 
 
 DACTYLITIS, SYPHILITIC, 175 
 Dilatation of stricture, continuous, 315 
 Divulsion of stricture, 310 
 Duration of syphilis, 76 
 
 EAR, syphilis of, 235 
 Ecthyraa, syphilitic, 145 
 Ecthymatous chancroid, 23 
 Epididymitis, chronic, 288 
 
 gonorrhoeal, 279 
 
 syphilitic, 221 
 Epilepsy, syphilitic, 211 
 Erythema, copaibal, 203 
 Encephalitis, syphilitic. 200 
 Excision of chancre, 93 
 Eye, syphilis of, 231 
 
 FF.VER, SYPHILITIC, 101 
 Fever, urethral, 32 i 
 Follicular chancroid, 22 
 Fumigation, mercurial, 122 
 
 GLANDS, abdominal, syphilis of. 200 
 
 abdominal lymphatic;, syphilis of, 203 
 
 lymphatic, syphilis of, 95, 171 
 Gleet. 257 
 Gonorrhoea, a cause of sterility, 281 
 
 cause of, 253 
 
 death due to, 276 
 
 injections in, 265 
 
 in the male, 249 
 treatment of. 261 
 abortive treatment of, 259 
 hygienic treatment of, 260 
 symptoms of, 253 
 
 female, 328 
 
 symptoms of, 328 
 complications of, 328, 334 
 treatment of, 329 
 Gonorrhoea! cystitis, 276 
 
 epididymitis, 279 
 
 folliculitis, 275 
 
 ophthalmia, 339 
 
 rheumatism, 334 
 Gumma of bone, 187 
 
 brain, 206 
 
 fauces, 108 
 
 iris. 232 
 
 liver, 201 
 
 lung. 194 
 
 mouth, 1C8 
 
 penis, 221 
 
 skin, 163 
 
 testicle, 223 
 
 HSART, syphilis of, 203 
 Hemiplegia, syphilitic. 210 
 Hereditary syphilis, 237 
 
 Herpetiform chancre, 87 
 Hetero-inoculatiou, 20, 90 
 Hot Springs of Arkansas, 107 
 Huuterian chancre, 87 
 Hygiene of anus in syphilis, 113 
 
 genitals, 113 
 
 mouth, 112 
 
 syphilis, 109 
 
 IMPOTENCE, SYPHILITIC, 225 
 Incubation of chancroid, 20-28 
 
 syphilis, 85 
 
 second, 100 
 
 Induration, specific syphilitic, 91 
 Infantile syphilis, 241 
 Inheritance of syphilis through father, 70 
 
 mother, (i!> 
 
 Inherited syphilis, 237 
 Injection of the urethra, 265 
 
 vagina, 330 
 Inoculation of chancroid, 10 
 
 ordinary pus, 11 
 
 syphilitic chancre, 13 
 Insanity, syphilitic, 212 
 Internal urethrotomy, 305 
 Inunction, mercurial, 124 
 Iodides and their use, 131 
 
 bad effects of, 133 
 
 dose of, 135 
 lodism, 134 
 Iritis gonorrhoea], 337 
 
 KERATITIS, interstitial, 246 
 Kidney, syphilis of, 219 
 Klcbs, helikomonads, 62 
 
 LARYNGITIS, SYPHILITIC, 192 
 Liver, amyloid degeneration of, 201 
 
 gumma of, 201 
 
 Locomotor ataxia, syphilitic. 215 
 Lymphangitis chancroidal, 44 
 
 syphilitic, 95 
 
 MALIGNANT SYPHILIS, 100 
 
 Marriage, the question of, in pyphilis, 70 
 
 Mastitis, syphilitic, 230 
 
 Meatotomy, 301 
 
 Mercurial fumigation, 122 
 
 teeth, 245 
 
 Mercury a cause of bone disease, 188 
 Mixed chancre, 87 
 Mixed treatment of syphilis, 120, 137 
 
 with iodides in excess. 138 
 Mucous membranes, syphilis of, 105 
 Mucous patches, 100 
 
 poisonous nature of, 04 
 
 treatment of, 129 
 Muscle, syphilis of, 178 
 
 syphilitic nervous symptoms in, 213 
 Myositis, syphilitic, 178 
 
 NAILS, syphilis of, 174 
 Nervous system, syphilia of. 205 
 Nodes, 185
 
 INDEX. 
 
 347 
 
 OPHTHALMIA, OONORBIKEAL, 339 
 Orchitis, syphilitic, 222 
 Osteocopic pains, 184 
 
 8, BYPHILITIC, 206 
 Papular syphilitic, 147 
 Paraphymosis, 274 
 Paraplegia, syphilitic, 214 
 Pemphigus, syphilitic, 242 
 Penis, syphilis of, 220 
 Perineal section with guide, 319 
 
 without guide, 322 
 Peritoneum, syphilis of, 119 
 Phagedaena, 38 
 
 treatment of, 41 
 
 of syphilitic chancre, 92 
 Phymosis, inflammatory treatment of, 273 
 Pigmentary syphilide, 152 
 Placenta, syphilitic, 228 
 Pleiad of syphilis, 95 
 Posfcbitis, inflammatory, 273 
 Pregnancy in syphilitic women, 227 
 Primary syphilis, 99 
 Pustular syphilide, secondary, 150 
 
 tertiary, 161 
 
 RECTUM, syphilitic stricture of, 197 
 Reinfectio syphilitica, 83 
 Rheumatism, gonorrhteal, 334 
 Roseola, 145 
 Rupia, 160 
 
 SALIVATION, treatment of, 126 
 Scaly syphilitic patches, 167 
 Secondary incubation of syphilis, 100 
 Signmnd's treatment of syphilis, 106 
 Spasmodic stricture, 290 
 Stages of syphilis, 98 
 Strapping the testicle. 287 
 Sterility due to gonorrhoea. 278 
 Stricture of larpe calibre, 295 
 
 treatment of, 301 
 
 of small calibre, 311 
 treatment of, 314 
 
 resilient, 304 
 
 spasmodic, 290 
 Snb-preputial chancroid, 35 
 Syphilide, cornee, 147 
 
 erythematous, 145 
 
 gummatous, 163 
 
 papular, 147 
 
 pigmentary, 152 
 
 pustular, secondary, 150 
 tertiary, 161 
 
 pustnlo-bulbous, 160 
 
 squatnous, 154 
 
 tubercular. 158 
 
 vesicular, 154 
 Syphilides, 145 
 
 general characters of, 143 
 Syphilis, 53 
 
 abortion due to. 228 
 
 a cause of amyloid degeneration, 201 
 
 course of, 55 
 
 duration of, 76 
 
 Syphilis, impotence due to, 225 
 incubation of, 85 
 influenced by constitution, 81 
 inherited, 237 
 
 through father, 70 
 mother, 09 
 
 treatment of, 246 
 in infant life, 241 
 in pregnancy, 72 
 the third generation, 78 
 malignant, 100 
 marriage during, 76 
 methods of contagion, 75 
 of the aptmeuroses, 180 
 
 arteries, 203 
 
 bones, 183 
 in inherited disease, 239 
 
 brain, 206 
 
 simulating sunstroke, 213 
 
 bronchial tubes, 192 
 
 burae, 180 
 
 cerebral arteries, 206 
 
 cartilages, 189 
 
 cornea, 231 
 
 ear, 235 
 
 eye, 231 
 
 female genital system, 226 
 
 fingers, 175 
 
 foetus, 238 
 
 genito-nririary system, 219 
 
 glands, lymphatic, 171 
 abdominal, 203 
 
 heart, 203 
 
 intestines, 196 
 
 iris, 231 
 
 joints, 182 
 
 kidney, 219 
 
 larynx, 191 
 
 ligaments, 182 
 
 liver, 200 
 
 lungs, 192 
 
 mammary glands, 230 
 
 mucous membranes, 165 
 treatment of, 130 
 
 muscles, 178 
 
 nails, 174 
 
 nervous system, 205 
 
 nose, 190 
 
 oesophagus, 196 
 
 penis, 220 
 
 peritoneum. 199 
 
 placenta, 228 
 
 rectum, 197 
 
 retina, 233 
 
 respiratory system, 190 
 
 sheaths of tendons, 180 
 
 akin, 142 
 
 special nerves, 216 
 
 spinal cord, 213 
 
 spleen, 202 
 
 stomach, 196 
 
 supra-renal capsules. 203 
 
 sympathetic nerves, 218 
 tendons, 180 
 
 testicles, 221
 
 348 
 
 INDEX. 
 
 Syphilis of the thymus, 203 
 
 toes, 175 
 
 tongue, 194 
 
 trachea, 192 
 
 vascular system, 203 
 
 veins, 204 
 
 vitreous body, 232 
 pathology of, 58 
 primary, 99 
 prognosis of, 79 
 secondary, 99 
 second attacks of, 83 
 stages of, 98 
 symptoms of, 103 
 tertiary, 100 
 
 transmission of, to animals, 17 
 treatment of, 104 
 
 by fumigation, 122 
 inunction, 124 
 
 hygienic, 109, 113 
 
 local, 128 
 
 mixed, 137 
 
 preventive. 108 
 
 specific, 114 
 
 tonic, by mercury, 117 
 
 when to commence, 116 
 
 stop, 120 
 
 two attacks of, 83 
 unity or duality of, 7 
 vaccinal, 65 
 versus cancer, 63 
 without chancre, 89 
 Syphilitic albuminuria, 219 
 alopecia, 172 
 aphasia. 212 
 bubo, 95 
 cataract, 233 
 chancre, 86 
 
 course of, 89 
 
 diagnostic tables of, 25, 97 
 
 excision of, 93 
 
 induration of, 90 
 
 treatment of, 92 
 countenance, 242 
 cyclitis, 233 
 dactylitis, 175 
 encephalitis, 206 
 epilepsy, 211 
 epididymitis, 221 
 facial paralysis, 217 
 fever, 101 
 hemiplegia, 216 
 insanity, 212 
 keratitis, interstitial, 245 
 
 Syphilitic locomotor ataxia, 215 
 
 lymphangitis, 95 
 
 optic neuritis, 233 
 
 orchitis, 222 
 
 pachymeningitis, 206 
 
 paraplegia, 214 
 
 paronychia, 175 
 
 pemphigus, 242 
 
 retinitis pigmentosa, 233 
 
 teeth, 240 
 
 virus, 61 
 
 in what contained, 63 
 Syphilization, 19 
 
 TATTOOING syphilis, 64 
 
 Teal's method of inunction, 125 
 
 Teeth, syphilitic. 243 
 
 mercurial, 245 
 Tenositis, syphilitic, 180 
 Tertiary syphilides, 180 
 
 syphilis, 100 
 Testicle, syphilis of, 221 
 Thymus, syphilis of, 203 
 Tonic treatment of syphilis by mercury, 
 
 117 
 Transmission of syphilis by milk, 67 
 
 semen, 67 
 
 through inheritance, 68 
 
 to third generation, 73 
 Tubercular syphilide, 158 
 
 UNITY or duality of syphilis, 7, Gl 
 Urethral chancre, 89 
 
 fever, 324 
 Urethritis in the male, 249 
 
 treatment of, 260 
 
 in the female, treatment of, 332 
 TJrethrotomy, external, with guide, 319 
 
 without guide, 322 
 
 internal, 305 
 
 of deep urethra, 315 
 Urine, retention of, in gonorrho3a, 272 
 
 VACCINAL, syphilis. 65 
 Vaginitis, gonorrhoeal, 328 
 Vapor mercurial bath, 122 
 
 domestic, 123 
 
 Vegetations, treatment of, 272 
 Veins, syphilis of the, 204 
 Vesicular pyphilide. 154 
 Virus of syphilis (unity or duality), 7, 61 
 
 ZEISSL-, treatment of syphilis, 106 
 Zittman's decoction, 140
 
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 The venereal diseases 
 
 CALIFORNIA COLLEGE OF MEDICINE LIBRARY 
 
 UNIVERSITY OF CALIFORNIA, IRVINE 
 
 IRVINE, CALIFORNIA 92664