LIBRARY OF CONGRESS. Shelf ..Z.4l UNITED STATES OF AMERICA. f V OUTLINES PATHOLOGY AND TKEATMENT OF SYPHILIS AND ALLIED VENEREAL DISEASES BY HERMANN VON ZEISSL, M. D. LATE PROFESSOR AT THE IMPERIAL-ROYAL UNTVERSITr OF VIENNA SECOND EDITION, REVISED By MAXIMILIAN VON ZEISSL, M. D. PRIYAT-DOCENT FOR DISEASES OF THE SKIN AND SYPHILIS, AT THE IMPERIAL-ROYAL UNIVERSITY OF VIENNA AUTHORIZED EDITION. TRANSLATED, WITH NOTES, By H. RAPHAEL, M. D. ATTENDING PHYSICIAN FOR DISEASES OF GENTTO-URINARY ORGANS AND SYPniLIS, BELLEVUE HOSPITAL OUT PATIENT DEPARTMENT : MEMBER NEW YORK. COUNTY MEDICAL SOCIETY, ETC. NEW YORK D. APPLETON AND COMPANY 1886 \ >'\ COPYKIGHT, 1886, By D. APPLETON AND COMPANY. All rights reserved. PREFACE TO THE AMERICAN EDITION. A treatise on Syphilis by one who has devoted his entire life to the study of this disease, and whose experience is the result of observation and treatment of upward of thirty thou- sand patients in private practice and in the wards of the Allgenieine Krankenhaus of Vienna, needs little additional tes- timony to attest its value. As a clinical observer of venereal diseases, and as a teacher, Professor von Zeissl stood de- servedly high in Europe. The concise and graphic descrip- tion of the various forms of venereal affections, the accurate delineations of the different phenomena of the pathological lesions, the terse and detailed account of the symptomatology and characteristic manifestations of the various phases pre- sented by the different specific diseases, the conscientious records of results obtained, bear evidence of the scientific thoroughness with which the investigations were pursued, and therefore must serve as a valuable guide to those desiring to study them. The prominence given to pathology in this work indicates the value placed upon it by the author as a means to the proper understanding of the diagnosis and treatment of the various venereal affections ; and if it can not be said that the work contains an abundance of remedies and formulae for the treatment of the different phases of the different diseases, iv PREFACE TO TEE AMERICAN EDITION. neither on the other hand is it overladen with polypharma- ceutical combinations. The few notes and prescriptions added by the translator will not, he hopes, be deemed superfluous. H. Eaphael. New York, May, 1886. PREFACE TO THE SECOND EDITION. The first edition of this book was composed for the pur- pose of placing in the hands of the student a brief guide to aid him in the study of Syphilis. Having been requested by my father to revise the second edition, it occurred to me that the reader would be pleased with it still more if, by making it as brief as possible, it should be as graphic and perfect in the description of the morbid picture of venereal diseases as possible. I sought to diminish the size of the book by omit- ting certain special subjects, giving greater prominence to clinical descriptions. Some chapters, which are only theo- retically important, or methods of treatment that are only of historical interest, have been briefly sketched. The syphilitic affections of the skin were taken entirely unaltered from the former edition, while the chapters on therapeutics of gonor- rhoea, of epididymitis, of strictures, of chancres and syphilis, as also the chapter on visceral syphilis and hereditary syphilis, have been almost entirely rewritten. Here and there parts of the fourth edition of the " Lehrbuch fur Syphilis," issued by my father and myself, were used. Professor von Schrotter aud Professor Mauthner were so kind as to write the articles on syphilitic affections of the larynx, trachea, and eye. I am fully aware that the book offers little that is new, but it is not intended that it should spread any new doctrines ; it claims vi PREFACE TO THE SECOND EDITION. only the modest task of presenting a comprehensible picture of venereal diseases and their treatment as briefly as possible to the practical physician, whom time will not permit to read extensive works upon every special branch of our science. It only remains for me to express the hope that this book will receive the same friendly judgment as the first edition, and that I shall succeed in concisely reporting my father's ideas, and at least preserve what he created. For the words of our great poet find their application in science too : " "Was du ererbt von deinen Vatern hast, Erwirb es, um es zu besitzen." Von Zeissl. Vienna, March, I884. CONTENTS. PAGE Introduction 1 The Venereal Contagions 3 SECTION I. GONORRHOEA (TRIPPER) VENEREAL CATARRH. Site of Gonorrhoeal Affection and Mechanism of Gonorrheal Infection . .17 Factors that usually favor Gonorrhoeal Infection 18 Gonorrhoea of the Male Urethra 19 Pathological Alterations in the Male Urethral Canal produced by the Gonor- rhoeal Disease 25 Morbid Phenomena which occur as Co-effects and Sequela? of Urethral Gon- orrhoea in Men 29 Prognosis of Gonorrhoea in the Male 30 Prophylaxis against Gonorrhoea, and Treatment of Acute and Chronic Gonor- rhoea in Men 31 The Indirect or Internal Treatment of Gonorrhoea of the Male Urethra . . 42 Catarrh of the Glans Penis and Prepuce, Balanitis, Balano-Blenorrhcea, Bala- nopyorrhoea, Balanopostheitis 46 Phimosis and Paraphimosis 47 Differential Diagnosis and Treatment of Catarrh of the Glans Penis and of the Resulting Inflammatory Phimosis and Paraphimosis . . . .48 Affections of the Lymphatic Vessels and Glands in consequence of Gon- orrhoea . . . .51 Inflammation of the Vasa Deferentia and the Epididymis . . . .52 Treatment of Inflammation of the Spermatic Cord and Epididymis . . .56 Chrome Hydrocele. Hernia Aquosa 58 Inflammation of Cowper's Glands 60 Morbid Alterations that are produced in the Prostate by Gonorrhoea of the Urethra 61 Inflammation of the Seminal Vesicles in consequence of Urethral Gonor- rhoea 66 Functional Disease of the Seminal Vesicle and of the Testicle. — Spermatorrhoea, Seminal Emissions, Pollutio Diurna 67 viii CONTENTS. PAGE Diseases of the Bladder caused by Urethral Gonorrhoea . . . .69 Diseases of the Kidney that are produced by Urethral Gonorrhoea . . 74 Gonorrhoea of the Female 78 1. Gonorrhoea of the Yulva. . . ■ . . . . . .78 2. Gonorrhoea of the Vagina 80 3. Complications of Vulvo-vaginal Gonorrhoea 83 (a) Diseases of the Glands of Bartolini and their Ducts . . .83 (6) Inflammation and Abscess of the Lymphatic Vessels in the Labia Majora and Minora, and of the Lymphatic Glands of the In- guinal Folds 85 4. Urethral Gonorrhoea in the Female 88 Gonorrhoea of the Rectum 89 Gonorrhoea of the Mouth and Nasal Cavities 90 Gonorrhoea of the Eye (Ophthalmia Gonorrhoica Blenorrhoica) . . .90 Treatment of Gonorrhoeal Ophthalmia 92 The Effects or Sequelae of Gonorrhoea in general and of Urethral Gonorrhoea in particular 93 Gonorrhoeal Rheumatism 94 Condylomata ; Vegetations ; Spitze or Moist Warts 97 Stricture of Urethra 101 SECTION II. SOFT CHANCRE OR CHANCROID. Action of Chancrous Virus and Development of the Soft Chancre . . .109 Pathology of the Soft Chancre 110 Course, Duration, and Cicatrization of the Soft Chancre .... 112 Varieties of Soft Chancre 113 Site of the Soft Chancre 115 Differential Diagnosis of the Soft Chancre . . . . . . .118 Prognosis and Treatment of the Soft Chancre 121 Prophylactic Treatment 122 Abortive Treatment ..... . . . . . 122 Curative or Methodical Treatment 123 Diseases of the Lymphatic Vessels and Glands (Lymphangioitis and Adenitis) in consequence of Soft Chancres 128 Buboes originating as a Result of Soft Chancres 132 Site, Shape, and Size of Chancroid Buboes 135 Differential Diagnosis and Prognosis of Buboes 137 Treatment of Diseases of Lymphatic Vessels produced by Chancroids . .139 The Treatment of Open Buboes . 141 Fistulae in consequence of Suppurating Buboes . 142 SECTION III. SYPHILIS. General Conception 145 Nature and Vehicle of the Syphilitic Virus 145 CONTENTS. ix PAGE The Transmissibility of Syphilis, or the Various Ways in which Syphilitic In- fection may take place 146 Transmission of Syphilis by Vaccination. — The Relation of Vaccine Lymph to Syphilitic Virus 147 Transmissibility of Syphilis to Warm-blooded Animals .... 149 First Manifestation of the Action of the Syphilitic Virus .... 149 Anatomy of the Syphilitic Initial Sclerosis 151 Site and Form of the Huntcrian Induration 153 Combined Effects of the Syphilitic Virus and of the Chancroid Virus . .155 Inoculability of the Sclerotic Ulcer 156 Significance, Duration, Course, and Differential Diagnosis of the Syphilitic Initial Sclerosis [Hard Chancre] 156 Unicity of the Syphilitic Infection 158 Affections of the Lymphatic System occasioned by Beginning Syphilis . .159 Induration and Hypertrophy of the Peripheral Lymphatic Vessels in con- sequence of Syphilitic Infection . 165 The Syphilitic Diathesis 166 Pathological Alteration of the Blood of Syphilitic Persons . . . .167 Eruptive Fever of Syphilis 168 Time of Eruption of General Syphilis 169 Localization of the Syphilitic Foci 169 The Cachexia produced by Syphilis 170 Combination of Syphilis 170 Succession and Phases of Syphilitic Affections 171 Development, Course, and Duration of Constitutional Syphilis . . .172 Mortality of Constitutional Syphilis 172 Development of Lymphatic Glandular Swellings originating in the Course of Syphilis (Multiple Adenitis) 174 Morbid Lesions of the Skin caused by Syphilis (Syphilitic Diseases of the Skin— Syphilides) 175 Definition and Classification of Syphilitic Skin-Diseases . . . .180 1. The Erythema Syphilide, Erythema Syphiliticum Maculosum et Papu- latum, Roseola Syphilitica, Syphilitic Spots 180 2. Papular Syphilides 186 (a) Lenticular, Papular Syphilide 188 (b) Small Papular Syphilide (Syphilis Papulosa Miliaris) . .189 (c) The Papular Syphilide, or Squamous Syphilide of the Palms of the Bands and Soles of the Feet (Psoriasis Palmaris et Plantaris), and Syphilitic Diffused Affection of the Epidermal Strata of the Hands and Feet (Syphilis Cornea) 192 (d) The Humid or Moist Papules, or Flat Condylomata ; Papules Humides ; Pustula Fcetida Ani ; Pustules, Plates, etc., of Va- rious Authors . . . 196 3. Pustular Syphilide 201 (a) The Acne-like Syphilide 202 (b) Varicella-like Syphilide, or Varicella Syphilitica . . . 204 (c) Impetigo Syphilitica . 206 x CONTENTS. PAGE (d) Ecthyma Syphiliticum ... ... . 209 (e) Rupia Syphilitica 211 4. Nodular Syphilide of the Skin ; Tubera Syphilitica ; Tubercula Syphi- litica ; Syphilitic Nodes of the Cutis and of the Subcutaneous Cellu- lar Tissue (Gummata) ; Syphiloma, according to Wagner . . .213 The So-called Pigment Syphilis 222 Syphilitic Affections of the Hair 222 Syphilitic Disease of the Nails 223 Syphilitic Affections of the Mucous Membrane 226 (1) Syphilitic Erythema of the Mucous Membrane ; Syphilitic Catarrhal Inflammation ; Erythema Syphiliticum Membranse Mucosae . . 226 (2) Syphilitic Papules on the Mucous Membrane 22*7 (3) The Syphilitic Node or Gumma of the Mucous Membrane . . 231 Syphilis of the Mouth and Fauces 233 Syphilitic Disease of the Tongue 238 Syphilitic Disease of the (Esophagus . . 244 Syphilitic Disease of the Stomach and Intestines 245 Syphilitic Affections of the Liver 247 Syphilitic Affection of the Spleen 250 Syphilitic Affection of the -Pancreas and of the Salivary Glands . . .250 Syphilitic Affections of the Larynx and Trachea 251 Syphilitic Acute and Chronic Catarrh 252 " Papules 253 " Infiltrations, Gummata 254 " Ulcers 256 " Perichondritis . . 261 " Cicatrices 261 " New Growths 263 Syphilitic Affections of the Bronchi and Lungs 263 Syphilitic Affection of the Kidney, Suprarenal Capsule, and Bladder . .265 Syphilitic Affections of the Testicle and Spermatic Cord . . . . 265 Syphilitic Affections of the Ovaries, Fallopian Tubes, and Uterus . . .270 Syphilitic Affections of the Mucous Membrane of the Genital Organs of Both Sexes . . . ... 271 Syphilitic Affections of the Corpora Cavernosa Penis 272 Syphilitic Affections of the Breasts . . 273 Syphilis of the Heart and Blood-Yessels 273 Affections of the Brain, Spinal Cord, and Peripheral Nerves, as a Result of Syphilis 274 Syphilitic Affections of the Nose 280 Syphilitic Affections of the Auditory Passages . . . . . 284 Syphilitic Affections of the Eye 285 Iritis Syphilitica 285 Affections of the Ciliary Body, the Choroid, and Yitreous Humor . . 290 Inflammation of the Retina and Optic Nerve 292 Affections of the Cornea, Conjunctiva, and of the Eyelids . . . 293 Affections of the Orbits, Lachrymal Sac, and of the Muscles . . . 294 CONTENTS. xi PAGE Syphilitic Affection of the Bones and their Envelopes 295 Syphilitic Inflammation of the Periosteum ; Periostitis Syphilitica . .297 Ostitis Syphilitica 300 Cicatrization of Syphilitic Ulcers of the Bones 302 Site and Effects of Periostitis and Ostitis 303 Differential Diagnosis of Affections of the Bones produced by Syphilis . . 304 Syphilitic Affections of the Joints 305 Syphilitic Affections of the Cartilages 307 Syphilitic Affections of the Muscles, Tendons, and Sheaths of Ten- dons 303 Syphilitic Affection of the Bursa? 310 Endemic Syphilis ; Leproid or Syphiloid Disease 311 Malignant or Galloping Syphilis 312 Hereditary Syphilis 315 Manifestations of Congenital Syphilis 319 Macular Syphilide in the Infant ; Erythema Maculo-papulatum Syphiliticum Neonatorum 320 Papular Syphilide in the Infant 321 Pustular, Gumroous, and Hemorrhagic Syphilide in the Infant . . . 322 Syphilitic Affections of the Mucous Membrane in the Infant . . . . 325 Syphilitic Affections of the Bones and their Envelopes 326 Affections of the Eye in consequence of Hereditary Syphilis . . . 328 Morbid Alterations of the Internal Organs resulting from Hereditary Syphilis 329 Diagnosis and Prognosis of Congenital Syphilis 333 Syphilis Hereditaria Tarda . . . 334 Treatment of Syphilis 334 Prophylaxis of Syphilis 337 Treatment of the Initial Lesions of Syphilis ; the Hunterian Indurated Chan- cre ; the Indolent, Multiple, and Strumous Buboes .... 340 Treatment of Secondary Phenomena of Syphilis 342 (A.) Expectant Method 342 Therapeutical Application of Iodine and Iodine-Salts against Syphilis . . 345 (B.) Medical Treatment 345 The Treatment of Syphilis by Vegetable Remedies ..... 350 Therapeutic Use of Mercury 352 Mercurial Preparations which are best adapted to be introduced into the Blood through the Digestive Organs 353 External Application of Mercury and its Preparations 358 (a) Mercurial Inunction Treatment 358 (6) Hypodermic Mercurial Treatment of Syphilis 371 (c) Treatment of Syphilis by Mercurial Fumigations .... 374 (d) Treatment of Syphilis with Baths containing Mercury . . . 375 (e) Treatment of Syphilis by the Application of Mercurial Suppositories to the Mucous Membrane of the Rectum 376 Pathogenetic Effects which Mercury and its Preparations may produce during Treatment ... 376 xii CONTENTS. Effects of Cold- Water Treatment, Sea-Baths, and Sulphur Thermal Baths on Syphilis and on Hydrargyrosis 380 Syphilophobia and Mercuriophobia on Hypochondria Mercurialis . . ,381 Syphilization 382 Treatment of some of the Local Syphilitic Affections 383 The Nursing of the Syphilitic Child and the Treatment of Congenital Syphilis 388 INTEODTJCTIOK Infectious discliarges from the genital organs of both sexes, and ulcerations on those parts, must have been known in olden times, even in the remotest antiquity. There is an allusion to an " unclean seminal discharge " in the third book of Moses (Leviticus, chap, xv), and the sanitary regulations prescribed by Moses himself indicate conclusively the actual infectious na- ture of such seminal discharges. It is likewise seen, from the writings of the old Greek and Roman physicians, that they treated ulcers of the genital organs which were caused by con- tagion. At the end of the fifteenth century many persons were at- tacked, as in an epidemic, with morbid phenomena, especially diseases of the skin, whose origin the physicians' of those times regarded as being due partially to telluric and partially to astral causes. These affections were supposed to originate in a gen- eral deterioration of the cardinal secretions of the body and the liver as being the fountain of the disease. JSTot until it became apparent that these diseases prevailed among the troops of Charles YIII, which occupied Naples in 1495, and occurred especially among those women with whom they had sexual in- tercourse, did many physicians become convincd that the dis- eases in question originated by transportation from one person to another — this transportation or infection occurring espe- cially during sexual congress, and starting with an affection of the genital organs. These circumstances led Fernelius and Bethencourt to call this disease venereal, or the veneria, and also "lues venerea." For the same reason it was also called mentulagra (from mentula, penis), when it attacked men, and pudendagra when it attacked women. At the time when it prevailed as a pest it received various names, based 1 2 PATHOLOGY AND TREATMENT OF SYPHILIS. mainly upon geographical grounds. The French called it " mal de Naples " and " la grosse verole " ; the Spaniards, " las bu- bas" (pocks). The Germans and Italians called it "mal de France " ; the Poles, the " Dutch disease " ; the Dutch and English, the "Spanish"; the Orientals, the "French"; the Portuguese, the " Castilian " ; the Persians, the " Turkish " ; and the Chinese, the "disease of Kanton" (Kouang tong Tschouang). But all these designations were supplanted by the name of syphilis, which has been universally adopted. This term was first applied to the disease by Hieronymus Fra- castorius, deriving it from a shepherd by the name of " Syphi- lus," whom he apostrophizes in an ode, as the first to suffer from -this disease because he had offended the gods. Others derive the name syphilis from the Greek word cncfrXos, broken ; others, again, from the words en;? and i\ia. The infectious discharges from the genital organs are called in males, "gonorrhoea" — fluxus sive profluvium seminis, from r) yovrj, semen, and pelv, to flow ; in females, " fluor " ; in Ger- man, " Tripper." The terms blennorrhosa and blennorrhagia mucifluxus, from to fiXevvos, or rj fiXevvoa, mucus, and pelv, or prjyvovcu, were first used by Swediaur. We are indebted for the designation of the word " chancre," as applied to a sore on the genital organs originating from sex- ual intercourse, to the French, who substituted the word chan- cre for cancer, which Celsus had selected to designate this dis- ease. With the word cancer Celsus wished to describe the spreading, corroding, malignant character of the ulcer. The physicians of the thirteenth and fourteenth centuries selected the words "caries," "caroli," or "taroli pudendum," to des- ignate such malignant contagious ulcers. THE VENEKEAL CONTAGIONS. Fernelius was one of the first to properly comprehend the connection between diseases of the genital parts and syphilis. He suggested the hypothesis of the existence of an animal poi- son which he called the venereal poison. This virus, Fernelius believed, developed not only in the purulent secretion of cer- tain ulcers of the skin and mucous membrane that originate during sexual intercourse, but also in the muco-purulent dis- charge of the inflamed or catarrhal affected mucous membrane of both sexes. From these two affections of the genital or- gans, Fernelius contended that the venereal virus passes into the secretions of the body and then attacks sometimes one or- gan and then again another. He was therefore of the opinion that syphilis, until then such a mysterious disease, resulted from well-known affections of the mucous membranes and of the skin covering the sexual organs, which we to-day desig- nate as chancre and gonorrhoea (clap). The opinion that gonorrhoea and chancre were the com- mencement of syphilis prevailed till the second half of the eighteenth century. In the year 1767 Balfour, an English surgeon, positively asserted that gonorrhoea and syphilis were essentially distinct diseases. Balfour's assertions, however, were stoutly opposed by John Hunter, who, in 1767, first instituted comparisons between the two diseases by perform- ing inoculations with the secretions of venereal catarrhal af- fections of the mucous membranes and of venereal ulcers of the skin. Hunter inoculated the penis and prepuce (whose is not stated) with pus which he derived from the urethra of a patient presumably affected with gonorrhoea. As ulcers de- veloped from these inoculations, upon which induration of the lymphatic glands of the right groin soon supervened, and a few months later ulcers of the tonsils and a roseola eruption 4: PATHOLOGY AND TREATMENT OF SYPHILIS. became superadded, which symptoms of constitutional syphilis were promptly cured by mercury, Hunter deemed the identity of gonorrhoea and chancre as complete, and consequently also of the contagion of gonorrhoea and syphilis as conclusive. The difference in the form of the manifestations of this contagion he believed to be due only to the differences in the anatomical structures upon which the lesion was produced. Upon the secreting mucous membrane the poison in question produces a catarrhal, upon the general cutaneous covering an ulcerative, process. The first one to oppose Hunter in this matter was Ben- jamin Bell, of Edinburgh. He adduced the following facts : Two young persons scarified the skin of their glans penis and prepuce with a lancet, and allowed bits of charpie dipped in gonorrhoeal matter to remain in contact with the scarifications for forty-eight hours. In one of the young men a balano-blen- norrhcea ensued ; in the other, some of the dripping pus gained an entrance into the urethra, in consequence of which a catar- rhal disease developed in two days in this canal. On the other hand, one of the experimenters, by carrying the pus of a venereal ulcer of the skin of the genital organs upon a probe several millimetres deep into the urethral canal produced a painful ulcer at tins place, which was followed by a suppurat- ing bubo. Notwithstanding this and many other similar ex- periments, the virus of gonorrhoeal with chancre contagion was supposed to be identical till the thirtieth year of the present century, when Ricord first took sides in the matter. By the aid of Recamier's vaginal speculum, which was used very little by his predecessors and contemporaries, Ricord disproved Hunter's views, by the fact that venereal ulcers may exist upon the mucous membrane of the vagina and of the neck of the uterus, and consequently the vaginal discharge may be tainted with that of the chancre. From 1831 to 1837 he per- formed 667 more inoculations with gonorrhoeal matter, and from none of these did any chancre-ulcers result. Finally, Ricord proved that not infrequently the matter that exudes from the urethra is due to a chancre-ulcer situated in that canal, which upon inoculation produces a pustule from which a chancre will develop. THE VENEREAL CONTAGIONS. 5 With these and other experimental researches all apparent contradictions were explained, and the independence of the gonorrheal contagium was incontestably proved in every way, both as regards its indirect as well as its direct effect. With the progress of science and more carefully observed clinical facts it soon became manifest that not all chancres were followed by syphilitic lesions. Hunter, who, although he looked upon gonorrhoea and ulcers on the genitals arising from sexual contact as the effects of one and the same poison, nevertheless maintained that not all the ulcers on the genital organs are of syphilitic nature. He only designated such ulcers on the genital organs chancre that were followed by syphilis. According to Hunter, the chancre was distinguished from all other sores on the sexual organs by a dense, hard, sclerotic base and by elevated indurated borders (Hunterian induration). All otherwise constituted non-indurated ulcers on the genitals were, in his opinion, not chancres ; they were simple, ordinary, non-infectious ulcers or secondary syphilitic sores. These sec- ondary syphilitic sores were said to be distinguished from the primary sores by the fact that they were not callous, did not spread rapidly, produced no adenitis, were not auto-inoculable, and healed rapidly. At first, Ricord made no distinction be- tween the indurated and non -indurated ulcers, calling them both ulcerating chancres, and deeming both to be the effects of one and the same virus. He called the virus " chancre-poison or primary syphilitic poison," which in some cases — not, how- ever, in all — is followed by syphilis, and which, according to the grade and phase of development, he embraced in the category of secondary and tertiary affections. Gradually, however, he approached the position held by Hunter, in so far as to admit that only that chancre which was situated upon a hard base, or left behind it a hard cicatrix, was capable of producing general syphilis, and such chancres he therefore called " infecting chancres." The induration thus established was looked upon as a criterion of commencing blood-poison- ing. The reason why induration resulted in one case and not in another, he maintained, was not due to the difference in the character of the virus, but partly to its more or less weakened power to infect (virulescence) and partly to the difference of 6 PATHOLOGY AFD TREATMENT OF SYPHILIS. tissue upon which it was implanted. He regarded the Hunte- rian or the infecting chancre merely as a variety of chancre-in- fection, and which is additionally distinguished from the other varieties by the fact that it occurs but once upon one and the same individual during his whole life. Finally, Ricord, like Hunter, held that the primary sore was the sole fountain of syphilis and denied the ability of secondary manifestations to transmit the disease from one person to another. This theory of Ricord, which has been called the unity or identity theory, was soon shaken by experience, which con- flicted with it. It was repeatedly observed that a person had simultaneously a soft and an indurated chancre near each other, that many persons had multiple contagious soft chancres, with- out being affected subsequently by syphilis, while in another person a single hard ulcer was followed by constitutional mani- festations. Lastly, numerous confrontations of infected and infecting patients showed that the indurated ulcer was always produced by similar or secondary syphilitic ulcers of the per- son infecting, while a soft chancre, attended only by local symptoms, propagated through contact only a local sore which was soft in character. All these circumstances led one of Ricord's scholars, Leon Bassereau, in 1852, to establish the proposition that the soft chancre was not a source of syphilis. In conjunction with Clerc, another pupil of Ricord, he pro- pounded a new theory, namely, the duality theory, by which he maintained the existence of two essentially different chancre- poisons — the soft and the indurated — both of which are in- debted to two totally different contagions for their origin. The soft-chancre sore, he maintained, was always a local disease, and was only capable of acting perniciously upon the general system by causing suppuration in the adjacent lymphatic glands. But the hard chancre always led to blood-poisoning and constitutional symptoms. Though, to be sure, it likewise causes swelling of the adjacent lymphatic glands, they never or very seldom pass on to suppuration, and the pus they con- tain can not by propagation produce a chancre. This new theory of Bassereau and Clerc was soon adopted by Ricord and Fournier, and formulated in the law that each variety of chan- cre was only capable of propagating its own kind. THE VENEREAL CONTAGIONS. 7 The soft chancre or chancroid may be produced by inocu- lation upon sound as well as upon syphilitically diseased tis- sues ; the hard chancre can only be reproduced by inoculation upon healthy tissues, and never upon any that is already syphi- litic. Clerc, it is true, succeeded, by inoculations with matter from a hard chancre, in producing ulcers, which he designated by the name of " chancroide," and which he believed to be of a similar nature as the soft chancre. He therefore maintained that the soft chancre was a bastard product produced by in- oculating a syphilitic person with an infecting chancre, which, if it were once developed, was capable of propagating itself in an endless series, without ever assuming the primitive char- acter of an infecting chancre. In Ricord's " Lecons sur le chancre " cases were, however, reported which were supposed to prove that Clerc's chancroids were capable of reproducing the infecting chancre and the in- fecting chancre a soft chancre, even upon an individual who is not syphilitic. In order to save the dualism theory that was now apparently tottering, Rollet, of Lyons, suggested the hy- pothesis that both poisons can be transmitted simultaneously, and the result of this transmission is a " mixed " chancre (chan- cre mulet), whose auto-inoculation upon the same or upon a syphilitic person would produce positive results. "While the French physicians continued to entangle themselves by one- sided views of the forms of the sores in a labyrinth of contra- dictions and names, other investigators deeming the contagions that formed the basis of the ulcers to be of prime importance, and supported by experiments as well as by exact clinical ob- servations, were soon able to throw new light upon the action of the soft chancre and of syphilis. The results of the re- searches instituted by Wallace, Waller, Heinecker, Lindemann, Daniellsen, Yon Barensprung, Hubbener, Lindwurm, Hebra and Kosner, Pelizzari, H. Zeissl, and many others, together with our own clinical experience, enable us to lay down the following principles : 1. The poisons of the soft chancre and of syphilis are totally different from each other. They have only in common the external quality that both of them are most frequently con- 8 PATHOLOGY AND TREATMENT OF SYPHILIS. tracted during sexual congress ; hence soft chancres, like pri- mary syphilitic lesions, are more often found upon the genital organs of both sexes. 2. The pus and tissue detritus, disorganized by the chancre- infection, are the vehicles by which the poison of the chancre is conveyed. The virus of syphilis is united especially with the disorganized detritus of the syphilitic inflammatory prod- uct, and also with the blood, and probably with the semen of syphilitic persons. The experimental inoculations performed with the blood of syphilitic patients produced positive results in some though not in all cases. Why all syphilitic parents do not beget syphilitic children is still unexplained. 3. Pus from an abscess or the contents of a non-syphilitic eruption on a syphilitic person, when transmitted to a healthy individual, have not hitherto, in our experiments, produced syphilis. 4. The poison of a soft chancre reproduces itself, if trans- mitted upon a syphilitic person, in the same manner as in a healthy one. The discharges from a soft chancre situated upon a syphilitic individual will always produce a soft chancre only. 5. If the secretions of a suppurating specific primary lesion are inoculated upon its possessor or upon another syphilitic per- son, there results upon some of the luetic (syphilitic) patients so inoculated an ulcer ; but this ulcer need not necessarily be a primary specific ulcer, because a person who is already luetic can not while he is still syphilitic again acquire syphilis. We maintain the correctness of the proposition that a primary syphilitic lesion, as such, can not be reproduced upon its pos- sessor. 6. The minimum quantity of blood-particles which is apt to be present in a chancre of a syphilitic person is not capable of producing syphilis. But if syphilitic inflammatory prod- ucts, such as papules or nodules, are made to undergo suppura- tion and disorganization by implanting upon them chancroid virus, a pustule may be produced, and if this detritus be then inoculated upon a non-syphilitic person, an initial syphilitic pri- mary sclerosis or hard chancre will develop. 7. Little as the purulent sputum of a syphilitic person when transmitted to a healthy person can produce in the latter syphi- THE VENEREAL CONTAGIONS. 9 lis, so little will the pus of an abscess or the contents of a non- specific eruption from a syphilitic patient produce syphilis upon a healthy individual. Only the pus or the structural debris of the products especially belonging to syphilis is capable under favorable circumstances of producing syphilis. The supposi- tion of the existence of a mixed chancre, in the sense advo- cated by the Lyons school, we have discarded long ago. To be sure, we have to admit that the secretion of a soft chancre, if implanted upon a syphilitic eruption, will exercise its de- structive action in the same way as upon perfectly healthy tis- sues; but if the disorganization of the syphilitic eruption through the chancrous virus has once been established, the re- sulting ulcer will then have nothing in common with the soft chancre. Now, if the pus of an inflammatory syphilitic prod- uct — for instance, a syphilitic papule brought to the stage of suppuration by irritating it with the secretion of a soft chan- cre — is implanted upon a healthy person, syphilis will be pro- duced ; while the same soft chancre if inoculated upon a syphi- litic individual at any place that is unaffected by syphilitic inflammatory product will occasion a soft chancre only ; and this, again, if inoculated upon a healthy person, will give rise to a soft chancre only, and produce no syphilis. 8. The syphilitic primary effect or lesion may appear in three forms : First, as a superficial erosion or deep ulcer with hard borders and hard base ; second, as a hard nodule or ker- nel, which in the progress of the disease breaks down ; and, third, as a hard nodule, that from its origin to its complete resolution shows not the least trace of breaking down. The syphilitic primary lesion is the first manifestation of general, constitutional syphilis. 9. The most important data of the syphilitic primary lesion are the peculiar cartilaginous hardness, whether the syphilitic chancre appears as a simple nodule or as a hard ulcer; next, the indolent swelling of the lymphatic glands that accompanies it and the scanty suppuration. 10. If a syphilitic person is inoculated with ordinary pus or any other irritating fluid, upon an incision made with a clean vaccinating-lancet, there will sometimes result, in consequence of this irritation, a syphilitic ulcer. 10 PATHOLOGY AND TREATMENT OF SYPHILIS. 11. There is no chancrous syphilis, no primary and no sec- ondary syphilis. It is only proper to speak of chancre-syphi- lis when it is desired to indicate that the chancroid poison was mixed with syphilitic poison. The Hunterian induration may indeed be looked upon as the first manifestation of syphilis that is about to develop, but is by no means to be regarded as a primary evil whose virus in the course of absorption will become converted into the so-called secondary syphilitic virus. To the principles enunciated under § 5 we must add a few words and also refer the reader to the chapter on the " Inoc- ulability of the Indurated Ulcer," which will be found fur- ther on. It is an irrefutable fact that it is possible, by inoculating a luetic individual with syphilitic pus and syphilitic ulcer-detri- tus, to produce pustules and ulcers. Now, the question arises, What is the nature of those ulcers, which Clerc, for the sake of brevity, styled " chancroides," and what happens if a healthy person is inoculated with one of them? Before we answer these questions, we have to premise a few remarks. It has been ascertained, through experiments made by many physi- cians, that even the pus from ordinary skin-disease — for in- stance, a pimple of the face — may in some cases be used for repeated auto-inoculation on healthy persons. In this way the principle of the greater vulnerability of the skin of a syphi- litic person was partially refuted, and we must restrict our- selves to the statement that we can obtain positive results in some cases by inoculating healthy persons with any kind of pus, but that such inoculations take effect more readily in syphilitic persons. It is, therefore, easy to comprehend why we can so often produce ulcers by inoculating syphilitic per- sons with the pus of a syphilitic eruption. The question next arises, What happens when we inoculate a healthy person with matter taken from such a " chancroid " ? The result may be of three kinds : First, the inoculation may not take ; or, second, an ulcer ensues which remains localized ; or, third, a syphilitic primary lesion develops, followed by consecutive general syphi- lis. Why an inoculation fails we are unable to explain. The second and third conditions we consider as explicable in this wise : The syphilitic contagium is not chemically soluble, and THE VENEREAL CONTAGIONS. \\ is not uniformly distributed in the blood. Now, if we bear in mind Chauveau's experiments with vaccine lymph, we can as- sume the following facts : That in vaccinating we only trans- mit lymph and such particles of matter which accidentally con- tain no syphilitic virus. In this case, if the vaccination takes, we will only produce a simple local ulcer, which does not bear the characters of a syphilitic primary lesion. But if we trans- mit pus and such particles as do contain syphilitic virus, we will, in the third case, produce a syphilitic primary lesion that will be followed by general, constitutional syphilis. The vac- cinated sore that remains localized may be compared to the in- oculated ulcers, which may be produced on luetic and healthy persons with ordinary pus, and which may be reproduced by repeated inoculations. But if it is intended to regard these inoculated ulcers as soft chancres, then every inoculated ulcer produced with any kind of matter would have to be considered as soft chancres — a statement which we are not yet inclined to make. From what has here been said, it is evident that we must adhere to the duality doctrine of Yon Barensprung and H. Zeissl, and consequently assume the existence of three venereal poisons, namely, the contagium of gonorrhoea, of the (soft) chancre, and of syphilis. We will first discuss the morbid pro- cesses of gonorrhoea, then the soft chancre, and lastly syphilis. SECTION I. GONORRHOEA (TRIPPER), VENEREAL CATARRH. The morbid process known as gonorrhoea is a catarrh of the urethral mucous membrane. With the word catarrh, how- ever, only one symptom — namely, the hypersecretory activity of the affected mucous membrane is brought into prominence. Every hypersecretion presupposes the presence of a hypere- mia. This hypersemia, in the vast majority of cases of gonor- rhoea, is very active, because, as a rule, it is the immediate con- sequence of a pathological irritation. However, mucous mem- branes in general, and the mucous membrane of the male urethra in particular, are exceedingly sensitive to morbid irri- tation. But, as is known, there are also stasis-catarrhs in which the hypersemia is passive in character, and consequently comes on very gradually. The immediate effect of hypersemia is a serous transudation into the mucosa and the submucous mem- brane (oedema of the mucosa), and an increased activity of the secretory powers of the mucous follicles, which produce a clear serous fluid (serous catarrh). Still another effect of the hy- persemia is an increased formation of epithelial cells and the production of mucus (epithelial and mucous catarrh). When the irritation of the tissues is very slight an increased forma- tion of epithelial cells only will ensue ; when it is somewhat severer but still moderate, the production of mucus becomes notably increased. But the increased flow of mucus does not only emanate from the open, patulous acinous glands, but also from the epithelial cells of the mucous membrane, whose protoplasm becomes transformed into mucous substance (mu- cous metamorphosis) — a procedure that has its analogy in the corneous transformation of epidermis-cells. If a still more GONORRHCEA, VENEREAL CATARRH. 13 intense irritation takes place, the epithelial cells will form pus- cells either through endogenous cell-formation or nuclear fis- sion, and the cavities of the follicles are filled up with a fluid containing pus-cells (inflammatory and purulent catarrh). As a result of the continued suppuration, many of the affected fol- licles are liable to undergo ulceration, which may involve the submucous tissue, and result in limited defects of the mucous and submucous tissues (catarrhal ulceration). Now, just as we may speak of a serous, epithelial or mu- cous, and purulent catarrh, so is it possible to differentiate be- tween a serous, epithelial or mucous, and purulent gonorrhoea. The distinction, however, between these forms can not be strictly maintained. In all forms of catarrhs, just the same as in gonorrhoea, more or less epithelial cells, mucous and pus corpuscles may occur together ; one or the other of these three elements may, however, preponderate in a given case, and thus establish the character of the secretion. The serous, epithelial, and mucous catarrhs, as regards gon- orrhoea, are the forerunning stages of the purulent catarrh of gonorrhoea. The disease may be arrested at any one of these stages by any inhibiting influence ; or, on the other hand, the inflammatory and purulent catarrh of gonorrhoea in its retro- grade development may undergo resolution from stage to stage to the mucous, epithelial, and serous form. If the pressure of the blood in the capillaries of the catar- rhally affected mucous membrane becomes so great that they rupture, capillary haemorrhage will ensue. The escaped blood- corpuscles cause the purulent discharge to become brown or black in color, and the bleeding mucous membrane to assume an inky appearance (the black or Russian gonorrhoea). All the phenomena described above which go to make up the anatomical symptom complex of a catarrh in general, and hence, also, of the venereal kind, undergo in the latter espe- cially a rapid transformation, so that the whole morbid process runs its course in a few weeks and the mucous membrane may again be restored to a perfectly normal condition (acute gonor- rhoea). Before, however, the mucous membrane again becomes perfectly normal, it remains sensitive for a long time and the least cause may reproduce the catarrh. These relapses may 14 PATHOLOGY AND TREATMENT OF SYPHILIS. recur very often, and their frequent repetition tend to render greater the disposition to contract new catarrhal attacks ; these relapses always last longer too. Through the recurrence of frequent relapses the morbid condition is apt to become per- manent (chronic gonorrhoea). The views now prevailing concerning the genetic factors of gonorrhoea are not very clear. At any rate, it is an undeni- able fact that the disease may be transmitted from one person to another. The question, therefore, arises whether the trans- mission can be explained by the fact that the morbific action of the secretion of gonorrhoea develops its irritating properties in the usual manner in the second individual, or whether the gonorrhoeal secretion possesses a peculiar specific power by virtue of which it infects. While some investigators look upon the morbid process of gonorrhoea as a result of ordinary irritation of the mucous membrane, others claim that it is produced entirely by a con- tagion, which is reputed to possess such intense power that it can act not only by indirect contact but also at a distance (aura gonorrhoea). In regard to the hypothesis, that any irritation of the mu- cous membrane, be it mechanical or chemical, is capable of producing a muco-purulent secretion, it is a fact that has been a matter of daily observation for a long time. Through sim- ple friction of the vulvar mucous membrane (manustupration), the frequent introduction of instruments (bougies or catheters) into the male urethra, the impaction of calculi debris in the latter canal, the wearing of pessaries in the vagina for a length of time, catarrh of the mucous membrane of these organs has frequently been produced. Swediaur engendered an obstinate discharge from his urethra by injecting it with ammonia. Osmic acid, when placed upon a mucous membrane, will pro- duce catarrh upon it ; even the vapor of the acid is capable, as is well known, of causing serious catarrhal irritation of the conjunctiva palpebrarum et bulbi and of the mucous mem- brane of the larynx and trachea. The decomposing secretion of the glans penis, containing as it does ammonia, may occa- sion blennorrhoea of the glans penis. The decomposing men- strual blood, the lochia, discharge from a cancer, a chancre in GONORRHCEA, VENEREAL CATARRH. 15 the urethra, all may induce a hypersecretion of the urethral follicles. The catarrhal hyaline secretion of the uterus, un- der certain conditions, will give rise in some men to a muco- purulent discharge from the mucous membrane of the urethra. As every catarrhal secretion may become aggravated into an inflammation attended by suppuration, it was supposed that the growth of the infecting power of the secretion kept pace with the growth of the catarrhal process till it became aggra- vated into a purulent condition. Some authors, therefore, maintain that the gonorrhceal discharge only becomes infectious when it has become purulent ; that the serous secretion during the prodromal stage and the mucous secretion during the stage of resolution, if they contain no pus-cells, possess no infectious properties. In our practice, however, we have seen numerous instances where men troubled only with the prodromal phe- nomena of gonorrhoea, i. e., a prickling sensation at the meatus urinarius, where not a trace of pus could be found in the urethral discharge, infected their wives and mistresses. We have likewise had the experience that the slight mucous secretion of gleet is capable of communicating a gonorrhceal disease. The facts here produced compel us to assume that the mor- bific potency of a gonorrhceal infection is not to be found in the pus-cells, but in a specific catalytic power of the secretion — i. e., in a contagion which adheres to the epithelial as well as the pus cells, and which we are not able to isolate any more than other kinds of contagium. The hypothesis that an ani- mal or vegetable parasite (Neisser's gonococcus) forms the basis of a gonorrhceal contagium has not yet been satisfactorily demonstrated. [This gonococcus, which Neisser discovered in 1879, he claims occurs so constantly in the pus of gonorrhoea, that he and other investigators were led to consider the virulency of the disease as being due to this micro-organism. This proposi- tion was subsequently confirmed by the successful inoculation of a pure culture of gonococcus. The gonococci are distin- guished by their relative size, and also by usually occurring in groups of two, four, and more couples, whose origin may be 16 PATHOLOGY AND TREATMENT OF SYPHILIS. recognized by the division of the primitive coccus. These cocci are flat on the surfaces, facing each other like "split peas," and the groups formed of two or more couples are like German rolls facing one another. This marked tendency to form groups that consist of numerous pairs of single cocci, distinguishes this from other kind of cocci, which may happen to be in the urine and discharges from the sexual organs, and which likewise occur in the form of diplococcus, but never constitute such large groups. The gonococci are found in the pus, some of them free and others upon and probably also in the epithelial and pus cells, but not in the granules. By examining a prepared sec- tion of the conjunctiva of an infant afflicted with blennorrhcea neonatorum, Bumm proved that the gonococci are only capable of penetrating cylindrical and not flat epithelial cells, that they penetrate down between epithelial cells, but reach only the topmost layer of the submucosa, sometimes arranged as if they followed the capillaries of the lymphatic vessels.] True, it is now generally admitted that there must be a gonorrhoeal contagion, because daily experience has shown that a minimum quantity of gonorrhoeal discharge is sufficient to morbidly affect a normal mucous membrane, as is often the case in the production of gonorrhoeal conjunctivitis. Accord- ing to the views of most experienced physicians, catarrhal se- cretions of other mucous membranes are also more or less con- tagious. We are, therefore, of the opinion that there are irri- tative catarrhs — i. e., catarrhs that may be produced by various irritants, chemical agents, and disorganized physiological and pathological secretions, and such catarrhs as are produced by a specific contagious matter, and which should be designated as purulent or virulent gonorrhoea. Although the irritative ca- tarrh is pre-eminently attended by a muco-epithelial secretion, still one is not justified, from this property of the secretion, in saying that its genesis is not virulent, because a mucous catarrh may be the beginning and end of one that is virulent. In regard to the prognosis, however, we can say that the mucous catarrh, as a rule, is irritative, and its cure much easier to effect than the other forms. GONORRHCEA, VENEREAL CATARRH. 17 Site of the Gonorrheal Affection and Mechanism of the Gonor- rheal Infection. Venereal catarrh mostly affects the mucous membrane of the genital organs of both sexes ; bnt it may also be conveyed by contiguity to the mucous membrane of the rectum and uterus, and by transportation of the secretion to remote mu- cous membranes — for instance, the conjunctiva. Yenereal ca- tarrh most frequently occurs upon the mucous membrane of the male urethra, and the vagina and vulva in the female ; less frequently the cervical canal of the uterus, and rarer still the female urethra, are involved. We have never had an oppor- tunity of seeing gonorrhoea of the nose and mouth. It is easy to conceive why the female vagina and vulva and the glans penis should by contagion become catarrhally affected. The morbific matter readily comes in contact with the genital parts during coitus. Less easy to comprehend, however, is it how the morbific agent can, during copulation, exercise its in- fluence upon the mucous membrane of the male urethra, the meatus being but a narrow slit, whose lips well-nigh close the opening of the urethra hermetically. We opine the modus operandi to be as follows : The external orifice of the male urethra during the act of coition, by the forcible intrusion of the membrum virile (erect penis) into the vagina, is mechani- cally slightly opened. By the separation of the lips a vacuum occurs, and by the laws governing such physical conditions a portion of the contagious and irritative fluid that happens to be in the vagina is sucked into the urethra and effectively re- tained there, because during the retraction of the organ that follows the lips of the meatus are closed again. That this ex- planation is correct is proved by the following facts : Of sev- eral men who successively copulate with the same woman, those will not become diseased who on account of their intense excitability ejaculate their semen when their membrum virile has barely been introduced within the vulva. Men who break off the act of coition before ejaculating the semen become affected sooner than those who complete it naturally yet quickly. Men who micturate immediately after copulating are less often affected than those who do not take that precaution. 2 18 PATHOLOGY AND TREATMENT OF SYPHILIS. The spermatic fluid during ejaculation, and the urine during micturition, seem to wash out the urethra from behind forward in a similar manner. Factors that usually favor Gonorrheal Infection. Short acts of coition frequently repeated, and abruptly broken off, favor gonorrheal infection, because, as the orgasms become longer, the female genitals become more irritated and incited to discharges. Hence it happens that copulation re- peated at frequent intervals with a woman suffering from ute- rine catarrh, or one who is menstruating often, produces serous, epithelial, or mucous gonorrhoea in the male. If the catar- rhal uterine secretion and the menstrual blood, per se, were capable of acting as irritants, the number of urethral catarrhs would be far greater. Even healthy, loving couples very often show, after a night of immoderate indulgence in sexual inter- course, the symptoms of commencing urethral and vaginal ca- tarrh. The relative size of the genital organs is also a factor that should be taken into consideration here. The greater the fric- tion which the vagina must suffer from a large membrum vi- rile, the more profuse and thicker will the catarrhal secretion be. A short, erect penis will scarcely ever be affected by a uterine secretion. Men with large meatuses become diseased more easily and quickly than those who have a very narrow orifice. A urethra terminating in a hypospadic meatus is oftener and more eas- ily infected than a normal one, because the gonorrhoeal secre- tion of the vagina, in accordance with the laws of gravitation, accumulates mostly upon the posterior wall of the vagina, and consequently the contact of the urethral orifice of the hypo- spadiac with the infecting and irritating matter occurs more readily. Another factor that favors gonorrhoeal infection is drunk- enness, because the act of copulation when attempted by a person in an intoxicated condition will take a longer time be- fore terminating in ejaculation, and the membrum virile is consequently retained longer in the vagina. A man who has but recently recovered from an attack of GONORRECEA, VENEREAL CATARRE. 19 gonorrhoea is much more readily infected than one who was not affected with the disease. There is no peculiar condition of the blood that will render a person especially prone to be affected with the gonorrhoeal contagium. Gonorrhoea of the Male Urethra. We make a distinction between serous, mucous, or epi- thelial and purulent catarrh of the male urethra. The cause, or circumstance, which in a given case produces a serous or mucous catarrh only, and stamps it with that character, con- sists mainly in the property which the morbific matter exer- cises upon the urethra. Upon that also depends the rapid or tardy development of the catarrh. The richer the mor- bific matter is in pus the quicker will the disease ensue, and the more intense will it be. Mucous secretion, for in- stance, catarrhal uterine discharge, or fluids entirely free from pus, like menstrual blood, or mechanical irritation of the ure- thra, as a rule give rise to serous, epithelial, or, at the most, mucous catarrh, while the purulent discharges of inflammatory catarrh of the urethra and vagina generally cause an inflamma- tory or purulent catarrh. The serous and mucous catarrh of the male urethra is either initial or terminal. The initial catarrh soon subsides under an appropriate treatment ; under unfavorable circumstances, however, it will merge into an inflammatory or purulent catarrh. The terminal catarrh, as a rule, assumes a protracted course, and is exceedingly obstinate. The initial serous and mucous catarrh has its site in the fossa navicularis of the urethra, the terminal catarrh in the pars membranacea and prostatica. The secretion of the terminal serous and mucous catarrh is frequent- ly more opaque and glutinous than that of the initial catarrh, because, owing to its site in the pars prostatica, the tubuli pros- tatici are also involved. The secretion of the prostate gland produced in consequence of unnatural and prolonged sexual irritation, and which finds its way into the urethra, is not to be mistaken for the mucous discharge of the initial serous and mucous catarrh. The inflammatory catarrh of the male urethra (urethritis purulenta, acute inflammatory gonorrhoea) runs its course in 20 PATHOLOGY AND TREATMENT OF SYPHILIS. the following manner : Twenty-four or forty-eight hours, sel- dom later, after an act of intercourse, the person feels a slight, unpleasant prickling sensation at the meatus which leads him to micturate frequently. Gradually, however, the mucous membrane of the meatus becomes swollen and a slight but clear translucent and tenacious secretion makes its appearance, which, under the microscope, shows mucous corpuscles and a few epithelial cells. If the patient is made to pass his urine into a glass vessel, the discharge will be seen to contain numer- ous flocculent and thread-like structures that swim about in the urine, which is otherwise clear. The discharge being slight, it therefore becomes inspissated in the meatus, sealing it up, thus preventing the patient from micturating easily. It gen- erally requires a few moments before the thickened discharge is washed away by the stream of urine. These symptoms are met with alike in both the serous and mucous gonorrhoea. In purulent gonorrhoea, however, the scene is soon changed. The tickling is transformed into a burning, painful sensa- tion. The mucous membrane of the meatus swells up so that it bulges outwardly and the orifice looks like the mouth of a fish. The secretion becomes more profuse, thicker, and ac- quires a greenish or yellowish-green, color. If at this stage of the disease a small quantity of the urine is collected in a glass vessel, it will appear opaque on account of the purulent secre- tion that is mixed with it. The pus-corpuscles swim about like particles of dust or minute animalcules in the urine, and then gradually sink to the bottom of the vessel because their specific gravity is heavier than that of the mucous flakes and epithelial cells of the mucous catarrh and the urine itself. The discharge slightly colors blue litmus-paper red, and under the microscope shows predominantly pus-corpuscles along with mucous and epithelial cells, sometimes also a few blood-cor- puscles* Yirchow has called attention to the fact that gonor- rhoea! pus-corpuscles are larger than those of ordinary pus. The purulent discharge appears by the fourth or fifth day, rarely not until the twelfth or fourteenth. As the discharge from the anterior part of the urethra gradually increases, the difficul- ties of urination also increase. The patient micturates either with a good, deal of pain, the urine coming away only in drops. GONORRHOEA, VENEREAL CATARRH. 21 or in a thin, weak, and interrupted stream, because the urethra, owing to inflammatory swelling of the mucous membrane, is temporarily narrowed, and the smooth, striated, muscular fibers of the urethra that propel the stream of urine are partially par- alyzed. Occasionally Wilson's muscle, the sphincter vesicae, contracts spasmodically, causing intense strangury. The spon- gy portion of the penis, like the mucous membrane, is en- gorged ; hence the organ is constantly in a semi-erect condition, and thus helps to render the urethra still narrower. In cases of intense inflammatory gonorrhoea of the male urethra, gastric disturbances and febrile movement not infre- quently become superadded. The former healthful appear- ance of the patient disappears as if by a blow, and he becomes pale and sickly-looking. This marked depressed condition of the general system is not, however, due to the effect of the gonorrhoeal contagion upon the blood, but is the result of the constant pain and disturbed sleep. The warmth of the bed causes frequent erections, and the swelled mucous membrane not being sufficiently distensible is dragged upon by the erec- tions of the corpora cavernosa, producing intense pains and disturbance of sleep at night. When the patient, despite the pain and utter exhaustion, finally falls asleep, he is not infre- quently awakened by a painful emission. The morbid phenomena here delineated persist for a longer or shorter period according to the dietary measures and regi- men the patient keeps. Under appropriate measures the swell- ing of the urethral canal subsides by the eighth day, and the dysuria markedly diminishes. At the beginning or end of the third week the purulent discharge decreases and becomes poorer in pus-corpuscles, while the mucous and epithelial cells begin to predominate. Gradually the mucous discharge also changes, so that only a few drops of mucus or muco-purulent discharge escapes from his urethra if he has not micturated for several hours. If the urine that is passed at this time is col- lected in a glass vessel, whitish shreddy structures (gonorrhoeal shreds), varying in length, are seen floating in it. If the shreds are taken from the urine they will contract into small gelatinous lumps, and microscopically are seen to be fatty degenerated epithelial cells and pus-corpuscles. These elon- 22 PATHOLOGY AND TREATMENT OF SYPHILIS. gated epithelial shreds may, it is true, originate in the ducts of Cowper's or Mery's gland ; still they are not to be considered as such in all cases, since they may form at any point of the urethral canal. After a while, the quantity of these shreds diminishes, and for some time, whenever the patient urinates, there may be but one such shred in the urine. Finally, this one too disappears, and in the course of six weeks' time a gon- orrheal process may be said to have reached its end. So long as any of these gonorrheal shreds is noticeable in the urine, the least cause may again start up the morbid process that is so near expiring. The oftener these relapses occur the more difficult is it to cure completely a urethral gonorrhoea. In some parts of the mucous membrane of the urethra permanent sensitive spots remain, attended by persistent though slight muco-purulent discharge. This condition is called gleet (after- clap) or chronic torpid gonorrhoea. Chronic urethral gonorrhoea may best be described as a persistent mucous stage in the retrograde development of the disease. Here the discharge containing mucous and epithelial cells is very slight, and is only seen at times, especially in the morning, at the meatus of the urethra, or, by squeezing the parts, a drop of matter is expressed. If the lips of the meatus are not agglutinated, micturition is easy, and no general and often no local disturbances of sensation are present. In some cases, however, the patients complain of occasional prickling sen- sations in the region of the fossa navicularis or at some point of the perineal part of the urethra, or, again, of some transient stitches that extend from the' latter spot to the anal opening. These sensations seem to be due to deep pathological altera- tions, which, however, vary so much that we are not justified in describing them under the common name of " chronic gon- orrhoea" — still less so, as a more correct diagnosis would essen- tially alter the prognosis and treatment of the disease. In acute gonorrhoea of the urethra the dysuria may, owing to the intense swelling of the urethral mucous membrane, be- come intensified into a condition of actual strangury. The turgescence of the capillaries of the mucous membrane may attain such a degree that they rupture at various points, some- times resulting in severe haemorrhage. The blood that is GONORRHCEA, VENEREAL CATARRH. 23 poured out into the urethra and coagulates there colors the purulent discharge reddish-brown or even blackish, and for this reason it is also called hcemorrhagic, Mack, and Russian gonorrhoea, because it is said to have been of uncommonly fre- quent occurrence among the Russian troops engaged in the wars at the beginning of the present century, owing to indis- cretion in the diet and hygienic regimen. Another uncommon feature of the inflammatory urethral gonorrhoea in the male is that the inflammation of the epithe- lial layer penetrates through the mucous membrane and the submucous tissue and involves the spongy portion of the ure- thra, in the meshes of which, especially in those of the corpus cavern osum urethrse, one or more painful swellings, varying in size from a pea to that of a lentil, form. If these peri-ure- thral inflammatory foci form in persons who are afflicted with frequent erections that last some time, the erections already so painful become still more intense, because the spongy portion in which the infiltration has taken place not only can not keep pace in the erections with the other portions of the erectile spongy body, but actually hinder it from becoming erect, and cause it to curve like the bow of a violin. This kind of erec- tions has been designated chorda venerea (chordee), because the patients claim that they have the sensation as if the penis is prevented from becoming erect by a tense cord drawn through the urethra. Now, in its erections the penis will be bent either downward or to one side, according as the corpus cavernosum or urethra is affected. Under judicious treatment the pains during erections cease in the third week, and the peri-urethral inflammatory nodes undergo absorption. If the absorption is incomplete, the inflammatory exudative hyper- trophies will remain, causing the affected spot of the spongy body to become obliterated, and during erections the member will curve toward the swelled spot, rendering it difficult of introduction into the vagina during intercourse. In some cases abscesses form in these peri-urethral infiltrations, which subsequently perforate the urethra and give rise to fine fistu- lous tracts. These abscesses most frequently break into the fossa navicularis in consequence of the inflammatory exuda- tion occurring in the sulcus coronarius near the frsenum. 24 PATHOLOGY AND TREATMENT OF SYPHILIS. In chronic gonorrhoea the catarrhal process may likewise, through indiscretion in diet or other injurious measures, be- come aggravated. The mucous catarrh becomes intensified into a purulent one, or even attains to a condition of croupous inflammation. This manifests itself in the following manner : The patient whose urethra is apparently almost well suddenly begins to feel intense itching in the perineal region, and this sensation is supplanted in a few hours by violent pains. The mucous discharge subsides almost entirely, but there is greater difficulty in making water, and the stream of urine becomes thinner. If a bougie is introduced, and after its removal a syringe full of water is injected, the returning fluid will bring away white membranous masses from two to three centimetres in length, consisting of a dense band-like or cylindrical fibrinous substance which has originated by fibrinous exudation upon the epithelial layer of the mucous membrane. These bands will break abruptly on being forcibly stretched. On the addi- tion of acetic acid they swell up and become clear like fi brine, whereas mucus becomes opaque and coagulates into shreds on the addition of an acid. According to our experience, this mor- bid condition seems mostly to be produced in the membranous part of the urethra in consequence of severe irritation by strong injections, especially solutions of bichloride of mercury. Urethral gonorrhoea has its starting-point in the fossa na- vicularis. This is evident from the fact that at the beginning of the disease patients complain of an itching sensation, and later of pain in this region. But the physician should not hastily assume that the gonorrhoea! process tarries in the fossa navicularis as long as the patient experiences tickling or pain in this locality. In this part of the urethra the sensorium commune of the entire territory of the genital organs seems to center, for here the patient feels all the morbid sensa- tions, in whatever manner or part of the urinary organs they may have been produced. Thus, calculi in the bladder, affec- tions of the prostate, and many other irritations, produced in the deeper parts of the urethra, are felt in the region of the fossa navicularis. At the beginning, during the initial serous or mucous stage, the congestion is certainly limited to the anterior part of the urethral canal ; but after a few days, espe- 25 cially in purulent catarrh, the congestion gradually extends backward, so that by the eighth or teuth day the entire mucous membrane of the pars pendula, and by the beginning of the third week that of the pars membranacea, is affected. The junction of the pars bulbosa to the pars membranacea of the penis, where likewise a navicular fossa forms, and where a num- ber of aggregated follicles exist, is the most difficult spot to cure — the follicular inflammation forming the greatest obstacle in curing a gonorrhoea radically. An inflammatory urethral gonorrhoea may be arrested at any point in its progress, from the fossa navicularis to the membranous portion, but at this point the disease is not only likely to become markedly aggra- vated because the existing follicles, that have been alluded to, become inflamed and undergo suppuration (gonorrhceal ab- scesses), but swelling and thickening of the tissues take place here preferably, which, if produced by stasis-catarrhs, will, ac- cording to the intensity, duration, and course, seriously affect the gonorrhoeal process. But, from experience, we are justified in saying that certain constitutional conditions, such as scrofula, tuberculosis, anaemia, gout, rheumatism, haemorrhoids, and all those irritations which, emanating from the rectum (intestinal worms) or bladder (calculi, etc.), are likely to affect the poste- rior part of the urethra, also contribute materially toward pro- longing a chronic catarrh of the urethra, and make it exceed- ingly difficult to cure. Pathological Alterations in the Male Urethral Canal produced by the Gonorrhceal Disease. During the life of the patient it is not possible to see throughout the whole extent of the urethra, with the unaided eye, the morbid alterations of the mucous membrane of the urethra. Examinations on the cadaver seldom offer an op- portunity of studying the morbid alterations of the urethral mucous membrane ; and the views of most reliable investiga- tors, based upon post-mortem research, refer more to such morbid lesions which have originated in consequence of a protracted chronic gonorrhoea than to alterations resulting from the acute form of the disease. The few cases of gonor- rhoea! disease which we had an opportunity of investigating 26 PATHOLOGY AND TREATMENT OF SYPHILIS. post-mortem, before the affection of the urethra had entirely disappeared, taught us that it only occasions such morbid changes as we are accustomed to find in catarrhs of other mu- cous membranes. The pathological alterations of gonorrhoea of the vaginal mucous membrane in the acute stage, or blen- norrhagic affection of the conjunctiva palpebrarum et bulbi, will form the truest representation of the lesions resulting from the disease under consideration. We find there redness and swelling of the mucous membrane, sometimes granulations, and not infrequently erosions, which bleed easily. In re- gard to the gonorrhceal discharge, in the acute stage of the disease, proliferation of the epithelial cells and transformation of the epithelium-cells into pus-corpuscles take place, while in the torpid stage epithelial cells undergo fatty degeneration and hyaline cells abound. Rokitansky expresses himself thus : " The catarrhal inflammation of the urethral mucous mem- brane has a tendency to run a chronic course. It is either uniformly distributed over the entire urethra, or sometimes from the beginning, at other times later in its course, is limited to one or more spots. These inflamed spots are found at any part as far as the prostatic portion, but most frequently at the fossa navicularis, and near the bulbous portion of the ure- thra. They are recognized by their dark-red color and the swelling of the mucous membrane ; sometimes, especially in the fossa navicularis, remarkable enlargement of the mucous glands and purulent collections are observed. At the same time the corpus spongiosum urethrse, at the places mentioned, in its innermost layer — at times, indeed, throughout its entire length — is swelled, and its meshes diminished in size, and conse- quently contains less blood. At these places an unyielding swelling, produced in the manner described, is readily per- ceived along the urethral canal. The longer the inflammation lasts, especially when its intensity is frequently aggravated, the less likely is it to get well entirely ; it is more apt to ter- minate in thickening of the mucous membrane, or strictures." Engel is unable to say a great deal positively regarding the diseases of the urethral mucous membrane, because in most cases it is impossible to distinguish an acute inflammation of the urethra from the chronic variety. Neither produces GONORRH(EA, VENEREAL CATARRH. 27 morbid lesions that are readily perceived or belong to them specially, and which are not likely to be met with in a condition of apparent health. And the discharge which in inflammation of other parts affords definite proof, is generally only limited in amount in urethritis — often, indeed, it is greatly diluted, changed, or washed away by the current of the urine, and in rare instances only is there any thick, purulent secretion. The urethral mucous membrane generally becomes thick- ened, rough, and dry in chronic gonorrhoea. Occasionally there have been found in the region of the bulb, less frequently in the navicular fossa, spreading ulcers, one centimetre long, with flat, projecting shreddy edges and uneven bases surrounding the entire circumference of the urethra, studded with condylo- ma-like excrescences (carunculse) and bridles of mucous mem- brane (Engel). They originate from the ulceration of the follicles found at those points, and in healing form white yielding or non-yielding cicatrices, according to the depth to which the ulcers have penetrated. In the fossa navicularis this ulcerative process may perforate the urethra, and a fistula may result, through which urine escapes during the act of micturition. To be able to diagnosticate a gonorrheal ulcer in the living subject, pure water should be injected several times in succession into the urethra. If pus, mucus, blood-corpus- cles, and especially structural detritus, come away after each in- jection, it is certain that an ulcer is present. Sometimes a bougie introduced into the urethra causes intense pain in pass- ing over the ulcerated spot. In some cases we found the ducts of Cowper's glands dilated to such a degree that they allowed the passage of fine probes. In the last decade the morbid lesions of the urethra, result- ing from various diseases, have been studied by direct ocular inspection. Desormeaux, as far back as 1853, used a complicated in- strument for that purpose, which, has since been considerably improved by several surgeons. The simplest apparatus was invented by Griinfeld. His instrument consists of an endo- scopic tube and a concave mirror ordinarily used in laryngo- scopy examinations. Gas, petroleum, or sunlight may be made available for illumination. 28 PATHOLOGY AND TREATMENT OF SYPHILIS. The " endoscope," so warmly recommended and employed by Griinfeld, is simply an endoscopic tube. It consists of a cylindrical metallic or bard-rubber tube, whose ocular end is dilated like a funnel, its inner surface blackened, and its visceral end open and polished smoothly. This tube is in- troduced by the aid of a conductor, and it not only serves the purpose of enabling the physician to obtain a view of the ure- thra, but also of applying remedies to it. Great tact and practical skill in the use of sounds and catheters will help one to employ the endoscope successfully. The instrument is introduced armed with the conductor, pushed into the deepest part of the urethra, when the conductor may be withdrawn ; the urethral surfaces may then be cleansed of mucus, discharges, etc., either by a plug of cotton- wool upon a wire, or by a stream of water from a long-nozzled syringe. Three things are to be noted, according to Griinfeld, in making examinations by the aid of the urethroscope : 1. The funnel, i. e., the shape under which the urethral mucous mem- brane presents itself, wherein the larger end of the funnel lies contiguous to the internal border of the tube, and the narrow end is directed toward the smaller lumen of the urethra ; 2. The central figure, i. e., the apex of the funnel corresponding to the point in the center of the field of vision, which is occa- sioned by the urethral walls meeting at a point ; and, 3. The urethral walls, the color and thickness of the mucous mem- brane, the condition of its vascular arrangement, its reflex sensibility, etc. Griinfeld distinguishes the following forms of acute gonor- rhoea : 1. Urethritis blennorrhoica ; 2. Urethritis membranacea ; 3. Urethritis simplex ; 4. Urethritis granulosa ; 5. Urethritis trachomatosa ; and, 6. Urethritis phlyctsenulosa or herpetica. In tirethritis blennorrhoica the field of vision is profusely cov- ered with pus. The funnel form is absent, the central figure is irregularly indented, or a single spot is seen from which two or three indentations radiate. The swollen mucous mem- brane that bulges up into the lumen of the tube is uniformly livid in color, and presents defects of reflection corresponding to the punctated losses of substance. The edge of the tube pro- duces in the thickened mucous membrane a temporary grooved GONORRHCEA, VENEREAL CATARRH. 29 impression, and the mucous membrane bleeds on the slightest pressure. In urethritis membranacea, Griinfeld found the morbid process limited to a certain part, to which the pus firmly adhered, the removal of which caused bleeding. Paral- lel with the axis of the urethra several gray or grayish- white strips of exudation were found firmly adhering upon the mu- cous membrane. In urethritis simplex there is often present only a hyper semic condition. Where the mucous membrane is somewhat more swollen, it will be found more reddened, and several bleeding points will also be detected. In urethritis granulosa a small quantity of muco-pus is found in the middle of the field of vision, resembling the point of the central fig- ure, the funnel is short, the center figure oval and slightly shorter, the reflex irregularly triangular, the mucous mem- brane of a uniform velvety redness, with a few solitary punc- tate elevations. The mucous membrane, in the majority of cases, acquires a certain degree of rigidity, as may be per- ceived from the gaping of the walls at the central figure. In some cases Griinfeld observed a purely granular trachomatous swelling. In the forms of urethritis attended by ulcerations, urethritis phlyctamulosa or herpetica, Griinfeld found a few small circular ulcers which attracted attention by their color and sharply defined edges.* Morbid Phenomena which occur as Co-effects and Sequelse of Urethral Gonorrhoea in Men. In gonorrheal disease of the male urethra, certain morbid alterations often coexist which have their site beyond the ter- ritory of the urethra and its adjacent parts, and which may be regarded as the co-effects of the urethral disease, while the propagation of the disease may give rise to certain mor- bid lesions in contiguous or adjacent organs or parts of or- gans. Among the co-effects we may mention balanitis, affec- tions of the lymphatic vessels of the penis, inflammation of * If the student desires further information upon this subject, he is referred to the work of Griinfeld, " The Endoscope in Diseases of the Bladder and Urethra," published in the " Deutsche Chirurgie," and to Griinfeld's treatise, " The Endo- scopic Examination of the Urethra," in our work on. " Syphilis," fourth edition. 30 PATHOLOGY AND TREATMENT OF SYPHILIS. the inguinal lymphatic glands, condylomata (warts'), and cer- tain rheumatoid affections of the joints, sheaths of muscles, and bursse. Of the diseases which extend by contiguity from the urethra to adjacent organs, we may mention affections of Cowper's gland, of the epididymis, prostate, bladder, ure- ters, and kidneys. Moreover, the morbid lesions produced by urethral gonorrhoea, when they supervene upon a severe form of the disease, are generally considered as accompanying phenomena of the disease; while those lesions produced by gonorrhoea of the male urethra and coming on sometime after the urethritis was apparently cured (strictures of the urethra, prostatic and vesical diseases), are described as sequelae. Prognosis of Gonorrhoea in the Male. Gonorrhoea of the male urethra affords a less favorable prognosis than gonorrhoea of the female urethra and vagina — a fact that might be inferred, even after leaving out of consid- eration certain co-effects which naturally can not occur at all in the female, but which in addition seem to be due to a higher function of the epithelial cells of the male urethral tract that has not yet been fathomed. To foretell the duration and course of a male urethral gonorrhoea is a difficult problem. Experience has only taught us so far that, when a mucous gonorrhoea has retained this character for several days after exposure to infection, it will under an appropriate treatment disappear sooner than a purulent gonorrhoea. This presump- tion of a speedy cure becomes almost a certainty when the female who communicated the disease to the patient suffers only from a mucous catarrh of the genital organs, or when the disease in the man can be ascribed to the temporary irrita- tive influence of the menstrual flow in the woman. The first inflammatory gonorrhoeal urethritis of a person is generally severer and more obstinate than the following ones of the same character. The shorter the intervals between the first inflam- matory gonorrhoea and those following, the milder will the lat- ter be. The greater the swelling and the eversion of the lips of the meatus, the more severe the disease may be expected to run. Hemorrhages, peri-urethral inflammatory exudations, GONORRHOEA, VENEREAL CATARRH. 31 infiltrations into one of the spongy bodies, affect the prognosis unfavorably. The healing of ulcerations takes a long time, and even a mucous catarrh of the deeper part of the urethral canal is very slow in getting well. A croupous gonorrhoea causes shrinking and contraction of the affected part throughout its whole extent. Lastly, hemorrhoidal conditions, scrophulosis, and especially pulmonary tuberculosis, tend to delay the cure of a gonorrhoea in the male for a long while. Prophylaxis against Gonorrhoea, and Treatment of Acute and Chronic Gonorrhoea in Men. Up to the present day we have not succeeded in finding a medicinal agent by the use of which, before or immediately after sexual intercourse, a gonorrhoea!, infection may be pre- vented. According to Diday's and our own experience, injec- tions with a solution of potash considerably diluted, or with slightly acidulated preparations, indeed even with pure water, directly after coitus, have a decidedly irritating effect; we would therefore recommend that such injections be not used till the membrum virile has been cooled off in a topical bath of cold water. The best security against contracting the disease is afforded by the use of the condom, made of various sub- stances, such as the intestines of sheep, fish-bladders, and India-rubber. Owing to the frequency with which these envelopes burst, they can not be relied upon as a sure protec- tion. As prophylactic measures which may possibly prevent the origin of the disease, the act of coition should be accom- plished as quickly as possible, and should not be repeated at short intervals ; the individual should abstain from having in- tercourse with menstruating women or those suffering from lochial discharges, and finally he should urinate directly after copulation and wash or bathe the penis in water. Inefficient as our measures are to prevent a gonorrhoea, so little are we at present able to abort the disease by treatment. Injections of caustic preparations — for instance, strong solutions of nitrate of silver (1 gramme to 30 of water [= gr. xvj to § j]) before the inflammation has begun to develop, as recom- mended by Ricord — may prove positively injurious to the patient and never afford any benefit. Indeed, all kinds of 32 PATHOLOGY AND TREATMENT OF SYPHILIS. caustic injections are apt to produce sloughing of the urethral mucous membrane, inflammation of the neck of the bladder and of the prostate gland, haemorrhage from the urethra, and the disease which the physician sought to nip in the bud will be vastly protracted and aggravated. In regard to large doses of balsamic remedies administered internally, with the object of aborting the disease, we hold that they merely give rise to severe digestive disturbances, without exercising any beneficial effects whatever. Hence we are only able to recommend a methodical treat- ment of urethral gonorrhoea corresponding to the intensity and the stage of the disease. The more intense the inflammatory phenomena and the discharge, the milder should the treatment be ; the milder the inflammatory symptoms, the more energetic, but not too energetic may the treatment be. If the treatment adopted consists in the introduction of remedies and medicated instruments into the urethra, it is called the direct method ; but if a cure is attempted by the action of remedies through the digestive and respiratory organs, it is known as the indirect method. It is of the utmost importance to regulate the diet and regimen of the patient. Whether the patient suffers from an acute or chronic gonorrhoea, he should be prohibited from drinking beer, wine of all kinds, champagne, and soda-water. In sensitive individuals these beverages may occasion dysuria, bleeding, and other symptoms denoting aggravation ; these un- favorable complications are likely to supervene in gonorrhoea, even without any special causes. The patient should likewise be prohibited from using asparagus, celery, and all other arti- cles of diet which stimulate the urinary organs or cause erotic sensations. Active exercise, such as running, riding, fencing, playing billiards, etc., should be prohibited, and as a measure of precaution the patient should be advised to wear a suspensory bandage with thigh-straps. Suspensory bandages with elastics which press upon the urethra are injurious and should not be used. Notwithstanding these precautions, the patient is not safe from an attack of inflammation of the epididymis. He is, of course, to abstain absolutely from sexual intercourse ; a single GONORRHCEA, VENEREAL CATARRH. 33 indulgence at this time is likely to produce the most injurious results, and a simple gonorrhoea may become gravely compli- cated. The best drink is, after all, pure water ; at the most, lemonade in quantities only sufficient to quench the thirst may be allowed. Diuretics are directly injurious. In regard to his food, the patient should be kept on a spare diet, consisting if possible exclusively of vegetables, milk, light tea and mild coffee, chocolate, soups, and stewed ripe fruit. If meat has to be permitted, it should only be in small quantity and at noontime. The patient should eat nothing late in the evening or shortly before retiring, in order to avoid seminal emissions. Were the gonorrhoeal patients to subject themselves to the above-described diet and remain strictly at rest, and in addi- tion make daily applications of cold water for several hours to the genital organs and peringeum, most cases of gonorrhoea would get vjell within four or six weeks without injections or internal medicine, or at the most with the aid of very little medicine. If the patient, in the course of an acute or chronic gonor- rhoea, is obliged to urinate frequently, or if blood is ejected with the last few drops of the urine, no injection should be made into the urethra nor any balsamic remedies administered internally. The frequent ischuria and the discharge of blood from the urethra or bladder are best relieved by the applica- tion of hot fomentations to the region of the bladder and over the penis and perinseum, by the introduction of suppositories of belladonna or morphine into the rectum, or the internal use of both these remedies or of extract of cannabis indica. Iron and ergotine may be employed if the haemorrhage continues or is severe. For this purpose we prescribe : 5 Extract, belladonnas (or raorph. raur.), 010 [= grs. jss.] ; Butyri de cacao, q. s. ; nt. ft. snppositor. parva No. 10. 5. Three suppositories, well oiled, to be introduced daily into the rectum. 5 Ext. cannabis indica ; Ext. semin. hyosciam., aa 0-30 [grs. v] ; Sacchar. alba, 3 - 00 [grs. xlvij] ; Div. in dosis No. X. 6. One powder to be taken every four hours. 3 34 PATHOLOGY AND TREATMENT OF SYPHILIS. ^ Liquoris ferri sesquichlor. soluti, 1*50 [gr. xxiij] ; Aqua destil., 100*00 [ § iii, 3 ij, 3ij] ; Syr. rubi idaei, 20-00 [ § ss., 3iv] ; S. One tablespoonful every hour in water. 3 Carbonatis ferri saccharat. ; Ergotini pur, aa 1*00 [gr. xvj] ; Sacchar. alba, 3'00 [gr. xlviij] ; Div. in dosis No. 10. S. Four powders to be taken daily. In very intense dysuria and very painful erections, the hy- podermic injection of morphia into the perinaeum will afford prompt relief. [For the control of the ardor urinse, alkalies, such as acetate of potash, with spirit of nitri dulcis and camphor-water, may be given, diluted in water, every three or four hours. In the acute stage, when the chordee is very severe, an injection of cocaine before going to bed, and another when the patient is attacked by it in the night, have rendered the best results. In some cases the cocaine answered admirably when all other agents failed.] No favorable effects are derived from the internal admin- istration of camphor. If the bleeding from the bladder does not cease under this treatment, cold-water applications should be substituted for the hot fomentations ; but the former should be discontinued if they aggravate the pains on micturition. If no dysuria be present, and the penis is not much swollen, injections may be ordered at once, but if painful urination or pain in the testicle ensue, the injections must be immediately discontinued, and the remedies above recommended for the dysuria, or the measures to be described in the treatment of epididymitis, may be resorted to. When no great amount of swelling of the penis, in consequence of the inflammation of the urethra, is present, injections may be begun. But the remedies to be injected must not be too strong or too con- centrated ; they should have no escharotic action, nothing more than an astringent effect. If the injections employed are of the proper strength, the pain from which the patient suffered during urination often subsides in from two to three days, and the discharge of pus also diminishes, while stronger injections GONORRHEA, VENEREAL CATARRH. 35 quickly aggravate the pains, the penis becomes swollen, fre- quent and painful urination and bleeding ensue, and the patient is rendered more miserable than ever. As has been remarked above, better results are obtained from mild astringent injec- tions, employed at proper periods and in a proper manner, than from any other measures. And yet many objections have been urged against using them. The most serious are that by the injections the contagious discharge is forced farther backward into the deeper parts of the urethra, and the in- flammation is consequently driven into the testes and bladder ; furthermore, that astringent or caustic injections accomplish nothing more than spasmodic contraction of the sphincter mus- cle of the bladder. Now, the contagion can not be forced backward, because the injected fluid coagulates the discharge, and in that way destroys its infecting properties. The second objection is refuted by a thousand-fold experience, which proves that the majority of strictures of the urethra are due to those morbid changes in the mucous membrane, resulting from per- sistent and violent gonorrhceal inflammation alone. We have found strictures in patients who for years had suffered from gonorrhoea, and submitted to no treatment at all. The ground- lessness of the statement that injections may have such an injurious effect upon the disease of the urethra as to cause the destruction of the epithelial cells of the mucous membrane, coagulate the protecting mucus, and corrode the superficial layers of the new, imperfectly solidified connective tissue, is proved by results obtained in the treatment of gonorrhceal disease of the eye, vagina, vulva, and rectum. If we do not advocate the abortive method by the aid of caustic agents, and concentrated astringent remedies (nay, more, we even urge that the greatest caution be exercised in the local treatment with astringent preparations), it is not because of the bad effects we fear the injections will have upon the mucous membrane, but on account of totally different circumstances. If a large quan- tity of even the mildest fluid is injected into the urethral canal, contracted through inflammation, the mucous membrane of that canal will be severely stretched or even torn. Furthermore, the sensitiveness of the male urethral mucous membrane, as compared with other mucous membranes, should not be lost 36 PATHOLOGY AND TREATMENT OF SYPHILIS. sight of. The mucous membrane of even a healthy urethra is markedly irritated by the mere injection of pure cold water. Hence an inflamed urethral canal requires to be handled with the utmost gentleness. The injections are best made with an air-tight but easy-act- ing syringe, made either of hard rubber or tin. Glass syringes are too fragile and seldom of uniform caliber. It should ter- minate in a short, blunt, and smooth end. As air forced into the urethra is, apt to produce spasm of the bladder, every parti- cle of air should therefore be expelled from the syringe. This is best accomplished by turning the nozzle upward and push- ing the piston home till the liquid flows out. The amount of fluid that may be injected into the urethra should be in pro- portion to the length and lumen of that canal. The injection may be made with the patient in any position, but it is best done when he is standing. The physician grasps the exposed glans penis between the thumb, index, and middle finger of the left hand; applies closely to the meatus the end of the syringe, held between the index and middle fingers of his right hand, while with the thumb, inserted in the ring of the piston, he slowly presses it home. In patients affected with hypospa- dias, and who sometimes have several openings situated behind each other — of which only the last is likely to lead into the meatus, while the rest terminate blindly — the penis has to be twisted upon its axis, so that the meatus, which is situated upon its under surface, is made to appear upon its upper surface, and the syringe is placed upon it almost perpendicularly. The first syringeful may be allowed to come away directly after being injected for the purpose of washing away the discharge that has accumulated in the canal, and then a second injection should be made and retained for a few moments by compress- ing the lips of the meatus as the syringe is being withdrawn. If the fluid is retained too long, the meatus urinarius is pulled and distended too much, and may become greatly irritated. The more slowly the fluid is forced into the urethra the more deeply will it penetrate. Injections repeated too often are injurious ; not often enough, are of little use. We recommend from four to six injections daily. For the purpose of ascertaining the progress of the urethral affection, and to modify its treatment GONORRHCEA, VENEREAL CATARRH. 37 accordingly, the injected fluid should be allowed to flow into a glass vessel from time to time, and the amount of mucus, epithelial cells, pus, blood-corpuscles, fibrinous masses, and structural detritus it contains, will afford the physician all in- dications necessary for that purpose. If the dysuria is aggra- vated by the injections, they must be suspended until the spasm and pain in urinating are entirely gone. Intense chordee and severe urethral haemorrhage likewise contraindicate the continuation of injections. In regard to the fluid that should be injected, we have been in the habit of using for many years a weak solution of permanganate of potash. We begin with 0*02 of permanganate to 200 grammes [gr. -J to 5 vjss.] of water, and gradually increase the strength of the solution, if the sensitiveness of the urethra permits, to 0*04 [grs. -§], in the same quantity of water. Owing to the readiness with which it is decomposed, a sufficient quantity of the medicine, to last two or three days only, should be prescribed. In a great many cases we succeeded with this remedy in subjugating a purulent catarrh in a very few days. If the discharge has already be- come mucous, we have recourse to the usual astringent reme- dies, such as alum and sulphate of zinc. Of alum, 5*00 to 250*00 [3iv to § viij] of water is tolerated ; of sulphate of zinc or of cadmium, from 0*30 to 0*50 in 200 grammes [grs. 5 to 8 in 3 vjss.] of water may be used. We generally employ the following formula : ^ Alumin. crudi, 5*00 [3 iv] ; Sulph. zinci, 0*50 [grs. viij] ; Aqua destil., 250*00 [ § viij]. M. To be injected four to five times daily. If the mucous membrane is very sensitive the acetates are preferable. They may be used in stronger doses. We gen- erally order — 3 Acet. zinei, 0'50 [grs. viij] ; Aqua destil., 150*00 [ § v]. Or acetate of alum, in the following manner : ^ Alumin. crudi, 1*50 [grs. xxiij] ; Acid, acetic concent., TOO [grs. xvj]; Aqua destil., 200-00 [ § vjss.]. 38 PATHOLOGY AND TREATMENT OF SYPHILIS. 5 Alurain. crudi ; Acet. plumbi basic, aa 1*00 [grs. xvj] ; Aqua destil., 200-00 [ § vjss.]. If the morbid sensitiveness of the urethra has entirely dis- appeared and a weakened condition of the mucous membrane of this organ is supposed to exist, alum in combination with tannic acid should be tried. We order the following combina- tion: ^ Alum crudi, 1*00 [grs. xvj] ; Tannin puri, 0'50 [grs. viij] ; Aqua destil., 200-00 [ \ vjss.]. If the muco-purulent discharge does not perceptibly dimin- ish after using these injections, it may be advisable to resort in addition to the indirect treatment and to employ both methods. If circumscribed infiltrations are present in the corpora cavernosa, we order cold water to be applied, and cause the infiltrated places to be rubbed with the following ointment : Yp Extract, belladonnse, l'OO [grs. xvj]; Ung. hydrarg., 10*00 [ 3 ijss.]. M. Ft. ung. S. A lump as big as a pea to be rubbed in upon the in- filtrated spot. As soon as fluctuation is detected, the abscess should be opened, in order to avoid the occurrence of urethral fistulse. In the treatment of those diseases of the male urethra that have been collectively called chronic gonorrhoea, the physician must first ascertain the morbid alteration of the urethra that keeps up the discharge. These morbid alterations may be a markedly relaxed condition of the mucous membrane and passive dilatation of the follicles, gonorrhoeal abscesses and granular erosions, croupous inflammation, beginning or already developed strictures, and the granular and trachomatous con- ditions described by Griinfeld. Those practicing endoscopy may by that means ascertain the character of the lesion ; up to the present date, however, we have not seen any brilliant results follow the treatment carried out by means of the endo- scopic tube. Those who do not practice it should examine the urine which the patient is instructed to pass in a glass vessel, GONORRHCEA, VENEREAL CATARRH. 39 and the injected fluid after it comes out from the urethra. To make the examination still more complete, a bougie or sound, sufficiently large in caliber, should be passed into the urethra ; and, taking into consideration all the circumstances present, the physician will be able, jper inductionem et exclu- sionem, to diagnose the actual condition of the canal. If he has diagnosed the presence of gonorrhoeal ulcerations, he should endeavor to prevent the formation of bridle cicatrices by the daily introduction of sounds for a long while, and after each passage of the sound some astringent should be injected into the urethra. In such cases we order nitrate of silver, with or without camphor, as in the following formulae : 3 Argent nitric, 0*20 to 0-50 [grs. iij to viij] ; Aqua destil., 200*00 [ 1 vjss.] ; Camph. mucil. gum. arab. subact., 0-10 [gr. 1£J. M. 5 Liq. ferri sesquicblor. soluti, gtt. x ; Aq. destil., 200*00 [ § vjss.]. M. If we suspect the existence of granulations in the urethral canal, we use some insoluble salt or oxide, in the hope of causing them to shrink ; for instance : 3 Magist. bismuth, 5 00 to 10*00 [Biv to viij] ; Aq. destil., 200-00 [ | vjss.]. M. 1$ Zinci sulphas; Plumbi acet., aa 1*00 [grs. xvj] ; Aqua destil., 200*00 [ § vjss.]. M. 3 Zinci sulph., 0*50 [grs. viij] ; Zinci oxid., 1*50 [grs. xxiij]-, Aqua dest., 200*00 [ ^ vjss.]. M. Must be well shaken before using. If these injections achieve no good result, a bougie, dipped in mucilago seminum cydoniorum, or gum-arabic, and after- ward in powdered bismuth, may be passed into the urethra beyond the granulations. As the greater part of the powder is apt to be rubbed off during the introduction of the bougie into the urethra, and but little reaches the diseased part, it is preferable to introduce the remedies in a solid form, mixed with gum-arabic and rolled out into long pencils, like bougies. When oiled, these are inserted into the urethra and pushed by the aid of a bougie into the membranous portion where the 40 PATHOLOGY AND TREATMENT OF SYPHILIS. disease is most likely to be located. The remedies recom- mended above may be prepared for this purpose in the fol- lowing manner : IJ Zinci sulph., 0'20 [grs. iij] ; Butyri de cacao q. s. ut f. bacilli urethrales tenues longitudine pollicis No. X. One of these sticks, having been pushed into the deeper part of the urethra, should be retained there by compressing the lips of the meatus; it will soon melt, and exercise its healing properties upon the affected parts. The patient should be told that, the first time he urinates after the introduction of one of these medicated bougies, he is likely to pass a few drops of blood. Good results are often obtained in chronic gonorrhoea by the introduction of steel sounds of the largest size possible into the urethra. In resorting to the use of sounds for the purpose of curing this disease, the physician should exercise the utmost care, because the forcible introduc- tion of hard solid instruments may readily produce false pas- sages and the patient be seriously injured. Generally it is quite difficult to pass the instrument through the prostatic portion of the urethra. To pass this part with the greatest ease it is necessary to depress the handle of the instrument till it lies be- tween the patient's thighs. The first few times the instru- ment is introduced it generally causes severe pains, and the operation should therefore be carried out with the utmost gen- tleness, and with the patient in a horizontal position. After all, a cure will only be achieved by the use of the sounds and injections of astringent medicine when there is no urethral spasm present. To subjugate this condition, the patient should apply warm fomentations to the bladder and penis, and medi- cated bougies containing morphia or extract of belladonna 0*01 (gr. -J) should be pushed into the urethra. After the spasm has completely subsided, the use of the sound and injections may be again resumed. [Of all the injections that have been recommended — and I have given them all a thorough trial, both in my clinic and private practice — I found none so efficacious as sulphate of zinc and belladonna, and now use it almost exclusively : GONORRHOEA, VENEREAL CATARRH. 41 5 Zinci sulph. ; Ext. belladonna, aa 0*60 = grs. x; Glycerine, 60-00= §ij; Aqua, 200-00= I vjss. M. S. For injection. Recently Dr. Bryant has proposed the irrigation of the urethral canal with a solution of corrosive sublimate, 1 to 40,000 parts of water. More than three years ago I endeav- ored to cure a number of cases of gonorrhoea by allowing various solutions to flow into the urethra from a fountain- syringe through a catheter, but I found the method trou- blesome, without deriving an equal amount of benefit from it. In protracted cases in which the deeper parts of the urethra are involved, and the acute inflammatory symptoms have en- tirely subsided, I cause deep urethral injections to be made with a long-nozzle syringe, or use Mitchell's medicated bou- gies. The latter, however, are not always tolerated, for they act as foreign bodies, and the pain they occasion does not sub- side till the melted ingredients of which they are composed have been ejected. In these cases I have very often succeeded in effecting a cure by making applications of a two-per-cent solution of nitrate of silver through an endoscopic tube with a fine brush. Having first ascertained the exact location of the affected part by means of conical probes, the tube is in- serted, pushed in so far that its internal end touches the dis- eased part, and then the solution is applied.] The use of cool sitz-baths is of material service when combined with the local treatment. In some cases it is useful to combine the local with the internal treatment by means of the ethereal-balsamic remedies, especially in those cases in which the local measures already recommended have been faithfully tried without accomplishing any good results, par- ticularly if no contraindications, such as digestive disturbances, are present. Lastly, attention should be paid to the possible presence of hsemorrhoids, hyperemia of the rectum, irritation of this organ by ascaridis, ansemia, scrofula, etc. These re- quire appropriate treatment before a successful result can be attained in obstinate cases of chronic gonorrhoea. 42 PATHOLOGY AND TREATMENT OF SYPHILIS. The Indirect or Internal Treatment of Gonorrhoea of the Male Urethra. The indirect or internal treatment consists in the employ- ment of certain remedies, which when introduced into the sys- tem are in greater part excreted by the kidneys, then pass with the urine through the urinary apparatus, and exercise in this manner a curative effect upon the diseased mucous mem- brane. This also explains the reason why these remedies are only effective in gonorrhoea of the male and female urethra, and not in gonorrhoea of the vagina and uterine canal, and have little or no curative properties in gonorrhoea of the eyes and rectum. These remedies may be introduced into the sys- tem either through the digestive or the respiratory organs — possibly also by a prolonged application upon the integument. Among these are the following remedies : Copaiba, balsam of Peru and Tolu, turpentine,, cubebs, ol. santal. flava, the so- called wood-oil, or gurgon balsam, and, lastly, certain prepara- tions of matico. Up to the present time balsam of copaiba has remained the favorite remedy. Its unpleasant taste, however, is a great hindrance to its administration, and many ways have been de- vised of disguising it. The best is by inclosing it in gelatine capsules ; each capsule usually contains from six to seven drops of copaiba (capsules de Mothes et de Eaquin). Others give balsam of copaiba in aromatic tincture, or in the form of pills (copaihine Mege of the French). If it is desired to administer it in its purity, it should be ordered to be taken three or four times daily, fifteen to twenty drops each time, on a lump of sugar, or in some liquor prepared as follows : ^ Tinct. aromat. acid., 5*00 [Biv] ; Balsam copaiba, 20-00 [f ss., 3iv]. M. S. Fifteen to twenty drops to be taken four times daily. For the purpose of administering it in pills, it is best com- bined with magnesia. Thus we order : 5 Bals. copaiba, 10-00 [ 3 ij, 3ij] ; Mag. ust. q. s. ut form. pil. pond., 0*30 [grs. v]. S. Six to eight pills to be taken four times daily. GONORRHOEA, VENEREAL CATARRH. 43 Or, the balsam of copaiba, made in pills and wrapped in wax, as in the following formula : ^ Ceraa albaa, 5 -00 [9iv]; Adde: Bals. copaiba, 10*00 [3viij]; Pulv. magnes. q. s. ut ft. massa pilul. forment pilul. pond., 0*30 [grs. v], consp. pulv. eodem. S. Eight pills to be taken three times daily. [The following are excellent formulae for administering co- paiba in emulsions or pills. These combinations are better tolerated and less objectionable on account of their disagree- able taste, and very efficacious : 3 Copaiba, 30-00 = |j; Liq. potasssB, 4 - 00 = 3 j ; Ext. glycyrrhizse, 15-00 = § ss. ; Spt. setheris nitrici, 30-00 = § j ; Olei gaultherise, gtt. xvj. Mix the copaiba and the liquor potassao and the ext. of liquorice and spirits of nitre first separately, and then add the other ingredients. (Bumstead.) S. A tablespoonful after each meal. B Copaibao, 60-00 = I ij ; Magnes. carb., 2*00 = 3 ss.; 01. menthse pip., gtt. xx ; Pulv. cubebas; Bismuth subnitratis, aa 60-00 = 1 ij. M. To be divided in pills of 0*3 grs. v each, and coated with sngar. In this prescription the cubebs serves as a stomachic ; the alkali and the bismuth are also good anti-dyspeptic remedies.] Balsam of Tolu is met with in commerce as an inspissated, resinous substance, which, before using, must be dissolved in spirits of wine. It has no unpleasant taste, but as a remedy is inferior to the other resinoids used in the cure of this The black Peruvian balsam is administered in the same manner, and in similar doses, but is seldom used, on account of possessing little medicinal virtue. The therapeutic properties of oil of turpentine are almost as great as those of balsam of copaiba, but this oil is even more unpleasant than any of the remedies already spoken of. 44 PATHOLOGY AND TREATMENT OF SYPHILIS. It is best administered in pill form, generally combined with an astringent or iron : 5 Zinci sulphas puri ; Terebinth, laricis, aa 1 00 [grs. xvj] ; Pulv. rad. ratanhiaa q. s. M. Ut ft. pil. No. 30, consp. pulv. cinnamonri. S. One pill three times daily. ^ Ferri sulph., 5'00 [3iv] ; Terebinth, laricis, 2*00 [grs. xxxj] ; Pulv. lycopod. q. s. u. f. pil. pond., 0*20 [grs. iij], consp. pulv. cinnamomi. S. Five pills to be taken three or four times a day. Cubebs, piper caudatum, may be administered either in powder or pill form ; for the latter, the ethereal extract or freshly powdered berry is well adapted. The following for- mulas may be used : ^ Pulv. piper cubebias recent., 20'00 [§ ss., Biv] ; Sacchar. lactis, 5*00 [3iv]. M. S. Divide in doses equale No. 12. To be put in capsules, and taken in forty -eight hours. 1£ Pulv. piper cubebiso recent, 20*00 [§ ss., Biv] ; Ext. juniper ; Syr. simplex, aa, 50'00 [ 1 jss., 3iv]. M. S. To be taken in twenty-four hours. If a cure is to be achieved by means of cubebs, the patient will have to take from 13*00 to 15*00 grammes [ 3 iijss. to 3 iv] of the remedy in twenty-four hours. Grimault, of Paris, has introduced the use of the so-called matico capsules. They contain an ethereal oil, prepared from the leaves of the drug matico, piper angustifolium or elonga- tum, extract of cubebs, and balsam of copaiba. We never succeeded in effecting a cure by the administration of matico- oil alone, but we did with matico capsules. The latter are preferable to the copaiba capsules, in so far as they are better tolerated, owing probably to the oil of matico, which seems to act as a stomachic. Of these matico capsules, from nine to fif- teen should be taken daily. The so-called " injection vegetal," made of matico, arid known under that name in commerce, contains ethereal oil of matico and sulphate of copper. GONORRHCEA, VENEREAL CATARRH. 45 Now, experience has shown that many persons suffer from vomiting and diarrhoea as the result of the internal administra- tion of the antiblennorrhoaa-balsamic remedies, and in others a prolonged use of these remedies will occasion chronic gastric and intestinal catarrh. But the injurious effects produced upon the digestive organs are not the only evils occasioned by them. In some patients they also give rise to a peculiar eruption of the skin. Attended by gastric and febrile disturbances, groups of pale, wheal-like eruptions develop about the wrists, hip- joints, and especially on the face. They resemble nettle-rash very closely, and, like the latter, cause severe burning and itch- ing, especially when the patients get warm in bed. This affec- tion of the skin is called urticaria balsa7nica, and, owing to its resemblance to roseola syphilitica, was until quite recently re- garded by some physicians — Cazenave, for instance — as proof that gonorrhoea was the initial disease of syphilis. That this assertion is incorrect is. proved by the fact that the eruption disappears as soon as the use of the remedy is discontinued. It is also asserted that the ethereal- balsamic remedies exer- cise an injurious effect upon the kidneys, in consequence of which Bright's disease is said to result. Now, if to the urine of a person who several hours previously had taken cubebs, co- paiba, or turpentine-oil, some strong mineral acid is added, an opalescent, gelatinous sediment is precipitated which might be readily mistaken for coagulated albumen, but it is distinguished from the latter by the fact that it again becomes soluble on boil- ing, or on the addition of alcohol, carbonate of potash, or am- monia. The researches of Berzelius and Johnson have shown that the constituent elements of the balsamic remedies are an ethereal oil and a resinous acid. The experiments of Drs. Weikart and H. Zeissl have proved that the precipitate above alluded to is not due to the ethereal oil. Consequently, we can explain its production by the following theory : The resinous acids are the vehicles containing the curative principles ; in the intestines or blood they combine with the potash or the soda and form a soluble resinous soap in the excreted urine — a resin- oid potash or soda. If to such urine a stronger acid than the resinous acid is added, for instance, nitric acid, the resinous acid that is insoluble in water is precipitated as a whitish sedi- 46 PATHOLOGY AND TREATMENT OF SYPHILIS. ment. Prof. H. Zeissl and Dr. "Weikart sought to make therapeutical use of the transformation which the resinous acid undergoes in the urine, by administering resinous acid alone or resinous soap to patients suffering from gonorrhoea. And they actually succeeded by this means in reducing the blennorrhoic discharge to the least possible quantity, and by a prolonged use of the remedy in suppressing it entirely. But no sediment, or at the most a feeble whitish cloudiness, was seen in the urine ; to produce even that, large quantities of the drug had to be administered. Hence it seems that the resinous acids, in their natural combination with the ethereal oils, pass out in the urine more quickly than isolated pure or saponified res- inous acids. It can not be maintained, however, that the ethereal oils of the balsams mentioned here are excreted from the system without producing any effect, because clinical ex- perience has shown that, when introduced into the system by inhalation, they accomplish some good results in urethritis and pyelitis. Dr. Bremond, Jr., claims to have obtained better effects from turpentine- vapor baths than from inhalations. Catarrh of the Glans Penis and Prepuce, Balanitis, Balance Blennorrhea, Balanopyorrhcea, Balanopostheitis. The sebaceous glands, glandulse Tysonii, situated in the fossa glandis and on the inner surface of the prepuce, secrete so large a quantity of sebum in some persons that it undergoes decomposition — especially when allowed to accumulate, and in those whose habits are uncleanly — and irritates the parts. These become inflamed and produce a profuse discharge. This follicular hypersecretion may be produced by friction of the secreting surfaces — for instance, in masturbators (especially when the preputial orifice is constricted) — by gonorrheal pus, or chancrous discharges, warts, syphilitic initial indurations, syphilitic mucous patches or eruptions on the glans penis and mucous membrane lining the prepuce, and epithelial carcinoma. Catarrhal disease of the glans and prepuce manifests itself by an itching sensation which gives rise to erections. Gradu- ally the tickling sensation becomes transformed into a painful feeling. The glans and the prepuce become oedematous ; the external surface of the latter becomes red and erysipelatous ; a GONORRHCEA, VENEREAL CATARRH. 47 profuse discharge wells up from the preputial orifice which has the odor of boiled carpeuter's-glue. "When neglected, erosions and even ulcers originate on the inner surface of the prepuce and on the glans penis ; the discharge becomes green- ish in color and purulent (pyorrhoea). The lymphatic vessels, situated on the dorsum of the penis, the superficial and deep inguinal glands become inflamed ; phimosis and paraphimosis may result ; indeed, it is even possible, especially when a chan- cre is present on the inner surface of the prepuce, that the latter, as well as the glans, will, in consequence of constant pressure or constriction, become gangrenous. Condylomata and vegetations are another result of catarrh of the prepuce and glans penis. In extreme cases balanitis, when associated with phimosis, may terminate in limited or extensive synechia between the glans and prepuce, rendering sexual intercourse exceedingly painful in consequence of the traction between the parts. Phimosis and Paraphimosis. Under the term " phimosis " we understand an abnormal constriction of the prepuce to such an extent as to make it im- possible to expose the glans fully. In some cases the prepuce can only be retracted sufficiently to expose the tip of the glans penis. The cause of phimosis is the disproportion between the size of the prepuce and that of the glans penis. This kind of phimosis is called temporary, in contradistinction from the per* manent or congenital phimosis. The latter condition is due to the structure of the prepuce, which, being too long, forms a funnel-like cap over the glans ; the preputial orifice is there- fore narrower than in persons in whom tins funnel-like cover- ing is shorter and more widely expanded. Again, if the frse- num extends up to the urethral orifice, it is difficult to retract the prepuce, and if force is used the frsenum will be dragged backward and the glans penis downward ; the former is often torn and the wound bleeds. Such long and narrow prepuces are usually traversed by large varicose veins, whose compres- sion during the existence of a balanitis will often occasion oedema. If a phimotic prepuce is forcibly retracted over the glans 48 PATHOLOGY AND TREATMENT OF SYPHILIS. penis, there results the condition known as paraphimosis. The preputial opening that is now drawn backward behind the corona glandis constricts it and causes it to swell up. The re- turn flow of blood from the glans is impeded, while the sup- ply is not retarded. In consequence of this, the glans swells still more ; a serous exudation takes place in that part of the prepuce anterior to the constricting point, whereby a semi- lunar swelling forms on the lower border of the corona glan- dis, which overlaps the constricting point — a condition that has been called the " Spanish collar.' ' Under unfavorable cir- cumstances the constricted parts may even become gangrenous. Differential Diagnosis and Treatment of Catarrh of the Glans Penis and of the resulting Inflammatory Phimosis and Para- phimosis. Balanitis with coexisting phimosis may be mistaken for gonorrhoea of the urethra. The diagnosis can only be based upon the course of the disease. The erosions upon the glans penis and internal surface of the prepuce produced by bala- nitis sometimes are ' not easy to distinguish from superficial chancroids, initial syphilitic lesions, and their consecutive phe- nomena. The chancroid ulcers, owing to their great tendency to inoculate, give rise to numerous deep, sharply outlined small sores ; thus we often have follicular ulcerations in the fossa glandis, and deep ulcers occasionally on the frsenum. In cases complicated with phimosis the existence of chancroids or chancres can only be ascertained by inoculation and the course of the disease. If the discharge exuding from the preputial orifice is mixed with chancrous virus, the inoculations will produce pustules after a longer or shorter period of incubation, according to the nature of the virus, and the pustules exhibit a tendency to run into ulcerations. Under appropriate treat- ment simple erosions heal in a few days, sometimes even in a few hours. They are distinguished from syphilitic initial le- sions by the total absence of induration or parchment-like hard- ness beneath them, while erosions which have arisen from ex- coriations of the efflorescences of roseola syphilitica are accom- panied by spots on the body, indolent glandular swellings, etc. In mild forms of balano-blennorrhoea, frequent cleansing GONORRHOSA, VENEREAL CATARRH. 49 of the glans and prepuce, and keeping these parts from coming in contact with each other by interposing bits of clean muslin, or a thin layer of cotton-wool, will suffice to effect a cure. The prof ase secretion may be quickly suppressed by the application of a strong lead-lotion four or five times a day, or an injection of nitrate of silver 0*10 or O20 to 50-00 [If to 3£ grs. to g jss. of water]. After the injection, compresses dipped in the solu- tion may be applied between the glans and prepuce. If it is suspected that there are erosions or ulcers on the glans and internal surface of the prepuce, a long stick of nitrate of silver should be inserted under the prepuce, and by a rapid move- ment the glans and prepuce are to be cauterized. In addition, the injections with the above preparation should be continued. If the febrile phenomena, the pain and swelling, are severe, and gangrenous sloughing is apprehended, the patient will have to go to bed ; the penis should be kept elevated, or fixed on the abdomen, and ice applied to it. If the danger from gan- grene does not abate, the constricted prepuce should be split, or circumcised. The latter, in our opinion, is the more appro- priate treatment. Splitting of the prepuce may be done in two ways. Either both layers of the skin are divided at once in the median line or the internal layer alone, the mucous membrane, is in- cised. The first method, which we resort to in congenital as well as in acquired inflammatory phimosis of moderate degree (where the prepuce is not very long), consists in retracting the foreskin as much as possible to the corona glandis, and passing a grooved director beneath the prepuce. Upon this one blade of a straight scissors is passed, and both lamellae are divided at once in the median hue of the dorsum of the penis to an ex- tent of about one to one and a half centimetre. The slight haemorrhage that follows is arrested by a few stitches inserted in the lips of the wound, and lead-water dressings are applied to the parts. The second method we employ in those cases of aggravated congenital phimosis in which markedly dilated veins anasto- mose in the foreskin. The prepuce is retracted as much as possible, so that the margin of its inner layer is exposed, and it is then snipped with a delicate pair of scissors to the extent 4 50 PATHOLOGY AND TREATMENT OF SYPHILIS. of two to four millimetres. This incision allows the foreskin to be retracted a little more, and an additional portion of the inner layer can now be exposed. With the points of the scissors the first incision is extended, snipping the mncons membrane only little by little, as the prepuce itself is being retracted grad- ually over the glans penis till the latter is finally entirely ex- posed. After this has been accomplished the bleeding is arrested, cold water dressings are applied to the glans, and the prepuce is restored to its normal position. Fresh pledgets of linen or cotton-wool must be inserted several times daily till the incised wound has completely cicatrized. Circumcision is indicated in those cases in which, in conse- quence of the accumulation of ichorous discharges, gangrene of the foreskin, or of the glans, or of both is imminent, or has already commenced. The operation is performed as follows : An as- sistant holds the penis of the patient (who lies on his back) in his left hand, and with the thumb and forefinger of his right hand draws back the foreskin as far as possible toward the co- rona. The operator then inserts a grooved director between the prepuce and glans, assures himself by sweeping the glans with the instrument that it did not pass into the urethra, car- ries it in the median line on the dorsum of the glans with the grooved surface facing upward as far as the fossa, and divides both layers of the skin either with a scissors or a sharp-pointed bistoury up to the fossa glandis. The flaps of the skin result- ing from the incision are amputated by the aid of a curved pair of scissors, with its concave surface directed toward the glans, following the course of the corona to the frsenum, taking care not to injure the corpora cavernosa or divide the arterial branches coursing in the frsenum. It is necessary to preserve the frsenum, because as a result of its division the integument of the penis loses its point of fixation, and the margins of the wound are liable to become displaced. Bleeding vessels should be tied or twisted ; the slight bleeding, however, is generally arrested by sewing up the wound. The operation may also be performed with the aid of Esmarch's bandage. Adhesions be- tween the glans and prepuce should be divided with the scis- sors. [This operation may be rendered perfectly painless by the use of cocaine, either by injecting a four-per-cent solution GONORRHCEA, VENEREAL CATARRH. 51 of the muriate of cocaine subcutaneously or simply brushing the skin and mucous membrane of the prepuce a number of times with it. In about five or ten minutes the skin will be found to have lost all sensibility, when it may be amputated and the stitches inserted without causing the patient any pain.] Paraphimosis calls for the reduction of the constricted glans as soon as possible. This operation may be carried out in the following manner : The physician places both his thumbs upon the glans of the patient, thereby compressing it laterally and at the same time pressing it backward, while with his index-fingers above and the middle fingers below the penis he endeavors to push the preputial welt forward over the co- rona glandis. If it be no longer possible to replace the fore- skin, the constricting welt should be divided with a sharp- pointed bistoury upon a grooved director inserted beneath the ring in the median line of the dorsum of the penis, after which the prepuce may be .brought down to its normal position. If the paraphimosis, however, has already existed for several days, it will be impossible to reduce the displaced prepuce; it will then be necessary to divide the collar-like welt with two circular and parallel incisions, and, sparing the corpora cavernosa, the strip of constricting band may be dissected out from the welt alluded to. The edges of the wound should be united with sutures. Affections of the Lymphatic Vessels and Glands in consequence of Gonorrhoea. Acute and chronic urethral gonorrhoea occasionally give rise to inflammatory swelling of the lymphatic vessels of the dorsum of the penis and of the lymphatic glands of the groin. The inflammation of the lymphatic vessels manifests itself by one or two smooth or nodular cords, as thick as the quill of a raven, running from the fossa glandis to the mons veneris, and by a linear oedematous, erythematous swelling of the skin. Pressure on the affected tracts, or pinching up a fold in the skin, causes marked pain. Owing to the swelling of these lymphatic vessels, the pain during erections is also aggravat- ed, and for that reason the organ is frequently curved toward the pubis. Under appropriate treatment inflammation of the 52 PATHOLOGY AND TREATMENT OF SYPHILIS. lymphatic vessels as a result of gonorrhoea disappears in the course of twelve or fourteen days. The lymphatic glands of the inguinal region are less fre- quently affected in consequence of gonorrhoea than the lym- phatic vessels. In the majority of cases resolution takes place in these inflamed inguinal glands ; but, in debilitated persons, or those afflicted with the tuberculous or scrofulous cachexia, the glands will undergo suppuration. The treatment of inflamma- tion of the lymphatic vessels and glands, in most cases, is lim- ited to the application of cooling lotions, since suppuration sel- dom ensues. In intense inflammation of the lymphatic vessels, inunctions of ung. hydrarg., in quantities of about the size of a pea twice daily in the course of the affected vessel, are of great benefit. Inflammation of the Vasa Beferentia And the Epididymis. The most frequent sequela produced by urethral gonorrhoea in the male is inflammation of one of the vasa deferentia and epididymis. Like pharyngeal catarrh of the mucous membrane traveling downward and attacking the larynx, trachea, and bronchi, so the catarrhal affection of the pros- tatic portion of the urethra not infrequently extends to the vasa deferentia and epididymis. The affection of these or- gans, consequently, is not to be looked upon as a metastasis, i.e., as a leap of the catarrhal affection from the urethral tract to the testis, but it originates through contiguity — in other words, the catarrhal process travels on from cell to cell, and as soon as it has reached the vicinity of the caput gallina- ginis — which usually occurs in the third week of a gonorrhceal disease — there is a possibility of the affection of a vas deferens with its corresponding epididymis. It is a wonder that the parts mentioned do not become affected in all cases of catar- rhal inflammation of the prostatic urethra, and, furthermore, that even in the most pronounced cases of inflammation of the epididymis the simultaneous implication of the vas deferens is not always apparent. This last condition, after all, has its analogy in the pathogeny of buboes that undergo resolution, and which originate, in the majority of cases, without any ap- parent inflammation of the lymphatic vessels. As a rule, how- GONORRHCEA, VENEREAL CATARRH. 53 ever, in epididymitis in consequence of gonorrhoea, there is found an inflammatory thickening of the corresponding vas deferens or spermatic cord, and seldom is a vas deferens af- fected without the coincident disease of the epididymis. In inflammatory affections of the vas deferens the patients complain of severe pains in the vicinity of the abdominal riug, through which the affected spermatic cord passes into the in- guinal canal. The pain spoken of becomes aggravated on touching the cord, the latter being readily felt as a dense, hard, round string, like a goose-quill. The loose connective tissue of the tunica vaginalis communis and the adjacent sub- cutaneous connective tissue of the scrotum become infiltrated with serum, and swollen. General disturbances of the system soon supervene. As in epididymitis, the patients complain of chilliness and a feeling of heaviness in the head ; the pulse becomes quickened, the temperature of the skin elevated. 2s ot infrequently nausea, and even vomiting come on ; usually an obstinate constipation is present (circumscribed peritonitis). In rare cases suppuration of the thickened spermatic cord may follow. The subjective symptoms of epididymitis usually come on suddenly. The patients claim to have felt at the beginning of the disease a sensation as if a drop of hot liquid had dropped into the affected scrotum. Soon after the affected testis ap- pears to them to have become markedly heavier and walking is irksome. During the first three days the diseased epididymis is felt as a doughy mass at the inferior part of the posterior scrotal wall. On the third or fourth day the swelling of the epididymis becomes more tense, and the organ usually descends still lower. In this manner a twisting of the axis of the testi- cle upon its transverse diameter takes place. We have likewise had the opportunity of confirming Dr. Bergh's observation, namely, that in some cases a twisting of the axis of the testicle upon its longitudinal diameter takes place, the epididymis ap- pearing at the anterior instead of at the posterior border of the testis. In the progress of the disease the testis itself swells up, sometimes attaining the size of a fist ; the increase in size, however, is not due to swelling of the parenchyma of the testicle, but to serous effusion into the tunica vaginalis 54: PATHOLOGY AND TREATMENT OF SYPHILIS. propria (acute hydrocele). Finally, there also occurs a serous infiltration into the loose cellular tissue of the scrotal integu- ment ; its wrinkles become effaced, and it acquires a bright- red color (erythma glabrum). These phenomena indicate that the epididymitis has attained its height, in which condition it usually remains for five or six days. On the tenth day of the disease, resolution begins, ushered in by febrile exacerbation, and the effusion into the subscrotal connective tissue and into the tunica vaginalis propria begins to be absorbed. The sub- jective and objective symptoms gradually disappear, so that the disease generally terminates by the beginning of the third week, leaving no trace behind it, save a painless hardness of the epididymis consequent upon hypertrophy of its connective tissue. This hardness generally does not interfere with the functions of the testicle ; occasionally it is liable to cause a temporary and even permanent impotence. In many grave cases of inflammation of the epididymis and of the vas deferens the semen undergoes morbid changes to such a degree as to be- come bloody when pollutions ensue (spermatorrhoea cruenta). In cases of bloody semen, the spermatozoa generally are totally absent. Occasionally, even after the termination of an epidid- ymitis, the semen for some time has a rusty color, due to the admixture of blood. Atrophy of the testicle as a result of epididymitis blennorrhagia we have seldom seen, and then only in those cases in which Frick's compressed bandage was ap- plied too energetically and for too long a time. In very rare cases a cheesy degeneration and necrotic dis- organization take place in the diseased epididymis, or in the surrounding tissues, without any coexisting tuberculosis in the lungs, prostate gland, or kidneys. Cheesy foci form, break through the tunica vaginalis and scrotal integument, and dis- charge a crumbling, cheesy pus. The borders of the perfora- tions in the scrotal integument then become agglutinated di- rectly with the exposed tunica albuginea, from which extensive exuberations of connective tissue are occasionally protruded, constituting a " fungus benignus." "Wendelin saw an epididy- mitis originate in a patient with chronic urethritis, which be- came associated with marked swelling of the funiculus and secondary peripheral inflammation, attacking the peritonaeum, GONORRHCEA, VENEREAL CATARRH. 55 going on to suppuration and perforation of the bladder and rectum. The case terminated fatally; no autopsy, however, was made. Another equally rare result of epididymitis is neuralgia, whose site can not be more explicitly described than that it is in the course of the pudendal plexus of nerves. This tortures the patients to such a degree that some of them, as reported by Michaelis, demand the operation of castration. The most frequent evil effects of epididymitis are the accu- mulation of fluid in the sac of the tunica vaginalis propria, known by the name of " hydrocele chronica." Inflammation of the spermatic cord and of the epididymis in consequence of urethral gonorrhoea is generally unilateral. One epididymis is as often affected as the other, but not both simultaneously. The disease in one generally comes entirely to an end before the other is attacked, and in such cases the left testis is always the one first affected. Although epididymitis terminates favorably in most cases, still in some fistulse form in the scrotum, and still more often a permanent accumulation of serum in the tunica propria en- sues. We have, moreover, observed that persons who have suffered from repeated attacks of epididymitis blennorrhagica, if they subsequently acquire syphilis, readily become affected with albuginitis syphilitica. The following painful lesion of the testis may be mistaken for a beginning epididymitis: There are certain, individuals who on becoming sexually excited, and without having an emission of semen, suffer such intense pain in the testicle at the slightest touch, and even without touching it, that the pain will cause them to faint. The absence of swelling in the vas deferens and in the corresponding epididymis, the statement of the preceding excitement, and, lastly, the exceedingly favor- able effect which the application of cold compresses produces in a few minutes, will show conclusively the true nature of the complaint. An epididymitis in cryptorchids may be mistaken for her- nia or swelling of the inguinal glands. But the absence of the testicle from the scrotum will guide the physician to a correct diagnosis. The differential diagnosis between blennorrhoic 56 PATHOLOGY AND TREATMENT OF SYPHILIS. epididymitis and an epididymis resulting from syphilis will be elucidated in the section on syphilitic disease of the testicle. Finally, we wish to say a word concerning an exceedingly rare morbid alteration of the testicle, which Yon Foerster has described under the name of chronic epididymitis terminating in atheromatous degeneration, and which may readily be mis- taken for gonorrhoeal epididymitis. In this lesion the testicle enlarges gradually, without any febrile phenomena, and the pain is not severe. Subsequently, the pain disappears entirely, while the enlargement remains stationary, and the only change noticeable in the testicle is that it becomes doughy. If such a testis is examined after death an atheromatous substance con- taining numerous crystals of cholesterine and liquid drops of oil may be pressed out of it. Treatment of Inflammation of the Spermatic Cord and Epi- didymis. The treatment of inflammation of the spermatic cord and epididymis does not vary very much. The main indication is to alleviate the pain, and to limit the inflammation and its effects as much as possible. We have seen the pain most quickly subjugated by the application of Horand's (Lyons) dressing, which we have modified. The dressing consists of three parts : (1) a sufficiently thick layer of wadding ; (2) a square piece of India-rubber cloth ; and (3) a muslin suspensory. The latter has a triangular, slightly concave shape, and at its upper mar- gin a hole is cut, through which the penis is passed. Its upper corners are provided with two long bands, or, better still, a belt may be used, with a buckle for the purpose of securing it around the abdomen. At its lower angle two thigh-straps or bands are fastened, which may be tied either to the buckles of the belt or drawn through the bands passing around the ab- domen, and tied to them. The lateral borders of the suspen- sory are incised, and each cut is provided with two short tapes. The apparatus is best applied when the patient is in the recum- bent position. The patient draws up the genital organs as high as possible against the symphysis pubis ; the entire scrotum is then covered with a layer of wadding ; the square piece of India-rubber cloth with a circular hole near its upper border GONORRHCEA, VENEREAL CATARRH. 57 through which the penis is passed is next placed upon the wadding, with the glossy surface directed toward it, and upon that the triangular piece of muslin. Finally, the belt is buckled, or the belly-band alluded to is tied around the waist ; next, the thigh-straps or thigh-tapes are made fast to the belt or belly- band ; and, lastly, the tapes at the side-cuts are tied over the dorsum of the penis as tightly as possible. By the aid of this apparatus the scrotum can be raised up nearly to the symphy- sis, and the pains disappear almost immediately after it is ap- plied, enabling the patient to pursue his calling. The epidid- ymitis is generally cured in about eight or ten days. If not, the apparatus may be retained for a longer period. Should the epididjmiitis be complicated with an acute hydrocele or in- flammation of the spermatic cord, the apparatus alone will not be sufficient to relieve the pain. If the pains are not relieved, or the patient has fever, he will have to go to bed, and the scrotum should be suspended in a towel as high as possible, or elevated by a pillow rolled up and placed between the thighs. Cold or cooling lotions may then be applied to the inflamed testicle. Xo ice-cold applications should be made, especially in tuberculous persons, in whom haemoptysis has been known to occur under this treatment. Some authors also claim to have seen gangrene of the scrotum produced by the applica- tion of ice. Compresses dipped in cold water or in lead-water are amply sufficient. For the relief of the pain, ung. bella- donnas, composed of extr. belladonna 5'00 (3 iv) and ung. iitharg. 20 '00 ( 3 v), may be rubbed in upon the scrotum. Xo mercurial ointment should be applied upon the scrotum, for it is apt to occasion a violent eczematous eruption and intense pain. If the pain is veiy great, morphia may be injected sub- cutaneously in the inguinal region. It is of the utmost im- portance in the treatment of epididymitis that the patient should have daily movement of his bowels. It is scarcely necessary to say that, upon the onset of an epididymitis, injec- tions into the urethra and the internal administration of bal- samic remedies must be immediately discontinued. There is another method recommended by Dr. Fricke, of Hamburg, for the purpose of causing the absorption of the effused fluid into the tunica vaginalis. This consists of strap- 58 PATHOLOGY AND TREATMENT OF SYPHILIS. ping the scrotum with strips of adhesive plaster. The strips should be half a metre (19 inches) in length and eight to ten millimetres (about an inch) in width. Before strapping the scrotum it and the pubis should be shaved. The physician now pushes the sound testis up toward its inguinal ring, al- lowing the patient or an assistant to hold it there. He next grasps the diseased testicle in his left hand, brings the long- est diameter of the scrotum in a line with the longest diame- ter of the affected testis, then encircles the upper part of the scrotum with a strip of adhesive plaster. Each subsequent strip of plaster is made to overlap the preceding one like shin- gles on a roof. Three or four longitudinal strips are laid upon the scrotum from side to side, and these are secured by a few more circular strips. This dressing should only be applied tight enough to retain its hold upon the parts. In three or four days it is generally so loose as to require to be replaced by another. It is now many years since we abandoned strap- ping the testicle, because its employment not infrequently produces the symptoms of shock, i. e., reflex paralysis of the vascular nerves, especially the splanchnic, through sudden and violent disturbance of the parts, and even gangrene of the scrotum in some cases followed. In cases of circumscribed acute hydrocele excellent results were often obtained from punctures with a sharp-pointed bis- toury. Abscesses of the epididymis should be treated in ac- cordance with the general rules of surgery. The hypertrophy of the connective tissue in the vicinity of the head of the epi- didymis obstinately resists all kinds of treatment, both local and general ; still, in some cases we have obtained good results from the internal administration of the preparations of iodine. Chronic Hydrocele. Hernia Aquosa. "When the serous effusion which is poured out in the course of an acute inflammation of the testicle, between the two lay- ers of the tunica vaginalis propria, is not absorbed after the in- flammatory phenomena have subsided, or, worse still, more and more effusion continues to form, there results a painless en- largement of the scrotum and distention of the tunica vaginalis propria, which has been called chronic hydrocele, or hernia GONORRHCEA, VENEREAL CATARRH. 59 aquosa, in contradistinction to acute hydrocele. The tumor may attain the size of a goose-egg, a man's fist, or even a child's head, according to the quantity of the fluid that accu- mulates in the sac. The testicle is always found located in the lower and posterior part of the distended tunica vaginalis. The fluid contained in the latter is clear and watery, and gen- erally contains a large quantity of salts and albuminoids, prob- ably also the so-called fibrogenous substance (Yirchow). As a result of injury, such as blows, squeezing, and the like, haemor- rhage readily occurs into the tunica vaginalis, whereby the serous fluid becomes bloody (hematocele). "When the hydro- cele lasts for a long while, excrescences not infrequently form upon the parietal or visceral layer of the sac. These become converted either into a fatty or cartilaginous substance, soon drop off and fall into the hydrocelic fluid (free or floating bodies of the tunica vaginalis). Sometimes the tunica vaginalis un- dergoes such a hyperplastic thickening that it becomes trans- formed into a leathery or cartilaginous callosity. This condi- tion is usually associated with the partial union of the two lay- ers. Such adhesions may give rise to the formation of bilocu- lar or multilocular cavities. We obtain positive proof of the presence of fluid in the tunica vaginalis if, on examining the scrotum with a light, it is found to be transparent, and fluc- tuation is felt in it. In hsematocele the scrotum, when ex- amined by the help of a candle-light, is less or not at all trans- parent. Before tapping a hydrocele, the absence of a hernia must be established beyond all doubt. Permanent pressure by the effused fluid may result in atrophy of the testicle and of the cremaster muscle. In a few rare cases we have succeeded, by simply tapping the tunica vaginalis, in curing chronic hydrocele. The best re- sults are obtained by injecting iodine into the cavity after the tapping, thereby setting up an adhesive inflammation which results in a union of both layers of the membrane. Or Lugol's solution may be used, the formula of which is as follows : ^ Iodi. puri, 5*00 [3iv]; Kali, iodata, 10*00 [3 viij] ; Aqua destil., 100-00 [ § iij, 3 ijss.j. Or equal parts of tr. iodine and spirits of wine may be used. 60 PATHOLOGY AND TREATMENT OF SYPHILIS. In those cases in which the tunica vaginalis has probably undergone a condition of sclerosis, no injection of iodine should be made, because, owing to the lack of vascular supply to the tissues, not only is a union of the opposing surfaces not to be expected, but sloughing of the testicle may be brought about. In such cases we recommend the radical operation for hydro- cele under strictly antiseptic conditions. [Yarious other remedies have been used, as injections into the tunica vaginalis, for the cure of hydrocele. Carbolic acid has been employed here with excellent results. The follow- ing is the formula for it : B Acid carbol. crystal., 10 parts; Glycerine, 90 parts. M. Of this solution four to six grammes ( 3 j to 3 jss.) are injected after the effusion has been drawn off' with a trocar and canula. I have succeeded admirably in exciting sufficient inflammatory action in the opposing surfaces of the sac by introducing through the trocar some crystals of red oxide of mercury on a thin, moistened whalebone rod directly after the hydrocele was tapped. But a certain percentage of failures will result from the use of any preparation, the only reliable method being the radical cure proposed by Yolkmann, and modified by Berg- mann, of Berlin.] Inflammation of Cowper's Glands. In very rare cases the inflammatory process extends from the bulbous and membranous parts to the excretory ducts of Cowper's glands. The disease of the glands can only be as- sumed to be present with certainty when the connective tissue surrounding them is also involved. In this case there originates, between the scrotum and anus, on the right or left side of the raphe, a more or less circumscribed swelling, which is pain- ful at the slightest touch. Micturition is somewhat difficult. Under appropriate treatment the swelling disappears entirely in ten or twelve days ; in very rare cases it terminates in sup- puration, opening externally or bursting into the urethra. As soon as fluctuation can be detected the abscess should be opened in order to prevent it from rupturing into the urethra. GONORRHOEA, VENEREAL CATARRH. 61 Morbid Alterations that are produced in the Prostate by Gonor- rhoea of the Urethra. Contrary to the views that were formerly entertained re- garding the structure of the prostate gland, it is now known to consist in greater part of muscular substance (sphincter vesicae externus) and of a number of tubular glands in addition to glandular structure. The excretory ducts of the prostate, like the follicles of the fossa navicularis of the urethra, are liable to become diseased through the propagation of the gonorrhceal discharge to the deeper parts of the urethra. Here, too, we distinguish a serous, mucous, and purulent catarrh. As a rule, the severity of the catarrhal disease of the prostate corresponds to the intensity of the catarrhal affection of the urethra. The serous and mucous catarrh of the prostate is generally the result of an inveterate gonorrhoea which the patient has neglected. It manifests itself by a drop of tenacious, albu- minoid matter appearing several times daily, unattended with pain, at the meatus, producing a dirty-grayish spot upon the linen, and rendering the spots stiff as if starched. These spon^ taneous discharges are most probably due to the occasional con- tractions of the muscular tissue of the prostate ; but the press- ure caused by the passage of faeces during the act of defecation doubtless also propels the discharge forward. Owing to the capillary engorgement which takes place in the prostatic por- tion of the urethra, the patient is troubled with dribbling of urine at the end of each act of micturition. The serous and mucous prostatic catarrh may remain in this condition for many years. Should the patient indulge in excesses in Baccho et Venere, dysuria, tenesmus, and ischuria will soon become associated with this harmless complaint. If the catarrh per- sists for a long time, the excretory ducts of the prostate will become dilated, and in time the discharge becomes inspissated, and concretions form in the crypts of the gland. Gradually the mucous membrane of the neck of the bladder also becomes attacked by catarrh, and, as a result, we then have frequently recurring spasmodic contractions of the neck of the bladder. The persistence of this muscular activity leads to hypertrophic development of the muscular element of the prostate. Chronic 62 PATHOLOGY AND TREATMENT OF SYPHILIS. prostatic catarrh, however, is manifested not only by difficulty in urinating, bnt also by febrile paroxysms, especially when it is complicated with stricture of the urethra. Purulent prostatic catarrh originates from the propagation of the acute purulent urethral gonorrhoea to the prostate, or also from injuries of the gland (the introduction of catheters, bougies, impaction of calculi). As a result of one or another kind of irritating causes, a serous transudation of the submucous tissue of the prostate and an exaggerated amount of secretion in the glandular part of the organ (serous glandular catarrh) are produced. During the time that these lesions are developing in the prostate the secretion of purulent matter in the urethra dies out, and the only discharge that then appears at the meatus is that from the prostate gland — a sticky and tenacious fluid. Gradually small collections of pus form in the gland, corre- sponding to the number of the excretory ducts affected. Pri- mary diffuse suppuration of the prostate occurs only in those cases which are traumatic in their origin. So long as the oede- matous swelling of the prostate is not very intense, the pus- corpuscles originating in the crypts become mixed with the normal secretion of the gland and form with it a gluey, yel- lcfwish-green fluid. In progressive suppuration the cavities of the gland gradually become filled with pus and dilated, next some of the glandular spaces coalesce and the entire prostate is then permeated by large cavities. These small abscesses break on the tenth day after the onset of the prostatitis, and, as a rule, rupture into the urethra. The pus tunnels its way into the rectum only in those cases in which suppurative inflam- mations have occurred repeatedly, and especially when insti- gated by traumatic causes. The muscular part of the pros- tate suffers no pathological alteration ; it is only in a constant state of contraction, thereby expelling the secretion, and causes tenesmus of the neck of the bladder and the anus. Patients suffering from prostatitis are troubled on the one hand with difficulty in defecation, and, on the other, from fre- quent desire to urinate. For the purpose of expelling the urine forcibly, the patients, taking a deep inspiration, endeavor to compress the bladder by the action of the diaphragm and the pressure of the abdominal walls. Through the action of GONORRHCEA, VENEREAL CATARRH. 63 the levator-ani muscle, however, the prostate is elevated and compressed against the symphysis pubis, thus causing still more compression of the urethra that is already narrowed, and en- tirely preventing the flow of the urine. Not till the patient, completely exhausted, becomes totally passive, and entirely avoids straining, will the urine flow in drops or in a very thin stream variously shaped, causing a violent burning sensation in the urethra. Like patients suffering from stone, those suf- fering from prostatic disease seek, by pulling or manipulat- ing the penis, to ease the flow of the urine. The introduc- tion of a catheter or sound is quite difficult, and such in- struments only will pass as have a large curve. Just at the moment when it is necessary to depress the handle of the sound for the purpose of passing it into the bladder, the beak is often turned to one side or the other, because the urethra, in conse- quence of the unequal enlargement of the prostate, has devi- ated from its normal position, and the instrument is twisted to the right or left, according as the right or left lobe is more swollen. When the central part of the prostate is swollen it is entirely impossible to introduce an instrument into the blad- der, or this can only be done by force. By a digital examina- tion per rectum, the anterior wall of the gut is found to be bulged out by a painful tumor. This painful condition of prostatitis generally lasts from five to eight days. Prostatitis terminates either in gradual absorption of the swelling or in suppuration. The latter is generally ushered in by febrile movement, indeed even a chill may occur. The moment the pus is evacuated the patient feels relieved. We have never seen infiltration of urine and fistulse following prostatitis. When the abscess bursts into the rectum, fecal masses may find their way into the cavity of the abscess, causing grave compli- cations, such as gangrene and pysemia. If the abscess opens into the rectum or urethra, the disease will almost always ter- minate unfavorably. Serous and mucous catarrh of the prostate may be mistaken for a condition of this organ that has been called jprostator- rhoea. In consequence of sexual excitement, unaccompanied by ejaculation, the prostate may pour out its secretion ; the patient becomes aware of this by finding a drop of sticky albu- 64: PATHOLOGY AND TREATMENT OF SYPHILIS. minous fluid upon his linen, and by the moisture of the lips of the meatus. At the same time he suffers from pain in the perineal part of the urethra during micturition. Strictly speaking, prostatorrhoea is no pathological con- dition, and of little consequence to the general system. Char- latans, however, make very extensive use of it, designating it as spermatorrhoea for dishonest purposes. In very rare cases extensive infiltration occurs in one of the ischio-rectal spaces, as a result of urethral gonorrhoea. This hinders the patient from walking, standing, defecating ; indeed, even lying on the affected side is irksome, but micturition and the introduction of a catheter are not prevented. On intro- ducing the index-finger into the rectum, the physician discov- ers on one side, but never at the anterior wall of the rectum, a very sensitive swelling, which subsequently may become ab- sorbed. In most cases, however, it undergoes suppuration, and the pus is evacuated into the rectum, a condition liable to re- sult in rectal fistula. To prevent this perforation of the rec- tum, an early incision should be made through the skin over the affected ischio-rectal space. In the vast majority of cases of inflammation and swelling of the prostate, resolution takes place. The more intense the pains are in the perinseum, and the greater the swelling of the gland, the greater is the probability that it will suppurate. In consequence of the suppuration, a large part of the gland is not infrequently destroyed. In scrofulous and tuberculous persons an unfavorable termination of the prostatitis may be anticipated. Opening of the prostatic abscess upon the peri- nseum seems to occur only in those cases in which the tissues surrounding the gland are affected more than its stroma. The irritative condition of the prostate may, in some cases, extend to one of the seminal vesicles or testicles, and thereby produce spermatorrhcea, or inflammation of these organs. Chronic prostatitis — i. e., serous or mucous prostatic catarrh — is at- tended by little danger, but in the aged may occasion prostatic hypertrophy. The first duty of the physician is to relieve the difficulty in micturition and the violent pains that radiate toward the perinseum, anus, and penis. This is effected by the application GONORRECEA, VENEREAL CATARRH. 65 of warm cataplasms, tepid sitz-baths, and narcotics adminis- tered internally and locally. Accordingly, we order twenty drops of tincture of cannabis indica every three hours, on a lump of sugar, or belladonna suppositories, if the rectum tol- erates them. If the pain is confined to one spot in the peri- naeum, and the dysuria is not very severe, cold compresses may be applied, and the following ointment rubbed in upon the perinaeum : ^ Extract, bellad., l'OO [grs. xvj] ; Ung. neapol. [ung. hydrarg.], 10*00 [ 3 ij, 3 jj]. M. Ft. ung. The rectum should be evacuated daily, either by the ad- ministration of castor-oil or by means of enemas of olive or castor oil. In order to keep open the canal for the passage of the urine, a Nekton catheter should be inserted and retained in the urethra until the swelling subsides or the abscess bursts. For the purpose of allaying the thirst, we recom- mend weak lemonade or sweetened water acidulated with acid. Halleri [aromatic sulphuric acid]. The diet should consist of broths, milk, stewed fruit, ice-cream, and the like. Abscesses and fistulse are to be treated in accordance with the rules of general surgery. For the hypertrophy of the gland that re- mains, the physician is unable to devise any remedy. In chronic catarrhal prostatitis, benefit may be derived from the internal administration of tinct. ferri chloridi, and the mineral waters, such as Franzensbad, Giesshubel, Rohitsch, Preblau, Kissingen, Selters, Luhatschowitz, and others. Should an ob- stinate mucous discharge from the urethra remain after the inflammatory phenomena have disappeared, we advise the pa- tient to take the following pills : 5 Iodureti ferri, l'OO [grs. xvj] : Spirit, terebinth., 0*50 [grs. viij] ; Ext. gentiana, q. s. ft. bolus, fermentur tales No. 10. S. One pill to be taken three times a day. [In acute prostatitis, as in affections of the organs in this vicinity generally, I have often succeeded in aborting the dis- ease by the application of five or six leeches to the perinseum, or at the margins of the anus, and, when the disease has become 5 66 PATHOLOGY AND TREATMENT OF SYPHILIS. chronic, one or more blisters over the perinaeum will almost always have a happy effect.] Inflammation of the Seminal Vesicles in consequence of Urethral Gonorrhoea. The colliculus seminalis may be described as the starting- point from which the inflammatory disease of the urethra and of the neck of the bladder attacks the organs that secrete and conduct the semen. It is even more difficult to de- scribe fully the pathological condition of the inflammatory process in the seminal vesicle than that of the prostate. We can only draw certain inferences from appearances found in the cadaver as to the nature of the disease. The experi- enced physician will be able, on examination with the finger in the rectum, to detect, in pronounced cases, inflammation of the seminal vesicle. The latter is situated on the posterior surface of the bladder, directly behind the prostate, and, when inflamed, will assume the form of an oblong oval, painful and hot swelling, having a doughy feel. The subjective sensations in inflammation of the seminal vesicle differ but little from those in prostatitis. There is but one symptom that belongs exclusively to the disease under consideration, namely, the erections are well-nigh constant, and so painful as to consti- tute priapism. According to the observations of Lallemand, Gosselin, and Pitha, involuntary seminal emissions occur, at- tended by burning pains, the semen occasionally being red from an admixture of blood (red pollutions), or yellow from pus. In the intervals between the involuntary emissions, dis- charges from the urethra containing spermatozoa mixed with blood or pus also take place. A continued fever becomes su- peradded very early to this local phenomenon. In cases of intense inflammation the seminal vesicle may become trans- formed into a veritable pus-receptacle, which gradually empties itself into the urethra, or ruptures posteriorly into the rectum. As a result of suppuration, the seminal vesicle may disappear \ entirely or become obliterated. If the disease assumes a chronic character, the seminal vesicle may undergo induration, calcifi- cation, and ossification. In tuberculous persons the exudation in and around the vesicle may undergo caseous degeneration. GONORRHCEA, VENEREAL CATARRH. 67 The result of grave disease of both seminal vesicles is sexual impotence. There are no special remedies that can be resorted to in the treatment of inflammation of these organs, and those that have been found efficacious in the treatment of prostatitis will, in general, also answer here. Functional Disease of the Seminal Vesicle and of the Testicle. — Spermatorrhoea, Seminal Emissions, Pollutio Diurna. The opinion prevails, not only among laymen but also among medical men, that spermatorrhoea is of very frequent occurrence ; but, according to our observation, it is quite the reverse. The disease occurs less frequently in consequence of the extension of gonorrhoea than from sexual excesses, onanism, etc. In most of the cases, the morbid condition which is looked upon as spermatorrhoea is really due to a constant discharge from the prostate (prostatorrhoea). Through excessive indulgence and unnatural gratification of sexual intercourse the secretory and excretory seminal or- gans are kept in a constant state of irritation, gradually pro- ducing exhaustion, atrophy and paralysis of the muscular ap- paratus appertaining to them. The beginning of the disease manifests itself by a rapid discharge of semen whenever the least excitement of the genital organs occurs, the erections, however, being short in duration and incomplete. Gradually the ejaculation of semen takes place even without any erotic thoughts or voluptuous sensations. "While at first the emissions only occur at night, perhaps several times in one night (polluti- ones nocturnse), later on they take place even in the waking hours, with the penis perfectly relaxed, without any erotic thoughts — sometimes, indeed, attended by unpleasant feelings. The least psychical excitement, the most insignificant disturb- ance of the genital organs, indeed the ordinary act of mictu- rition and defecation, are sufficient at times to produce an ejaculation of semen. Under these circumstances this fluid gradually loses its consistency, becomes watery, and resembles an albuminous secretion mixed with viscid mucus ; the sper- matozoa constantly diminish in numbers. Finally, it is not ejaculated, but oozes out from the urethra. This constant loss of seminal fluid produces a remarkable mental and physi- 68 PATHOLOGY AND TREATMENT OF SYPHILIS. cal exhaustion of the patient. In some cases, marked psy- chical disturbances, spinal diseases, and paralysis, may grad- ually supervene. The urine of these patients is generally tur- bid, and cloudy, and has the odor of freshly-ground bone, due to its being mixed with semen. Notwithstanding the great loss of the seminal fluid, some of the patients are said to be capable of procreation ; in most cases, however, prolonged spermatorrhoea produces impotence. The treatment of spermatorrhoea is not satisfactory. The efforts of the physician are limited to measures that will pre- vent all mental and psychical influences which directly or indi- rectly irritate the genital organs, and which will brace up the drooping spirits of the patient. For the purpose of prevent- ing the seminal emissions the patient should keep cool, live upon a nutritious but unstimulating diet, moderately indulge in light wines, take cool baths and frictions, cold douches to the perinseum, and clysters of cold water, methodical use of the cold-water cure, or sea-baths. Hypochondriac patients should be urged to take exercise, try country air, so as to become in- vigorated in every possible way. "We administer internally, against the frequent emissions : ]$ Lupulini puri, 0-50 [grs. viij] ; Camphora, 0*10 [gr. jss.] ; Sacchar. alba., 2*00 [grs. xxxii]. M. Ft. pil. No. X. S. Two pills to be taken during the day, and one directly before going to bed. Or we prescribe : 1$ Carb. f erri sacchar., 2*00 [grs, xxxij] ; Camphora, 0-20 [grs iij] ; Pulv. secale cor. ; Sacchar. alba., aa 5'00 [Biv]. M. Div. in dos. aequalis No. XV. S. Three or four powders to be taken daily. If the erections are incomplete, or premature ejaculation of the semen takes place, iron and quinine will be found bene- ficial, and may be prescribed in the following manner : 3 Tr. ferri acet. aether., 2*00 [grs. xxxij] ; Tr. cort. chinas vinos, 50'00 [^ jss., 3iv]. M. S. One teaspoonful to be taken four times daily in sweetened water. GONORRECEA, VENEREAL CATARRH. 69 We also use the following : 3 Extr. quassias, 20*00 [ f ss., 3iv] ; Sulph. ferri puri, 2*00 [grs. xxxij] ; Pulv. cort. cinnamom., 2-00 [grs. xxxij]. M. Ft. pil. No. CXX. S. Ten pills to be taken daily two or three times. In those cases in which the erections and ejaculations do not take place at all, jet the semen flows constantly, we use : IJ Acid, phosph. dil. ; Sulph. quinine, aa 2 - 00 [grs. xxxij] ; Camphora, 0-50 [grs. viij J ; Ext. cascarillad, q. s. ut fiant pil. pond., 0'15 [grs. ijss.]. S. Four or five pills to be taken three times daily. Bromide of potassium may also be prescribed in these cases. We generally order half of the following mixture, to be taken morning and evening : $ Kali bromat., 5'00 [3iv] ; Aqua destil., 100-00 [ § iij, 3 ijss.] ; Syr. cort. aurant., 12-00 [3 iij]. M. Locally, we advise the use of the following measures : Wax bougies (sonde a demeure) to be introduced and kept in the urethra, injections of tanno-glycerine into the urethra (0*50 [grs. viij] of tannic acid and 200*00 [ 3 vj, 3v, 3j] of glycerine), the injection of a weak solution of oil of cam- phor (1£ to 2 grammes [grs. xxiij to xxxij] of camphor to 25 grammes [3 vj, 3ij] of olive-oil) into the deeper parts of the urethra through a soft catheter, faradization of the genital or- gans, and the introduction of a cool steel sound. Little or no benefit is derived from cauterizing the deeper parts of the urethra with nitrate of silver, as recommended by Lallemand, while the danger attending this procedure is considerable. Diseases of the Bladder caused by Urethral Gonorrhoea. The bladder, as a rule, only becomes affected, as a result of gonorrhoea, in those cases in which the disease has already in- volved the prostatic part of the urethra. At the beginning the disease generally attacks the neck of the bladder only ; gradually, however, the fundus is also affected. The disease 70 PATHOLOGY AND TREATMENT OF SYPHILIS. of the neck of the bladder has an acute character, while that of the fundus is chronic. Hence we distinguish an acute and a chronic catarrh of the bladder. Acute catarrh of the bladder manifests itself by evidences of intense hyperemia and a moderate amount of secretion of mucus, the chronic form by a profuse discharge of catarrhal secretion. So long as the catarrhal disease is limited to the neck of the bladder, the patients complain of frequent desire to urinate and to defecate. If the patient endeavors to relieve himself, he only succeeds, under the most distressing pains, in passing a few drops of concentrated acid or neutral urine. After the last of the urine has been voided, one or more drops of blood as a rule follow. The urine is generally clear ; on cooling, however, a sediment forms, which contains desquamated epi- thelium-cells, mucus, sometimes also blood and pus-corpus- cles. The discharge from the urethral mucous membrane is then reduced to a minimum. A digital examination per rec- tum, in most cases, causes an unbearable pain in the region of the prostate, and the introduction of a catheter is usually im- possible, because the neck of the bladder, in consequence of the spasmodic contraction, is impassable. Although febrile phenomena are present in all cases of disease of the neck of the bladder, nevertheless, not all of the patients are compelled to remain in bed ; but if the tenesmus increases to a condition of ischuria, violent febrile symptoms, preceded by a severe chill, will ensue. If not relieved promptly, the ischuria may cause rupture of the bladder and uraemia. When properly managed, the acute phenomena will be re- lieved in from eight to twelve days. The inflammatory affec- tion of the neck of the bladder, however, not infrequently extends to the excretory ducts of the prostate and vasa defer- entia. A permanent hyperemia of the colliculus seminalis remains, and as a result the patient, at each ejaculation, feels as if a hot needle were thrust through his perinseum. Acute cystitis may relapse from the slightest cause, in which case a permanent hypertrophy of the apex of the trigonum Lieu- todii (la luette vesicate of Amussai) not infrequently develops, causing difficulties in voiding the urine and ejaculating the semen. GONORRHCEA, VENEREAL CATARRH. 71 The extension of the inflammatory disease of the urethra to the neck of the bladder is promoted or occasioned by vari- ous influences. Chief among these are a liberal indulgence in fresh, unfermented beer, unfermented wine, champagne, and soda-water. In addition, injections unskillfully and vio- lently, or too often made, or of too strong solutions, may lead to the development of acute catarrh of the neck of the blad- der. It is very often occasioned by the violent use of sounds and catheters, and by the impaction of calculi. Lastly, an acute vesical catarrh, may also be produced by the use of can- tharides. If acute vesical catarrh is not carefully treated, still more, if the injurious influences continue, such as the urethral injec- tions, the introduction of catheters or sounds, or the internal use of balsamic remedies, a chronic vesical catarrh, or gonor- rhoea of the bladder, will be produced. In old persons, who, as is well known, not infrequently suffer from prostatic hy- pertrophy, and in spinal paralysis, a chronic vesical catarrh will readily be produced under the pernicious influences that have been mentioned. In chronic catarrh of the bladder, febrile phenomena and pain appeal* only at times. The latter consists not only of annoying calls to urinate often, but pains also dart toward the meatus. The urine is cloudy and opaque, because it contains a notable quantity of pus and mucous corpuscles, blood-coagula, epithelial cells, and a large amount of salts, phosphates, urates, etc. It emits an ammoniacal odor, and re- acts alkaline. The alkaline condition is occasioned by the mu- cus from the bladder, which acts as a ferment, and as a con- sequence carbonate of ammonia develops from the urine while still in that viscus, and this salt in its turn causes additional irritation. Under unfavorable conditions the catarrhal secre- tion in the bladder may attain such a degree that large lumps of mucus, pus, and blood are discharged every time urine is voided. The sediment becomes tenacious and ropy, an alter- ation produced by the action of the carbonate of ammonia of the urine upon the mucus and pus. Chronic vesical catarrh gives rise to more important patho- logical alterations than the acute variety. It results in hyper- trophy of the muscular coat of the bladder (la vessie a colonne), 72 PATHOLOGY AND TREATMENT OF SYPHILIS. with simultaneous thickening of the mucous membrane, and in consequence of these lesions paralysis of the viscus may follow. Gradually the ureters, the pelves, and even the kid- neys may become diseased. The mucus, pus, and blood-coagula that remain in the bladder may serve as the starting-point for the formation of calculi. Finally, suppuration and ulceration of the bladder may take place, and hence it is readily under- stood how chronic catarrh may terminate in death, either di- rectly or by retention of urine, and uraemia. Disease of the bladder is the most serious complication of urethral gonorrhoea. It has a tendency to relapse and to become permanent. So long as the vesical affection is limited to the mucous membrane of the neck the prognosis is still favorable, but if the disease has extended to the fun- dus of the bladder the physician should be guarded in his prognosis. When the neck of the bladder only is affected, the main duty of the physician will be to relieve the vesical spasm and the painful micturition. This is best achieved by the removal of all causes, discontinuance of the injections, and of the in- ternal administration of the balsamic remedies that had been employed in the treatment of the gonorrhoea. For the purpose of allaying the vesical tenesmus, there is nothing better than the local and internal employment of the anti-spasmodic and narcotic remedies. Care should be taken, however, in the use of the latter to prevent constipation. We have used for a long time, with great benefit to the patient, equal parts of in- fusion of herba Herniarise and chenopodium ambrosioides, of which two or three cupfuls, sweetened with milk and sugar, should be taken daily. This infusion has the additional advan- tage of diluting the concentrated urine in the bladder without causing diuresis. In case this remedy affords no relief to the vesical tenesmus, the following preparations may be used : ]J Extr. sem. hyosciami ; Extr. cannabis indica, aa 0*50 [grs. viij]; Sacchar. alba, 3*00 [grs. xlviij]. M. Div. in pulv. No. XX. S. One powder to be taken every three hours. GONORRHCEA, VENEREAL CATARRH, 73 B Camphora; Ext. cannabis indica, aa 0*50 [grs. viij] ; Sacchar. alba, 3*00 [grs. xlvij]. M. Div. in dos. seq. No. X. S. One powder to be taken every two or three hours. If these narcotics also fail to give relief, suppositories of belladonna, containing 0*01 [gr. -J-] of the extract,* should be resorted to. In patients who do not suffer from constipation, suppositories containing morphia, in quantities similar to that of the belladonna, or hypodermic injection of morphine in the peringeum, may be employed. In the majority of cases warm sitz and ordinary baths, and the application of flannels dijyped in hot water, wrung out, and applied over the bladder, afford considerable relief. The diet of the patient should consist only of soup and milk. Sweetened water, to which a few drops of acid Halleri [aromatic sulphuric acid], or diluted milk of almonds, is the best drink for him. Formerly, it was cus- tomary to use, in acute catarrh of the bladder, oleaginous mixt- ures and decoctions of linseed with syrupus Diacodii ; in our opinion, however, the decoction contains but a slight amount of linseed-oil, and of this very little is excreted with the urine and finds its way into the bladder. If retention of urine has occurred, the bladder should be evacuated by the aid of a soft catheter. In cases in which the effusion of blood from the capillaries of the neck of the blad- der continues, tr. ferri chlorid., administered internally, will be found beneficial. [Nothing serves the purpose so well here as blistering the perineum. When all other remedies have failed, one or two blisters applied upon the peringeum not only arrested the bleeding, but gave prompt relief to the vesi- cal tenesmus.] In chronic vesical catarrh the physician will be called upon to evacuate the urine and the ropy secretion several times daily, and to diminish the secretion of mucus as much as pos- sible. With this object in view, the patient should be allowed to drink water plentifully ; also mineral waters containing iron, such as Marienbad, Franzensbad, Giesshubler, Ottoquelle, Ro- * [I have found this quantity entirely insufficient — half a grain at least being necessary.] 74 PATHOLOGY AND TREATMENT OF SYPHILIS. hitscher, Luhatschowitzer, Wildungen, etc. In addition astrin- gents, such, as alum, tannic acid, or decoct, f oliorum uvse ursi, should be used, as in the following formulae, for the purpose of arresting the secretion of mucus by the mucous membrane of the bladder : 5 Fol. uvsb ursi, 20*00 [ § ss., ^ iv] ; Ooque c. q. s. aq. comm. per \ h. sub. finem coct. ; Adde: Flav. cort. aur., 10-00 [3 viij]; Stet in infuso fervids per i hor. vase clauso. Colat, 300-00 [ | ix, 3 vj]. Adde: Syr. althae, 30*00 [§j]. M. S. Half a teacupful to be taken every three hours. 3 Glycerini puri, 20-00 [ § ss., 3 iv] ; Tannini puri, 0*50 [grs. viij] ; Aq. destil., 50'00 [§jss., 3 iv]; Syr. ononidis spin., 15*00 [ § ss]. M. S. To be taken in twenty-four hours. We are unable to say anything in favor of the use of lime- water or tar- water, or of a solution of corrosive sublimate, in this complaint. If the muco-purulent secretion of the vesical mucous mem- brane does not diminish from the use of the mineral waters and astringent remedies, it will be necessary to remove mechani- cally the secretion and urinary sediment that stagnate in the bladder. For this purpose, we cordially recommend the pro- cedure suggested and published by Drs. Erunner and H. von Zeissl, of filling the bladder with liquids by hydrostatic press- ure without the aid of a catheter. If the bladder does not evacuate its contents spontaneously, a catheter having a large eye should be introduced, and the organ should be carefully washed out with some weak antiseptic preparation, such as a solution of carbolic acid or the like. For the purpose of coun- teracting the alkaline condition of the urine, we give internally potas. chlor., 0*50 [grs. viij], per diem, in solution, with very good result. Diseases of the Kidney that are produced by Urethral Gonorrhoea. ]STo morbid conditions that originate in consequence of gonorrhoea of the urethra escape the notice of the physician GONORRHCEA, VENEREAL CATARRH. 75 so often as those that develop in the kidneys. The genesis of these kidney lesions was but imperfectly known to within a comparatively recent period. Many physicians ascribed the diseases of the kidney that complicated gonorrhoea exclusively to the' large doses of the resinous diuretics which the patients took. On the other hand, Chomel and Raver maintain that neither the resinous remedies nor the diuretica acria exert any unfavorable effect upon the kidneys. Still, we have proof that even small doses cause, occasionally, haemorrhage and ecchymoses of the neck of the bladder. From this point the hypersemia may extend along the mucous membrane of the ureters and pelves of the kidneys to the papillae and the straight renal tubules, and produce within the latter catarrhal proliferation of the cells. Now, it is easy to perceive how a catarrh of the bladder, merely by extension, may occasion disease in the kidney, since irritation of the neck of the blad- der not infrequently occurs even in gonorrhoeal urethritis treated without any balsamic remedies. Further, because this coexisting catarrhal affection of the straight tubules of the kidneys, occasioned perhaps idiopathically, is accompa- nied by albuminuria, the resinous remedies were charged with having caused the nephritis. It is all the more easy to make this mistake, because it is possible, even in healthy kidneys, after the use of copaiba, cubebs, etc., in large doses, to pro- duce for several days an opacity of fresh urine by the addi- tion of strong mineral acids, which is remarkably like that caused by the presence of albumen. This opaque sediment, however, is not albumen, but the resinous substance precipitated by the acid. But, even if the opaque sediment proves to be albumen, the lesion can only be regarded as a catarrhal ne- phritis desquamativa, and not diffuse nephritis. Now, it is a settled fact that the kidneys, in most cases, are not attacked by acute gonorrhoea, even if the latter extends to the pros- tate and bladder, and that it only produces a catarrh of the straight renal tubules when it has existed for a long time and involved the bladder. We have only been able to demonstrate in the cadaver the presence of suppuration in one or both kid- neys in those cases in which bad strictures had already formed as a result of gonorrhoea, followed by hypertrophy or ulcera- 76 PATHOLOGY AND TREATMENT OF SYPHILIS. tions of tlie prostate, with or without purulent catarrh of the bladder. Inflammation of the jpelves of the kidneys, in conse- quence of gonorrhoea, occurs more often than is supposed. The diagnosis of this condition is based upon the presence of febrile movement analogous to intermittent fever, of an amount of albumen in the urine correspondingly greater than the pus in it, the microscopical demonstration of pus-corpuscles, and irregular pavement epithelium of the renal pelvis. The urine in pyelitis has an acid reaction, being directly the reverse of the condition that appertains to catarrh of the bladder that has existed for a long time. The patients complain mostly of a dull pain in the region of the kidney, and the organ itself is sensitive on pressure. In most cases the patient complains — if not at first, at any rate later in the course of the catarrhal nephritis — of a dull, sometimes of a violent pain in one or both lumbar regions, which becomes aggravated at the slightest touch, and usually extends downward along the course of the ureters. Not in- frequently the disease manifests itself by more or less severe febrile movement. The urine in such cases is markedly di- minished at first ; later, in most instances, it is increased, and is generally of a pale-yellow color. As a rule, it contains a moderate amount of albumen ; but, notwithstanding the pres- ence of albumen, the specific gravity is lower than normal. After standing for some time the urine deposits a sediment, in which the epithelial cells of the ureters and bladder, along with mucus and pus-corpuscles, hyaline casts, cylindrical epi- thelium, and occasionally fibrine casts are found. The urine reacts slightly acid, but, if the disease persists for a long time, it will become alkaline, owing to the decomposition of the salts of the urine in the bladder. We then find the well-known cof- fin-lid-like crystals of the triple phosphates ; sometimes blood- corpuscles are also present. The condition of the extravasated blood will serve to show whether the blood that is mixed with the urine originates in the bladder or in the kidneys. Blood coming from the ureters generally forms clots, shaped like casts of these tubes. In haemorrhage from the bladder the blood is not intimately mixed with the urine, and the urine that is voided at first is only slightly red in color, but that voided later GONORRHCEA, VENEREAL CATARRH. 77 becomes as intensely red as if it were pure blood. In hemor- rhage from the kidney the blood is thoroughly mixed with the urine, and the latter has a uniform color from the beginning to the end of micturition. For the purpose of ascertaining defi- nitely the presence of blood-corpuscles in the urine in slight renal haemorrhages, the urine should be subjected to the potash test, which consists in boiling some of it in a test-tube, adding a few drops of a solution of caustic potash, and then boiling it again. The solution precipitates the phosphates, carrying the coloring-matter of the blood with them, and the sediment is thereby colored red. The course of a renal catarrh occasioned by gonorrhoea is usually rapid and favorable. The prognosis depends upon the intensity of the primary disease. If the vesical catarrh is in- tense and purulent, there is danger that the catarrhal nephritis will become suppurative. Renal catarrh, due to gonorrhoea of the bladder, generally disappears when the primary disease disappears. Hence the treatment of the vesicle and renal catarrh mast go hand in hand. Eegarding the therapeutics of the disease of the blad- der, we refer the reader to what has already been said above. The patient should avoid everything that is liable to produce marked fluxion to the kidney, especially food and drink sea- soned with much salt, and also all kinds of diuretics. Cold water, weak lemonade, and milk of almonds are best suited for drinks, and milk and milk-diet as food. Stimulating the skin by means of hot baths is especially useful. The following may be employed for the purpose of arresting the secretion of the mu co-pus : 3 Tannini puri, 1*00 [grs. xvj]; Camphora, 0'50 [grs. viij] ; Sacchar. alba, 5*00 [3iv]. M. Div. in dose No. 15. S. Four powders to be taken daily. I£ Glycerini puri, 20*00 [ § ss., J>iv] ; Tannini puri, 1*00 [grs. xvj] ; Aqua destil., 100*00 [ § iij, 3 ijss.]. S. To be taken during the day. In profuse renal haemorrhage we administer tr. ferri mur. In very obstinate bleeding and persistent lumbar pain, cold 78 PATHOLOGY AND TREATMENT OF SYPHILIS. compresses should be applied to both renal regions. The treatment of the pyelitis consists in the internal administration of tannic acid in the manner described above. [In renal haemorrhage, and also in pyelitis, I can heartily recommend the use of dry cups over the lumbar region as often as may be deemed necessary. From twenty to forty cups may be applied and repeated. It has rendered me excellent service where other much-vaunted remedies failed.] Dittel obtained very good results from the inhalation of the ethereal balsamic remedies. Gonorrhoea of the Female. We distinguish (1) gonorrhoea of the vulva, (2) of the va- gina, (3) of the uterus, and (4) of the urethra. The most frequent form is vaginal gonorrhoea, next is vulvar and uterine, and the rarest is the urethral form. Usu- ally several parts of the genito-urinary mucous membrane are affected at the same time. Yaginal gonorrhoea is very often associated with vulvar or uterine, urethral with vulvar or vagi- nal, vaginal with urethral and uterine gonorrhoea. The en- tire genito-urinary tract is very seldom attacked in toto by gon- orrhoeal disease. The causes of gonorrhoea in the female are infection, ex- cessive sexual intercourse, and mechanical and chemical irrita- tion of the mucous membrane. Constitutional diseases, such as chlorosis, scrofula, syphilis, and similar blood dyscrasise, ir- regularities of menstruation, abortions and difficult confine- ments, neoplasms, and surgical operations, may also occasion a mucous catarrh or prolong one that has originated in some other manner. 1. Gonorrhoea of the Yulva. Two kinds of vulvar catarrh may be said to occur: an idiopathic variety and one that has been produced by propa- gation from adjacent parts. Idiopathic vulvar catarrh origi- nates mostly in consequence of onanism, but may also be caused by the gonorrhoeal discharge of men. "Vulvar catarrh originat- ing through propagation results from the action of vaginal or urethral discharge of women affected with gonorrhoea, or it ac- GONORRH(EA, VENEREAL CATARRH. 79 companies soft chancres and syphilitic affections situated on the vulva. The pathological lesion consists either of a hyperemia of the affected mucous membrane or its consequent effect (serous, mucous, or epithelial catarrh), or the follicles are inflamed and become filled with pus (vulvitis purulenta). Yulvar catarrh be- gins with sensual itching, which changes to a burning sensation. If any part of the mucous membrane is denuded of epithe- lium, or excoriations and erosions such as usually occur on the labia majora and minora at the fourchette are present, the pa- tients will suffer severe pain during micturition. If the disease becomes aggravated the parts of the vulva, provided with loose connective tissue, become swollen. The nymphae become en- larged to three and four fold their size, and, as a consequence, project in front of the labia majora and are strangulated by them. In milder forms of the disease — serous, mucous, or epithelial catarrh — the discharge from the vulva is slight, mucoid, and tenacious. In purulent vulvitis it is considerable in quantity, thick like cream, and yellowish-green in color, emits a peculiar, fetid odor, irritates the adjacent mucous membrane, and produces erythema of the skin in the genito- crural and inguinal folds. Warts and condylomata are some of the most frequent effects of vulvar gonorrhoea. Mild cases get well soon, if the diseased parts are washed several times daily, and the sound parts are protected by com- presses of muslin or wadding. If the inflammation of the mucous membrane is intense, compresses, dipped in cold water and frequently changed, should be ordered, and pledgets of lint, dipped in a solution of lead or of zinc, placed between the labia majora. ]$ Ext. Saturni [plumb, acet.], 5 - 00 [3iv]; Aqua destil., 200*00 [ § vj, 3 v, 3j]. M. S. For external use. 3 Zinci mur., 2*00 [grs. xxxij] ; Aqua destil, 200*00 [ § vj, 3 v, 3j]. M. S. For external use. Excoriations that exhibit no tendency to cicatrize may be touched with the solid nitrate of silver. 80 PATHOLOGY AND TREATMENT OF SYPHILIS. 2. Gonorrhoea of the Yage^a. We distinguish a serous, mucous, or epithelial, and a puru- lent catarrh (kolpitis), according to the severity of the inflam- mation. Every vaginal gonorrhoea begins by an undefined sensation, something between tickling and pain. In the serous and mu- cous catarrh, the vagina is only slightly sensitive, especially at the beginning of the morbid process. In kolpitis the burning sensation is more marked ; the introduction of the finger or of a vaginal speculum gives rise to unbearable pain. Micturition also causes more or less pain in vaginal gonorrhoea. The dis- charge of a mucous gonorrhoea of the vagina is thin, whitish, like mucus, or yellowish ; the discharge of the purulent variety is thick, like cream, and has a yellowish-green color. The dis- charge of both varieties has an acid reaction, in contradistinc- tion to the discharge from the inflamed mucous membrane of the urethra, and of the cervix uteri, which reacts alkaline. This acid reaction seems to be due to the fact that the virginal vulvo-vaginal mucous membrane furnishes a smegma-like secre- tion containing a fatty acid, while the follicles of the cervical portion of the uterus furnish a mucous secretion. Examined with the aid of a microscope, the discharge of a vaginal gonor- rhoea is found to contain mucous corpuscles, a few pus-corpus- cles, cast-off epithelium cells, and now and then a few blood- globules. In attempting to make a digital examination during the initial stage of the disease, the vaginal orifice is found to be contracted and the temperature of the canal increased. Its mucous membrane is felt to be either soft and smooth, or rough and dry. On examining with a speculum a vagina that is affected with gonorrhoea, the mucous membrane, after the discharge that has accumulated at the mouth of the speculum has been wiped away with some cotton on a whalebone rod, is found to be swollen, dotted with red spots, here and there ex- coriated, and turgid with blood. Occasionally the anterior part of the vagina especially is studded with minute granula- tions, which have originated through swelling of the follicles and of the papillae of the mucous membrane. In pregnant GONORRHCEA, VENEREAL CATARRH. 81 women these granulations attain an enormous size (vaginitis or elytritis papulosa). As it is not possible to use the speculum in young girls, we succeeded very well, in some cases, in lighting up and examining the vagina by the aid of Griinfeld's ure- thral endoscope. Gonorrhoeal disease of the vagina generally begins at the lower third of the canal and gradually extends to the fornix, indeed, sometimes to the cervical canal of the uterus. The general condition is but slightly affected by a mucous gonor- rhoea. The purulent form, on the contrary, is attended, espe- cially at the beginning, by fever, lassitude, loss of appetite, back-ache, vicarious menstruation, and other functional disturb- ances, on account of which the patients acquire a chloro-ansemic appearance. The local disturbances consist of erythematous redness of the external surfaces of the genital organs, caused by the discharge from the vagina flowing over them. The duration of a vaginal gonorrhoea depends upon the habits of the patient, certain constitutional conditions, and the manner of treatment. A purulent gonorrhoea, in women who are otherwise healthy, can be cured in about fourteen days, pro- vided menstruation does not interrupt the treatment and the cure, which it is apt to do, experience having shown that it will start the disease anew, after it was entirely checked. If the treatment of an acute vaginal gonorrhoea is abandoned too early, and the woman indulges in sexual intercourse, the inflammation either relapses or the catarrhal hypersecretion becomes permanent {chronic vaginal gonorrhoea). However, even a vaginal gonorrhoea which, at its incejMdon, was of the catarrhal mucous form, may, through unfavorable circum- stances, especially anaemia and frequent and irregular menstrua- tion, become protracted and difficult to cure (leucorrhosa). The discharge from chronic catarrh is almost colorless, more mucous than purulent. As a result of the chronic process, and still more from the astringent liquids used against it, the mucous membrane becomes hypertrophied, loses its velvety appearance, feels rough and dry, like tanned leather (xerosis vagina), and causes a grating noise when a speculum is introduced. For the purpose of curing a vaginal gonorrhoea, the woman, above all things, must practice the utmost cleanliness. In 6 82 PATHOLOGY AND TREATMENT OF SYPHILIS. cases of intense swelling of the mucous membrane, cold com- presses, cool sitz-baths, or the cold-water vaginal douche, by means of the fountain-syringe, should be employed. After the inflammatory swelling has subsided, and the hypersensi- tiveness has diminished, mineral astringents, and, if these fail, vegetable astringents and tonic fluids, may be injected into the vagina. These injections may be much stronger than those used in urethral gonorrhoea in men. "We prescribe the following : I£ Alum crudi, 10-00 [3viij]; Aqua destil., 500-00 [§ xvj]. M. S. For external use. 3 Cortic. quercus or radio, ratanh., 50-00 [§ jss., Bviij] ; Coque cum aqua, 1000*00 [ § xxxij] usque ad remnant 500-00 [ I xvj] cola. M. S. For external use. 3 Zinci sulph., 5-00 [3iv]; Aqua destil., 500-00 [ § xvj] ; M. S. For external use. 3 Tr. ratanhise or catechu, 50*00 [ § jss., 3 viij] ; Aqua destil., 500-00 [ I xvj] ; Alum, crudi, 5-00 [3 iv]. M. S. For external use. B Tannini puri, 5-00 [3iv]; Glycerini, 50-00 [ I jss., 9 viij] ; Aqua destil., 500-00 [ § xvj]. M. S. For external use. These preparations must be used by the patients at least three times daily. They may be injected into the vagina with a uterine or fountain syringe. By the aid of the speculum the nurse or the physician will be better able to apply the remedies to the diseased places. After the injections the vaginal walls should be wiped as dry as possible with cotton-wool, and, for the purpose of keeping them apart, the vagina should be tam- poned with pledgets of charpie, dipped in the astringent lo- tions. These should be changed every two hours, otherwise the blennorrhoic secretion with which they become saturated will undergo decomposition and irritate the mucous membrane. If the pledgets of lint have strings attached to them it will be quite easy to remove them from the vagina. GONORRHCEA, VENEREAL CATARRH. 83 If the discharge, notwithstanding the frequent employment of the injections, does not cease — as is usually the case, espe- cially in elytritis papulosa — a speculum should be introduced into the vagina, and, after cleansing it of secretions, the mu- cous membrane should be cauterized with the solid stick of nitrate of silver, making circular sweeps with it as the specu- lum is being gradually withdrawn. The vagina should be immediately tamponed with dry absorbent cotton, but this must be removed in a few hours, and the injections again used. It is necessary to repeat these cauterizations of the va- gina every two or three days, and, failing to accomplish a cure in this way, pledgets of lint, dipped in a solution of alum or of bismuth, should be inserted and allowed to remain for two or three hours, and then followed by injections. [Quite re- cently a solution of bichloride of mercury (1 part to 5,000 or 10,000 of water) has been used with excellent results.] 3. Complications of Vulvo-vaginal Gonorrhoea. {a) Diseases of the Glands of Bartolini and their Ducts. We distinguish (1) disease of the gland and of the con- nective tissue surrounding it, and (2) disease of the duct itself. The first lesion is better known and of tener comes under treat- ment. Both originate usually from the extension of the vul- var inflammation to the walls of the excretory ducts and the gland itself. The disease, however, may also be produced by masturbation, since abscesses of the gland and of the labiae have been met with in virgins. Both affections generally oc- cur unilaterally. Inflammation of the gland is ushered in by febrile move- ment and constantly increasing pain in the affected labium, which swells up immensely. In the course of six or eight days a periglandular abscess forms, which finally bursts on the surface of the mucous membrane of the labium, or, in rare cases, a gangrenous condition ensues, producing an intensely fetid discharge. Inflammation of the excretory ducts runs either an acute or chronic course ; but even an acute inflammation causes only a moderate degree of pain, is unattended by fever, and does 84 PATHOLOGY AND TREATMENT OF SYPHILIS. not give rise to any enlargement of the labium. A tenacious, mucous, sometimes also purulent discharge flows constantly from the excretory ducts, a condition that is liable to become chronic. If the discharge can not escape readily, the duct will become distended, ampulla-like, to its utmost capacity, and then some of the matter will be poured out periodically, or the bulging diverticulum that projects on the inner surface of the affected labium undergoes suppuration and ruptures. Periglandular abscesses occur more frequently than abscess of the diverticulum or of the excretory ducts. Abscesses of the excretory duct are more superficial than the periglandular ones. They are not so painful, burst and cicatrize sooner than the latter. The walls of the glandular abscess are un- even, shaggy,, markedly red, and bleed readily. The walls of the diverticulum are smooth and glistening. Catarrh of the excretory ducts is very obstinate, and often resists all kinds of treatment. Swelling and abscess of the glands of Bartolini may readily be mistaken for hernia labialis. The latter is generally lo- cated in the central part of the labium majus, and from that point it turns to the side of the vagina in the direction of the tuber ischii, and, with a finger in that canal, the direction of the tumor is readily followed. The diagnosis may be estab- lished beyond a doubt by examining the internal abdominal ring and by percussing the tumor. The other morbid alterations of the labia which are liable to be mistaken for inflammation and abscess of the glands of Bartolini are atheromatous and other cystic tumors of the labia. There is a disease of the labia, that occurs very rarely in Europe, and which consists in an enormous hypertrophy of one or both labia. This is known under the name of elephan- tiasis arabum pudendum. In the early stages of the disease the diagnosis may be established by the presence of a local, persisting, or frequently recurring erysipelas. In consequence of this erysipelas, the so-called lymphatic oedema, as is well knOwn, develops, and after a while causes the elephantiatic hy- pertrophy of the labia. In the further course of the disease, that form which has been hitherto described as elephantiasis GONORRHEA, VENEREAL CATARRH. 85 glabra pudendorum may develop into the variety to which has been applied the term elephantiasis arabumfusca, on account of the glandular appearance of the affected parts of the skin, and the deep-brown color of the epidermis. In regard to the therapeutics of the disease, we wish to make the following observations : If the gland is affected, the patient, in the beginning of the disease, must keep perfectly quiet, and cold should be applied. When softening takes place, the compresses should be renewed less often, so that they may become warm and act as cataplasms, and the swelling lanced as early as practi- cable, and, if possible, externally, to prevent the lips of the wound from being infected by the vulvar or vaginal discharge. In catarrhal disease of the excretory ducts, cool sitz-baths and pledgets of muslin dipped in astringent solutions, such as tan- nic acid, zinc, or copper, laid upon the gland, have been found useful. A diverticulum that is in danger of undergoing sup- puration should be slit open and touched with lunar caustic once daily. Non-suppurating diverticula of long standing should likewise be slit open, and a weak solution of nitrate of silver (040 [gr. If] to water 100-00 [ § iij, 3viij]), should then be injected through the cut by means of an Anell's syringe. (b) Inflammation and Abscess of the Lymphatic Vessels in the Labia Jlajora and Ifinora, and of the Lymphatic Glands of the Inguinal Folds. These lesions occur especially in suppuration of one of the glands of Bartolini. They are due to the same pathological condition, and develop in the same manner as inflammation of other lymphatic vessels and sympathetic buboes (see Affec- tions of the Lymphatic Vessels and Glands in consequence of Soft Chancre). 3. Uterine Gonorrhoea and its most Frequent Complica- tion : Erosions and Granulations of the Os Uteri. Uterine gonorrhoea occurs very rarely as an idiopathic dis- ease. As a rule, it is caused by propagation of the morbid process from the vagina. For that reason the cervical canal alone is found affected in most cases, and the body of the 86 PATHOLOGY AND TREATMENT OF SYPHILIS. uterus becomes involved only when the disease has existed for a long time. Gonorrhoea of the cervical canal manifests itself partly by subjective and partly by objective symptoms. The subjective complaints are : Dull, unpleasant sensations, emanating from the pelvic cavity and radiating toward the lumbar region, fre- quent desire to micturate, and a general feeling of discomfort. The objective symptoms observed in an examination with a vaginal speculum are as follows : A gelatinous, collodion-like, ropy discharge oozes from the mouth of the uterus. This is excreted from the follicles lying between the plica palmatis of the cervical canal, tenaciously adheres to the secreting sur- faces, and reacts alkaline. During pregnancy it appears in cheesy flakes. This discharge corrodes the posterior lip of the cervix, and, in consequence, it often becomes streaked with bloody erosions. Uterine gonorrhoea seldom disappears entirely ; generally it merges into a chronic catarrh, because, as has been learned through experience, the mucous membrane of the cer- vix uteri, of all the genital mucous membranes, has the great- est tendency to become affected with chronic catarrh. In con- sequence of this chronic catarrh the follicles found there grow and become dilated into polypoid growths, which • sometimes protrude through the os uteri, become strangulated and drop off (ovula Nabothi). Should the morbid process involve the cavity of the uterus, irregular menstruation will ensue, it will become dilated, the secretions that have accumulated within become decomposed, and occasion the so-called physometra — i. e., accumulation of air within the uterine cavity. When the catarrh has existed for a long while, the mucous membrane undergoes various morbid changes. It is traversed by varicose vessels, studded with ecchymotic and discolored pigmented spots ; the ciliated epithelium is destroyed, the glands at the os excrete fat and hyaline matter instead of normal mucus, and become converted into cysts ; many of them when grouped together develop into polypi. The walls of the uterus become thickened ; prolapsus and displacement of the organ may take place. If the catarrh has extended to the Fallopian tube, ste- rility will either be the result, or the fecundated ovum remains in the vicinity of the os internum, and gives rise to placenta GONORRHCEA, VENEREAL CATARRH. 87 praevia (Schroder). Infection with gonorrhoeal virus may oc- casion even metritis and parametritis. The digestive organs and the nutrition become unfavorably affected on account of these lesions, and functional disturbances of the uterus ensue. The appetite is diminished, vomiting occurs frequently, gastric catarrh ensues, followed by passive dilatation of the stomach. The patients become emaciated and anaemic. In regard to the question of the infecting property of the uterine discharge, we coincide, from personal experience, with the opinions of Cooper and Kicord, that it will produce gonor- rhoea in men, but of a, milder form. It will do this especially when it is profuse in quantity and contains many pus-cells, when the woman neglects to keep her genital organs clean, and when intercourse is repeated at short intervals with passionate ardor. This condition may obtain more frequently in illicit intercourse than among sedate married couples, and will also serve to explain those cases in which a woman suffering from uterine disease will communicate gonorrhoea to strangers who succeeded in infringing upon the rights of the husband, while the latter escapes infection. As a result of uterine catarrh, less frequently of severe, protracted vaginal catarrh, small erosions occur on the cervix and sometimes (especially in coexisting syphilis) in the cervi- cal canal. The coalescence of many of these erosions will form large bleeding spots, which are destitute of epithelium- cells. After the expulsion of the glands of Nabothi the ero- sions in the cervical canal may become converted into excavated minute ulcers, that heal by the formation of flat, grayish-white cicatrices. Not infrequently granulations, which vary in size from a millet-seed to that of a lentil, and which bleed readily, form upon the eroded surfaces. Hennig regards them as vas- cular papillae of the mucous membrane that have not yet cica- trized, or as new growths, which have sprung from the granu- lar proliferation of the papillae. In consequence of these erosions and granulations disturbances in the nerves of the sex- ual organs of the female, which manifest themselves in hyster- ical convulsions and the like, seem to be produced. So long as inflammatory phenomena in and about the uterus exist, sexual intercourse must be strictly interdicted, complete 88 PATHOLOGY AND TREATMENT OF SYPHILIS. rest should be enjoined, the diet restricted, and cold applica- tions made over the abdomen and sacrum, free movement of the bowels procured, and whatever vaginal and uterine dis- charge is present should be carefully removed by injections of tepid warm water. If the inflammatory phenomena have al- ready disappeared, the cervical canal should be cauterized two or three times a week with the solid nitrate of silver, at the same time cooling sitz-baths prescribed, and the uterine douche employed. No injections of nitrate of silver should be made into the uterine cavity, because we have seen violent uterine colic and even inflammation of the uterus and of the ovaries produced by them. Healing of the erosions and granulations can only be achieved by persistent and zealous treatment of the primary catarrhal disease of the vagina or uterus. We have seen excellent results from penciling the eroded surfaces with a solution of nitrate of silver or copper. The imperfect digestion and assimilation, the anaemia and chlorosis, must be improved by the administration of good food, tonics, such as iron, wine, mineral waters, and baths, and a residence in the country. 4. Urethral Gonorrhoea in the Female. Although the pathological lesions which are produced by urethral gonorrhoea are the same in the female as in the male, still it is not so dangerous nor is it apt to assume such a pro- tracted character in the former as in the latter. This is owing to the fact that the urethra of the female is shorter, fewer adjacent organs are so intimately connected with it, it does not participate in erections as in the male, and, being more ex- posed, it is more accessible to the application of remedies. The disease manifests itself in the same manner as in the male, by a tickling sensation at the meatus, which soon changes to a real pain, and is aggravated by urinating. The most sig- nificant symptom is the presence of a mucoid or muco-purulent discharge, which can be pressed out of the urethra by running the finger over it in the vagina from behind forward. This discharge should not be mistaken for the mucoid or puru- lent discharge of the inflamed mucous follicles which occur in the crypts on both sides of the female urethra. This fol- GONORRHCEA, VENEREAL CATARRH. 89 liculitis can be cured in a few days by the use of astringent remedies. Among the accidents which may be associated with a female urethral gonorrhoea, dysuria is the most frequent, because, ow- ing to the shortness of the urethra, the neck of the bladder is more often involved than in the male. Haemorrhage in gonor- rhoea of the female urethra occurs very seldom, and is very slight. Inflammation of the inguinal glands is exceedingly rare, but warts and condylomata are remarkably frequent re- sults of the disease under consideration. The treatment of urethral gonorrhoea in the female is almost identical with that of the male. In women who will not submit to injections, cooling baths and the internal administration of the ethereal balsamic remedies should be ordered. In obstinate chronic urethral gonorrhoea the gradual introduction of the solid stick of argent, nitratis once into the urethra has accom- plished a cure in many cases. Gonorrhoea of the Rectum. Gonorrhoea of the rectum is a very rare disease. It may be produced in either sex by direct contagion, as in unnatural sexual intercourse (pederasty), or by want of cleanliness, the discharge from gonorrhoea of the genital organs running down to and coming in contact with the mucous membrane of the rectum. Hence this disease is met with more frequently in women than in men, the cause just mentioned exercising its effects with greater facility in the former. The skin of the perineum and around the anus in such cases is, as a rule, erythematous and excoriated. If folds of mucous membrane, in consequence of haemorrhoids, protrude from the anus, the parts will become infected with still greater facility by the discharge from the genital organs. The discharge from the rectum is pre-eminently purulent, has a disagreeable odor, and not infrequently is mixed with blood. It flows continuously, and is especially profuse before defecation and after the expulsion of flatus. It produces ex- coriations and Assures in the folds of the anus, especially in those cases in which infection has resulted from pederasty. In rectal gonorrhoea the patients suffer from pains only during 90 PATHOLOGY AND TREATMENT OF SYPHILIS. defecation. During the intervals they complain only of a constant burning or itching in the anus, and a frequent desire to go to stool. In the most pronounced cases the mucous mem- brane of the anal aperture is reddened and swollen. We have never met with a case of chronic rectal gonorrhoea resulting from contagion, and it is probable that the discharge from other diseases occurring in this region, such as hsemor- rhoidal tumors, syphilitic moist papules, or chronic eczema, has been mistaken for that of gonorrhoea of the rectum. "Warts and condylomata are the most disagreeable effects of rectal gonorrhoea, for especially the latter may attain to such dimensions as to interfere with defecation. The treatment of gonorrhoea of the rectum consists of rest, general baths, or protracted sitz-baths, and injections of water into the rectum ; the movement of the bowels being prevented by a restricted diet, and the administration of opiates (and when that condition has been attained the rectum should be immediately washed out with clysters of water). For the purpose of checking .the secretion of pus, a one-per-cent solu- tion of tannic acid or of alum should be injected into the gut. In the intervals between the injections pledgets of lint dipped in the same solution should be inserted into the anal aperture. Excoriations or fissures should be touched with the nitrate of silver stick. Gonorrhoea of the Mouth and Nasal Cavities. We have never, either in hospital or private practice, met with a case of gonorrhoea of either of these cavities, though it is asserted in some of the older works that the disease occurs in both sexes, the mucous membrane of the nose and mouth being affected in the same manner as the conjunctiva. Gonorrhoea of the Eye. (Ophthalmia Gonorrhoea Blennor- rhoica.) By Docent Dr. Hock, of Vienna. The term ophthalmia blennorrhoica is applied to a disease of the conjunctiva of the eye, in which there occurs a profuse discharge of muco - purulent matter, attended by increased lachrymation, intense swelling, and redness of the mucous GONORRHCEA, VENEREAL CATARRH. 91 membrane, proliferation of the papillary bodies, and sometimes actual ecchymosis ; in addition a serious inflammatory swelling of the eyelids and the adjacent integuments may occur, and, in some cases, affection of the eyeball itself, resulting in kera- titis and panophthalmitis. The disease begins with symptoms of a severe catarrh, which within a few days reaches its height. At this point it presents the following morbid picture : The eyelids, especially the upper one, are swollen to the size of a child's fist, and the integument of the lids and that surrounding them is reddened, tense, hot, and oedematous. The upper lid overlaps the lower, its cilia are agglutinated to one another and to the skin of the lower lid by thick, yellowish matter, some of which has dried and formed crusts. If after the removal of the crusts an at- tempt is made to raise the upper lid with the fingers, a quan- tity of yellowish matter gushes out, the lid becomes everted, and the intensely swollen conjunctival mucous membrane bulges out. In the tarsal parts the conjunctival connective tis- sue is seen to be of a deep-red color and intensely swollen, the papillae congested to such a degree as to give it a velvety or warty appearance ; sometimes the latter may be seen with the naked eye as minute excrescences, between and upon which a grayish-yellow matter has accumulated, which occasionally solidifies and acquires the character of a false membrane. If the lids are separated by the aid of an eye-speculum, the ocular conjunctiva, the caruncle, and the semi-lunar fold are seen to be red, thickened, and uneven, the former swollen and forming around the cornea an oedematous, transparent florid or livid wall like a parapet, under which the cornea is buried, its cen- tral part only being visible. Generally the patient also suffers from febrile movement. Of the causes of gonorrhoeal ophthalmia it is only necessary to mention here the direct transportation of gonorrhoeal matter to the conjunctiva by the fingers of the patient and of the in- fection of the sound eye with the discharge from the diseased eye. Some authors, Neisser among others, also claim to have found micrococci in the discharge of eyes affected with blen- norrhcea. Ophthalmia blennorrhoica runs an acute course ; it gener- 92 PATHOLOGY AND TREATMENT OF SYPHILIS. ally reaches its end in three or four weeks. Although in some cases the disease runs a most violent course, attaining its high- est intensity in thirty-six or forty-eight hours, resulting in ulceration and perforation of the cornea, yet in others the symp- toms are very mild and slower in their progress, and the disease yields much more readily to appropriate treatment. Hence a complete restitutio ad integrum is observed only in the milder class of cases. It is true that even in the severer class a cure will be achieved, but always with more or less marked cicatri- zation of the cornea, anterior synechia, partial corneal staphy- loma, and cataract. Often, however, it results in complete phthisis cornese, panophthalmitis with consequent atrophy of the eye-bulb. Sometimes proliferation of the papillae remains after a blennorrhcea, a condition which, in some cases, is ob- served even during the progress of the disease, though in others not until it has run its course. (Chronic blennorrhcea, trachoma, conjunctivitis granulosa.) Treatment of Gonorrhceal Ophthalmia. (1) Immediately after the conjunctiva has been infected with gonorrhceal matter it should be washed thoroughly with some antiseptic preparation, such as a hve-per-cent solution of natr. benzoic, or a two-per-cent solution of boracic acid, or, for want of either, with pure water, or with a two-per-cent solution of argent, nitric, for the purpose of checking the action of the infecting matter. (2) At the beginning of the disease the patient should be put on a strictly antiphlogistic diet, and the eye should be re- peatedly washed with the antiseptic solutions just mentioned. In contractions of the pupil, atropine (0*10 [gr. 1 £] to water, 30-00 [ g j]) in solution should be dropped into the eye. (3) If the blennorrhoic process is very intense, the hrst care of the physician should be to protect the sound eye from in- fection with the gonorrhceal matter by bandaging it carefully and keeping the patient in a proper position (in this case he will be compelled to stay in bed). (4) Zealous cleansing of the eye with cold water or antisep- tic lotions, application of ice, local abstraction of blood during exacerbations, laxatives, and cooling drinks and low diet should GONORRHCEA, VENEREAL CATARRH. 93 be strictly enforced. Should the chemosis of the conjunctiva and the swelling of the eyelids be very great, the external can- thus must be divided ; the lower lid, which is now released, may then be everted by means of Gaillard's snare, and the haemorrhage that follows may be allowed to go on for a little while. The most important part of the treatment of the eye, how- ever, is the use of caustics. It consists of the introduction of a solution of nitrate of silver (two to four per cent) or of the solid stick, composed of nitrate of silver and nitrate of potash (equal parts, or one of the former to two of the latter) fused together. The entire 'palpebral conjunctiva should be pen- ciled with one of these agents once every twenty-four hours, the excess of the caustic, neutralized with a solution of salt and the chloride of silver, which thus forms, washed away with water. In cases of intense turgescence of the palpebral conjunctiva and in chemosis of the ocular conjunctiva great benefit will be derived from scarifications of the membrane, the tension of the swollen tissues and the stasis of the circulation being there- by relieved. Should the cornea become opaque, or ulcers form on it, atropin in solution must be dropped into the eye several times a day, but not simultaneously with the caustic. In im- pending perforation of the cornea, or when the perforation has already taken place with its consequent effects, in prolajDSUs of the iris, etc., the treatment indicated for these conditions must be resorted to. The Effects or Sequelae of Gonorrhoea in general and of Urethral Gonorrhoea in particular. By the term effects or sequelae of gonorrhoea we under- stand morbid lesions which generally remain a long while after the disease that has produced them has disappeared. These morbid lesions are such as are exclusively produced by gonor- rhoea in the urethra itself and beyond its sphere. To these belong gonorrhceal gout or rheumatism, and stricture of the urethra and its effects. Again, they constitute those morbid processes which originate partly from any kind of gonorrhoea, but especially in consequence of the irritation of the gonor- 94 PATHOLOGY AND TREATMENT OF SYPHILIS. rhoeal discharge upon the adjacent integument and mucous membrane. These include condylomata. Gonorrheal Rheumatism. Gonorrheal rheumatism or gout is one of the rarest complications of gonorrhoea in both sexes. Writers on the subject are not yet agreed. In regard to its nature and con- nection with the gonorrhoeal disease, some maintain that it is purely an accidental complication. Others, again, say that every physiological and pathological process in the genital organs of both sexes may light up rheumatism, and therefore call it " genital rheumatism." Were this the case, rheumatic affections would be much more frequent in the female ; but, on the contrary, gonorrhoeal rheumatism only occurs in the latter, when attacked by gonorrhoea of the urethra — one of the rarest gonorrhoeal affections in women. The so-called old- style unicists claimed that gonorrhoeal rheumatism is a rheu- matic diathetic disease, that has originated in consequence of the absorption of the gonorrhoeal virus, which they compare to the rheumatic pains occurring in syphilis. Other writers are of the opinion that the gonorrhoeal process gives rise to a chloro- anaemic condition of the entire system that leads to lesions of nutrition, produces peculiar secondary diseases of the serous membranes, the scrotum, joints, synovial sacs, etc. It should not be forgotten that rheumatic diseases not only occur in catarrhal affections of the urethra occasioned by non-virulent agents, but also in those produced by mechanical causes. Hence gonorrhoeal rheumatism would not be so exceedingly rare if there were such a condition as a blennorrhoic diathe- sis ; and, in addition, preputial, vulvar, and vaginal gonorrhoea should likewise be capable of causing rheumatoid disease. This, however, is not the case. In sixty-two cases of gonor- rhoea, Fournier observed only one case of rheumatism, and even this is too high a number, when it is remembered that many cases of gonorrhoea get well without the aid of a physician. We agree, therefore, with Fournier, that rheumatism originat- ing from urethral gonorrhoea is occasioned less by the blen- norrhagia than by the individual pathological condition of the urethra, an irritation of it, like the occasional production of GONORRHCEA, VENEREAL CATARRH. 95 articular inflammations by the introduction of a catheter or sound into the urethra. Hence, only certain persons are at- tacked by gonorrhoeal rheumatism, and are afflicted by it as often as they contract a gonorrhoea. We have only met with muscular and articular rheuma- tism ; never with rheumatic inflammations of the synovial membranes or of the periosteum, nor with rheumatic affec- tions of the sciatic nerves. The knee-joint was most fre- quently affected ; still, any other joint in the body is likely to suffer. One joint only, as a rule, is attacked at a time. In some cases the rheumatic affection is noticeable at the very beginning of the urethral gonorrhoea. In many cases, however, the rheumatism does not appear until the urethral disease has become torpid. Gonorrhoeal rheumatism originates suddenly. The joint was perfectly well a few hours before the attack came on. If the arthritic rheumatism appeared almost simultaneously with a purulent gonorrhoea, the inflammation of the joint will develop very rapidly and cause marked swell- ing of the soft parts which surround the joint. These kinds of joint-affections keep pace with the gonorrhoea, and, like it, disappear under judicious treatment in about six or eight weeks. But if the joint-disease appears after the gonorrhoea has existed several weeks, the former will then develop less rapidly, and, like the urethral disease, assume a chronic, pro- tracted character that obstinately resists the most appropriate treatment. Chronic, like acute gonorrhoeal articular rheumatism, is ushered in by febrile phenomena ; in the acute joint-affection they are, however, much more violent. In the acute disease, the fever as a rule subsides in about six or eight days. If the articular disease does not assume a favorable course, the fever will remain, though at a lower degree. In chronic gonorrhoeal rheumatism, the fever, it is true, lasts longer, but it is less severe. It, however, rises just as in the acute articular rheu- matism, whenever an exacerbation of the articular affection takes place. No exudation into the capsule of the joint can be detect- ed in all cases ; but in some an actual hydrarthrosis of con- siderable dimensions with characteristic fluctuation develops. 96 PATHOLOGY AND TREATMENT OF SYPHILIS. The integument over the swelling of the affected joint, as a rule, is neither reddened nor thickened ; in some cases, how- ever, an erythema glabrum develops upon it. The affected joint is sensitive to such a high degree that the least move- ment causes the patient the most intense pain. The serous exudation that has accumulated in the cavity of the joint may, under favorable circumstances, be absorbed. Under the influence of a constitutional disease, however — for instance, scrofula or tuberculosis — the absorption of the exuda- tion is not only delayed, but a permanent articular dropsy, hy- drarthrosis, arthrocele blennorrhagica, tumor blennorrhagicus, originates in some, though exceedingly rare, cases. Some very reliable authors mention a still rarer termination of gonor- rhoeal rheumatism — namely, suppuration in the joints. A total or partial union of the joints, ankylosis, occurs oftener than the two preceding terminations already mentioned. Gonor- rheal rheumatism has a settled character — i. e., it does not travel from one joint to another. We have never seen it at- tended by pericarditis or endocarditis. The articular disease exercises no influence upon the gonorrhoea! discharge, neither diminishing nor increasing it; still, we have noticed that chronic and acute articular rheumatism subside only when the last traces of the gonorrhoea have disappeared. The prognosis of gonorrhoeal rheumatism, in general, is favorable, the joints, as a rule, recovering fully their normal condition. Ankylosis occurs very rarely — usually in the knee- joint alone. Hydrarthrosis most frequently originates in the knee-joint. Suppuration of the joints may cause death by pyaemia. The articular affection does not last the same length of time in all joints ; the disease of the shoulder-joint does not last nearly as long as that of the knee- and ankle-joints ; disease of the joints of the phalanges disappears more quickly than that of other joints. Chronic gonorrhoeal disease of the joints generally lasts many months; in tuberculous and in badly nourished persons, sometimes more than a year. The articular disease requires absolute rest and antiphlo- gistic treatment, such as cold applications and leeches to the affected joint. Hypodermic injections of morphia will be re- quired to assuage the intense pains. When the febrile phe- QONORRHCEA, VENEREAL CATARRH. 97 nomena are very high, the patient should be subjected to a strict diet, cool or acidulous drinks only allowed, and a daily movement of the bowels secured. If hydrarthrosis has formed, cold or warm applications should be made, with or without ammonia, 50*00 [J jss., 3iv] to water 1000*00 [Oij], according to the congestive condition of the articular swelling. When no inflammatory redness is present, iodine, or some of its com- pounds, like the following, may be used locally : 3 Iodureti plumbi ; Ext. belladonna, aa 5'00 [3iv] ; Ung. litharg., 100-00 [ § iij, 3 ij, 3ijl; Ung. elemi q. s. ut tiat emplastr. molle. S. To be spread upon a piece of chamois-leather or muslin, of the thickness of the blade of a knife, and laid upon the affected joint. In hydrarthrosis of the knee we have occasionally seen good results from the use of a compress-bandage, made of plaster of Paris, starch, or water-glass. In other cases a plaster composed of gum-ammoniac and acetum scillse is beneficial. In cases of chronic hydrarthrosis, good results are sometimes derived from the sulphur thermal baths. The treatment of suppuration of the joints, of fistulge, necrosis, etc., belongs to the domain of surgery. The existing gonorrhoea must be treated with appro- priate local and internal remedies. Constitutional diseases, of whatever nature, such as scrofula, tuberculosis, syphilis, etc., demand careful and special attention. Condylomata ; Vegetations ; Spitze or Moist Warts. One of the most frequent morbid changes that are met with in consequence of gonorrhoea, in both sexes, is the formation of warts, or cauliflower-like growths, on the genital organs and their vicinity — on places where pus, sebum, or gonorrhceal discharge is allowed to remain for some time, and, owing to its decomposing effects, the integument or mucous mem- brane becomes so irritated and macerated that the epithelial layer is destroyed. On these places hyaline granules, of the size of a pin's head, form, which gradually assume the shape of a cone or cock's comb, resembling more or less a dendritic vegetating growth. After these vegetations have attained a certain size they grow very rapidly. The less the parts on ■7 98 PATHOLOGY AND TREATMENT OF SYPHILIS. which these cauliflower excrescences grow are cleansed, the more quickly and abundantly these vegetating excrescences will sprout, the more profuse and succulent they will be, and the more readily will they bleed. The cleaner and drier the parts on which these warts are situated are kept, the more quickly will those that already exist shrink, and the less likely are new ones to sprout. If one of these excrescences is cut off at its base, two bleeding points may be noticed on the cut sur- face, one of which corresponds to the entering, the other to the emerging capillary vessel. Histogenetically regarded, two directly opposite views pre- vail in reference to this lesion. While some writers look upon the growth as a hypertrophic proliferation of the tegumentary papilla, others hold that the origin of condyloma is mainly due to an exuberant growth of the cells of the rete Malpighii, at the expense of the tegumentary papillae, whose cells spread their prolongations not only upward but also downward, like a cock's comb, forcing their way in between the papillae. The epidermal cells have a very slight tendency to undergo a cor- neous change, and even the uppermost layers retain the succu- lent condition of the Malpighian cells. The whole is covered by a very thin corneous layer. No nervous filaments have yet been detected in the exuberant growth spoken of. Warts or condylomata are most frequently met with upon the glans penis, especially in the fossa coronaria, on the corona, on the foreskin, especially its internal or mucous membrane ; on the frenulum, on the large and small labia, in the urethra and vagina, on the os uteri, at the lower part of the rectum, on the navel, on the skin of the genital organs generally, and in the neighborhood of these organs. If the condylomata are situated upon the integument or mucous membrane of the co- rona glandis or prepuce, in a person with phimosis, they will be reddened and softened like raw flesh, owing to the fomen- tation they are constantly subjected to. If they are situated upon exposed places they will be dry, corneous, yellowish or whitish in color. The vegetations that are situated upon the mucous membrane of the vagina are so brittle that they are often broken off by the introduction of the speculum. Condylomata assume a different shape according to their GONORRHCEA, VENEREAL CATARRH. 99 location. If the warty growth is compressed between two opposing surfaces, the so-called cock's-comb-like vegetation will originate. If the condyloma is subjected to pressure from above, the excrescence will gradually be flattened and assume the form of a mushroom. On places where the growth may freely develop, linear pedunculated, strawberry-, mulberry-, or cauliflower-like excrescences will originate. If many such growths are in close juxtaposition, they will mutually compress one another, and acquire smooth surfaces, which are separated by narrow fissures, and form clusters similar to the blossoms of thyme ; hence the old writers called them acrothymion, or thymos. These warty efflorescences cause a good deal of me- chanical obstruction, and, moreover, owing to the alteration which they undergo in their course, exercise an unfavorable influence upon the general system. Thus, they may occlude the preputial opening and the meatus urinarius, preventing the removal of the smegma from beneath the foreskin, the flow of the urine, and the ejaculation of the semen. In a similar man- ner the female urethral meatus and the vulvar aperture may become occluded by pointed condylomata, and micturition and coitus may likewise be rendered difficult. By the growth of large condylomata around the anus, in both sexes, defecation may become very difficult and painful. Those condylomata that are situated upon places where they are subjected to con- tinual friction or pressure readily become gangrenous. Ordi- nary condylomata may be mistaken for epithelial carcinoma, for the cauliflower tumor of Clark on the os uteri, and for the flat specific condylomata. The manner of development, the course, the attendant phenomena, the result of the treatment that has been resorted to, will aid the physician in forming a correct diagnosis. It is very easy to mistake vegetations for the flat syphilitic condylomata, for both kinds maybe met with at the same time. Experience as well as experiment has proved that condy- lomata are transmissible by direct contact. Condylomata possess remarkable powers of reproduction: one shoot may be cut off, and five others will grow in its place. The small warts, not bigger than a millet-seed, and sprouting close to each other, are the most difficult to get rid of. 100 PATHOLOGY AND TREATMENT OF SYPHILIS. Pedunculated warts may be removed with Cooper's scissors, or tied and allowed to fall off. When the warts are cut off, enough mother-tissue should be taken away with them. The wounds should be moistened with a solution of ferrum chlo- ridum, to check the bleeding and prevent the future growth of the condylomata. The local application of a solution of chloride of iron is especially useful in large aggregated condy- lomata ; the astringent action of the iron contracts them, and prevents bleeding if they are subsequently cut off. Tincture of iodine acts in a similar manner, but far less effectively. The concentrated acids very seldom answered our expectations. Solutions of corrosive sublimate in spirits of wine, or in sul- phuric ether, 0*5 [grs. viij] to 50*00 [§ jss., 3iv], rendered much better service. Plenk's paste acts more intensely than the solution of mercury ; it may be prepared in the follow- ing manner : ]J Sublim. corros. ; Alum crudi; Carbon, plumbi ; Oamphorss ; Spirit, villi ; Aceti vini, aa 5 -00 [3iv]. M. S. For external use. The precipitate is applied to the warts with a eamel's-hair brush. Plenk's paste, however, is apt to produce unpleasant effects, such as intense oedema and mercurial stomatitis. The hard, dotted warts are readily removed by the use of arsenious acid or iodide of arsenic mixed with mercurial oint- ment. For this purpose we prescribe : ]$ Acidi arsenicosi, 0-20 [grs. iij] ; TJng. hydrarg., 5*00 [3iv] ; M. Ft. ung. 1$ Arsenic, iodat., 0-20 [grs. iij] ; Ung. hydrarg , 5*00 [3iv] ; M. Ft. ung. A lump of salve, of the size of a lentil, is applied to the warts several times a day upon some wadding. Moist, secret- ing condylomata are sometimes made to shrink by dusting them GONORRHCEA, VENEREAL CATARRH. 101 with pulverized alum, calomel, oxide of iron, sulphate of iron, and savin-powder. If the prepuce is phimosed, it mast be split or amputated, in order to expose the condyloma. Large aggregations of warts on the labia are most appropriately treated by ligation or with the galvano-cautery, or the thermo-cautery of Paquelin. In tying condylomata, not more than one root should be embraced in each ligature, because the tying of many large aggregated clusters of excrescences has, in some hi stances, produced tetanus and terminated in death. But, whatever method be selected for the removal of condylomata, cleanliness and keeping the parts dry should always be enforced. Cold applications alone, constantly and properly made, have caused the vegetation to fall off in cases that have resisted repeated cauterizations and excisions. Strictures of the Urethra. One of the most frequent sequelae of urethral gonorrhoea in the male is stricture of the urethra. The contraction may take place at any part of the urethra, save in the prostatic por- tion. An obstruction to the passage of a catheter or sound only forms in the prostatic portion of the urethra when the prostate, from inflammation, hypertrophy, or swelling, has be- come so large that it compresses the lumen of the urethra from without inward. We may classify strictures in the other parts of the urethra, according to Dittel, as spastic, inflammatory, and organic varieties. By the term spastic strictures we un- derstand transient constrictions of the lumen of the urethra, occasioned by spasmodic contractions of the muscular apparatus of that canal. One can easily convince himself of the existence of such a stricture by attempting to introduce a large sound. It will be grasped and held tight at some point, but by patiently waiting, refraining from exercising the least pressure with the instrument, and allowing it to lie quietly for a while in the urethra, it will soon, almost of its own accord, slip into the bladder. Some very good surgeons deny the existence of this form of stricture of the urethra. Many prominent authors, however, such as Esmarch, Dumreicher, Albert, Hunter, and others, maintain with justice that this form of urethral con- tractions does occur. The spasm mostly affects the muscular 102 PATHOLOGY AND TREATMENT OF SYPHILIS. tissue surrounding the membranous portion of the urethra, the transverse perinei profundus muscle; in other instances the spasm attacks the urethra at various points and occasionally may become so intense that it is not possible to withdraw the sound, which is already partially in the urethra, giving one the impression that it is firmly held there. Transient strictures due to spasmodic contractions of the urethra manifest themselves by the patient being attacked by a sudden desire to urinate, after having emptied the bladder a little while before without any difficulty. The urine, after much pressure, pain, and a burning sensation, comes away in drops, or is expelled spasmodically (dysuria), or it can not be voided at all (ischuria). These strictures may occur even in persons who never snfiered from gonorrhoaa, after having had their feet wet, or after indulging too much in imperfectly fermented or still fermenting drinks, new beer, etc. These symptoms, however, almost always accompany organic strict- ures of the urethra. In regard to the treatment of this condi- tion much benefit will be derived from belladonna supposito- ries, moist warm applications and warm sitz-baths twice daily. In addition, the patient must abstain absolutely from the use of all kinds of drink that are liable to irritate the bladder, such as champagne, cider, new beer, and fresh wine. In regard to the inflammatory strictures we will say briefly that they are pro- duced by thickening and swelling of the mucous membrane. These strictures develop in consequence of gonorrhoea, or after operations on the rectum or on the external genital organs in the female. The organic strictures of the urethra may very properly be divided, as proposed by Dittel, into two chief groups. One main group is occasioned by proliferation of the connective tissue, the other by the development of a structure heterolo- gous to the tissues of the urethra. "We will only speak here of the first form, that form which occurs so frequently as a result of gonorrhoea. Dittel briefly calls this kind of urethral stricture, when it is in a state of exuberation, callous stricture ; when in a state of shrinking, atrophic stricture. The symp- toms of organic stricture of the urethra are as follows : The stream of urine becomes thinner and changes its direction. GONORRH(EA, VENEREAL CATARRH. 103 Simple division of the stream of urine is of no pathognomonic value, and in most instances is occasioned by the agglutination of the meatus with mucus. The bladder is never entirely emptied of its contents, and in consequence thereof the patient is compelled to urinate oftener. That part of the urethra be- hind the stricture is often dilated like a diverticulum, and, if the stricture lasts for a long while, rupture of the urethra may occur, terminating in infiltration of urine and fistulous open- ings behind the stricture. In long-standing stricture of the urethra, catarrh of the bladder will develop, and may be fol- lowed by pyelitis, nephritis, and death. In regard to the form of the stricture, it is sufficient to say that it varies very much. It may be a sharply defined pro- jection, or only a ridge stretched directly across the lumen of the urethra ; or, again, a resisting, hypertrophic circular band. Sometimes caruncle-like granulations form ; and, finally, the contractions, in some cases, are produced by angular deviation of the urethra from its normal course, in consequence of cir- cumscribed lateral atrophy of the connective tissue surrounding the urethra. Strictures in the membranous portion often occur from the cicatrization of gonorrheal ulcers that have burrowed and un- dermined the mucous membrane. In like manner, adhesive inflammations may give rise to strictures in the urethra. Strictures are most frequently found in the membranous portion or in the anterior part of the pendulous portion. Oc- casionally two and even three strictures are found behind each other. For the purpose of diagnosing a stricture, the physician, in the first place, should get a view of the stream of urine, the patient being required to urinate in his presence. A perfectly clear stream of urine, which does not deposit any sediment, excludes a severe stricture. The patient should not be allowed to urinate directly before it is proposed to examine him with instruments. The examination is best conducted with the patient lying on his back, while the physician stands at his left side. Having warmed and oiled the sound (which should be as large as will enter the meatus), and retracted the fore- skin, the physician, holding the penis between the thumb, in- 104 PATHOLOGY AND TREATMENT OF SYPHILIS. dex, and middle fingers of his left hand, and the instrument be- tween the thnmb and index-finger of his right hand, inserts the instrument into the meatus, the little finger of his right hand resting upon the body of the patient for support, thus afford- ing the hand rest and security. In this way he guides the instrument as it passes into the bladder. The penis is drawn up on the sound more than the instrument is pushed into the urethra. If an obstruction is encountered, the next smaller- sized sound should be tried ; and if a number eight sound does not pass, it will be better to resort to English gum-elastic or conical bougies. 'No metallic instruments smaller than number eight should be used, on account of the imperfect sensation which they transmit to the fingers, and the risk of making a false passage with them. Conical elastic instruments without bulbs are not worthy of recommendation, because they easily become imprisoned in some of the dilated follicles and cause irritation. If no sound can be passed through the stricture, an attempt should be made to pass an English elastic catheter ; and if this too fails, it will be necessary to resort to the use of fili- form bougies. In this case it will be well to try the procedure recommended by H. von Zeissl, which consists in filling the urethra with filiform bougies well oiled, and pushed clear down to the stricture, and then a trial should be made carefully with one after another to pass it through the stricture. One of them will then surely go through. Having succeeded in pass- ing the instrument at last through the entire length of the urethra, it will then be necessary to map out the proper course of treatment to be pursued. There are three methods of treat- ment, namely, slow or gradual dilatation, rapid dilatation, and division of the stricture. We only practice gradual dilatation and division of the stricture from without inward. We will first speak of the gradual dilatation. If the stricture is so small as to permit only a filiform bougie to be passed, a catgut bougie should be inserted, and allowed to remain in the urethra until it has be- come distended to its utmost capacity. If, during this time (half an hour to an hour), no unpleasant symptoms have been produced, an effort should be made to pass a fine English gum- elastic bougie. If we have finally succeeded in passing this GONORRHCEA, VENEREAL CATARRH. 105 instrument, no further trials should be made at the time ; but the next day another effort may be made, commencing with the size left off on the previous day, and afterward using larger bougies gradually. Having finally succeeded in passing through a thin gum-elastic catheter, it should be left in the bladder, and tied in for twenty-four hours, if no unpleasant effects are produced. In this way dilatation is accomplished much more rapidly ; on the next day a larger instrument may be introduced, and so on, till the urethra admits the largest- sized sound. If a catheter is retained in the urethra, the urine should be drawn off every three hours, or as soon as ischuria comes on. Should symptoms of nervous irritation, urethral fever, or other unpleasant signs manifest themselves, it will be necessary to remove the instruments immediately. In regard to the symptoms of irritation produced by the introduction of an instrument into the bladder, we have the following observa- tion to make : Some persons do not tolerate the passing of an instrument into the urethra even if they have no stricture whatever. A little while after the instrument is inserted they are seized with a chill, followed by high fever, violent head- ache, or at least a sensation of discomfort in the head. These phenomena generally soon disappear entirely ; in some cases, however, they often reappear, sometimes lasting several weeks, till the patient either becomes habituated to the passage of the sound, or has been cured of his stricture. This violent irrita- tion, which Dittel calls nervous reaction, may be allayed by small doses of morphine, administered from half an hour to two hours before using the instrument. Should this fail, and the nervous phenomena come on with equal severity after each attempt at dilatation, the gradual dilatation of the stricture will have to be abandoned and external urethrotomy performed. If the urethra has been injured during the introduction of an instrument, a similar state of reaction, which Dittel calls surgi- cal fever, is liable to ensue. The latter in reality differs only from the nervous reaction by the fact that the patients did not suffer from any phenomena of irritation during the previous dilatations. The phenomena of irritation are, however, most violent when the kidneys and bladder are seriously diseased at the same time. This affords us a guide in treatment. If the 106 PATHOLOGY AND TREATMENT OF SYPHILIS. introduction of an instrument into the urethra is tolerated, it may be allowed to remain in it a long time. If reaction takes place, or the patient is already advanced in life, we will have to be content with keeping the instrument in the urethra for a short time only, from five minutes to half an hour, and to introduce it only every other day. It is absolutely neces- sary, before beginning the treatment of a stricture, to make a careful microscopical and chemical examination of the urine. Pyelonephritis, for instance, is liable to become aggravated so rapidly, even if the dilatation is practiced with the utmost care, that death ensues in a very few days. Hence we practice external urethrotomy — the so-called houtonniere — in patients who do not tolerate the dilatation of the stricture with instru- ments. Gradual dilatation, to be successful, requires a year's after-treatment, i. e., the constant introduction of instruments. If this is discontinued, even for a short time, the stricture con- tracts again, and the treatment must be renewed. We will describe the two methods of division of a urethral stricture, viz., division of the stricture from without inward and from within outward — urethrotomia externa et interna. The division of the stricture from without inward is now per- formed in those cases in which the stricture is so tight that even the finest filiform bougie can not be passed, or in those in which febrile or nervous reaction ensues whenever a dilating instrument is introduced. For the details of this operation, we refer the reader to the special works on surgery. We have obtained excellent results from the boutonniere. We have discarded entirely internal urethrotomy and rapid dilatation. Both methods, it is true, relieve the patient from his stricture very quickly, but they expose him to the great danger of infil- tration of urine, and, like the harmless gradual dilatation, re- quire a long after-treatment. The dangerous character of this operation, and the fact that strictures after having been divided return in as severe a form as before the operation, if no after- treatment is carried out, and that a certain degree of pervious- ness of the urethra is always presupposed to exist for the pur- pose of admitting the necessary instruments, are the reasons why we never perform this operation. [By injecting a syringeful of olive-oil into the urethra, so GOJSTORRSCEA, VENEREAL CATARRH. 107 as to distend it fully, the passage of the bougie will often be materially facilitated. Sometimes injections of ice-water have served a very useful purpose by causing contraction of the en- gorged tissues, and thus rendering the strictured parts per- meable to a bougie or catheter. In this connection, I would add that in retention of urine coming on suddenly, in conse- quence of engorgement of the tissues following a debauch, coitus, or exposure to cold, a hot bath, with a full dose of mor- phine administered internally, has often accomplished excellent results. When these remedies fail, it will be necessary to anaesthetize the patient for the purpose of introducing a cathe- ter to draw off his urine. If time permits, I often succeed, by blistering the peringeum, in reducing the engorgement of the strictured part of the urethra to such a degree that bougies or catheters pass with comparative ease. Mr. Tevan, of London, resorts to leeching the peringeum for the same purpose. In regard to internal urethrotomy, in properly selected cases the operation will be of signal benefit, especially when time is an element to be considered. Where the method of di- lating a stricture with sounds or bougies requires many months, internal urethrotomy will achieve the same result in as many weeks ; though, to be sure, the after-treatment with sounds can not be dispensed with after this operation any more than in any other method.] SECTION II. SOFT CHANCRE OR CHANCROID. The term " chancre " has generally been applied to an nicer the origin of which has long been ascribed to a contagions spe- cific matter, which was itself reproduced in the nicer. Up to the present time we have not succeeded in establish- ing a clear, scientific, and comprehensive definition of that ulcer which is commonly called (soft) chancre. "We know no more regarding the contagious element which is capable of giving rise to soft chancres than we do of the na- ture of contagions in general. The conception of the contagion is an abstract one. We only know that, if a minimum quantity of the discharge from such an ulcer comes in contact with liv- ing cutis or mucous membrane, it will produce in a short time at that place an ulcer analogous to the parent-ulcer, and from this fact we conclude that the discharge possesses contagious properties. Uninjured epidermis and epithelium-cells are a protection against the action of the chancre-virus. There is no special congenital predisposition or susceptibility to the action of the chancre-poison, neither is there any particular immunity or freedom from it. All warm-blooded animals are susceptible to the action of the chancrous virus. The effect of the poison of the soft chancre is said to be markedly increased when a difference exists in the superiority of the race between the infected and infecting. Newly-born children and nurslings resist infection by a chancroid less than adults, possibly be- cause their cutis is more richly supplied with blood-vessels. Different tissues are also differently affected by the contagion. Thus, the virus spreads more rapidly in loose, spongy tissues, SOFT CEANORE OR GEANGROID. 109 rich in blood and lymphatic vessels, than in textures that are poor in vascular supply. The submucous, subcutaneous, and interstitial connective tissues are very susceptible to the invasion of the chancre-poison. On the mucous membrane the chancroid ulcers are generally smaller than on the common integument. The chancrous poison never attacks serous and fibrous tissues, and very rarely those of a cartilaginous nature. Some parts of the skin afford the virus a more favorable soil than others. Larger chancrous ulcers will form more rapidly upon the inner surfaces of the thighs than upon the skin of the intercostal spaces or upper extremities, and upon the skin of the hypochondria quicker than upon the lateral surfaces of the thorax. Active local disturbances of the circulation of the skin — hyperemia, stasis, cedematous swelling, and especially a tendency to purulent infiltration — favor the destructive action of the chancrous poison. Action of Chancrous Virus and Development of the Soft Chancre. If chancrous matter in some way gets under the epidermis or epithelial cell-layer, a bright-red spot about the size of a lentil makes its appearance at the point of insertion in from twelve to twenty-four hours. By the next day this spot be- comes raised, and forms a kernel surrounded by a red areola. On the third day the kernel is transformed into a pustule, the areola spreads in extent corresponding to the growth of the pustule, and the skin within this areola is hard to the feel. It is sensitive and painful when pressed upon with the finger. On the fifth or sixth day the pustule collapses and dries up, forming a crust, and the red areola becomes smaller. On re- moving the crust, a circular, deep, or shallow ulcer, with sharp, undermined borders, is brought to view, whose bottom is cov- ered with a layer of grayish matter. The soft chancre develops on the mucous membrane in a similar manner, but here the pustules burst much earlier. If the chancrous matter penetrates into a sebaceous follicle, an acne or furuncle-like pustule will form, which also becomes transformed in from twelve to twenty-four hours into an ulcer. Excoriations and fissures become transformed by contact with chancrous matter directly into ulcers without the intervention 110 PATHOLOGY AND TREATMENT OF SYPHILIS. of the pustular stage. The ulcers, however, are not round, but shaped like the excoriations or fissures, being mostly gaping and irregular. Multiple chancroids, originally circular, may coalesce and then form one chancroid irregular in shape and form. The chancrous ulcer enlarges proportionally in depth and circumference, but, when finally it begins to heal, the surface of the sore granulates, and a disposition to cicatrization is manifested. Sometimes the margins of the chancroids do not mark the limit of the action of the chancrous contagion. If a chancrous ulcer is cut through, the wound soon becomes an infected sore, the chancroid spreading and involving the entire incision. The chancrous ulcer emanates from the inflammatory altera- tion of the tissues, by which the affected structures become disorganized, passing through the conditions of fatty degenera- tion, softening or deliquescence (molecular disintegration), or the layer of tissue that is attacked by necrosis forms a diph- theritic membranous slough, which by excessive suppuration is subsequently detached and cast off. From the very begin- ning of the ulcerative process an active inflammatory plastic condition in the form of a slightly hard swelling becomes manifest. This proves microscopically to be papillary cell- infiltration, and causes the delimitation or the demarkation of the chancroid. Pathology of the Soft Chancre* In the soft chancre, as in every other kind of suppurating sore, a distinction may be made between the base and edges of the ulcer. The transition between the border and bottom may be very sharp. Ulcers whose bases are on a level with their edges are called superficial or flat chancroids : they resemble more or less lardaceous, yellowish excoriations. The base of the ulcer is uneven ; it has a jagged appear- ance, like worm-eaten wood. This uneven appearance is due to the fact that some portions of the tissue attacked in the ulcerative process resist the sloughing action more than others. The surface of the chancroid usually has a yellowish or lardaceous appearance produced by the fatty degeneration or SOFT CHANCRE OR CHANCROID. Ill molecular disintegration of the tissue-elements. Sometimes we find upon the surface of the sore a whitish-gray or greenish coating, if it contains any coloring-matter of the blood, simi- lar to the pseudo-membrane of diphtheritis of the fauces, and, like the latter, adhering tenaciously to the structure beneath. Such chancroids are called diphtheritic chancroids. They originate from intense infiltration of the connective tissue of the soft chancre with newly formed cells, which compress the cap- illaries of the cutis or mucous membrane and interfere with their nutrition. The diphtheritic layer is necrosed tissue in the form of a slough. This slough, when the sore is about to heal, is surrounded by a fissure — the so-called line of demarkation, which bleeds slightly, and is a result of the inflammatory re- action that has taken place in the outskirts of the dead material. The matter that forms from this inflammation accumulates between the sound tissue and the slough, and finally is thrown off. A diphtheritic chancroid generally causes greater de- struction of tissues. In many cases the base of the ulcer exists only for a very brief time, as in a soft chancre that perforates the frsenum or labia minora. Those parts which before the perforation formed the borders of the chancroid, afterward constitute its base. The base of the sore furnishes a secretion which consists partly of molecular matter, fatty degenerated tissue-detritus, and partly of pus-corpuscles in which generally some blood- globules are mixed. In places provided with numerous seba- ceous glands, the discharge will become mixed with rancid sebum, and acquire a most offensive odor, as in chancroids of the fossa coronaria. The anatomical process of healing is as follows : Deep in the tissues on which the chancroid is located a marked degree of development of the vessels takes place. These markedly vascular tissues are the germinating soil of granulations or mi- nute warts. These granulations may develop sparingly or in large numbers. Those which sprout in a normal manner form a velvety covering which is gradually transformed into cica- tricial tissue. In some cases the granulations proliferate so abundantly that the bottom of the sore rises above its edges (ulcus elevatum, fungosum, frambcesoides). 112 PATHOLOGY AND TREATMENT OF SYPHILIS. The margins of the chancroid, in most cases, are thickened and swollen, because the papillae of the cutis involved are infil- trated with cells. The cells that have accumulated here, how- ever, degenerate as rapidly as those at the bottom of the sore ; hence also is seen the markedly dentated and undermined con- dition. When healing begins, the margins of the ulcer become adherent to the base by the growth of granulations, and then they become level with it. As a result of the stimulated en- largement of the cutis-papillae, a marked proliferation of the epidermis begins, which goes on toward the center of the ul- cer. Cicatrization of the chancrous ulcer will progress rapidly or slowly, according to the character of its edges. The less they are undermined, the smoother and flatter they are, the sooner may they be expected to cicatrize. Hyperemia and anaemia of the borders delay cicatrization. If the granulations under the edges of the ulcer sprout up too profusely, the mar- gins will become raised up and everted to such a degree as to form a wall around it. From excessive plasticity of the cellu- lar infiltration, this wall may become callous, so that the chan- croid ulcer acquires a hard ring around it (annular chancrous ulcer). Outwardly, the borders of the ulcer, so long as the destructive process goes on, are surrounded by a red hyperae- mic zone. "With the subsidence of this hyperemia, the de- structive process also subsides, and then the granulations begin to grow beneath the undermined margins. The acute zone abuts against apparently normal tissue — we say apparently nor- mal, because it is impossible to know how extensively the tis- sues around a soft chancre are morbidly altered by the ulcer- ative process. Course, Duration, and Cicatrization of the Soft Chancre. The destructive process in a soft chancre varies consider- ably as regards duration. In one case its progress is rapid, in another it is very slow. In one case the ulcer barely attains the size of a lentil, in another it becomes remarkably large. Now, the superficial surface of the papillary layer is barely destroyed (flat chancroid) ; and again not only the entire thick- ness of the cutis is perforated, but even the subcutaneous and submucous tissue is involved in the destructive process, where- SOFT CHANCRE OR CHANCROID. 113 by sometimes entire organs, such as the glans, urethra, or labia, are destroyed. The tendency to gangrenous suppuration is not due to any specially specific infectious character of the dis- charge, but to a peculiar idiosyncrasy of the individual affected, although it can not be denied that in scrofulous and tubercu- lous persons, and those suffering from hunger and want, a soft chancre, as a rule, will grow to larger proportions than in healthy individuals. The depth to which the virus of a soft chancre, by infecting, may penetrate into the tissues, and the pus contained in the discharge from an infecting chancroid, seem to exercise greater influence upon the destructive pro- cess than the condition of the patient. But, in addition to the habits of the individual, local and external influences must be taken into consideration. The pus that is allowed to remain too long a time upon the surface of the chancroid not only acts as an irritant and is destructive to the granulations, but it also infects the parts in its vicinity. Arterial and venous haemor- rhage at the site of the sore favors the tendency to further ul- ceration. Mechanical injury of the sore, such as tearing and rubbing, chemical irritation from improper remedies, soiling with physiological secretions and pathological excretions, exer- cise similar unfavorable influences. In those cases in which none of these injurious influences obtain, the destructive process generally lasts from four to five weeks, and cicatrization requires about fourteen days more. The infectious property of the treated or untreated chancroid diminishes gradually as the granulations form on its periphery. The cicatrix alone does not fill up the space formed by the loss of substance ; the ulcer diminishes in addition through the re- traction of the skin. The shallower the ulcer, the less marked will the scar be. For a time the fresh scar is hypersemic, discol- ored, and slightly resistant ; after a while, however, it becomes pale and supple. The scar of a soft chancre, as a rule, does not break open again. Varieties of Soft Chancre. An erethistic and an atonic chancroid are distinguished ac- cording to the degree of the inflammatory irritation of the tissue involved in the suppuration. In the former there is a 8 114 PATHOLOGY AND TREATMENT OF SYPHILIS. marked inflammatory condition of the surrounding parts ; in the latter, the inflammatory reaction is absent, the discharge is slight and thin, the granulations grow very slowly, are dry, granular, and bleed easily. If a more intense degree of inflammatory phenomena ap- pear in the vicinity of a soft chancre of the skin, an erysipela- tous swelling will ensue. However, intense inflammation may give rise to stasis, by which not only the parts involved in the ulcerative process become necrosed, but also the parts adjacent. These varieties are called gangrenous chancroids, and this des- ignation is especially applicable to those with black sloughs, in contradistinction to those that are covered with a yellowish- white pseudo-membranous diphtheritic coating (called by Wal- lace ulcers with white gangrenous sloughs). If molecular necrosis comes on with unusual intensity, and if it progresses with such rapidity as to destroy a comparatively large section of tissues in a few hours, we have to deal with a variety of soft chancre that has long been known as the cor- roding or phagedenic chancroid. But even in this kind several varieties are recognized, such as the phagedeno-diphtheritic, the simple phagedenic, and the serpigino-phagedenic chancroids. The first occurs when one of the layers of sloughed tissue forms a lardaceous pseudo-membrane that adheres firmly to the sur- face of the ulcer. Phagedenic sores are called simple when they spread uniformly in every direction, and the serpiginous forms are those which, while spreading in one direction, form granulations in another. In regard to the serpiginous-pha- gedenic chancroid, we again distinguish a false and a true ser- piginous variety. The first kind spreads only downward toward the depending parts of the organ affected, and is due to a want of cleanliness ; the second generally extends upward. The false serpiginous form really depends upon repeated auto- inoculation. In these cases the initial chancroid is always situated at the highest point, while the newly formed sores occur at the lower and depending points. This kind of appar- ently serpiginous soft chancre is generally seen in the fossa corona gland is and on the inner surfaces of the labia majora. The simple phagedenic chancroid occurs far more fre- quently than the serpiginous variety. SOFT CHANCRE OR CHANCROID. 115 Phagedena is apparently entirely due to the condition of the system, for these forms of soft chancre are found especially in weak and depraved individuals. The mode of life of these individuals is another very frequent cause. The abuse of spir- ituous liquors is an especially potent factor which seems to favor the production of the phagedenic condition; hence Ricord assumed the existence of an ulcus oniophagedsenicum. Active mercurial treatment, coexisting scrofula, tuberculosis, or anaemia — in short, all the influences which tend to under- mine the system, particularly favor the production of the pha- gedenic condition. The long duration of the soft chancre, and the equally long persistence of the infecting property of its secretion, are marked peculiarities of this form of the disease. Site of the Soft Chancre. A chancroid may occur on any part of the human integu- ment and mucous membrane that can be reached by contact. However, since most soft chancres are acquired through sexual intercourse, it is easy to comprehend why the majority of them must occur upon the genital organs of both sexes. But there are also other places of the human body upon which chancroids are often met with, though not, however, as often as on the genital organs. Thus, injuries on the fingers of physicians and midwives constitute points of insertion of the chancrous virus. Wet-nurses affected with chancres on the genital organs will carry the infecting poison to the moist nipples if they rub the latter with their fingers which have been soiled with the dis- charge from the sore. In those given to the practice of sodomy, the soft chancre may form upon the lips, the tongue, mucous membrane of the rectum, etc. Numerous cases have convinced us that the statement which Eicord made long ago, to the effect that the head was proof against the soft chancre, is incorrect. Chancroids discharging profusely are apt in un- cleanly persons to produce, by auto-inoculation, multiple soft chancres. The experiments of syphilization have shown that hundreds of soft chancres may be produced in the same person. Any part of the integument of the penis from the free border of the prepuce to the mons veneris may afford a site for a soft chancre. The prepuce, however, is the part that is 116 PATHOLOGY AND TREATMENT OF SYPHILIS. most frequently attacked, especially its anterior or free margin, its inner surface, the frsenum, the corona glandis, and less fre- quently the external meatus of the urethra ; but the scrotum is also occasionally the site of the soft chancre. . In the female the soft chancre is most frequently met with upon the labia niajora and minora, on the posterior vaginal commissure, and at the vulvar orifice, more rarely in the vagina and vaginal portion of the uterus. In unclean women, suffer- ing from soft chancres on the genital organs with profuse dis- charge, the matter coming in contact with excoriations around the anus will convert the latter into chancroids. The peculiarity, situation, and functional activity of the tissues, spoken of here, on which a soft chancre is apt to occur, exercise a greater or lesser degree of influence upon the devel- opment and course of the chancrous sore. Chancroids of the prepuce are very obstinate and difficult to cure, because the foreskin is frequently stretched in its movements over the penis, and the sore is prevented from heal- ing. In addition, it is apt to become soiled by the urine and the glandular sebaceous secretion. In congenital phimosis, or that acquired from temporary swelling of the prepuce, the preputial chancroid is even more frequently and more mark- edly exposed to mechanical and chemical injuries. Soft chancres of the mucous membrane of the prepuce usually be- come complicated with catarrh of the glans and of the pre- puce. Preputial chancroids often give rise to chancroids on the glans through infection by contact. In cases of marked contraction of the preputial opening, such a degree of disturb- ance of the circulation occurs as to produce gangrene of the foreskin and glans. Impending gangrene of the prepuce mani- fests itself in the following manner : The patient complains of severe pain in the affected part, the prepuce swells enormously, becomes red, has a high temperature, and a foul-smelling, purulent discharge flows from the preputial orifice. If the impending dangerous condition is not quickly subjugated by appropriate treatment one or more blue spots appear on the external surface of the prepuce. In a few hours they become transformed into a black gangrenous slough, which after a while is cast off. The gangrene either limits itself to one or SOFT CHANCRE OR CHANCROID. 117 several points on the foreskin, an opening forms, through which the glans penis, till now imprisoned in the preputial pouch, is laid bare ; or the gangrene sloughs away the entire prepuce, attacks the glans itself, and destroys the greater part of it. If the arteria dorsalis penis is corroded by the sloughing process, dangerous haemorrhage may supervene, as ligature of the vessel involved in this gangrenous process almost always proves futile. Chancroids of the frcenum are situated either on one or both sides, or on the margin of this membrane. In the two former conditions, perforation almost always takes place. The perforated spot, as a rule, cicatrizes very slowly and very rarely. In most cases, the bridge of the skin that has remained intact breaks down, often causing serious haemorrhage from the arte- rial twigs that run along the free margin of the fraenum, that is difficult to arrest. Usually, the fraenum is entirely destroyed, and an ulcer results, that extends from the point of attachment of the fraenum, near the fossa coronaria, to the urethral orifice, and from this point it may even encroach upon and attack the mucous membrane of the urethra. Soft chancres at the mar- gin of the fraenum spread very quickly in the loose connective tissue existing between the two lamellae of that part ; may •lay bare the urethra, and even perforate it. They are the most frequent cause of swelling of the inguinal lymphatic glands. A chancroid may occur on any part of the glans penis. In coexisting contraction of the preputial orifice, chancrous impres- sions will result on the mucous layer of the prepuce ; and when cicatrization ensues, the foreskin may become firmly united to- the glans. In the shallow pits or crypts which are found on the dorsum of the glans penis, and which are the rudiments of the sebaceous follicles that exist here in the embryonal state, soft chancres assume the shape of follicular ulcers. Superficial chancroids cicatrize very quickly. If the chancrous destruc- tive process penetrates into the corpus cavernosum glandis, and assumes a phagedenic character, it may destroy such a large portion of the glans, owing to the spongy and vascular nature of the tissues, as to result in actual mutilation of the organ. In consequence of the exceedingly thin layer of the subcuta- 118 PATHOLOGY AND TREATMENT OF SYPHILIS. neons connective tissue, the cicatrization of such chancroids progresses very slowly. Chancroids of the external meatus urinarius are situated either npon one or both lips, and thence may spread into the nrethra. After cicatrization has taken place, the ostium ex- ternum urethra (the orifice) acquires a funnel shape. We have never, either during the life of the patient or at the autopsy, met with chancroids that have originated within the urethra behind the fossa navicularis. The numerous sebaceous glands existing in the fossa coro- naria glandis become diseased from the action of the chancrous poison, and assume the form of acne-like tubercles. These are transformed into ulcers of the size of a millet-seed, and may surround the entire fossa coronaria, like a string of pearls. Fi- nally, even the sound parts between the ulcers are destroyed, and they then coalesce into one ulcerating groove. If such a follicular ulcer spreads to and attacks the subcutaneous con- nective tissue of the dorsum of the penis, a fistulous track from the fossa coronaria to the mons veneris will result. In the female, soft chancres at the posterior commissure readily become phagedenic or gangrenous, because the physio- logical secretion and pathological excretions produced in the uterus and vagina, as well as the urine, are liable to accumulate there. As a rule, chancroids on the os uteri are not disposed to attack the deeper tissues ; nevertheless, marked loss of sub- stance and serious haemorrhage have been observed. Differential Diagnosis of the Soft Chancre. The soft chancre may be mistaken for herpes on the geni- tal organs, for an ordinary sore, the initial lesion of syphilis, and the cancer-ulcer. It is only possible to mistake a chancroid for herpes on the genital organs during its initial pustular stage. The distinctive features of the two are as follows : The herpes vesicles gener- ally appear in groups ; soft chancres commonly only one at a time. The former are barely as big as a pin's head ; the lat- ter, as a rule, are larger. A group of herpes vesicles has one common, erythematous red base ; each soft chancre is sur- rounded by a marked, slightly infiltrated red zone that is -per- SOFT CHANCRE OR CHANCROID. 119 ceptible to the touch. The herpes vesicles may exist for sev- eral days before bursting ; the chancrous pustule breaks in ten or twelve hours after it has made its appearance. The ruptured herpes vesicles dry up, without undergoing ulceration, forming a thin orbicular scale corresponding to the old vesicle. After the bursting of the chancre-pustule, a loss of substance ensues that has a tendency to spread. A chancroid always leaves a depressed cicatrix after it which lasts for a variable period ; herpes leave cicatrices that are visible but a few days, and indistinctly depressed or discolored. Herpes of the genital organs, in most cases, is an habitual disease, which may come on without or long after sexual intercourse. The pustule of a soft chancre begins about twenty-four hours after a suspi- cious cohabitation or infection with chancrous discharge. Lacerations and excoriations originating after sexual inter- course may, from neglect of cleanliness or improper treatment, assume an ulcerating character, and then be mistaken for chancrous ulcers. The course of these sores, or inoculation performed with their secretion, will quickly dispel all doubt. Ordinary ulcers heal readily enough when kept clean and properly managed ; and a pustule produced by inoculation with their secretion soon dries up and heals. The most important point in reference to the prognosis is the differential diagnosis between a soft chancre and the initial syphilitic ulcer. The syphilitic initial lesion rests upon a marked, sharply defined cellular infiltration, which bears no relation to the slight ulceration and suppuration. The soft chancrous ulcer is seated upon a base that has become somewhat resistant in consequence of the reactive inliammatory process. The initial lesion of syphilis, when grasped between the thumb and index-finger, shows the consistence, resistance, and elasticity of fibroids and enchondromata. The soft chan- cre, pinched up in a fold between the thumb and forefinger, will have at the most an oedematous or doughy feeling. Only tardy or repeatedly cauterized soft chancres, situated in the sulcus coronse glandis and genito-crural fold, sometimes occa- sion a temporary indurated inflammation of the connective tissue that may be mistaken for the hard consistence and elas- tic resistance characteristic of the syphilitic tissue induration. 120 PATHOLOGY AND TREATMENT OF SYPHILIS. In the soft chancre the inflammatory induration disappears spontaneously in a comparatively short time, and is not at- tended by hard, indolent swelling of the lymphatics. The syphilitic infecting ulcer is distinguished by its hyperplastic adventitious structure; the soft chancre is pre-eminently a destructive process. The syphilitic primary lesion, as a rule, develops very slowly, and, after a protracted incubation period, the soft chancre appears within a few hours or days after in- tercourse. The ulcerating process in the initial lesion of syphi- lis attacks layer after layer of the indurated deposit, the necrotic process proceeding from without inward, owing to the intense cellular infiltration. The capillaries in the part then become occluded, and the uppermost layer of the neo- plastic formation dies for want of a blood-supply ; conse- quently, the discharge from this lesion is very slight. The ulcerative process of the soft chancre proceeds rapidly, consti- tuting a purulent dissolution of the tissues; hence the dis- charge is quite profuse. Primary syphilitic lesions resembling erosions occasionally cicatrize so rapidly that they entirely es- cape observation ; in the soft chancre such rapid cicatrizations never occur. The scar of a syphilitic sore is hard to the feel, because the hyperplastic deposit remains for a long time ; the scar of a soft chancre never becomes hard. The cicatrix of a primary syphilitic chancre often breaks open again ; that of a soft chancre hardly ever. The cellular infiltration of a syphi- litic primary lesion, after being absorbed, may reappear after a long while without the recurrence of infection (repullulation of the syphilitic initial sclerosis) ; in the soft chancre such a condition never takes place. In the cicatrized syphilitic Hun- terian induration, deep depressions originate, as a result of atrophy ; in the scar of the local venereal chancroid, such de- pressions are never observed. Indolent swelling of the lym- phatic glands and diseased condition of the lymphatic vessels, as a rule, are the accompaniments of the initial lesion of syphi- lis, and seldom undergo suppuration ; as a result of the soft chancre, however, the lymphatic vessels and glands are quite often affected (in twenty out of one hundred cases), and gener- ally they undergo suppuration. Although we have enumerated here certain peculiar features and differences of form, and laid SOFT CHANCRE OR CHANCROID. 121 stress upon the essential distinctive symptoms for the purpose of specializing the characteristics of the soft chancre and the primary lesion of syphilis, still, to be candid, we must admit that here, as in other instances of natural phenomena, excep- tions and peculiarities of condition sometimes occur. The in- itial sclerosis may be indistinct, or the indolent swelling of the glands may be absent altogether, and yet a chancre may be followed by syphilitic manifestations. It is much easier to mistake a soft chancre for an epithe- lial cancer, as the latter very often occurs on the prepuce, glans penis, and scrotum, and is frequently attended by suppuration of the adjacent lymphatic glands. Epithelial cancer generally occurs in the form of a papillary, wart-like growth, which soon becomes necrotic, and gradually attacks the deeper structures whereby the textures upon which it is situated soon become eroded (ulcus rodens). Cancerous ulceration progresses more by death of the upper cell-strata of the deficiently nourished skin than by suppuration. Hence, we usually find here flat erosions whose upper surface is tolerably dry. Xow, while the base of the ulcer purifies itself, new papillary growths originate on its borders, by the death of which the destruction of the tissues spreads farther and farther. From these papil- lary growths, comedos or sebaceous plugs, consisting of flat or cylindrical epithelial cells, may be pressed out, through the proliferation of which the skin and subcutaneous tissue are de- stroyed (Klebs). Prognosis and Treatment of the Soft Chancre. The prognosis of a soft venereal ulcer depends (1) upon its location, and (2) upon the state of the inguinal lymphadenitis. In regard to its location, some kind of chancroids, especially phagedenic and gangrenous forms, cause greater destruction and mutilation of the parts than others. Arterial haemorrhages may take place from erosion of the arteria dorsalis penis and of the arterial branches in the frgenum, and cause considerable trouble. In regard to the occurrence of inflammation of the inguinal lymphatic glands, experience has shown that in twenty out of one hundred cases of soft chancres suppurating adenitis of the 122 PATHOLOGY AND TREATMENT OF SYPHILIS. groin takes place, that it occurs more frequently in the male than in the female — in the male, especially when the chancroid is situated on the frsenum and on the internal surface of the prepuce ; and in the female, in consequence of the chancroids occurring in the lacunae on both sides of the urethra. In re- gard to the affection of the inguinal lymphatic glands, small, rapidly cicatrizing chancroids do not admit of a prognosis that is more favorable than other varieties. The treatment of the soft chancre is either prophylactic or abortive, curative or methodical. Prophylactic Treatment. Besides the condom we have no remedy or agent that will protect one against receiving the virus of a chancroid, or will render it harmless to the system after it is brought in contact with some part of the living cutis or mucous membrane. Even the highly praised lotions which have been recommended to be used immediately after exposure to a suspicious intercourse, prove entirely useless in very many cases. By thoroughly washing the genital organs immediately after cohabitation, we may succeed in removing any infecting substance that may have been lodged there, and in this w T ay we may probably, but not positively, prevent the virus from taking root and exer- cising its effects. Abortive Treatment. Kicord succeeded in preventing the further development of the chancroid pustules which he had produced by inocula- tion by timely cauterization, thus bringing about cicatrization and healing, and thereby obviating the extension of the disease to the adjacent lymphatic vessels and glands. It was found, in the course of experience, that the pustules of soft chancres, and of erosions contaminated with the pus of a soft chancre, if thoroughly destroyed within seventy-two to ninety-six hours after infection had taken place, will be arrested in their further development. But if a longer time than that just mentioned has elapsed since exposure to the action of the virus, or if an adjacent gland is already attacked by inflammation and swell- ing, cauterization of the infected spot will be entirely useless. SOFT CHANCRE OR CHANCROID. 123 To be effectual, the caustics must also destroy sufficient adja- cent sound tissue. For this purpose a great variety of caustics has been recommended. Nitrate of silver, caustic potassa, pure or combined with unslaked lime (Yienna paste), or Fil- hos's caustic (equal parts of caustic potash and unslaked lime cast in molds like a pencil), chloride of zinc, fluid, or combined with some simple substance in powder (pulv. secalis or pulv. rad. liq.), as Canquoin's paste, or in the form of pencils recom- mended by Kobner (zincum mur., gram. 1 [grs. xvj], kali nitric, 0*20 to 040 [grs. iij to vj], melted and quickly wrapped in tin-foil and preserved in glass tubes or bottles), butyr. antimo- nii, chloride of mercury, 0*50 to 5*00 or 10*00 water [grs. vij to 3iv or 3 ij, 3ij], sulphuric and nitric acid, and the actual or galvanic cautery. In the abortive treatment we only employ nitrate of silver in stick or a concentrated solution (a saturated solution is eleven parts of the nitrate to ten of water). This solution destroys the tissues that are impregnated with the chancrous virus more effectually than the solid stick of nitrate of silver. ~No wet compresses should be applied to the cau- terized spot ; it should be kept dry, for the purpose of keep- ing the eschar produced by the caustic from dissolving and flowing over adjacent parts. After the slough produced by the caustic has been cast off, some astringent preparation may be applied by means of cotton-wool compresses. The part on which the virus of the chancroid has been lodged may also be excised. But, in the first place, the oper- ation can not be carried out in every case ; and, secondly, it is not always effectual, because we are not sure when the chan- crous poison ceases to be active, nor to what extent the incision should be made around the affected spot. Curative or Methodical Treatment. If the abortive treatment has failed, if more than five days have elapsed since infection took place, if one or more of the adjacent lymphatic glands is already irritated or inflamed, the methodical or curative treatment should be instituted. It has to fulfill the following objects : To prevent the extension of the ulcer in breadth and depth ; to protect adjacent parts against auto-inoculation ; to promote the cicatrization of the 124 PATHOLOGY AND TREATMENT OF SYPHILIS. ulcer ; and to check the swelling and suppuration of the neigh- boring lymphatic glands. These objects are attained parti y by appropriate regimen and conduct on the part of the patient, and partly by proper local treatment. The patient should avoid all active exercise, such as fenc- ing, riding, dancing, etc. If there are already signs of active inflammation in the affected parts, especially if any of the glands of the vicinity are tender or painful, the patient will do well to go to bed. His diet should be light, spirituous or other stimulating drinks should be interdicted, or at the most al- lowed in moderate quantities, and only to those accustomed to their use. The chief indication in local treatment consists in keeping the affected parts scrupulously clean, which is best accomplished by the speedy removal of the discharge from the sore, by pro- tecting it from contamination with physiological secretion and pathological excretion. This is best achieved by repeatedly washing the diseased part (topical baths), and by the applica- tion of iodoform. Iodoform in powder should be dusted upon the ulcer, and a bit of absorbent cotton dipped in a two-per-cent solution of carbolic acid in water, and squeezed out well, is then applied. To prevent the dressing from becoming too dry, it should be covered with a piece of gutta-percha, and the whole secured by a bandage. This dressing must be renewed two or three times a day, according to the quantity of the discharge. If the penis is markedly swollen, the patient should be confined to bed, and the organ kept upon the abdomen. In the majority of cases the ulcer becomes clean in a short time under this treatment. If granulations have begun to form, the iodoform dressing may still be used, or only a carbolic-acid solution ; or, still better, empl. hydrarg. may now be substituted for either, especially if the patient desires to leave the bed. Exuberant granulations should be repressed by touching them from time to time with the solid nitrate of silver, which will also expedite the cicatri- zation of the sore. If under this treatment the ulcer remains stationary, and, still more, if it enlarges markedly and rapidly, which is a most unusual circumstance, or assumes a diphtheritic character; if SOFT CHANCRE OR CHANCROID. 125 the discharge is profuse, and granulations are slow to appear, one of the following preparations should be resorted to : 5 Cupri sulphurici, 0*50 [grs. viij] ; Ung. elemi., 50-00 [ § iss„ 3 v]. M. Ft. ung. A bit of this salve, of the size of a lentil, is smeared upon a small strip of muslin and applied to the ulcer two or three times a day, after bathing the organ in tepid warm water. In diphtheritic or phagedenic chancroids, that do not heal under the application of iodoform, an emulsion of camphor, caustic potash, or nitrate of silver, with balsam of Peru may be em- ployed — like the f olio wing : 5 Camphora, 5*00 [3 iv]; Mucil. g. arab. ; Aqua destil., aa 50-00 [ § j, 3 vj]. M. I£ Kali caustic, 0*10 [grs. jss.] ; Aqua destil., 50*00 [ gj, 3 vj. M. Yp Argent, nitrici, 0*10 [grs. jss.]; Balsam. Peruvianas, 30-00 [ § j]. H. Ft. ung. In ulcus luxurians or elevatum [fungous], a strong astrin> gent, or mild caustic, should be resorted to. In dry granular ulcers, with callous edges and scanty secre- tion, lint moistened with glycerine, or the empl. hydrarg., should be applied. In phagedenic soft chancres general treatment will be neces- sary in addition to the use of local remedies, because the phagedena in all probability is due to scrofula, tuberculosis, anaemia, scorbutus, habitual digestive disturbances, etc. It will, therefore, be necessary to resort to the remedies most effectual in the treatment of these various diseases. Mercury is to be strictly avoided in the treatment of phagedena. We have rarely succeeded in arresting the progress of phagedsena by caustics, but we are able to recall numerous instances in which we obtained the happiest results from the use of acetate of lead or citrate of iron, combined with tincture of opium. In simple phagedenic chancre we therefore recommend — I? Ext. saturni, 2*00 [grs. xxxij]; Aqua destil., 100-00 [ § vjss.J ; Tr. opii eoinp., 5*00 [3 iv]. M. 126 PATHOLOGY AND TREATMENT OF SYPHILIS. ^ Citr. ferri, 1-00 [grs. xvj] ; Aqua destil., 100-00 [ | vjss.] ; Tr. opii couip., 2'00 [grs. xxxij]. M. One of the most reliable remedies, besides iodoform, we found to be a mixture of chloroform and glycerine, one part to six. The tartrate of iron, one part to six, is recommended by Eicord as a specific against phagedena. Excision of the phagedenic chancroid, at the most, can only be recommended when it is situated upon the frsenum, the free margin of the prepuce, and at the edges of the labia majora or minora. In the treatment of gangrenous chancroid it will be neces- sary first of all to ascertain the causes that brought about the gangrenous condition. These are apt to be : Grave stasis, a profuse flow of blood in the phlegmonously inflamed part, and mechanical obstruction to the return of the blood, when the supply is excessive ; this may occur as the result of pressure, strangulation, phimosis, and paraphimosis. In any event, rest in bed should be recommended, ice-cold applications made, and in men the penis should be kept upon the abdomen, for the purpose of diminishing the supply of blood to the part, and ac- celerating its return. In congenital or phlegmonous phimosis, in which the retraction and extension of the prepuce for the purpose of cleansing the parts cause intense pain and irritate them, besides rendering the chancroids almost inaccessible and preventing the local application of remedies, it will be more advantageous to split the prepuce, or to perform circumcision. Arterial haemorrhage caused by gangrene must be arrested by the application of the ligature, compression, or transfixion. If these methods fail, chloride [or persulphate] of iron, or the actual cautery, should be used. In all cases of phimosis, where there is no danger of gangrene, and the patients decline to be circumcised, injections of solution of nitrate of silver should be made into the preputial pouch four or ^ve times a day, and retained there for a few moments. Or, after injecting water into the pouch, and then drying it as well as possible, the glans should be cauterized by inserting a solid piece of nitrate of silver between it and the prepuce, and rapidly rubbing it all over. After the injection or cauterization three or four pieces SOFT CHANCRE OR CHANCROID. 127 of compressed sponge, each about two and a half centimetres long and two millimetres thick, according to the distensibility of the prepuce, should be inserted between the prepuce and glans, and renewed several times daily. In this manner the preputial sac is sometimes dilated to such a degree that after the cicatrization of the chancrous ulcers it can be retracted with the utmost facility. We do not recommend this method of treatment very strongly, preferring early circumcision for the relief of this complication. In cases complicated with paraphimosis, circumcision will almost always be required. If the patient absolutely refuses to have it done, the penis is to be laid upon the abdomen, cold- water dressings applied to it, and attempts made to apply ap- propriate remedies, by means of camel' s-h air brushes, between the folds of the constricting prepuce. If dangerous stasis, in consequence of the constriction, takes place in the prepuce or glans penis, the operation will have to be performed without further delay. In chancroids of the ostium externum urethrse, it will be the duty of the physician to prevent contraction of the ure- thral orifice during cicatrization. This is best effected by in- serting into the meatus plugs of charpie, or some other mate- rial, dipped in some resinous or other kind of ointment, or pieces of bougie, which should be secured to the penis by tapes and adhesive plaster, and which the patient may remove before micturition. Iodoform, made into sticks with some solidifying substance, is also very well adapted for this pur- pose. Chancrous ulcers at the anus require prolonged washing and sitz-baths after each stool. In perforating chancroid of the frcenum, pledgets of lint, smeared with ointment of sulphate of copper, should be care- fully introduced, several times daily, into the hole, or the per- foration touched with the solid nitrate of silver. If the swell- ing is very great and the pain intense, dividing the bridge is the most appropriate procedure. Ricord has suggested an excellent measure for this purpose, by which the bleeding is avoided and the further progress of the ulceration restrained. Two waxed ligatures are passed through the opening, and are 128 PATHOLOGY AND TREATMENT OF SYPHILIS. then separately tied upon the bridge of the fraenum, one thread after the other. The part between the two tied ligatures breaks down in a few hours or days, or it may be cut through at once, without fear of causing haemorrhage. In the female, scrupulous cleanliness must be enjoined, and carried out with even greater rigor than in the male, because the sebaceous and mucous follicles of the genital organs, ow- ing to the presence of chancroids, are stimulated to hyper- secretion. The discharge from the chancroid sores, and the secretion from the genital organs, flowing over the adjoining parts, will cause erosions to form at the genito-crural fold, on the perinseum, and around the anus, which soon develop into chancroids. Menstrual blood, the lochia, and vaginal catarrh, delay for a long time the cure of a soft chancre, if it is situated upon the vulvo-vaginal mucous membrane, and especially on the posterior commissure. Care should therefore be taken to cure the existing catarrh as soon as possible, sitz-baths taken often, vaginal douches repeatedly resorted to, and the sore frequently and thoroughly cauterized with the solid crayon of silver. This method is all the more applicable in the female, because the chancroids, in the vast majority of cases, are situated upon the mucous membrane, and bear strong cauterizations better than those in the male, situated upon the common integument. Aside from this, the treatment differs in no respect from that of chan- croids in the male. Chancroids situated upon the upper part of the vagina or neck of the uterus must be cauterized through the speculum, with a long caustic holder. The parts that are likely to come in contact with a chancroid should be protect- ed, by inserting repeatedly between them pledgets of wad- ding, saturated with some disinfecting solution, to prevent auto- inoculation. Diseases of the Lymphatic Vessels and Glands (Lymphangioitis and Adenitis) in consequence of Soft Chancre. Daily experience has shown that the lymphatic glands, situated in the vicinity of a collection of pus or ichor, which, are produced idiopathically or by infection, furthermore those in the vicinity of inflammatory deposits of a malignant nature, very often become inflamed and swollen. In some cases they SOFT CHANCRE OR CHANCROID. 129 undergo resolution, but in others terminate in suppuration. These forms of swelling of the lymphatic glands are due to the agency of the lymphatic vessels, the fluids originating from the irritative lesions, indeed even viable cells and particles of dead structures, being taken up by them and conveyed to and de- posited in the corresponding lymphatic glands. As a result of this condition only those glands become affected in which the diseased lymphatic vessels terminate, while the lymphatic ves- sels which run toward the primarily diseased spot undergo no perceptible morbid alteration. Occasionally, however, the mor- bid matter that has been absorbed also irritates the lymphatic vessels. In many cases there is found a swelling of the thickness of a cord under the skin, upon the dorsum of the penis, running from the local sore to the nearest lymphatic glands. This cord-like swelling is nothing more than a lymphatic duct, thickened by coagulation of lymph, as a result of absorption of diseased fluids from the original lesion. This thickening of the lymphatic vessel may be ushered in with marked inflam- matory phenomena, or without the least constitutional disturb- ance. Purulent urethral and preputial catarrh, erethistic ul- cers, soft chancres upon the external genital organs, generally give rise to painful inflammatory swelling of the lymphatic vessels. Initial syphilitic lesions likewise produce disease of the peripheral lymphatic vessels ; in the latter case, however, no inflammatory manifestations occur. The first form of disease of the lymphatic vessels is called inflammatory ; the second is spoken of as irritative. In both cases the affected lymphatic cord may be uniformly distended throughout its entire length, or knotty in one or more places. These lymphatic nodules are called bicbonuli, while the swell- ing of the lymphatic glands is called bubon, or bubo. If the patient is carefully and properly treated, the affected lymphatic duct will regain its normal thickness. In the con- trary event, and especially if the cause of the disease of the lymphatic vessel is a soft chancre, the inflamed nodules in the lymphatic duct will undergo suppuration. The integument covering the swelling of the lymphatic vessel ruptures, and a chancrous ulcer develops at this place. In swellings of the 9 130 PATHOLOGY AND TREATMENT OF SYPHILIS. lymphatic vessels, as a result of syphilitic initial lesions or of urethral catarrh, suppuration seldom occurs. The affections of the lymphatic vessels of the external gen- itals, that have been just described, occur most frequently in the male on the dorsum or sides of the penis, and along the frsenum. They are very seldom met with in the female, and then only on the labia majora. Disease of the lymphatic ves- sels which start from the preputial orifice may produce tem- porary phimosis. Lymphatic ducts that have undergone sup- puration will require a much longer time to get well than would be required for resolution of non-suppurating inflamma- tion. Affections of the lymphatic vessels and swellings of the lymphatic glands do not always have the same course and ter- mination. The swelling of the lymphatic vessels may become absorbed, while that of the glands goes on to suppuration, or vice versa. Swelling of the lymphatic glands may originate without coincident swelling of the afferent lymphatic vessels, in the same manner as an epididymitis may occur without thickening and inflammation of the spermatic duct. The morbid matter that has been transported to the glands does not always occasion inflammation in them ; sometimes it only causes an irritation. In the course of the complaint this irritation may develop into a painful inflammatory lesion, acute swelling of the glands, or it causes, without any increase of the temperature and without any pain, an hypertrophy of the glands through increase of the hyperplastic element, forming chronic or indolent glandular enlargement. The acute or chronic state of the glandular swelling, and its future destiny, depend first upon the character of the morbid matter trans- ported to the glands by the lymphatic vessels, and, secondly, upon the constitutional condition of the individual. If in- tercellular substance, pure, or gonorrheal pus, originating from excoriated places, is transported to a gland in a person in all other respects perfectly well, an acute glandular swell- ing will be produced, which will either terminate in reso- lution or suppuration, according to the behavior and constitu- tion of the patient. But if matter from a soft chancre in a state of acute inflammatory suppuration is conveyed to the gland, the latter will to a certainty undergo inflammation and SOFT CHAN GEE OR CHANCROID. 131 suppuration. If the discharge or the detritus of an initial or secondary syphilitic ulcer is conveyed to the gland, an indolent glandular swelling mil result, which only undergoes suppura- tion when certain pre-existing conditions co-operate, or when a new irritation favoring suppuration is transported by addi- tional matter. Of all the lymphatic glands in the human body, the glands in both inguinal regions are the most fre- quently affected in the manner described. All glandular tu- mors are now called bubon, because formerly the Greeks called the inguinal glands bubones, or buboes (ftovftwves;). Physiologically considered, the glandular affection deline- ated above may be called resolution buboes. But, if the source of the absorbed fluid is taken into consideration, we might speak of common, gonorrheal, chancroid, and syphilitic buboes. Further, since absorption-buboes are always preceded by some morbid alteration, they may be designated as deuteropathic or secondary buboes. Protopathic or idiopathic buboes (bubons d'emblce of the French) are said to occur when the glandular hypertrophies were not preceded by any lesions of the adjacent skin or mu- cous membrane, and consequently did not originate by absorp. tion of noxious matter. Cazenave, Yidal de Cassis, and Diday are even of the opinion that chancroid and syphilitic virus are capable of causing disease of the lymphatic glands without previously establishing any purulent foci on the skin or mu- cous membrane. Yirchow maintains that all glandular hyper- trophies are preceded by a lesion of some kind, and where none is found he asserts that it has disappeared, as in the so- called idiopathic adenitis, while the enlargement remains. He says, moreover, that in tender, irritable lymphatic glands, such as are generally found in scrofulous persons, any lesion which in a robust person would be of no consequence whatever is liable to produce the most severe and obstinate glandular swell- ings. We can not, however, refrain from expressing our opin- ion that, in consequence of constitutional conditions, such as scrofula, leukaemia, or syphilis, lymphatic glandular enlarge- ment may originate without having been preceded by any le- sions of the adjacent parts. These kinds of glandular hyper- trophies are called constitutional buboes, or adenitis. 132 PATHOLOGY AND TREATMENT OF SYPHILIS, Buboes originating as a Result of Soft Chancres. Swelling of the lymphatic glands, occurring in consequence of a soft chancre, generally soon undergoes suppuration. Ow- ing to their rapid development, these buboes are called acute buboes, and, assuming that the pernicious matter that was con- veyed to the glands was chancrous virus, virulent or chancroid buboes. However, even soft chancres may give rise to indolent disease of the glands. It is still a mooted point whether, in such cases, any chancroid pus has been absorbed, or whether other factors play a part. This form of indolent glandular swelling may, later on, after weeks or months have elapsed, assume an acute character, and in its subsequent course differ in no respect from those affections of the glands that are ush- ered in by acute symptoms. A virulent bubo usually originates in the first week after the appearance of the soft chancre ; sometimes, however, after the latter has completely cicatrized. This form of retarded adenitis indicates that the pernicious matter that has been ab- sorbed is being slowly transported to the glands. But if such a glandular swelling does not undergo suppuration, or if, in case it suppurates, the pus by inoculation in persons unaffected with syphilis occasions no ulcer, we may assume that the chan- crous sore, at the time the discharge was absorbed from it, no longer generated any virulent matter. It is highly probable that by the absorption of the chan- croid virus, at first, only one or a few glands are affected. The original size of the glandular swelling is barely as large as a pea. The swelling generally begins with severe pains, which are aggravated by the least pressure, and occasionally accom- panied by febrile movement. Gradually the territory beyond the affected gland becomes sensitive, the skin covering the glandular tumor also becoming tender. Even the movements of the limb on the same side as the glandular swelling cause in- tense pain. The skin over the swelling gradually increases in redness, and it is difficult to pinch it up in a fold — a proof that it and the subjacent connective tissue have already become united to the affected glands. In the course of the disease the capsule of the suppurating gland bursts, the surrounding con- nective tissue imbibes the virulent matter, terminating in a SOFT CHANCRE OR CHANCROID. 133 purulent fusion of the entire mass. A virulent or chancroid bubo is therefore generally a complication of suppuration of the connective tissue and of the lymphatic glands. After the pus has formed, the febrile phenomena usually subside, and the pains on moving the corresponding limb are less severe. Grad- ually the swelling points, the skin over it becomes livid red at the highest point, the epidermis peels off, and, finally, the ab- scess breaks and pus escapes. Up to the point of rupture, adenitis originating from ab- sorption of chancrous pus is analogous in its development to those lymphatic swellings of the glands that are caused by or- dinary or gonorrheal pus. In a patient who is suffering from gonorrhoea and chancroids at the same time, it is therefore im- possible to say, before the inguinal abscess has broken, whether it originated from the absorption of the gonorrheal or chan- crous pus. After it has broken open it may be diagnosed as being probably a case of chancroid bubo. A positive diagnosis that the glandular abscess is a chancroid bubo, or, more cor- rectly speaking, a glandular chancroid, can only be made from the course of the abscess, and the result of inoculations made with the pus from the abscess. If the glandular swelling opens spontaneously, or is opened by the surgeon, a thick, cream-like pus escapes, like that from other acute abscesses ; but, in chronic suppurating lym- phatic swellings, thin pus containing cheesy particles, like that of cold abscesses, is discharged. If some of the matter from the abscess, taken indiscriminately, is inoculated under the skin, a pustule will form in some cases, which may become transformed into a chancroid ulcer ; in others, again, it soon dries up and forms a crust. If, however, an inoculation is made with matter taken from the bottom of the abscess, from a spot where two or three niche-like excavations are found, the pustule produced will almost always be transformed into an ulcer. These excavations are distinguished by the fact that their bases appear to be more jagged and covered with a larger amount of molecular detritus than the rest of the bottom of the abscess. From all indications they are the depots of those lymphatic glands to which the chancroid virus was conveyed by the lymphatic ducts. 134 PATHOLOGY AJSTD TREATMENT OF SYPHILIS. The opening of an abscess, however, does not terminate the morbid process that has become established in the glands and adjacent connective tissne, as is the case in ordinary ab- scesses of the glands, or of the cellular tissue ; for instance, in gonorrheal buboes, in which the latter, after being opened, quickly become smaller and cicatrize. The chancroid virus that was transported to the glands and connective tissue produces its characteristic effects here, as in a soft chancre of the skin. The bottom of the abscess secretes a thin, ichorous fluid, which corrodes the adjacent tissues, especially the margins of the ab- scess, undermining them and giving them a jagged appearance. An ulcer of the skin, which gradually enlarges and has the characters peculiar to a cutaneous chancroid, originates from this abscess. Sometimes the margins of the ulcer are under- mined and almost deprived of nutrient vessels, livid in color, and slightly overlap the bottom of the ulcer. In other cases, the margins proliferate, and undergo a condition of sclerosis, becoming everted and forming a wall of cicatrized callosity. A period of eight, ten, or more days may elapse from the time a virulent bubo begins until distinct fluctuation is felt. The softening which takes place sooner or later depends main- ly upon the behavior of the patient and the care with which the chancroid is treated, and also upon his constitutional con- dition. Glandular chancroids require a longer time to run their course than chancroids of the skin or mucous membrane, because glandular tissue and connective tissue heal much more slowly than ordinary skin and mucous membrane. All forms of disturbances of nutrition, such as scrofula, tuberculosis, scorbutus, etc., exercise greater influence over the ulceration produced by a bubo than over a soft chancre of the skin. In favorable cases, the abscess closes by the end of the fourth week after it was opened. During this period the open bubo may present all the morbid changes that are observed in a chancroid on the skin. It may be attacked by phagedena, and the phagedena may assume a serpiginous character. The surface of the ulcer may become covered with a diphtheritic membrane. Lastly, the bubo may also become gangrenous. The loose connective tissue in which the glands generally are imbedded is more readily destroyed by the inflammatory pro- SOFT CHANCRE OR CHANCROID. 135 cess, and hence bubo-ulcers, especially the gangrenous variety, occasionally assume inordinate proportions. Fistulse may form, undermining and destroying the tissues, and by eroding blood- vessels cause haemorrhage that may endanger life. The closing of a glandular chancroid takes place in the same manner as in a chancroid of the skin, partly by the formation of cicatricial tissue from the periphery toward the center, and partly by the retraction of the integument. Large glandular chancroids, however, do not cicatrize as quickly as soft chancres of the skin. At the bottom of the latter the tissues are of a homologous nature, while fascia, hypertrophied and ulcerating glands and lymphatic vessels forming arches and prolongations are found in a bubo. The glandular chan- croid offers numerous conditions which are favorable to the decomposition of animal matter. Under the influence of gen- eral morbid conditions, such as hospitalism, or in consequence of irritating dressings and ointments, the proliferating granu- lations suddenly become pale, wilted, and collapsed, and under- go cheesy or gangrenous degeneration. ISTot only is the cica- trization interfered with by these morbid conditions, but the growth of pus-cells is greatly fostered. The restitution of the epidermis, as a rule, progresses from the margins of the ulcer, or small islands of epithelial cells spring up at a distance from the margin. Chancroid buboes occur more frequently in men than in women, owing doubtless to the fact that in the latter most soft chancres are situated upon the mucous membrane of the gen- ital organs, and also because females, as a rule, lead a more quiet life. Site, Shape, and Size of Chancroid Buboes. As a rule, the glands situated nearest the chancroid become affected. The chancroid virus seldom overleaps adjacent glands and attacks those at a distance. Thus, in consequence of a soft chancre on the genital organs, the inguinal and femo- ral glands ; on the lips or tongue, the submaxillary and sublin- gual ; on the fingers, cubital or axillary, or also the jugular or subclavical glands of the corresponding extremity, become af- fected. The inguinal glands are not always affected on the 136 PATHOLOGY AND TREATMENT OF SYPHILIS. side corresponding to the situation of the chancroid on the genital organs. The soft chancre may be situated on the right side, while the inguinal glands on the left are diseased, or the reverse is the case. This fact is explained by the anastomosis of the absorbent lymphatic vessels. Chancroids situated upon the median line of the penis, especially those on the fraanum, are apt to produce tumefaction of the lymphatic glands on both sides. Fissures in the folds of the mucous membrane of the anus, ulcers or furuncles on the tuber ischia or on the bui> tocks, likewise give rise to swelling of the inguinal lymphatic glands. - The glands found in the inguinal triangle are divided into the superficial and deep by the fascia of the region. The su- perficial glands are numerous, covered by the fascia superfici- alis, and lie imbedded in the meshes of adipose tissue ; there are only three or four (sometimes only one) deep glands which lie directly upon the sheath of the femoral vessels. The superficial inguinal glands are affected much more fre- quently than the deep, and when the latter are affected, in consequence of a soft chancre, it is not caused directly, but by imbibition from a superficial suppurating gland or the contigu- ous connective tissue. Suppuration of the deep glands is much more dangerous than that of the superficial ones. The form of the glandular tumor is more distinct in lean persons than in stout ones, and thus it often happens that in women with pendulous abdomens no swelling can be seen, al- though they may have suffered from febrile phenomena and complained of pains in one of the inguinal regions for several days. Acute chancroid buboes vary in shape. Inguinal swell- ings of the lymphatics are generally elliptical ; their principal axis is in a line with the inguinal fold. Axillary and jugular glandular tumors are usually round. A glandular swelling formed by the inflammation of one gland only will present a smooth surface ; but if several adja- cent glands are involved, it will present, at least at the begin- ning, an uneven, hilly lump. This form of swelling of the in- guinal glands not infrequently acquires a shape like a wallet, owing to Poupart's ligament being stretched transversely across it. SOFT CHANCRE OR CHANCROID. 137 The size or circumference of the glandular swelling de- pends, above all, upon the constitutional condition of the patient. Thus, large buboes form in scrofulous persons when affected with chancroids. It seems that the chancroid virus in these patients causes more irritation and increase of hyperplastic exudation into the glandular substance than destructive action. Hence, under appropriate treatment, resolution of the bubo is soon achieved ; but should purulent degeneration occur, which usually happens by the third or fourth week after the swelling has appeared, it will only affect the connective tissue surround- ing the glands, while the glandular parenchyma escapes. In these cases, fistulse often result. This kind of glandular in- flammation is known as strumous buboes. It is more difficult to demonstrate suppuration of the glands than of the subcutaneous cellular tissue, because the former are situated at a greater distance from the skin than the lat- ter. In buboes formed of many glands, not infrequently cheesy degeneration or purulent foci develop, and gradually either coalesce into a common cavity or rupture separately, forming multiple buboes. Differential Diagnosis and Prognosis of Buboes. Buboes of the groin, before they are open, may be mistaken for an inflamed testicle that has been retained in the inguinal canal ; for a strangulated or reducible hernia ; and, lastly, for a varix of the vena saphena at the point where it dips into the vena cruralis. The diagnostic features of a non-descended inflamed testicle are : The absence of one testicle from the scrotum ; the pecul- iar pain on touching the swelling ; and, lastly, its characteristic hardness. Glandular swellings, before pus has formed in them, are harder to the touch than a testicle. An epididymitis, in addition, is distinguished from a suppurating bubo by the ab- sence of softening. The symptoms of a reducible hernia are : The tumor is soft, compressible, and becomes smaller when the patient assumes a horizontal position — larger when he stands, coughs, or sneezes. On pressing an enterocele, borborygmi are heard, and, attended by a gurgling noise, the prolapsed gut slips back into the abdomen. In strangulated hernia there 138 PATHOLOGY AND TREATMENT OF SYPHILIS. are, in addition to the general symptoms, colic-pains, flatulence, etc. The percussion-sound is generally tympanitic. Later, the symptoms of inflammation and the evidences of gangrene ensue, followed by vomiting of stercoraceous matter. The characteristic symptoms of varix are : The rise and fall of the tumor, synchronous with inspiration and expira- tion, its increased tension when the saphena vein is com- pressed above it, and its collapse when the vein is compressed below it. Open inguinal buboes are apt to deceive the physician by the similarity they sometimes present to epithelial carcinoma situated in the inguinal region. In regard to the differential diagnosis, we refer the reader to what has been said concern- ing the differential diagnosis between a soft chancre and epi- thelioma. The character and ultimate result of a bubo can not be definitely decided at its commencement. It is only possible to infer from the existing or preceding chancroids that the be- ginning bubo is the result of absorption of the chancrous virus, and that it will inevitably suppurate. But if the chancroid was cicatrized long before the bubo began, we are justified in assuming that the pus from the soft chancre was brought to the glands at a time when the former was no longer virulent, and in this event suppuration need not necessarily ensue. The constitutional condition of the patient, his behavior, and the character of the chancroid, play an important part, and should be taken into consideration in forming a prognosis. In feeble, anaemic, scrofulous, tuberculous, and cachectic persons, the sup- puration and cicatrization of a bubo never progress satisfac- torily. Not infrequently they are interrupted by the super- vention of a gangrenous, inflammatory condition of the sub- cutaneous cellular tissue, especially when the patient is confined in an unhealthy atmosphere — for instance, in a hospital. Vio- lent exercise aggravates the inflammation and the tendency to suppurate. The greater the number of the glands affected, the larger the abscess will be, and the longer the cavity will take to cicatrize. If the soft chancre becomes phagedenic, the suppurating bubo will also assume a phagedenic character. Gangrenous buboes are exceedingly dangerous. The hyper- SOFT CHANCRE OR CHANCROID. 139 plastic enlarged glands, having been deprived of their capsules, project into the cavity of the abscess and prevent its cicatri- zation. Treatment of Diseases of the Lymphatic Vessels produced by Chancroids. In inflammation of the lymphatic vessels of the dorsum of the penis, however it may be produced, the organ is to be put on the abdomen and wrapped in compresses dipped in ice-water. Suppurating bubonuli should be incised, and the open lymphatic abscess, if it has originated in consequence of a soft chancre, treated precisely like a chancroid on the skin. If evidences of inflammation of the lymphatic vessels ap- pear, no irritating caustics or lotions should be applied to the chancroid. Treatment of Buboes before they are opened. The abortive treatment may be resorted to in the hope of arresting the beginning inflammation of the glandular and connective tissue, and of avoiding or limiting suppuration. In buboes caused by soft chancres it is seldom successful ; it may prove more successful in contagious catarrhs of the urethra or the glands, in swelling of the glands due to a syphilitic initial chancre, or in cases in which a simple lesion in coexisting scrofula was the cause of the glandular swelling. First of all, everything should be avoided that may increase the irritation of the glands. The patient must stay in bed ; but, in torpid, strumous buboes of cachectic persons, moderate exercise in the open air is beneficial. Cold compresses should be applied to the glandular swelling, if it presents an inflamed rather than a hyperplastic indolent character ; but if the least pulmonary catarrh be present, these applications should be made with the utmost caution. We have found the compress or T-bandage to be very useful in hyperplastic swelling of the lymphatic glands, for the purpose of encouraging absorp- tion. Blisters, with or without the local application subse- quently of a concentrated solution of corrosive sublimate, in our hands, failed almost entirely. In view of the pharmaco- dynamic action of iodine, the tincture of iodine may be em- 140 PATHOLOGY AND TREATMENT OF SYPHILIS. ployed for that purpose, painting the skin over the swelling with it by means of a camel's-hair brush. The irritating effects of this remedy may be diminished by the addition of an anodyne. We therefore order the following compound : ^ Tr. iodine, 30*00 [ f j] ; Tr. belladonna, 10-00 [3 viij]. M. S. Fur external use. ^ Tr. iodine, 30-00 [ § j] ; Tr. gallar., 15-00 [ § ss.]. M. S. For external use. If the skin nevertheless becomes irritated, we order iodine plaster instead of the tincture, in the following manner : ^ Iod. plumbi, 5*00 [3 iv] ; Emplas. diachyl. comp., 50-00 [ § jss., 3 iv]. Ung. elemi q. s. ut fiat einp. molle. The plaster is spread upon muslin or soft leather, and applied to the glandular swelling. Iodine, after all, is best adapted to accomplish resolution in indolent strumous buboes. As the odor of iodine is disagreeable, we employ instead the basic acetate of lead, and have obtained at least as good results with it as with iodine. Compresses dipped in a solution of acetate of lead are applied to the swelling and changed several times a day, securing them to the parts with a spica bandage. Under this treatment the hyperemia and redness of the skin disappear, and the swelling diminishes in size. If, however, despite the application of the lead-water com- presses, suppuration takes place, and fluctuation is detected, the pus must be evacuated under strictly antiseptic precautions. First, the hairs should be shaved off, the parts washed care- fully, and while the operation is being performed a stream of a two-per-cent solution of carbolic acid should irrigate the parts. The abscess may be punctured with a sharp-pointed bistoury, or laid open by careful dissection with a scalpel in a line running along the inguinal fold. The latter course is especially recommended to the inexperienced. We have known instances in which very good physicians injured the arteria cruralis while puncturing a bubo. At first a small opening should be made : if no pus escapes at once, a blunt probe, pre- SOFT CHANCRE OR CHANCROID. 141 viously dipped in the disinfecting -fluid, should be inserted into the wound, and the little finger (also washed in the same fluid) being placed in the wound to ascertain by the sense of touch whether any important organs are in the way, the cap- sule of the gland, and the glandular substance itself, should then be broken up. If pus be present, which is sure to be the case when pressure with the probe at any one spot of the unopened glandular tumor causes very severe pain, it will soon flow from the wound. A director is then passed into the wound, and the cavity freely laid open. It is best to remove the undermined skin at once, in order to have a uniform wound without any pockets. Any divided blood-vessel must be tied. Particles of the disorganized gland should be carefully scraped away with the scoop. After the operation is finished the wound should again be washed with a two-per-cent solution of carbolic acid, then dried with Brun's wadding, and powdered with iodoform; next, several layers of antiseptic gauze made into a compress and laid upon it are covered with a piece of gutta-percha cloth, and the whole secured by a spica bandage. This dressing must be re- newed every day, and the subsequent treatment of the wound is conducted in accordance with the general rules of surgery. The use of caustic pastes for the purpose of opening buboes has been discarded, as they are unsurgical. In anaemic patients, in whom very little pus is present, we may first attempt to puncture the abscess with Graefe's cata- ract-knife, allowing the pus to escape, and then applying lead- water compresses. In this manner, in some cases, a cure was achieved, the skin that had already been raised by the pus again uniting with the parts beneath it. The Treatment of Open Buboes. A bubo that broke open spontaneously, or was opened with a knife, originating in consequence of gonorrhoea or an ero- sion, should be treated like an ordinary abscess of the lymphatic glands or connective tissue. But, if it be the result of a soft chancre still in full progress, it is to be regarded as a chancroid of the glands and cellular tissue, and treated like- a soft chancre of the skin, taking into consideration, however,, the location 142 PATHOLOGY AND TREATMENT OF SYPHILIS. and structure of the diseased foci. A glandular chancroid forms an ulcerating cavity in which pus mixed with tissue- detritus ma j easily accumulate. These cavities should, there- fore, be washed out several times a day, either with a syringe or by irrigation, or by means of sitz-baths, in which the patient is kept for a long time. After this the cavities should be packed with pledgets of cotton dipped in a solution of carbolic acid or chloride of zinc, chlorate of potash, caustic potash, or, better still, powdered with iodoform. A spica compress band- age should then be applied. IXypertrophied glands, whose cap- sules have been destroyed, and which project into the cavity of the abscess, should not always be cut away. It is preferable to paint them several times a day with a weak solution of caustic potash or soda, or once a day with a concentrated solution of nitrate of silver. We have also seen good results from filling the cavity with a compound consisting of balsam of Peru, 20*00 [ 5 ss., 3 jv] aud arg. nitric, 0*05 [gr. j]. Occasionally, we have derived much benefit by injecting once a day a little basic acetate of lead, with a Pravaz syringe, into the exposed hyperplastic enlarged glands. Hypertrophied lymphatic cords should be divided with the scissors, and callous margins of the skin removed. In commencing gangrene, we apply an emul- sion of camphor, or fill the cavity of the abscess alternately with pledgets of cotton dipped in chloride of lime and with plaster of Paris and tar or iodoform, and cover the whole with ice-cold applications. If the gangrene can not be checked, the actual cautery should be employed, or the patient put into a bath. Lastly, the room occupied by the patient should be thoroughly and frequently ventilated, because in damp, dark, and badly ventilated rooms buboes readily assume a putrid character. Fistulae in consequence of Suppurating Buboes. Fistulse result either from the burrowing of pus, or they are the consequences of a progressive inflammation of the sub- cutaneous or intermuscular cellular tissue and of the cellular tissue of the sheaths of vessels and fascia. They run either superficially under the skin and fascia superficialis, or form sinuosities deep between the tissues. Fistulse may last for SOFT CHANCRE OR CHANCROID. 143 years, and thereby render the patient cachectic. The danger from them increases with their extent ; those penetrating deeply are more dangerous than the superficial ones. At- tended by inflammatory phenomena, an infiltrated swelling forms at the external end of the fistula, which soon becomes soft and breaks, in many cases at a distance from the original abscess. As a result of this burrowing, the fistulae acquire a very tortuous course, having branches that lead in different directions, but are connected by one parent canal. They may become filled up with granulations whereby the lumen of their canals is plugged up. In consequence of these granulations, they may become cicatrized like cords, temporarily or perma- nently, or the walls are only lined with cicatricial tissue while the suppuration continues. This variety of fistulae may occur above and below Pou- part's ligament. Those situated below Poupart's ligament be- come serious when they burrow beneath the sheath of the fem- oral vessels and between the abductors of the thigh, or when they extend into the lesser pelvic cavity along Gimbernat's ligament. The greatest danger in fistula appears when gan- grene gives rise to erosion of some of the arteries — for instance, the circumflex. To prevent fistulas from forming, the physician will find it necessary to bring about a union of the undermined skin with the subjacent parts, or, by making a counter-opening, or, by freely laying open the abscess, to evacuate the pus. Eo fistu- lous tract should be laid open till all hopes of resolution are gone, and the inflammatory phenomena plainly indicate that pus has formed. With that object in view, cold- water appli- cations should be made, and changed as often as they become warm, and the tract should be compressed with appropriate dressings and bandage. The fistula may either be slit open with a scissors or bis- toury upon a grooved director, or a ligature may be passed through and allowed to ulcerate its way out. The former method is better adapted in superficial, straight fistulas — the latter in deep, tortuous ones. By the use of the ligature, haemorrhage is avoided, which, in a patient already exhausted, may prove very serious. This measure, moreover, brings about 1M PATHOLOGY AND TREATMENT OF SYPHILIS. a more speedy closure of the tract than by slitting it open. The ligature may be either of silk well waxed, or an elastic drainage-tube. By means of a probe armed with the ligature or drainage- tube, an effort is made to find the terminal opening of the fistula. If it terminates at a point on the skin in the vicinity, the instrument is pushed through, and one end of the ligature is brought out at the lower opening ; but if the tract termi- nates blind, and the point of the probe is felt beneath the skin, the probe should be withdrawn, a grooved director in- serted, and an incision made with a bistoury on its point ; after which the probe, armed with the ligature, may be passed through the fistula. If the tract penetrates perpendicularly into the tissues, an effort should be made, by inserting into it compressed sponges, laminaria, or the like, to convert it into a funnel-shaped cavity, whose larger aperture is directed out- wardly, and by the application of stimulating dressing make it close up. If this fails, a drainage-tube of the proper length and thickness should be inserted. Finally, by cleansing the fistula frequently, and by applying caustic or antiseptic reme- dies, such as weak solutions of caustic potash or carbolic acid, Lister's paste or iodoform, a union of its walls may be brought about. If a lardaceous membrane (fatty and molecular de- generated connective tissue) forms along the fistulous passage that has been laid open, pledgets of lint dipped in a weak so- lution of caustic potash, acetate of iron, iodo-glycerine, or chloride of zinc, should be applied once or twice daily. SECTION III. SYPHILIS. General Conception. By the term syphilis is meant a blood-poisoning, produced by a peculiar animal virus, as the result of which various mor- bid lesions, occurring in a more or less constant series, are oc- casioned in the different tissues of the human body, and in which the specific inflammatory products, and the blood from the affected person, when transmitted to other healthy persons, produce in the latter similar morbid effects. Nature and Vehicle of the Syphilitic Virus. The syphilitic contagion adheres to all textural elements and textural detritus ■ produced by suppuration or bionecrosis in consequence of syphilis. It is most abundant in disorganized syphilitic papules and the sloughing initial sclerosis or hard chancre. The blood and semen of virile syphilitic persons do not seem to be totally, and at all times, tainted with the syphi- litic element. In this way may be explained the variable re- sults obtained from inoculations with the blood from syphilitic persons, and the fact that a syphilitic father will at one time beget a healthy child, and at another a syphilitic one. The milk, saliva, tears, and urine, do not seem to form a vehicle for the transportation of the syphilitic virus. Hence those pathological secretions that have no connection with syphilis — for instance, gonorrheal discharges, the matter from eczema, the sputa of pneumonia in a syphilitic person — can only be- come infectious syphilitically when they are mixed with syphi- litic blood or syphilitic detritus. 10 146 PATHOLOGY AND TREATMENT OF SYPHILIS. The contagion of syphilis, from all accounts, is a fixed principle. There is no snch thing as syphilitic miasm. Neither the microscope nor chemistry has so far been able to furnish us with any more definite information regarding its nature. Some authors claim to have discovered a peculiar micro-organ- ism which is present in the blood and the morbid lesions, and which engenders the syphilitic disease; unfortunately, how- ever, the discovery still lacks confirmation. The Transmissibility of Syphilis, or the Various Ways in which Syphilitic Infection may take place. Syphilis may be transmitted either directly by contact with syphilitic tissue-elements or by procreation on the part of syphilitic parents. The manifestations of the first form are called " acquired " syphilis {syphilis aequisita), those of the latter hereditary syphilis (syphilis hereditaria). The con- tagion of syphilis being, as stated, a fixed principle, it begins to manifest itself at some given point, and thence infects the entire system. The infection of the system must be preceded by a solution of continuity, and it is entirely immaterial whether it is produced at the same time or some time before the syphi- litic virus took effect. The uninjured epidermis, as a rule, forms a protection against infection by syphilis. In most cases the lesion and the infection take place through coitus, during which, by friction or maceration, the epidermis or the epithelial layer at some point on the genital organs is abraded, and the denuded spot on the skin or mucous membrane is readily acted on by the syphilitic virus. The virus may, however, also gain an entrance into the system through many other places — for instance, the mouth, tongue, cheeks, eyelids, forehead, nipples, fingers, etc. The transmission is either direct from a dis- eased to a well person, or it is indirect. The direct transmis- sion of the syphilitic virus usually takes place during coition, kissing, wet-nursing, operations by surgeons, midwives, nurses, etc. The indirect infection may occur by utensils, cigar-hold- ers, pipes, surgical instruments, bandages, etc. Even persons who are well may serve as agents in transporting the virus without becoming themselves affected, simply affording a tem- porary shelter for it at some place on their bodies — for instance, SYPHILIS. 147 in the vagina, or under the nails. The syphilitic contagion, under favorable circumstances, may give rise to syphilis in all persons who hitherto had not been affected with it. ]STo age, no temperament, and, as it seems, no nation, have, as regards syphilis, any special immunity, nor again any special suscepti- bility. Syphilitic tissue-elements retain their powers of infec- tion for a long but uncertain period ; syphilitic papules, for instance, are capable of communicating the disease after many months. Transmission of Syphilis by Vaccination. The Relation of Vac- cine Lymph to Syphilitic Virus. During the early part of this century many physicians re- ported numerous instances in which, in consequence of vacci- nation, hard, protracted, indurated ulcers formed at the site of vaccination, followed subsequently by syphilitic eruptions of the skin. The question now arises, How is the transmission of syphilis, in consequence of vaccination, brought about ? Our opinion is, that syphilis can only be transmitted by vaccination when syphilitic germ-elements are transplanted at the same time with the vaccine lymph. These elements are the blood of a syphilitic person, and the molecular detritus, or the pus origi- nating from syphilitic eruptions. We only agree in the opin- ion of Yiennois in so far as to admit that in some cases syphi- lis may be transmitted by means of the vaccine lymph taken from a syphilitic person, when the vaccine virus becomes mixed with some blood from that patient. This manner of transportation also serves partially to explain the fact that, in the class of vaccinations in which blood has simultaneously been transported, only a few of the vaccinated became syphi- litic. The experimental inoculations of healthy persons with the blood of syphilitics have shown that the results vary very much. Those inoculations in which some syphilitic blood was trans- mitted with the lymph taken from a normal vaccine vesicle correspond to those cases of vaccinal syphilis, in which a cir- cumscribed, hard initial node formed at the place of vaccina- tion after the vaccine vesicle had gone through the successive stages of normal development, dried into a crust, and sub- sequently fell off. Syphilis may, however, also be transmit- 148 PATHOLOGY AND TREATMENT OF SYPHILIS. ted in vaccinating with lymph, taken from a syphilitic per- son, and mixed with tissue detritus resulting from syphilitic disorganization. The results of the inoculations which Pick and Krause obtained by using the matter of bullous or pustu- lar eruptions on syphilitic persons justify us in assuming that in patients affected with latent or florid syphilis, if vaccinated with cow-pock virus, a vesicle or pustule may be produced that gradually develops into a little ulcer. JSTow, such a vesi- cle situated upon a syphilitic patient may be mistaken for a vaccine vesicle, and its contents, if used, may serve as a means of transmitting syphilis ; the disease is sure to be transmitted if some of the pus it contains is used. This view also serves to explain the fact that in some cases the vaccinations failed, and yet at about the end of the third week after the person w T as vaccinated a circum- scribed syphilitic sclerosis of the tissues developed at the point of vaccination. The theory that vaccine lymph in its passage through a syphilitic system likewise becomes syphilitic, i. e., acquires the property of syphilis in addition to being cow-pox, is refuted by numerous vaccinations performed upon healthy persons by some of the most reliable investigators who used vaccine lymph taken from syphilitic patients, and invariably produced normal cow-pox — never syphilis. Were the cow-pox lymph of syphi- litic individuals charged with the contagion of vaccine and of syphilis, every person that is successfully vaccinated with it would also become affected with syphilis. But this does not happen. From the preceding remarks it is evident that the follow- ing rules should be observed in performing vaccination : (1) The child from whom the vaccine virus is taken, and his parents, should be subjected to a most careful examination. (2) In view of the faet that congenital syphilis rarely breaks out before the end of the third week after birth, no vaccine lymph should be taken from a child under eight weeks of age. (See Hereditary Syphilis.) (3) "No vaccine lymph mixed with blood or pus should be used under any circumstances. [The surest way of avoiding transmission of syphilis by SYPHILIS. 149 vaccination is to discard humanized vaccine entirely, and use animal vaccine lymph only.] Transmissibility of Syphilis to Warm-blooded Animals. Whether syphilis can be transmitted to animals, and pro- duce in them manifestations similar to those produced in man, is still an open question. While some investigators — for ex- ample, Klebs and Martineau — report successful inoculations in apes and hogs, neither Neumann nor myself succeeded in pro- ducing either a primary local effect or any other manifestation of lues by inoculating this class of animals with syphilitic pus or blood. In one ape whom we inoculated in three places on the back with the pus of a soft chancre, we succeeded in pro- ducing pustules which soon became converted into ulcers that healed within three weeks. Many similar experiments fur- nished us equally striking proof of the difference between a soft chancre and syphilis. First Manifestations of the Action of the Syphilitic Virus. The first manifestation of the action of syphilitic poison is presented at the spot where the virus was deposited and ab- sorbed. The first external manifestation that appears at the place of infection varies, however, according as the syphilitic con- tagion is associated with an irritative factor, i. e., pus or ichor, or with some harmless ffuid, such as blood, serum, or lymph. In the former event, there appears at the place a circumscribed hyperemia and swelling, the latter passing in a few or several days into a condition of purulent softening or ulceration of the tissues. The swelling and suppuration appear there all the more quickly and more intensely, the deeper the solution of continuity through which the syphilitic virus took effect. The tissues, in persons who had not been previously affected with syphilis, do not assume for a long while at the place of infec- tion those pathognomonic alterations which we would recog- nize as evidences of luetic infection. But if the infecting con- tagion was not combined with pus-cells, but only with such fluids as are usually secreted on the superficial surface of the sclerotic ulcer {intercellular exudation), or with the blood of a syphilitic individual ; and, above all, if at the place of infection 150 PATHOLOGY AND TREATMENT OF SYPHILIS. there was no deep solution of continuity, but only a sim- ple excoriation — no suppuration will take place, and the ex- coriation will heal quickly. After a longer or shorter period {first period of incubation), a nodule, varying in size, will form. At the junction of integument with the mucous mem- brane this resembles a moist papule that is just beginning to grow. Kepeated observations, however, have taught us that per- sons affected with latent, feeble syphilis, though having no syphilitic effects on any part of their bodies, may communicate the disease to their wives, although it is not possible to dis- cover any initial syphilitic lesion in the latter, and have not become pregnant. In these women syphilis manifests itself by extremely rapid emaciation. In the further course of the disease they lose their hair; sometimes periosteal pains and swellings come on on some of the bones, and subsequently the menses become profuse and recur frequently. On becoming pregnant they will often abort. In what manner the syphi- litic contagion, in such cases, has gained an entrance into the system, is not yet clearly known. We know just as little in what manner a woman who suffers from latent syphilis is capa- ble of communicating the disease to her husband. Possibly, in such cases, the blood has served to transmit the infection, some bleeding erosions or excoriations having occurred on the genital organs. In those cases in which the action of the luetic virus mani- fests itself in the form of an ulcer, the tissues at the base of the ulcer begin, at the end of the third or fourth week, to con- dense more or less markedly, or, if it is already cicatrized, the cicatrix becomes hard. If the action of the virus began in the form of a nodule, molecular disorganization will ensue a few days after it appeared. The disorganization is confined either to the upper layers, the epidermal or epithelial covering only being destroyed, and the infecting focus simulates an erosion, or the disorganization extends deeply into the nodule, and sometimes occasions a marked loss of substance. The solidification of the tissues at the base of the ulcer and the growth of the nodule are identical processes, and both of them give rise to that gradual hardness and increasing induration of SYPHILIS. 151 the tissues which are designated by the term initial sclerosis of syphilis. The sclerosis does not originate at once, but gradually, and develops with well-marked remissions. For a time it is at a stand-still in its development, and then it suddenly takes a for- ward step. It may attain the size of a lentil, pea, or bean ; it may also extend over a large area of tissue. The lips, the labia majora or minora, or the skin over half of the glans or body of the penis, may become indurated. Absorption begins in the center of the induration, as is shown by the diminished hard- ness of the tissues at this spot. After the hardness has entirely disappeared, a bluish-red discoloration, corresponding in size to the induration, remains behind. The discolored spot gradually grows pale, finally becoming whiter even than the normal skin {pigment atrophy). If the induration disappears by absorp- tion, a central depression only will form ; but if the induration undergoes disorganization a depressed cicatrix will remain. Anatomy of the Syphilitic Initial Sclerosis. The macroscopic picture of a syphilitic initial sclerosis va- ries according as it has developed upon an ulcerated or eroded spot on the skin, or is undergoing development or resolution. If a cutaneous ulcer acquires a sclerotic condition through the reception of syphilitic virus, the solidification of the tissues will, at first, be limited to the margins and base of the ulcer ; gradually, however, the parts beyond also become affected. If no noteworthy loss of substance, either through injury or ulcer- ation, took place at the point of infection before infection oc- curred, an infiltrated node will form, which gradually increases both in circumference and in depth, grows harder and denser, and finally forms a firm tubercle with well-defined outlines, which sometimes feels like a solid encapsulated piece of carti- lage. The upper surface of the infiltrated spot may in a few days undergo ulceration, in consequence of granular degenera- tion. An ulcer, varying in form and extent, may thus be pro- duced ; it presents a flesh-colored, finely granular, readily bleed- ing, velvety appearance, secreting a thin, sometimes gummy discharge, in which are found a very few pus-cells. Here, too, 152 PATHOLOGY AND TREATMENT OF SYPHILIS. the space beyond the line of deroarkation surrounding the ulcer very slowly undergoes sclerosis. In consequence of the pressure which the sclerotic node exercises upon the capillary vessels of the affected tissues the supply of blood to the parts is diminished to such a degree that, when the node is incised, a sound is heard like that produced by cutting cartilage, and very little blood flows. This pressure upon the capillary vessels may also be the reason why the sclerotic tissue is not removed by softening and suppu- ration, but is destroyed by the slower process of fatty degenera- tion and absorption, or by necrosis, layer by layer from without inward. External and local influences, such as friction, cauteri- zation, etc., may bring about a more rapid degree of necrotic disorganization of the sclerotic tissues. Softening and puru- lent infiltration then become superadded, and extensive de- struction will ensue. In addition, a large or small part of the necrotic tissue may be destroyed by gangrene, and the node may then become so excavated as to leave only a hard shell behind. After the slough has been cast off and a permanent cicatrix formed, this will give it the characteristic hardness. This process differs from the sloughing that takes place in a soft chancre by the fact that the latter destroys normal tissues, while in syphilitic initial ulcers morbid products that have been deposited are destroyed. Sclerotic places that have undergone necrosis cicatrize yery slowly, and even when they have fairly cicatrized they do not always remain so, since syphilitic sclerotic cicatrices often break open again. This may happen so long as the sclerotic tissues are not entirely absorbed and replaced by perfectly normal material. After the sclerosis has disappeared, an exca- vation results, in consequence of atrophy that has begun in the center, and this has a semiotic significance. Under the microscope, the initial sclerosis of syphilis pre- sents very dense cellular infiltration which is not particularly characteristic. The cellular infiltration affects the papilla of the skin and the subcutaneous connective tissue, and is espe- cially abundant in the adjacent tissue of the blood-vessels, the adventitia of the latter being frequently involved in the infil- tration. In most instances the lumen of the vessels is only SYPHILIS. 153 diminished in size ; still, they may also be entirely occluded. We agree with Ziegler that the induration of the primary lesion of syphilis is produced by the long persistence of the libers of the connective tissue, notwithstanding the profuseness of the infiltration. The majority of the cells are small ; some- times they are large, epithelioid ; some of them have numerous granules. If the primary luetic lesion undergoes resolution without disorganization, a markedly discolored spot remains in its place, which subsequently becomes perfectly normal. If the node undergoes suppuration, a scar will remain. Site and Form of the Hunterian Induration. There is no place on the common integument on a person unaffected with syphilis at which a Hunterian chancre can not originate. No place possesses any immunity, neither does any possess a special qualification for producing it. It occurs most frequently on the genital organs of both sexes. In the male, on the internal surface of the prepuce, on the glans in the fossa coronaria, on the frsenum, and on the penis gener- ally ; in the female, mostly on the edges of the labia, at the anterior and posterior commissure, and on the prseputium cli- toridis. On the mucous membranes, the sclerosis is less dis- tinctly marked in general, and sometimes is totally overlooked. Hence it happens that, on the parts of the female genital or- gans, where infection naturally occurs most frequently — for in- stance, in the vestibule and introitus vaginae — a sclerotic node is very seldom detected on the mucous membrane. On the other hand, it develops more distinctly on the os uteri, where, how- ever, it can only be definitely diagnosed by the aid of a uterine speculum, into which the indurated os uteri does not glide like a normal os, but shoots in in consequence of the elasticity it has acquired through the Hunterian induration. If the specu- lum be pressed against the indurated os, or if pressure is made upon the latter with a wooden rod through the instrument, the fibro-plastic material deposited in the part will appear like a mass of transparent mother-of-pearl. Hunterian indurated chancres may be produced on the con- junctiva of the eye, on the mucous membrane of the nares, on the cheeks and chin, by transportation with the fingers and 154: PATHOLOGY AND TREATMENT OF SYPHILIS. under the nails, and by kissing. Sclerotic chancres on the lips and tongue of both sexes occur by kissing, sexual deprav- ity (cunnilingus\ by transmission by the agency of utensils, pipes, etc. Indurated chancres on the lips generally extend only as far as the vermilion border, and seldom reach beyond it to the mucous membrane. The Hunterian initial sclerosis is frequently seen upon the nipples of the breast, where it originates in wet-nursing syphilitic children. It often occurs on the fingers. Only one syphilitic initial sclerosis, as a rule, is met with on a person ; but, if several places become infected at the same time, all the parts are apt to become indurated. The form of the induration depends upon the character of the infected portion of the skin, and also upon the depth to which the syphilitic virus has penetrated. The deeper the virus pene- trates into the tissues, the more pronounced will the induration be; the more spongy the tissues of the infected place, the more diffused will it be. If the syphilitic poison has pene- trated below the integument, round or semicircular nodules, as hard as fibroids, will originate. If, during infection, the le- sion affected only the epidermis layer, and the solution of con- tinuity is an extensive erosion or excoriation, the induration of the tissues will be like a thin plate, having the hardness of chondroid tissue, and the fingers experience a sensation on pinching up a fold of the skin as if a bit of parchment is imbedded in the sore {chancre jparcheminee of Eicord). This last form occurs almost exclusively on the mucous membrane of the prepuce, where in retracting it the chancre becomes everted in the same manner as one everts the tarsal cartilage of the eyelid. In addition, it possesses the peculiarity of cica- trizing with surprising quickness. Frequently the phimotic prepuce becomes converted into a hard, dense, cartilaginous •funnel. In congenital constriction of the prepuce, the lips of the foreskin are often lacerated during intercourse in several places, into which the syphilitic virus is apt to be deposited, and all the lacerations afterward become indurated. The orifice of the prepuce then becomes converted into a dense ring, pro- ducing almost total phimosis, that is not relieved until resolu- tion of the indurated deposit has taken place. If the poison of syphilis adheres to one of the sebaceous follicles— a condi- SYPHILIS. 155 tion that generally happens when a follicle is deprived of its epithelium by seborrhceal disease — the induration that then takes place in the follicle will assume the form of a cylinder standing on end. But if a number of contiguous sebaceous glands become infected, as is often the case in those situated in the fossa coronaria of the glans penis, a hard wall originates from the coalescence of these indurated glands and encircles the glans like a wreath. If both, lips of the meatus in the male are the site of the syphilitic infection, the orifice becomes transformed into a dense, patulous, funnel-shaped opening, which feels like cartilage. Combined Effect of the Syphilitic Virus and of the Chancroid Virus. In the same way that an individual may be infected at the same time or in succession on two different parts of the body — on the genitals with a soft chancre, on the lips with a con- stitutional ulcer or syphilitic chancre — so both poisons, that of the soft chancre and of constitutional syphilis, may be depos- ited on the same part of his person simultaneously, or one after another. In such a case, both contagions may develop their local effects together. The chancroid develops and the indu- ration follows ; indeed, if both poisons are deposited at the same time and place, the soft chancre will have been far ad- vanced before the induration manifests itself. Generally, this does not occur till the eighteenth or twentieth day from the time the chancroid appeared. If the syphilitic virus has been absorbed several days before the poison of the soft chancre was deposited on the same spot, the induration will appear a few days after the chancroid. If a soft chancre is inoculated upon a syphilitic indurated base, it will display all the modifications it usually shows on the normal skin and mucous membranes. A superficial and deep phagedenic, or other variety of chancroid, may originate upon a syphilitic, indurated chancre. In the latter case, the phagedena will destroy the induration, and the chancrous ulcer will be surrounded like a hard shell by the ex- cavated indurated tissue. But if the induration was in process of development when the infection with the chancroid took place, the tissues adjacent to the phagedenic chancre will be 156 PATHOLOGY AND TREATMENT OF SYPHILIS. destroyed by tlie phagedena, and the induration will spread peripherally in the contiguous tissues that are unaffected by the soft chancre. In both cases the cicatrization of the chan- croid progresses very slowly. This, we think, is due to the fact that no retraction of the skin can take place here, because the chancroid is surrounded by indurated tegumentary tissue. Cicatrization is effected by a process of new growth, connect- ive tissue fibrillae effecting, in this way, the closing up of the ulcer, while the rest of the original induration now surrounds the cicatrix like a wall in the form of a hard ring that fre- quently desquamates (circular induration). Under general anti- syphilitic treatment the fibro-plastic exudation will be absorbed, rendering it possible for the retraction of the skin to take place, and expediting cicatrization. Inoculability of the Sclerotic Ulcer. As has been repeatedly stated, inoculations with the dis- charges from syphilitic infecting foci, especially suppurating initial indurations and syphilitic papules, will produce pus- tules and ulcers in those affected with these lesions, and in other syphilitic persons. Hence, the auto-inoculability of an ulcer upon a person affected with it is of no great value as a diagnostic aid for the purpose of deciding whether an ulcer is a syphilitic initial sore or a simple venereal sore (chancroid). This is all the more true, since even pus of n on- venereal origin will produce on syphilitic persons a series of inoculable ulcers. Therapeutically, however, the auto-inoculation of syphilitic infecting foci must be taken into consideration for the purpose of carefully isolating suppurating sclerotic indurations and syphilitic papules, lest they produce ulceration by impression upon adjacent normal tissues. Significance, Duration, Course, and Differential Diagnosis of the Syphilitic Initial Sclerosis [Hard Chancre]. A fully developed syphilitic initial sclerosis is of the ut- most importance from a diagnostic and prognostic point of view, because from the moment it originates the effects of the commencing syphilis may be recognized. The patient is un- der the influence of the syphilitic diathesis so long as the in- SYPHILIS. 157 duration lasts, and it only becomes less significant when it has entirely disappeared along with the constitutional phenomena. Left to itself, a primary induration that is situated upon the common integument will undergo desquamation attended by repeated congestions of the part. The epidermal covering of the induration, which is frequently renewed, has a peculiar glossy appearance and dark-brown color merging into redness. The upper surface of the nodule often degenerates after re- peated desquamation — a condition which, if preceded by sexual intercourse, will lead the patient to believe that he has been infected anew. The consecutive ulceration may begin in the center as well as at the upper surface of the nodule, or eccen- trically, and may remain superficial or attack the deeper layers. It may originate at several points simultaneously and progress rapidly, and thus resemble phagedena — a phagedena that con- sumes the entire nodule without attacking the parts around it. This kind of phagedena vanishes all the more quickly when the ulcer is not interfered with by caustics or irritating reme- dies. Sometimes, though rarely, the primary sclerosis undergoes a peculiar softening. The center of the nodule liquefies, form- ing a yellowish, purulent, or ichorous fluid, which, as in an ab- scess, gradually escapes outwardly through several small open- ings. The remaining walls of the abscesses that form in the primary induration disappear by absorption. A second scle- rotic nodule occasionally originates in the immediate vicinity of the first one, although recurrence of the infection has not taken place. The size and extent of the induration possess no prognostic significance respecting the benign or malignant character of the syphilis. Small and recent indurations usually are more amenable to treatment than those which are large and old. On the appearance of the eruptive fever and of the cuta- neous syphilide the induration generally becomes small, and soon disappears entirely, leaving behind a copper-colored spot, which, as a prognostic sign, is of no less importance than the induration itself. So long as this discolored spot is not en- tirely absorbed, the syphilitic diathesis is not cured, even though all the other symptoms of the skin and mucous mem- 158 PATHOLOGY AND TREATMENT OF SYPHILIS. brane produced by the syphilis have vanished, or perhaps have not yet appeared at all, because the induration has been treated with mercury from its very inception. According to our experience, it sometimes happens that an induration that has well-nigh disappeared, grows again after a longer or shorter period, and attains its former proportions (chancre redux), a condition that has been described as repul- lulation of the sclerotic node. This is, in so far, of prognostic importance, as it proves the obstinacy of the disease, and may be considered a prodrome of the speedy eruption of a syphilide. We have seen indurations last three months, even when the patient was treated with mercury from their very incep- tion. Very often they last eight or nine months, and even longer. With regard to the differential diagnosis, syphilitic initial sclerosis may easily be mistaken for epithelioma. The micro- scopic examination, to be sure, will furnish satisfactory evi- dence of the nature of the morbid alteration ; but the expe- rienced clinical physician will also be able to exclude syphilitic induration from the continuous disintegration of the carcinom- atous infiltration, and from the absence of the solitary, degen- erating, peculiar, rosy-red, velvety sclerotic ulcer. The dif- ferential data between soft chancre and a Hunterian indurated chancre have already been described. "We have repeatedly seen in children, who had been cir- cumcised according to the orthodox Hebrew rite, a distinct indurated node undergoing disintegration, situated in that part of the foreskin which remained, and in the glans penis, with coexisting hyperplastic enlarged lymphatic inguinal glands, that sometimes suppurated. Yet the children never suffered from secondary syphilis, having been kept under observation long enough to settle that point. Hence it seems that this kind of induration must be ascribed to the unskillful manner in which the operation, especially the laceration of the mucous mem- brane of the prepuce, was performed. Unicity of the Syphilitic Infection. Since other specific diseases, such as scarlatina, measles, etc., seldom occurred more than once in the same person, it was SYPHILIS. 159 supposed that this might also be true of syphilis. And, in fact, instances of persons having syphilis twice are very rare exceptions. Experiments undertaken for the purpose of con- finning this belief have proved that inoculations of persons with syphilitic virus who are still under the influence of the syphilitic diathesis produce no indurated chancres. From the results of these experiments Ricord was able to formulate the dogma of the unicity of syphilis (iincite de la syphilis) — i. e., any one who had or has syphilis, or, what amounts to the same thing, has had a Hunterian indurated chancre, never can get it again ; more correctly speaking, never can be infected again by syphilis. Ricord explained this law, which he an- nounced, by the assertion that the syphilitic poisoning, when once produced, lasts forever, and our treatment is only able to cause the manifestations of the disease, but not the disease itself, to disappear. This dogma of the unicity of syphilis is not, however, so invariably true as Ricord claims. H. Zeissl and other physi- cians have had repeated opportunities of observing reinfection in one and the same person. The reinfection with syphilis of a person who has had the disease proves that he was totally cured of his first attack. According to Diday, three important corollaries may be deduced from this law, namely : (a.) Syphilis can be cured radically. (b.) The length of time necessary for a radical cure of syphilis is at least twenty-two months. (ressions. The eroding gummata of the bones occur not only on the periosteum of the long tubular and flat bones, but also on the periosteal layers of the dura mater and on the medullary mem- brane. They are met with singly or multiple, in the latter case always in groups. Deposits of these gummata are some- times found on the internal and external bones of the skull. Yirchow has seen several times an external gumma-node cor- responding with one internally, and in one case the bone became perforated. 300 PATHOLOGY AND TREATMENT OF SYPHILIS. Ostitis Syphilitica. In consequence of syphilis, the medullary spaces of the bones may be the site of inflammatory deposits, like the gelat- inous new growths between the periosteum and bone in peri- ostitis, the fine connective-tissue meshes that contain fat be- coming generating places for the new growth. So long as the neoplastic connective tissue retains the gelatinous composition, so long is the affected part of the bone soft, and easily cut with a knife. If absorption sets in early, the diseased bone again becomes perfectly normal ; if not, the condition of th6 part gradually becomes altered. The affected part becomes sclerotic, like ivory, eburnated, or it degenerates into a state of osteoporosis, or is destroyed by suppuration (caries profun- da, according to Eokitansky). The favorable termination is in osteo-sclerosis, in which the affected bone is both thicker and heavier, but not otherwise impaired. The case is altogether different with osteo-porotic bone ; this is soft, can be bent, and has a markedly waxy color. When it undergoes suppuration, the cells and the spaces in the meshes are dilated and filled with ichor. The bone is discolored, brittle, or livid, if the granulations exuberate in the spaces ; it resembles a putrid piece of flesh, and is readily broken down by the pressure of the finger, and may be cut with the knife. It has lost its firm, cortical substance, and is permeated throughout with pro- liferating granulations. In other cases, a new bone has origi- nated from the osseous cortical substance, which goes on grow- ing, while internally it continues to suppurate, producing an appearance as if the carious bone had become inflated. Occa- sionally, a circumscribed collection of ichorous matter takes place ; it is sometimes surrounded by a hypertrophied osseous substance, and is lined internally by a layer of rich vascular granulations. The process of ulcerative destruction consists in the fusion of the bone-substance with the walls of the medul- lary spaces and with the bone-cells, which become dilated and filled with a mass of finely granular detritus. The fusion of the intercellular substance goes on while the salts of lime are being diminished. The marrow undergoes degeneration into a fatty ichor, as a result of the destruction of its fatty cells. SYPHILIS. 301 Adjoining the suppurative process of the bone, the soft parts are always affected to some extent with inflammation, which terminates partly in new hyperplastic deposits, and partly in purulent infiltration. The periosteum becomes hypertrophied and united to the adjacent connective-tissue proliferations, forming a gelatinous or fibrous bulbous mass, infiltrated by purulent deposits, in which the muscles are agglutinated. The latter grow pale and are destroyed. According to cir- cumstances, the purulent collection, in or on the bone, will burst externally, sometimes a large ulcer then results, or one or more straight or crooked, simple or ramifying long canals (fistulse, sinuses) form, in the vicinity or at a distance, whose openings are generally surrounded by a rampart of granula- tions, or they burrow their way into a joint. The granulations have a characteristic appearance, resembling a hen's anus, and always indicate the presence of dead bone. Gummata occur not infrequently in the medullary spaces. Leber t, Rouget, Gosselin, Follin, Virchow, and Chiari have seen them in this locality. Thus, necrosis of the bones of the skull, in the course of constitutional syphilis, generates pe- culiarities which led Virchow to assume that this necrosis be- longs to the gummous form. The necrosis here goes on from within outward; the dead piece of bone begins to detach itself by the formation of an indented line of demarkation from the still living indurated bone, the borders of the latter frequently projecting over the necrosed piece. Sometimes several points of necrosis are met with near each other or at remote places ; in the former case they coalesce and cause terrible destruction. On its external surface the dead piece of bone has large holes, which coalesce inwardly, looking very much as if the gumma had originated within it ; but the in- closing necrotic substance is at the same time indurated and heavy, presenting a most peculiar appearance. Chiari has observed gummata in the medullary canal of long bones, which, during life, seldom produced any clini- cal symptoms. They may be absorbed or cause induration of the osseous tissues or central necrosis. Syphilitic affec- tions of the bones not infrequently result in spontaneous fractures. 302 PATHOLOGY AND TREATMENT OF SYPHILIS. Cicatrization of Syphilitic Ulcers of the Bones. Rokitansky and Virchow state that a syphilitic osseous scar possesses remarkable peculiarities. According to the former, the parts surrounding an ulcer of the bone display not infre- quently induration combined with hyperostosis. Virchow de- scribes the syphilitic osseous cicatrices in the following words : " Every specific scar in a bone is characterized by a lack of pro- duction of bone-substance in its center, while a superfluity forms at its circumference." If the bone, says Virchow further, is totally destroyed at one place, as is often the case in the bones of the palate, nasal septum, or of the skull, nothing, or at least no ossific matter, will form in its place. Nowhere is this so strikingly to be seen as on the skull, where the orifice, on its inner surface, is covered with a membrane so capable of producing ossification as the dura mater. The latter soon thickens at the site of perforation, and when the necrotic piece of bone is removed a scar forms, on whose borders the external skin, and the soft parts covering the skull, the bone, and the dura mater are fused together into a common mass, and afterward appears as a white, angemic, dense, thickened substance. The longer it lasts the denser and shorter it grows, so that the natural arching of the skull at this point disap- pears, the entire scar gradually becoming flattened. If the entire thickness of the bone is not affected with necrosis, an irregular depression will result after the dead piece of bone has exfoliated. But little newly formed cicatricial tissue is found later in this depression, and the loss of substance here is hardly ever replaced by regenerative processes. The only sign of regeneration is found at the margins. These, which originally were very abrupt, gradually become thinner, and subsequently, by the interposition of a bony rind, usually are transformed into a space that is permeated by grooves and fissures. As induration and hyperostosis of the surrounding bony parts regularly take place here, the places resemble very much those that have been produced by inflammatory atrophy without necrosis or suppuration. SYPHILIS. 303 Site and Effects of Syphilitic Periostitis and Ostitis. Any part of the skeleton may become affected by syphilis. The cranium, the palate-bones, the clavicles, the sternum, and the tibiae are, however, most frequently diseased, probably be- cause these parts are more liable to be affected by external causes, such as changes of temperature, the air, and especially mechanical injuries. Bones with many angles, such as the pha- langes, the metacarpal and metatarsal, are very rarely affected. Those enlargements of the bones of the pelvis, which at the time of Kilian were described as acantho-pelvis or thorn-pelvis, may perhaps sometimes originate from syphilis. Periostitis and osteomyelitis may occur in the bones that have been men- tioned. The diaphyses alone of the tubular bones are almost exclusively attacked ; the epiphyses become affected in excep- tional cases only, especially in congenital syphilis. The ter- minations of periostitis and ostitis vary in different bones. Thus ossifying, ulcerating, and gummous periostitis, osteo- sclerosis, osteoporosis, caries, and necrosis, occur on the bones of the skull, while the intra-maxillary portion of the superior maxilla is pre-eminently liable to suffer from suppurative ostitis. Specific caries and necrosis seldom originate in the inferior maxilla; frequently, however, ossifying or indurating perios- titis develops here. Some of the nerve or vascular trunks may be compressed by osteophytes, whereby neuralgias, palsies, and disturbances of circulation will be produced. Thus, we saw the ischiatic nerve compressed by an exostosis on the great sacro-ischiatic foramen, and the corresponding limb was paralyzed. Paraly- sis of the facial nerve and of the corresponding side of the face may be produced by an osteophyte near the stylo-mastoid process. Again, an exostosis or a gumma on the sella turcica, on which the optic commissure rests, will compress the nerve of vision to such a degree that the patient may become totally blind. Osteophytes and exostoses in the orbit of the eye may give rise to exophthalmos. By ossification of the internal auditory meatus permanent deafness may ensue. Ossific hy- pertrophies on the inner plate of the cranium may, by pressure on the brain, produce convulsions, epileptic attacks, and soft- 304 PATHOLOGY AND TREATMENT OF SYPHILIS. ening of the brain. If a gumma over the frontal sinus under- goes softening, or if a large or small piece of the cranium at this place becomes necrotic, fatal haemorrhage, by opening into the superior longitudinal sinus, or meningitis may result. Caries of the mastoid process may perforate into the tympanic cavity, thereby causing detachment and removal of the ossicles of the ear, and this will be followed by deafness. Differential Diagnosis of Affections of the Bones produced by Syphilis. Many of the extreme opponents of the mercurial treatment maintain that all the affections of the bones occurring in syphi- litic persons are brought about by the use of mercury, and that syphilis, per se, is not capable of producing either ostitis or periostitis. Still others, who do not deny the existence of syphilitic-bone diseases (Mathias), contend that specific affec- tions of the bones are a combination of syphilis and mercurial- ization — syphilis that has been modified by a treatment with mercury. But neither Overbeck's experiments nor Kussmaul's clinical observations furnish any evidence that mercurial dis- ease of the bones occurs. Mercury attacks only the maxillary bones with periostitis and necrosis, and then only in conse- quence of mercurial stomatitis, when the mineral was used in- judiciously and in excessively large doses, and was followed by gangrene of the mucous membrane, and the periosteum of the maxillae. There then originate those large, pumice-stone-like, porous, hypertrophic growths which are known by the name of osteophytes, and differ strikingly from syphilitic affec- tions. It is impossible to determine at present from an anatom- ical standpoint whether any given affection of the bone is of scrofulous, syphilitic, or gouty nature ; nor will it ever be pos- sible, as Engle says, to characterize any form of osteophyte as pathognomonic of this or that dyscrasia. If the disease of the bones be not of a gummous character, the clinical physician will have to rely upon a number of symptoms to form a diagnosis just as he is compelled to do in specific diseases of the skin and mucous membrane. The diagnosis is rendered all the more difficult by the fact that in many cases most of the symp- SYPHILIS. 305 toms of syphilis are absent, because specific affections of the bones very often occur without any syphilitic manifestations on the skin and mucous membranes. In opposition to this view, Ricord maintains that exostoses originating from syphilis oftener affect the upper surface, while those resulting from scrofula affect the parenchyma of the bone. Rokitansky and Yirchow assert that the plano-convex osteo- phyte deposited upon the cranial bones is a form of disease peculiar to syphilis. We have already alluded to the fact that both of these authors maintain that specific cicatrices of bones are peculiarly constituted. In regard to gout or rheumatism, we believe that this dyscrasia produces the gouty nodes rather upon the small joints — for example, the fingers and toes ; and, further, that it deposits its inflammatory prod- uct in the form of a powder upon the cartilages of the joints, while syphilis affects the shaft of the bone. Syphilis of the bones occurs more frequently in women than in men ; furthermore, it is a frequent symptom of heredi- tary syphilis occurring in youth. Syphilitic Affections of the Joints. Arthropathies originating from syphilis occur very seldom. The few joint affections in syphilitics that came under our ob- servation generally attacked the knee and ankle, more rarely the acromial joint, and rarest of all the elbow- joint and wrist- joint. "We have no positive evidences that syphilis exercises any influence in the production of joint affections. Some of the arthropathies which we noticed on syphilitic patients were recent, appeared in an acute manner, and were attended with violent pains ; some consisted of degeneration of the joints, hydrarthrosis, tumor albus, and ankylosis. In most cases anti- syphilitic treatment exercised no beneficial influence over the affection of the joint, while general and local treatment di- rected against the presumable underlying chlorosis, scrofula, or gout, was crowned with better success. But even those affections of the joints which get well under antispecific treat- ment afford no proof that they were of syphilitic nature. "We are only justified in maintaining that a joint is the site of syphilis when it is pathologically demonstrated that the spe- 20 306 PATHOLOGY AND TREATMENT OF SYPEILIS. cific morbid product of syphilis, gumma, is found in the struct- ures entering into the conformation of the joint. Till then the occurrence of specific affections of the joints will remain doubtful, to say the least. Lancereaux mentions two cases of syphilitic affection of the knee-joint in which gumma-like tumors were found in the synovial capsule and in the liga- ments of the joint. Recently many authors — especially Nekton, Lancereaux, Chassaignac, Archambault, Loicke, and Erlach, in Berne ; Bergh, in Copenhagen; Yolkmann, in Halle; and Taylor, in New York — have called attention to a disease of the phalangeal joints, originating from syphilis, which has been described as dactylitis syphilitica. Specific dactylitis occurs in the fingers and toes. The af- fected phalanges are markedly increased in thickness, so that they are unable to retain their position between the fingers, and lie upon their fellows. The swelling, moreover, is not only noticeable on the diseased phalanx, but also on the ad- joining phalanges. The skin of these phalanges is bluish in color, the swelling is tense, and on pressure felt to be elastic, but leaves no depression; it is more prominent on the dor- sal than on the volar surface of the affected bones. The movements of the diseased joints are more or less interfered with, and on forcible motion crepitation may be felt in the joints ; active movement is almost impossible. The pain even on pressure is generally slight. In those cases that came un- der our observation, the first and second phalangeal joints were most frequently involved ; the metacarpo-phalangeal joint not so often. Syphilitic dactylitis is due to gummous deposits in the sub- cutaneous connective tissue, periosteum, bone, and the textures entering into the formation of the joint. The diagnosis of the specific origin of this affection can only be firmly established by the previous and present history, and the result of treat- ment. In most cases an appropriate treatment will bring about complete recovery ; sometimes there results a pyoar- throsis, or the disease terminates in atrophy of the diseased phalanx, while the integument, joint, and tendons remain normal. SYPHILIS. 307 Syphilitic Affection of the Cartilages. The cartilages of the nose, eyelids, and larynx, in conse- quence of syphilis, may undergo the same kind of morbid al- terations, attended by suppuration, as are observed on the con- tiguous skin and mucous membrane. If only a small piece of mucous membrane overlying the perichondrium is destroyed, the affected cartilage will be perforated at that point, as is the case with the cartilage of the septum nasi ; or if the cartilage itself is attacked, a piece of it will slough away by carious ul- ceration, as is often seen to occur on the epiglottis. In either event the rest of the cartilage suffers no textural changes. The case is altogether different with the thyroid cartilage — here perichondritis and ossification of the cartilage likewise take place without inflammation. The larynx loses its natural elasticity, and pressure on the lateral surfaces of the thyroid cartilages causes pain. Aside from the fact that in perichon- dritis the mucous membrane of the larynx is markedly swollen, the aryepiglottic ligaments degenerate into fibrous welts, the vocal cords become thickened, and thus lose so much of their mobility that, on account of the ossification of the thyroid car- tilage, the laryngeal cavity is no longer surrounded by elastic but by tense walls, thus causing marked interference with phonation. Caries or necrosis of the thyroid cartilage in con- sequence of syphilis occurs very seldom. But if ulcers form in the broad part of the mucous membrane, corresponding to the cricoid cartilage, the part of the cartilage that has become denuded will become ossified and carious. If the caries then attacks the upper border of the cricoid cartilage itself, the joint connection with the arytenoid cartilage is destroyed, the latter ossifies, and then likewise becomes necrotic. The adhe- sions on the cricoid and thyroid cartilages then become so feeble that one of the arytenoid cartilages may be coughed up, or an abscess forms in the vicinity through which the cartilage is expelled. If the abscess encroaches upon the cornua of the hyoid bone, the latter will also become necrotic and expelled through the aperture. This kind of degeneration and destruc- tion of the cartilages of the larynx may also originate from laryngeal tuberculosis. 308 PATHOLOGY AND TREATMENT OF SYPHILIS. Syphilitic Affections of Muscles, Tendons, and Sheaths of Tendons. Disease of some of the muscles is a painful and not infre- quently a grave affection that occurs in the later stages of syphilis. Specific disease of the muscles is sometimes accom- panied by pains like those of muscular rheumatism. The pains gradually increase in severity till they attain such an intensity that the muscles become perfectly rigid and immovable. They are then in a state of constant contraction. The pains in some parts of the muscles will be considerably aggravated by con- tact. They often subside, but increase in severity when at- tempts are made to extend the limb forcibly. The disease of the muscle results from a chronic local inflammation of the muscular sheath, in which a circum- scribed hypertrophy caused by proliferation of connective tis- sue ensues, so that the primitive muscular fibers are destroyed and absorbed. At the places where the muscular structure is destroyed, the connective tissue that proliferates from the peri- mysium may, under certain circumstances, according to Nek- ton, increase to the size of a hazel-nut or hen's egg, and con- stitute a gumma. Contrary to Nekton's statement, however, we were seldom able to discover a muscular node by the sense of touch ; nor, as a rule, did we find any change in the color of the skin over the affected parts. The morbid alteration is usually situated in the belly of the muscle, but is said to occur likewise in the tendinous part. According to our observations, syphilitic contractures took place in the vast majority of cases in the biceps brachii, next in the biceps femoris, once only in the left sterno-cleido-mas- toid, in consequence of which collum obstipum originated. There are some cases of strabismus occurring in syphilitic patients which may not be due to peripheral or central affec- tion of the nerves of the ocular muscles, but to gummous alterations in the ocular muscles themselves. Nekton has seen gummata in the biceps brachii, pectoralis major, mas- seter, in both gemelli, in the rectus abdominis, and in the semi-membranosus. We once saw a patient in whom gummous tumors formed SYPHILIS. 309 in the peroneus of the right leg and in the tibialis posticus of the left leg. The tumor of the tibialis posticus diminished markedly in size after the internal use and local application of iodides. The gumma in the peroneus degenerated and broke through the skin, spreading downward till it reached the corresponding malleolus. Syphilitic muscular disease, when recognized early and treated rationally, lasts only a short time ; left to itself it will last a much longer time. If the connective tissue which pro- liferates into the muscular fibrillse is absorbed, the affected muscles may be completely restored and capable of perform- ing their function ; but if the morbid lesion has lasted for a long while, the muscle becomes atrophied and forever re- mains contractured. Specific muscular tumors may become soft and break through the skin above them. It is claimed that restitution of the muscle is possible even after the skin has been ruptured, if the morbid changes of the muscle do not extend too deeply. In the latter event, the muscle in- variably atrophies. There is no doubt whatever that the sheaths of the tendons, like any other organ or part of an organ, may become affected by syphilis. Diseases of the tendinous sheaths are, however, very rare, few instances being recorded in medical literature. In the year 1868 Yerneuil reported the occurrence of serous effusion into the tendinous sheaths of the extensors of the fingers in syphilitic patients. In Yerneuil's four cases, all of which were observed in women, the affection of the tendinous sheaths occurred simultaneously with the outbreak of secondary mani- festations. There was considerable exudation, but it never ex- tended to the forearm ; it fluctuated distinctly, and the swell- ing was sharply defined ; the skin was not changed. Fournier, commenting on the report of Yerneuirs cases, says that he has seen six cases of this kind, and thinks the disease is of fre- quent occurrence. This author met with syphilitic affections of the sinews and tendinous sheaths on the extensor muscles of the toes, on the tendo- Achilles, on the biceps of the upper and lower extremity, on the supinator longus, peroneus, etc. Ac- cording to Fournier, " painless tumors with marked exudation 310 PATHOLOGY AND TREATMENT OF SYPHILIS. occur ; but sometimes inflammatory phenomena, attended by redness of the skin, are present. In other cases, little or no fluctuation is felt, the tumor is doughy, or the affection can only be recognized from the impaired function of the muscle and painfulness of a tendon on pressure. Gummata have also been observed on the sheaths of tendons. Thus, Baumler men- tions a case reported by Nunn, in which a pale, yellowish tu- mor, half the size of an orange, formed in the tendons on the dorsum of the foot, in a person forty-five years of age, who for twenty years had suffered from syphilis. It was expelled by suppuration through the skin — a similar one having been ex- pelled in the same manner, some time previously, from the sinews on the side of the knee." Chouet, in his valuable work, also describes a case of a gumma which developed in the tendinous sheath of the anterior peroneus muscle of the right side. The gumma underwent degeneration and slough- ing. This lesion appeared fifteen or sixteen years after the person became infected. We saw in a person affected with syphilis bilateral hygroma of the forearms, corresponding to the common extensors. Syphilitic Affection of the Bursse. We have never had an opportunity of seeing an undoubted case of syphilitic affection of the bursse ; hence, we can only refer to the writings of other specialists upon this specific affection. Keyes, for the sake of analogy, divides syphilitic affections of the bursse into the secondary and tertiary forms. He has never seen a case of secondary bursitis with or without exudation into the bursa ; still, he thinks the existence of this lesion, comparing it to other similar affections of the joints and of the tendons, is very probable. Allusions to the occur- rence of secondary syphilitic bursitis without effusion are found in the writings of Jules Yoisin, Fournier, and Adolphe Yafner. Gosselin, Fournier, and Verneuil have described graph- ically inflammation of the bursa with effusion. Secondary syphilitic inflammation of the bursa causes little inconvenience, and may therefore easily be overlooked. Tertiary affections of the bursa, on the contrary, are not so unusual. According to Keyes, it is not possible to divide them into the gummous and SYPHILIS. 311 hyperplastic forms, as there is no proof of the occurrence of the latter. All the known cases are of the first form. There are no post-mortem observations of this disease. From a clinical point of view, however, two kinds of gummous bur- sitis may be distinguished : One occurs by the extension of the disease from adjacent tissues ; the other originates in the bursa itself. Keyes relates fourteen cases — seven of which are not yet reported — of tertiary, specific bursitis. In twelve the bursee were primarily affected. The bursse in the vicinity of the knee were affected eight times ; those over the patella on both sides, in three cases ; on one side, in two cases ; over the tuberosity of the tibiae, in one case ; between the insertion of the semitendinosus and the lateral ligament of the knee-joint, each one — upon both sides alike, and upon one side alone. In the other four cases, the bursa was affected on one side only over a malleolus, under a corn, in the palm of the hand, and over the olecranon process. Both sexes are equally affected by it ; but, in all of the six women, the bursse of the knee only were diseased. The average age of the patients was thirty-five years. The shortest time that elapsed between the occurrence of the chancre and that of the bursitis was one and a half year ; the longest, eight and a half years. In half of the cases, an injury was found to be the causal factor that started the lesion. In all cases the disease ran a painless course till the skin became involved. Fluctuation could only be detected in some cases, and then indistinctly. Antisyphi- litic treatment generally brought about a rapid recovery — in all, marked improvement. For further information, we refer the reader to the works of Chouet and Yiday. Endemic Syphilis ; Leproid or Syphiloid Disease. During the last century, and until quite recently, attention was attracted to a peculiar form of disease that appeared like a pest in various parts of Europe and America. Sometimes this was regarded as a modification of leprosy (lepra seu elephantiasis grsecorum), and then again as a degenerated syphilis ; and, ac- cording to the relative view of the matter, was described either as leproid or syphiloid. These forms of disease were popu- larly designated according to the place or province where they 312 PATHOLOGY AND TREATMENT OF SYPHILIS. occurred inost frequently. Thus, in Norway and Sweden it was called " Badesyge " (from rada, bad, miserable, and syge, pest) ; in other places — the Holstein, the Ditmarsian, or marsh — the Jutland disease ; in the Austro-Hungarian Empire, SherVvejo or Scherlievo, after a village in Fiumaner County. There are still other synonyma : mat di Fiume, di Fueine, mat di Bagussa, di Breno, Falcadine. It was also spoken of as Lithuanian or Courlandian and Hessian syphiloid. In Servia the disease belonging to this group was called Frenga ; in the Bukowina, in Liebenbiirgen, in Koumania, Boala ; in Greece, " Spirokolon, orchida, and FrangoP In French Can- ada it was known by the name of mal de la Bay de St. Paul, mal Anglais, maladie des ehoulements, the Ottawa disease, and as Canadian syphiloid. In Scotland syphilis occurring endemically was described as siavvin, sibben, or sibbens, owing to the resemblance of the moist cutaneous nodes, which the evil engendered, to a cluster of Scottish strawberries, which in the Celtic dialect is called sivvin. On closer investigation these endemic diseases proved, in the vast majority of cases, to be hereditary and acquired syphilis ; but especially the in- veterate and neglected variety, the so-called tertiary manifesta- tions. In addition, many other ordinary chronic diseases of the skin, such as chronic eczema, lupus, psoriasis, etc., were in- cluded. These endemics of syphilis were soon subjugated by the sanitary regulations that were established for the control of the patients, and by hospitals, where the disease was treated by antisyphilitic remedies. [Malignant or Galloping Syphilis. By the term malignant or galloping syphilis (already al- luded to on page 172) is meant a form of syphilitic disease that runs an exceedingly rapid course, but which differs very little from ordinary syphilis in the essential features of the fundamental malady. The lesions of the different manifes- tations present only the characteristic trait of running an ex- tremely rapid course. Ordinarily, the morbid phenomena, after the acute stage of the eruption has passed, lapse into a markedly chronic condition, but in the galloping form the disease retains its acute character, and the eruptions that f ol- SYPHILIS. 313 low succeed one another very rapidly, so that the lesions com- monly denominated tertiary appear within a few months from the time the patient became infected. The secondary period, which ordinarily lasts two and three years, is here only of short duration ; indeed, in some cases no secondary phenomena are noticeable at all, the very first eruption being tertiary in char- acter, the disease sometimes overleaping the secondary and lapsing into the tertiary stage in perhaps three months from the time infection took place. None of the constitutional phenomena of malignant syphi- lis, including the primary initial lesion, display any marked deviation from the corresponding manifestations of cases that run an ordinary course. Neither the site nor the formation of the initial indurated lesion, neither a gangrenous, nor any other peculiarity of the chancre, has any effect in producing this form of syphilis. Even the first eruption usually presents nothing peculiar, though the one following may assume a ter- tiary character. In some cases, again, the first general mani- festation of the disease may be a pustular eruption and the efflorescences, instead of desquamating and healing, are rapid- ly converted into ulcers. In that case the ulcerating tertiary syphilides differ from their prototype of ordinary syphilis by appearing in greater numbers, the entire body being cohered by them. They vary greatly in form, and are more confused and irregular in the cases that run a rapid course. Gummata of the skin are seldom or never seen early in malignant syphilis, a circumstance that is easily explained by the rapid course of the disease, and by the great tendency of the morbid product to undergo suppuration. Specific affections of other organs, of the mucous membranes, bones, viscera, etc., present as lit- tle diversity in malignant syphilis as the morbid products of those organs in cases that run an ordinary course, differ- ing only as regards the time of their appearance. There is but one symptom that is pathognomonic of this variety of syphilis, namely, the occurrence of febrile phenomena pre- vious to the outbreak of each successive eruption, while in ordinary cases the several eruptions are not generally ushered in by fever. The most important feature in the course of galloping 314 PATHOLOGY AND TREATMENT OF SYPHILIS. syphilis, as already intimated, is the early appearance of what has been denominated tertiary phenomena, and the total ab- sence or brief duration of the secondary stage. But as the lesions of syphilis have been arbitrarily classified, and no symptom or group of symptoms is indicative of the stage of the disease, it is impossible to draw a line between the cases that run a normal and those that run a rapid malignant course, according to the period that has elapsed from the time infec- tion occurred till the appearance of the first eruption. Still, it will not be amiss to consider those cases in which tertiary manifestations appear in the course of the first year as belong- ing to the galloping or malignant variety. It will also be self- evident that, when the disease runs such a rapid course, the various manifestations will be complicated by preceding and subsequent morbid phenomena. Hence we have in galloping syphilis new outbreaks of eruptions before the preceding ones have been cured, and these eruptions or the lesions of the vis- cera always manifest the late character of the disease. Notwithstanding the rapidity of the course and the severity of the various manifestations that characterize malignant syphi- lis, instances have been known in which the subsequent out- bursts of morbid phenomena occurred at longer intervals, the eruptions were less severe and fewer in numbers, the succeed- ing efflorescences being papular and segregated instead of ul- cerating and aggregating ; and, finally, even this galloping ma- lignant syphilis seems to have run its course, and the disease, like an extinct volcano, has apparently died out. In regard to the diagnosis there is nothing in the phe- nomena of galloping syphilis that is likely to render it more difficult than in ordinary cases. Indeed, the multiplicity and profuseness of the eruptions, and the severity of the ulcera- tions are apt to render it all the more easy. But in regard to the prognosis the case is altogether different. It is evident that the terrible and frequent eruptions, the intensity of the ulcerations, the recurrence of the febrile phenomena, must ulti- mately exhaust the patient and terminate in death. Another circumstance that adds to the gravity of the prognosis in ma- lignant syphilis is the danger to the internal organs, especially the brain, which may be attacked early in the disease ; some- SYPHILIS. 315 times, indeed, before the expiration of the first year. Such cases usually terminate fatally (Fournier). In regard to the causes that will produce galloping syphi- lis in a certain class of patients, little definite is known. There is good authority for saying that the malignant or galloping form was quite common when syphilis first appeared epidemi- cally ; it is now, however, quite rare. Unquestionably it de- pends upon certain conditions of the constitution of the patient for its production — cachexia, 'alcoholism, depraved habits, 'or the like — and which render the system less able to resist the virulency of the syphilitic poison on the one hand and less amenable to treatment on the other. Still, I can recall two in- stances where none of these conditions obtained, both patients being entirely free from any discoverable taint that could have served as a cause for the production of this form, since they were middle-aged, well-developed men with good previous histories. The results of the treatment of this particular form of syphilis may be readily inferred from its character. It is ex- ceedingly obstinate to treatment, and successful results are ob- tained in exceptional cases only. The exhaustion consequent upon the extensive drain upon the system from the numerous and severe ulcers, the debilitating intercurrent febrile attacks, or the speedy encroachment of the disease upon some of the important viscera, will nullify the physician's efforts and hasten the fatal end.] Hereditary Syphilis. By the term hereditary syphilis is meant that species of syphilis that is inherited from syphilitic parents by the progeny begotten by them. Hereditary syphilis is mainly characterized by the fact that the individuals affected by it never present any primary specific lesion. In the majority of cases heredi- tary syphilitic children are born with the evidences of the dis- ease, or the manifestations develop during the first few weeks of extra-uterine life. Generally, the signs of hereditary syphi- lis appear during the first three months after birth. In very rare cases the symptoms do not come on till the time of pu- berty of the unhappy victim, this form being designated by 316 PATHOLOGY AND TREATMENT OF SYPHILIS. the term syphilis hereditaria tarda. Hereditary syphilis may, therefore, be subdivided into two varieties, viz. (1) syphilis hereditaria prcecox (which appears a short time after birth), and (2) syphilis hereditaria tarda (which does not appear till a long time after birth, usually at the period of puberty). In regard to the theory of inheritance, we may, relying upon our experience and that of other authors, lay down the following aphorisms : 1. If one of the parents is syphilitic at the time the child is procreated, it may be syphilitic. 2. There are cases in which syphilitic parents, even while still manifesting evidences of recent syphilis, procreate healthy children. 3. "When a mother, healthy at the time of procreation, gives birth to a child who has inherited the disease from the father, the mother will suffer from latent syphilis at the most, because till now only three cases are known of mothers be- coming infected by the hereditarily syphilitic children whom they suckled. (The infection of the mother by a syphilitic child, through the placental circulation, according to Ricord and Diday, is called choc en retour.) The circumstance that mothers never, or very seldom, are infected by their own children during wet-nursing, is now known as Colles's law. 4. If both parents were sound at the time of procreation, and the mother acquires syphilis during pregnancy, the child may, after being begotten, become syphilitic. The later in the period of gestation the infection of the mother occurs, the more probable is it that the child will remain well, because the contagium of syphilis has a shorter period in which to ex- ercise its effect upon the child. This kind of infection of the children is called infectio in utero (Kassowitz), or, according to Yajada, post-conceptional humoral infection. The placenta is no obstacle to the passage of the contagium from the mother to the foetus, or the reverse. 5. The more recent the syphilis in the parents, the more probable is it that the child will be infected, and the graver the manifestations in the latter are apt to be. Generally, the infants are still-born, or come into the world bearing specific manifestations. SYPHILIS. 317 6. If the disease in the parents is latent, the child will de- velop syphilis a long time after its birth. Grave forms of the disease are then rare, still they are not always absent in chil- dren of such parents. 7. The longer the time which has elapsed after the specific symptoms in the parents have disappeared, the less probable is it that they will beget syphilitic children. 8. In the majority of cases, syphilis in the parents gradu- ally grows feebler, so that, after begetting some syphilitic chil- dren, they finally procreate healthy ones. These aphorisms are the conclusions of our experience. No infallible dogma for hereditary syphilis and its dissemi- nation, however, can be laid down, and we and others have certainly met with exceptional cases, which will afford food for thought concerning the dissemination of the disease. No doubt that, by closer observation and more accurate knowledge gained concerning heredity in general, the mystery that still envelops much that is strange and hidden in the study of this chapter of syphilis will be solved, and the progress of science in the future will find the key to these problems. In regard to the influence that syphilis exercises upon preg- nancy, it may be premised that the foetus very often dies in utero very early, and then the macerated foetus {infantes semi- cocti), presenting the appearance of having been scalded, is aborted. Whether the death of the foetus is the result of dis- ease of the foetus itself, or of the uterus and placenta, has not yet been definitely decided. Pollnow regards hydrops sangui- nolentus as an intra-uterine disease of the foetus, and heredi- tary syphilis as one of the most frequent causes of it. Barnes thinks that syphilis engenders a morbid condition of the uter- ine mucous membrane — a chronic inflammation — and since the placenta which develops from the latter is the organ through which the foetus derives its nutriment, the latter must natu- rally die when its fountain of nutriment is diseased. Yirchow found morbid alterations in the maternal part of the pla- centa that reminded him strongly of gummous tumors {en- dometritis 'placentaris gummosa). Frankel has also demon- strated, in the fetal part of the placenta, a degeneration pro- duced by cellular proliferation of the placental follicles, which 318 PATHOLOGY AND TREATMENT OF SYPHILIS. may cause compression and obliteration of the follicular ves- sels, and finally terminate in fatty degeneration and atrophy of the placental follicles. Oedmanson found, in five cases of abortions produced by syphilis, alterations in the umbilical vessels and in the placenta. The umbilical vessels presented atheromatous inflammation of their walls ; in the main branches thrombi were found constituting the picture of interstitial pla- centitis. H. Zeissl noticed that the placentae of syphilitic women are comparatively smaller, feebler, and wilted, fatty, pale, and friable ; the surface facing the uterus presents small or large spots of so-called hepatization, which, in the upper strata, are infiltrated with calcareous incrustations. Children, who are overcome by the syphilitic diathesis during intra-uterine life, are either born with the manifesta- tions of the syphilis, or the latter appear in the first few days after birth. However even children begotten by fathers suf- fering from latent syphilis may come into the world apparently well, and remain well during early infancy. Later we notice the gradual formation of infiltrations (falsely called lupus syphilis hereditaria) upon some parts of the skin, with simul- taneous destruction of the soft palate and the nasal bones (ozwna syphilitica), the occurrence of hyperplasia on the cranial or tubular bones, etc. ; phenomena which formerly, even more than now, were deemed evidences of scrofula. Hence, as has been remarked, a congenital syphilis may be said to occur which manifests itself in utero, or a few days after birth, and an inherited syphilis, which casts off its mask later during youth. If syphilitic phenomena appear in a nursling several months after birth, such as we see in the first phases of acquired syphilis, they should not be regarded as the results of inherited syphilis, but of syphilis acquired per partum or postpartum. In regard to mothers who give birth to children with he- reditary syphilis, we wish to add, that Hutchinson believes that repeated bearing of syphilitic foetuses gradually engenders a specific poisoning of the mother, and that the consequences of this poisoning often appear very late, in which case they manifest themselves at once as tertiary phenomena. Baren- sprung maintains that the semen of a syphilitic man, which, SYPHILIS. 319 under ordinary circnmstances, is innocuous for the woman, will infect her as soon as he impregnates her. "Women who, at the time of conception, are affected with recent syphilis, seldom give birth to a viable foetus ; they generally abort or miscarry at the beginning of the eighth month or earlier. Ac- cording to Whitehead, four per cent of syphilitic infected moth- ers abort. We can not confirm the views of Mayer and Bednar, that all mothers affected with constitutional syphilis are abso- lutely sterile ; still, H. Zeissl met with many cases of women suffering from internal syphilis who were unfruitful. He saw women who had no signs of syphilitic primary lesion, or any specific exanthema, affected with periostitis and falling out of the hair, and with intense anaemia, which phenomena disap- peared upon antisyphilitic treatment. He believes that in these cases the semen of the syphilitic man was the medium of infection of the woman. Manifestations of Congenital Syphilis. Congenital syphilis engenders morbid alterations similar to those produced by the acquired form. Infants affected with marked hereditary syphilis at the time of birth are, as a rule, badly nourished ; the skin generally, and that of the face espe- cially, is wrinkled, giving them the appearance of a weazened, marasmatic old man. The morbid alterations of the general skin resemble very much the analogous eruptions of acquired syphilis in the adult. According to our experience, however, congenital syphilis of the skin appears only under three main forms, namely, macu- lar, papular, and bullous syphilide. We never saw rupia, ecthy- ma and cutaneous nodes in infants. As a sign of hereditary syphilis manifesting itself in the earliest period of infancy, Hutchinson mentions the peculiar curving of the upper incisor teeth ; this lesion is said to be due to a faulty development of the dental sacs that keeps pace with the general atrophy of the body. As a consequence, the permanent incisors remain short and narrow, being wide at the base, and their angles rounded ; their lower borders are deeply indented in the center ; they have a dirty-yellowish color, and seem to be semi-transparent. Similar signs, if they appear on 320 PATHOLOGY AND TREATMENT OF SYPHILIS. the other teeth, are said to be of no diagnostic value. We are not inclined to attach much importance to them. Macular Syphilide in the Infant; Erythema Maculo-papulatnm Syphiliticum Neonatorum. This syphilide generally develops in the first weeks of in- fancy, if the new-born child does not come into the world with it. A late appearance of macular syphilide in the infant always indicates that it was not infected in utero, but outside of it, post jpartum or per partum. Macular syphilide of the new-born presents the same characteristics as its prototype in the adult, originating through acquired syphilis. Most of the spots that attract attention are situated on the sides of the thorax, be- coming sparser toward the sternum ; they are never seen on the neck and face ; a few occur on the forehead where the hairs cease to grow. If the affected child is not treated promptly and judiciously, other syphilitic phenomena quickly make their appearauce on different parts of the body. Flat, copper-colored nodules, as big as a lentil, then form on the palms of the hands and soles of the feet, and on the heels, and soon become covered with yellowish scales, which may be easily pulled off, or excoria- tions and fissures (rhagades) originate on the places mentioned, especially on the heels. Frequently the grooves near the alee nasi are remarkably red, and covered with fine, whitish scales, while mucous-membrane papules are present at the angles of the mouth and nasal orifices, upon which the mucus has dried and formed crusts. These kinds of humid cutaneous or mu- cous-membrane papules form in the folds of the buttocks, in the hollow of the knee, at the anus, scrotum, and in the genito- crural folds of both sexes. The papules that are met with on the latter places soon lose their caruncular condition, from causes already mentioned, and are then likely to be mistaken for intertrigo. The denuded corium on these places secretes a yellowish, glutinous fluid that speedily putrefies. In many infants, erythema maculo-papulatum syphilitica appears, as in the adult, on the internal surface of the prepuce, on the glans penis, and on the labia minora. Or circumscribed dark spots, varying in size from that of a lentil to that of a bean, occur on SYPHILIS. 321 those places, which become excoriated by catarrh of the glans or of the vulva (that is frequently present), and are transformed into bright red abrasions. In some cases, a few solitary lenticular papules are found among the roseola-spots, mostly on the elbow and on the in- ternal surfaces of both thighs. We never saw macular syphi- lide on the new-born or nursling without the simultaneous presence of moist papules on some places, for instance on the anus, labia majora, angles of the mouth, and between the toes. The cervical, axillary, and other glands seldom swell up to such an extent in consequence of syphilis congenita in the in- fant as in the adult. So long as no phenomena of suppuration supervene, macu- lar syphilide in the new-born child runs an apyrexial course. We can recall but one case of recovery of a child affected with syphilis congenita maculosa. All the others became anaemic, and terminated their miserable existence in about two or three weeks, from complications with exhausting diarrhoea, bron- chial catarrh, or pneumonia. Papular Syphilide in the Infant. We found that papular syphilide, in its various metamor- phoses, occurs less frequently than the macular form in the new-born, and, in regard to location, succession to and combi- nation with other syphilides, it behaves precisely as does its prototype in the adult. We have rarely seen the so-called papulo-miliaries or lichen miliaries syphilitica as the result of congenital syphilis. In children who do not bring papules into the world with them, the eruption will not develop simul- taneously on all the places where they usually occur ; this accounts for the finding on such infants of young and old papules. In rare cases, the papules are grouped together so closely, on some places, that their scales form an almost unbroken coat-of-mail. Most of the scales, in the two cases that came under our observation, occurred on the back, sides of the chest, on the palms of the hands and soles of the feet, and, in part, on the forehead and nape of the neck. 21 322 PATHOLOGY AND TREATMENT OF SYPHILIS. Pustular, Gummous, and Hemorrhagic Syphilide in the Infant. We observed pustular or bullous cutaneous affection in the new-born more frequently than papular syphilide. Infants either bring it with them into the world, or they become affected by it during the first week after birth. In the latter case, brownish-red spots or papules, varying in size from that of a lentil to that of a pea, slightly elevated above the level of the skin, are found on the forehead, especially near the eye- lashes, in the face, now and then on the chin, on the buttocks, on the extensor and flexor surfaces of the extremities, and, in greatest numbers, on the palms of the hands and soles of the feet. Within three or four days, most of these spots and flat papules are changed into flabby pustules, containing yellowish- green, thin pus, of the size of a pea and larger. The pustules are not perfectly round; here and there, especially on the palms of the hands and soles of the feet, they are indented and irregular, as the result of the coalescence of several ag- gregated efflorescences. The center of the pustules collapses speedily, whereby the umbilicated depression ensues. But, while the central depression of the cover of the pustule dries, and forms a thin crust, the remaining purulent contents raise the contiguous epidermis, and the pustular wall that has not yet dried is thereby increased in circumference. The red- dened cutis beneath the thin crust is found somewhat injured, as in varicella and impetigo of the nursling and adult, but by no means very seriously. This is a somewhat hastily sketched morbid picture of the cutaneous disease which is generally described as pemphigus syphiliticus neonatorum, a synonym, which H. Zeissl deems incorrect, since neither transparent vesicles form, nor, as in pemphigus foiiaceus, do the contents of these blebs, that speedily become opaque, wash away the epidermal covering, resulting sometimes in the exposure of a large extent of inflamed cutis. H. Zeissl therefore deems it more correct, in accordance with the laws of analogy, to de- scribe the eruption under consideration as varicella syphilitica confluens neonatorum, because in the latter, as in the confluent varioloid syphilide of the adult, an umbilicated depression of some of the pustules containing thin pus, recurs. SYPHILIS. 323 Severe excoriations generally occur on the heels as an ac- cessory phenomenon in the bullous or pustular syphilides of the new-born. The nasal cavities of most of these infants gradually become occluded by the drying of the secretion of the Schneiderian membrane, in consequence of which breath- ing through the nose becomes difficult, if not impossible — the little patient being obliged to gasp for breath, and unable to suck the breast. If the precarious existence of a new-born child affected with pustular syphilide is prolonged for a fort- night or more, paronychial swellings will form on some of the ungual joints of the fingers and toes ; most of these swellings begin to suppurate near the matrix of the nail, whereby the latter is subsequently cast off. We have never seen onychia sicca in children afflicted with hereditary syphilis. The same is true of the falling out of the hair and eyebrows as a result of syphilis congenita. Pustular syphilide is attended by a rapid pulse, and for that reason the patients are very restless. All infants affected with this syphilide that came under the care of H. Zeissl (most of them foundlings) died before they attained the age of two or three weeks ; those that were born with the eruption seemed even more wretched, and succumbed in a week. Those that are attacked by the bullous form frequently die in utero. It is very difficult to distinguish between the pustular syphilide and pemphigus cachecticorum of the new-born. The only sign by which, according to our observation, these two cutaneous diseases can be distinguished from each other is, that in pemphigus cachecticorum the bullae dry, form crusts, and exfoliate much more quickly than in pemphigus syphiliti- cus. After pemphigus cachecticorum has formed crusts and exfoliated, the former efflorescence quickly becomes covered with a new epidermal layer, while the pustules in the so-called pemphigus syphiliticus are more persistent, and after they have exf oliated new skin very seldom forms upon them ; nor do any new pustules originate in the former on the places where some had already been located. While all the new-born children afflicted with syphilitic pemphigus that came under our ob- servation died, those suffering from the cachectic form some- times recovered under good nursing and care. 324 PATHOLOGY AND TREATMENT OF SYPHILIS. In infants we very rarely saw impetiginous or the so-called crustaceous syphilide in the form of small, impetiginous crusts on the scalp. We have not met with acne syphilide, ecthyma, or rupia in the new-born as a result of syphilis ; on the other hand, in the few cases of rupia in grown-up children that came under our observation, we could always detect the spot where the infection took place, and thus prove that the child acquired syphilis after it was born. From personal experience we feel equally justified in denying the statement that vesicu- lar syphilides, such as herpes and eczema syphilitica, ever occur in infants. We have repeatedly seen nodular syphilide, or suppurat- ing or perforating tubercles, as a symptom of hereditary syphi- lis, but only in children several years of age, in the form of nodes that became transformed into confluent serpiginous ul- cers. This lesion never occurs in the form of scattered nodes in the new-born or nurslings. So far we have met with no cases of syphilis hemor- rhagica, such as have been reported by Baltz, Behrend, Deah- na, and others. Hemorrhagic syphilis, according to Behrend, is a peculiar morbid alteration in the circulatory apparatus which occurs almost exclusively in inherited venereal disease ; Baltz is the only one so far who has described a few cases that have been observed in the adult. It is characterized by ecthymous eruptions on the skin, in the subserous tissues and the meninges of the brain ; and probably also in the paren- chyma of the organs ; furthermore, by haemorrhage from the navel, after the cord has fallen off, so that we may have pur- pura and omphalorrhagia syphilitica, in combination or sepa- rately. Either may occur with profuse bleeding from an acci- dental injury, or from the apparently sound mucous membrane of the mouth, nose, or intestinal canal. Behrend regards the marked fragility of the blood-vessels and diminished coagulability of the blood as causes of the bleeding which is produced by syphilis. Hsemorrhagic syphi- lis is not identical with haemophilia, for the latter represents a permanent diathesis that will last through life ; the former, a transient haemorrhagic diathesis. SYPHILIS. 325 Syphilitic Affections of the Mucous Membrane in the Infant. In congenital syphilis, as in acquired syphilis of the adult, the mucous membranes are affected mostly in those parts that are visible. Accordingly, the nasal mucous membrane, espe- cially at the margin of the nares, the mucous membrane of the mouth from the red border of the lips to the fauces and larynx ; furthermore, the mucous membrane of the anus and genital organs — where it merges into the common integument — will be affected. Of all the places the lips, especially the angles of the mouth, are the most frequent sites of specific affections ; next to this the isthmus f aucium, the tongue, the internal surface of. the cheeks, and the lips ; furthermore, the mucous membrane covering the cartilaginous part of the nasal septum. We have never seen any syphilitic diseases on the posterior wall of the fauces, pharynx, and the higher regious of the nasal passages in infants and older children. Very frequently, on the contrary, the mucous membrane covering the vocal cords and Morgagni's cavity of the larynx is swollen and diseased — a condition which, owing to the inaccessibility of the parts, is only detected by the crying of the infants, who then emit peculiar piping-shrill tones. The morbid alterations of all the parts just mentioned manifest themselves by permanent redness, erythema, or by the formation of scattered or confluent papular inflammatory foci. The epithelial cells on the papular inflamed spots are either pearly-white, the opacities disappearing if the papules are absorbed, or if they degenerate and suppurate the epithelial cells are destroyed, whereby the affected places are transformed into erosions that bleed readily or into superficial ulcers. Sup- puration ensues on the places that are most exposed to press- ure or friction — thus, on the lips, at the angles of the mouth, and at the margin of the anus. At these places the denuded swollen cutis generally cracks, and then quite deep fissures and rhagades form. These bleeding crevices become covered with crusts composed of blood and matter, and render sucking and defecation painful. This process recurs on the tonsils, uvula, and palatine arch. In the nursling we have seen vegetations (pointed condy- loma) occur only on the mucous-membrane papules at the anus. 326 PATHOLOGY AND TREATMENT OF SYPHILIS. We have only seen gummata, and deep ulcers resulting from them, in the mucous membrane of the mouth, fauces, and nasal cavity — -never in that of the rectum or external genital organs. Once we observed deep ulcers in the tonsils in coexisting gum- ma of the tongue. Syphilitic affection of the nasal mucous membrane — coryza syphilitica neonatorum — originates in the following manner : The nasal mucous membrane, especially that of the cartilage of the nasal septum, becomes markedly red and slightly swollen. Occasionally the epithelium even here is opaque or abraded, and at first secretes a profuse but thin mucus, which gradu- ally becomes thicker, yellowish, purulent, and finally ichorous. The mucous membrane of the nasal tracts is eroded by the irritating discharge and bleeds easily, the discharge becom- ing streaked with blood. Like the mucous membrane of the septum, the margin of the nasal orifices and the skin of the upper lip become excoriated. The thicker the discharge, the larger the amount of blood that exudes, and the greater the number of blood-coagula, the more will the already swollen nasal passages become narrowed, so that the little patient is almost totally unable to breathe with the mouth shut. Suck- ing the breast then becomes an unspeakable torture, as the occasionally coexisting affection of the tonsils itself renders that process exceedingly difficult and laborious. We have met but one case of the sinking in of the bony nasal framework by preceding necrosis of the vomer or ethmoid. ]STo case of stink- nose (punaise) in the new-born came under our observation. Some years ago J. Neumann published the report of an au- topsy on an infant that died from congenital syphilis, and in whom the ethmoid was destroyed, and the bony framework of the nose had collapsed. All or some of the morbid alterations of the mucous mem- branes, just described, very seldom occur alone ; in most of the cases, they accompany the morbid lesions of the common integu- ment, already described above. Syphilitic Affections of the Bones and their Tunics. The skeleton of children suffering from hereditary syphilis may not only be attacked by those diseases of the bones with SYPHILIS. 327 wliicli we became acquainted in studying the lesions occurring in persons with acquired syphilis, but in addition it is subject to most remarkable and characteristic morbid alterations. The latter consist essentially in a disturbance of the normal growth of the bones of the infantile skeleton, and represent sometimes atrophic conditions of the pre-formed cartilaginous and osseous substance, and again of new growths of the bony structure. The most frequent, and probably the earliest, bone-affection which is caused by hereditary syphilis is disease of the epiphy- sis of the tubular bones, such as the cartilage-bone junction of the ribs. Wagner, Waldyer, and Kobner maintain that this process is especially pathognomonic of the intra-uterine origin of syphilis. Kobner regards it even as a new pathological dif- ferential sign between the latter and acquired syphilis of young children. These authors invariably found in all the congeni- tally syphilitic children dissected by them, even in abortions of the seventh month, the alterations of the ossification bound- aries of the tubular bones and ribs. Even when the altera- tions seemed to be macroscopically absent, which was seldom the ease, they could be positively diagnosed microscopically. In most cases gummata were found simultaneously in the in- ternal organs, and mucous-membrane or cutaneous syphilide, and syphilitic lesions in the placenta were also present ; but, even when all these were absent, the bone-cartilage boundary was sufficiently marked. These observers saw macroscopically all the stages of those alterations from the simple spreading of the cartilage proliferation-zone and the spongy layer of Guerin ; from the irregular, shaggy encroachment of the ossification-zone and of the cartilage up to the total detachment of the epiphysis, by a widened yellowish zone between the calcareous cartilage and the grayish-red, pulpy substance developed from the spongy portion of the bone. The microscope shows, on the cartilage- bone boundaries, that the young medullary spaces are choked up with granulation-tissue, consisting of small, round, or angu- lar and spindle-shaped elements, mixed up and attached to one another by prolongations. In addition, we find sometimes a thick, sometimes, again, in case the epiphysis becomes de- tached, a semi-fluid substance like a sub-periosteal gummata ; it never becomes purulent, as Wagner claims, nor is it devoid of 328 PATHOLOGY AND TREATMENT OF SYPHILIS. vascularity. The second characteristic which they discovered is the extremely imperfect development of the osteoblasts, de- scribed by Gegenbauer and Waldyer — large, multiple-shaped cells ready to become ossified, which in the normal bone are found in a continuous layer like epithelial cells, but occur here singly and very imperfectly developed. In their place small granulation-cells, or long, spindle-shaped elements, are present. In addition to these constant alterations periostitis ossificans was found in the vicinity of the epiphysial boundary, though only in the most advanced cases. Waldyer and Kobner de- scribe this lesion as syphilitic granulation-growth. The inflammatory disease of the " growing cartilage," ac- cording to Parrot, produces those peculiar pseudo-paralyses, which sometimes occur in the extremities of children afflicted with syphilis congenita. The causes of motor disturbances are the suppurating processes resulting from an abscess situated above or below the joint, and which separates the epiphysis from the diaphysis, though the nerves and muscles remain totally uninjured. In addition to the epiphysial detachment mentioned by Lewin, C. Pellizzari and Tafani speak of fract- ures and infractions in the diaphysis of the ribs, and Par- rot describes erosions and perforation of the skull (craniotabes and plagio-cephalia). New growths of bony substance and osteophytes occur especially on the lower epiphysial ends of the long bones, and on the cranium in the vicinity of the anterior f ontanelle (Par- rot's natiform skull). It is easy to comprehend how the disturbances of nutrition in the growing bones, caused by hereditary syphilis, may be one of the causes of rachitis. Affections of the Eye in Consequence of Hereditary Syphilis. Ophthalmo-blennorrhoea very often occurs in children who suffer from congenital syphilis ; it sometimes originates when the catarrhal process of a syphilitic coryza is transmitted through the lachrymal ducts to the conjunctiva of one or both eyes. Whether that lesion in which the remnants of an irido- choroiditis that has run its course in utero — namely, the union of the iris and cornea, the latter being covered more or less SYPHILIS. 329 with organized material, and intercalar staphyloma — are found, should be described as the effects of hereditary syphilis, is a mooted question even among oculists. Equally uncertain is the question regarding the connection of keratitis parenchy- matosa in infancy and youth with hereditary syphilis. Ocu- lists speak more positively regarding the occurrence of iritis ex syphilide hereditaria. The diagnosis is based upon the marasmatic condition of the infants, upon the protracted char- acter of the disease, its tendency to form synechia and occlu- sion of the pupil, and upon the extraordinarily rare occurrence of ordinary iritis in childhood. Morbid Alterations of the Internal Organs resulting from Hereditary Syphilis. The most constant and frequent alterations resulting from hereditary syphilis are found in the liver. Schott describes the liver in syphilitic new-born children as follows : "It is usually enlarged, dense, reddish, or yellowish — hence, on in- cising it, it is seen to be speckled in some places ; the outlines of the acini are obliterated in most cases, but the incised tissue was found uniform ; the more dense and doughy incisions were glossy and lardaceous. In another case there was found, in the hepatic parenchyma, over the large vessels, a roundish, yellowish, white, dense node as big as a pea, around which whitish welts ramified in different directions." In regard to the forms of syphilitic affections of the liver in the infant, Schott says further : " "While the forms of he- patic syphilis in adults vary, perihepatitis, accompanied by lobulation of the liver, or interstitial hepatitis, or, lastly, gum- mous nodes being present, in children with hereditary syphilis^ we find hardly anything beyond induration, seldom any nodes ; still, even when nodes are present, we can not always safely con- clude that the case is one of syphilis, since other processes, such as effusion of blood in the liver, may also occasion them." We, too, have seen repeatedly in the liver of syphilitic chil- dren, sharply outlined, yellowish- white nodes as big as a hazel- nut, proliferation of connective tissue, and cicatricial retractions. Many physicians look upon an enlarged spleen as an im- portant clinical symptom denoting hereditary syphilis. Klebs 330 PATHOLOGY AFD TREATMENT OF SYPHILIS. found, in the pancreas of a foetus six months old, a number of gumma-nodes, and syphilitic lesions in the lungs, liver, and kidneys. Further, he mentions a case of syphilis in the infant described by Cruveilhier, in which the pancreas was trans- formed into a white, dense, lardaceous mass ; at the same time gumma-nodes were present in the thymus gland and white syphilitic pneumonia was noticed. In twenty-three cases of disease of the epiphysial margin of the bones and enlarge- ment of the spleen, Birch - Hirschf eld found the pancreas affected thirteen times. The morbid lesion consisted of pro- liferation of the interstitial tissue and atrophy of the glandu- lar parenchyma. Olivier, Cruveilhier, Forster, and Wagner saw, in the lungs of infants who died from syphilis, lobular indurations which, when cut into, were found to be yellowish, red, or gray in color, the center being cheesy ; these indurated deposits were pronounced by them gummata or syphilomata. "We, too, have seen similar indurated spots of the size of a hazel-nut in the parenchyma of the lungs in the cadavers of syphilitic infants. Diffused syphilomatous infiltration may extend over both lungs, or affect half of one lung, or even less. The infiltrated places are destitute of air, reddish-gray or yellowish-gray, smooth, ho- mogeneous, and secreting a meager amount of opaque fluid, the bronchial tubes are normal in width, filled with air and puru- lent mucus, the mucous membrane is pale and thickened, and the bronchial glands hypertrophied. Under the microscope the inter-alveolar tissue is seen to be dilated by a deposit of atrophied or fatty degenerated cells and granules, albumen, and fat-molecules ; between these is found a slight amount of homogeneous basement substance. The mucous membrane of the small bronchi is uniformly infiltrated with a deposit of cells and nuclei, and in some places there are elevations with broad bases. The pleurae of syphilomatous lungs are gen- erally normal ; the pulmonary tissue is firm, heavier, and only slightly dilatable. Kobner and "Waldeyer have also noticed, in the lungs of hereditary syphilitic patients, numerous nodu- lar gummata and diffused, inter-alveolar, small-celled granula- tion-proliferations. Klebs thinks that intra-uterine renal syphilis is not infre- SYPHILIS. 331 quent, and lie describes a case of this kind in which gnmmous deposits, containing granular tissue that had been transformed into spindle-cells, were found in the kidney. Virchow claims that he has seen several times, in congeni- tal syphilis of the new-born, enlargement and fatty degenera- tion of the supra-renal capsule. In the cadaver of a boy six days of age Forster observed fibroid degeneration of Peyer's intestinal glands, which he presumes was the effect of hereditary syphilis. These glands projected above the level of the mucous membrane, the pro- jection increasing toward the center of the plaque ; the color was grayish-red, the upper surface dense and glossy. On sec- tion, the thickened patches were found to be hard, glossy, and gray, and could not be torn off from the unaltered muscular coat. The ulcers extended to the upper end of the ileum. Higher up ulcers in groups of twos and threes were found of four to six millimetres in length, while those in the ileum were mostly eight to twelve millimetres in length. The ul- cers were oval or round ; here and there they displayed a tend- ency to form a ring. There were no normal Peyer's patches to be seen. Simple inflammatory swelling of the solitary fol- licles, but no ulcers, were found in the colon. The mesenteric glands, and the small, firm spleen, were normal. The micro- scopical appearances were as follows : The hypertrophied pro- jecting plaques consisted only of a dense network of connective tissue, which extended as a uniform layer from the upper surface to the muscular coat, and was quite poor in cells and granules. In the center of the plaque, where it appeared rough, the connective tissue broke down into a mass of finely granular detritus. The villi ceased at the borders ; the cylin- drical and lenticular glands were entirely absent. Poth describes similar appearances found at the autopsy of a child ^.yq clays old. Schott states that he found, in the cadaver of a child that died with pustular syphilide, tumefaction of the intestinal glands, similar to that observed in scarlatina, typhoid fever, and, in rarer cases, in leukeemic conditions. Mracek found syphilitic affections of the small intestines in ten out of nearly two hundred cases. There were either 332 PATHOLOGY AND TREATMENT OF SYPHILIS. diffused inflammatory or typical syphilitic lesions, and the lat- ter were partly in the form of infiltration around Peyer's plaques, partly in the form of irregularly scattered nodes and granules. In both forms there were infiltrations of small cells into the intestines, the hyperplasia starting from the adventitia of small arteries. The occlusion of the caliber of the canal, caused by these infiltrations, interfered with a proper blood-supply to the part, and resulted in the degeneration of the deposits and nodes by anaemic necrosis. In the brains of the cadavers of children that succumbed to congenital syphilis, and were examined by Schott, only one kind of alterations was found, namely, gelatinous tumors as big as a hazel-nut beneath both anterior lobes. A microscopi- cal examination proved that their structure was similar to that of the tumors described by John Miller, and which Wagner found in the vicinity of the corpora quadrigemina in a person who died from puerperal fever. Eroadbent seldom found the brain affected in infantile syphilis, and he believes that some cases of tubercular meningitis were mistaken for infantile syphilis of the brain. Hutchinson has observed nervous affections in consequence of hereditary syphilis, which manifested themselves by con- vulsions with simultaneous kerato-iritis and atrophy of the optic nerve in a child eighteen months of age. Hughlings Jackson saw a case of facial paralysis and para- plegia in a syphilitic child suffering from hereditary syphilis. We found in a hereditary syphilitic child numerous gum- mata in the brain, and marked thickening of the right facial nerve. Henoch saw several cases of affection of the testes in con- sequence of hereditary syphilis. According to Henning, mor- bid alterations may also occur in the treasts of children suf- fering from the hereditary disease. In consequence of congenital syphilis, morbid alterations may occur in the thymus gland, in addition to those originat- ing in the permanent organs. Paul Dubois found accumulations of pus in the thymus, especially in those infants who suc- cumbed to a congenital pustular syphilide. In the year 1858 SYPHILIS. 333 Widerhofer dissected a female infant that died from a pustu- lar syphilide several hours after birth ; after the removal of the sternum the thymus attracted attention by being almost double the normal size. Its external surface contained several spots about the size of millet-seeds, which, owing to its thin cov- ering, permitted the purulent contents of these places to be seen. They appeared like small cavities. A longitudinal incision laid open a cavity of the size of a hazel-nut, whose apparently smooth walls contained a thick, yellowish, purulent fluid. Yel- low, syphilitic nodes were imbedded in the substance of the liver. Wedl's microscopical examination corroborated the ex- istence of a true abscess of the thymus gland. Diagnosis and Prognosis of Congenital Syphilis. Congenital syphilis in the infant can no more be recog- nized by one symptom than it can in the acquired variety in the adult. A positive diagnosis can only be made by passing in review the whole train of symptoms and studying the en- tire pathological picture and all the phenomena present. The prognosis of congenital syphilis is extremely unfavor- able. More than two thirds of the cases that die from syphilis belong to the congenital variety. The morbid lesions origi- nating in utero, or shortly after the birth of the infant, ob- served by H. Zeissl, almost invariably terminated fatally. Pus- tular eruptions, grave cases of coryza, affections of the viscera, are the most dangerous symptoms. Infants in whom syphilis breaks out at birth, or shortly after, die sooner than those in whom the disease appears after the lapse of several days. Those who are brought up on artificial food die sooner than those who are nursed by a healthy mother or wet-nurse, and properly cared for. Congenital syphilis usually puts an end speedily to the precarious life of these new-born children by lobular pneumonia and exhausting diarrhoeas, accompanied by bloody stools and vomiting. Infants, whose life is prolonged by judicious treatment, usually remain backward in their de- velopment, and retain marked indications of having passed through a serious disease, such as the caving in of the bridge of the nose, prominent frontal protuberances, opacities of the cornea, cicatricial lines radiating from the angles of the eyes, 334 PATHOLOGY AND TREATMENT OF SYPHILIS. mouth, nares, and anus (Hutchinson). Later marked peculiari- ties of character develop, and special tendencies to neuroses and mental disturbances. Syphilis Hereditaria Tarda. In rare cases syphilis that is inherited from the parents does not appear till many months, indeed, sometimes even many years, after birth. This form of inherited syphilis, described as hereditaria tarda, appears almost exclusively with the phe- nomena of the gummatous period of syphilis, which differ in no respect from that of acquired syphilis. As an effect of inherited syphilis appearing late in youth, the mucous membrane of the cheek, mouth, and fauces, especially, is attacked, and the hard palate becomes perforated. Similarly syphilis hereditaria tarda seems to have a special predilection for the mucous membrane of the nose, and not infrequently terminates in destruction of the cartilaginous, indeed, even the bony nasal framework. Gum- mata of the skin are comparatively rare, while periostitis, espe- cially of the long tubular bones, occurs quite often. The diag- nosis can only be established by ascertaining carefully the history of the patient, and by excluding acquired syphilis. The symptoms mentioned by Hutchinson — the peculiar indenta- tion of the permanent incisor teeth of the second dentition period — in our opinion, is of no great value. We have never seen a case of hereditary syphilis which appeared after the age of nineteen years. Treatment of Syphilis. We will now describe in detail our views regarding the treatment of syphilis, which are corroborated by Diday, H. Zeissl, and Barensprung. Like any other disease, syphilis may get well spontaneously in a long or short time ; and if a spontaneous cure takes place, it is likely to be definite. Allow- ing syphilis to run its course spontaneously under a carefully regulated diet is called the hygienic or expectant method of treatment. In addition to the expectant method, there is the treatment of syphilis with mercury, iodine, and vegetable reme- dies. There is no doubt whatever that mercury will cause the symptoms to disappear very rapidly in the majority of cases. SYPHILIS. 335 But it is equally certain that when mercury is employed very early — as soon as the primary lesion is detected, or the first eruption appears — the symptoms then present will, it is true, speedily disappear; but obstinate relapses are more likely to follow than when syphilis is first allowed to spend its fury. In other words, mercury, if employed in the first few weeks of syphilis, will, it is true, soon dissipate the symptoms, but is no more able to annihilate the syphilitic diathesis in a short time than the expectant or iodine treatment — on the con- trary, if used too early, it retards complete recovery. In our opinion, mercury should not be used till eight or ten weeks after the first eruption has appeared, unless the latter is too slow to disappear under expectant or iodine treatment, or dan- gerous phenomena threatening some of the organs of sense, the viscera, or the central nervous system supervene. We coincide in the opinion of H. Zeissl, " that it is not the mer- cury that is injurious, but the improper time chosen for em- ploying it against syphilis." True to the precepts of H. Zeissl's school, our method in the treatment of syphilis, briefly stated, is as follows : In patients affected with an initial primary lesion, but who are still en- tirely free from specific phenomena, such as glandular enlarge- ment or eruptions, the treatment is confined to the local lesion. If the first syphilitic phenomena appear upon the common integument in the form of a macular or papular eruption, we prescribe no anti-specific remedies for the patient, even when suppurating papules are present in the mouth, on the lips, or on the tonsils, but seek to expedite their involution, and to render them less painful by prohibiting the use of tobacco and cauterizing them with the solid nitrate of silver, or by penciling them with a solution of tanno-glycerine (tannic acid, 5-00 [3iv], to glycerine 20*00 [Jss., 3iv]). If the eruption has not entirely disappeared at the end of eight weeks, or if no improvement is perceptible, we then prescribe the prepara- tions of iodine. If the symptoms of the disease have not entirely disap- peared after the expiration of eight weeks more, the treatment with mercury may be resorted to without any fear concerning the future course of the disease. Our favorite remedies are 336 PATHOLOGY AND TREATMENT OF SYPHILIS. Zittman's decoction and the inunction of bine mass. By pur- suing the course mentioned, a smaller number of inunctions are necessary to cause the symptoms of the disease to disap- pear than if a mercurial treatment is instituted from the begin- ning. We seldom employ mercury subcutaneously or adminis- ter it internally. Another important question that presents itself to the syphilologist is, whether the treatment of the disease is com- pleted when the symptoms that were present at the time the patient came under observation have disappeared. This ques- tion can only be answered by the statement that the disappear- ance of the symptoms is no proof that the diathesis has been eradicated ; for otherwise no relapses would follow after a longer or shorter interval. We agree, therefore, most decided- ly, with the French writers, especially Fournier and Marti- neau, that the treatment of syphilis should be continued as long as possible. True, it is not necessary that the patient be constantly under the eye of the physician ; the subsequent treatment may, in fact, be left to himself, it being necessary to instruct him to apply for medical- aid again as soon as any symptoms recur. We think it is very important for the patient, even when all the symptoms of the disease have disppeared, to continue the treatment with iodine for a long time, at least for a whole year. If a patient desires to be treated with mercurial prepara- tions, as is now and then the case, a cycle of ten to twelve in- unctions may be tried during the first year, albeit no symptoms of syphilis manifest themselves. We know, indeed, from experiments which Hebra and H. Zeissl instituted, that even healthy persons tolerate large numbers of inunctions of mer- cury without the least injury. Taking this fact into consid- eration, we allow the patients, after the symptoms of syphilis have disappeared under the above-described method of treat- ment, to resort to the iodine baths at Halle, if their means and the season will permit. As soon as they return from the baths, iodide of potassium or sodium is again employed, with intervals of longer or shorter duration, depending upon the appearance of symptoms of iodism. But, if the circumstances are such that the patient can not travel to the baths, he should drink SYPHILIS. 337 iodine-water at home for a long time, and then go back to the use of one of the preparations of iodine. So far we have been perfectly satisfied with the results ob- tained by the method of treatment described, the prolonged use of the iodides never having proved injurious to the patient. But, in view of the statement of Fournier and other authors, who assert that grave symptoms of affection of the central nervous system ensue in those cases of syphilis that have not been treated at all, or only insufficiently, we always prolong the treatment as much as possible. We are convinced that mercurial preparations play only a subordinate part in a course of anti-specific treatment continued for a year or more ; but to treat syphilis with mercury for full five years, as some of the French physicians do, is hardly justifiable. It is not safe to declare a patient permanently cured if at least a year has not elapsed after the last symptoms disap- peared. We will next say a few words regarding the prophylaxis of syphilis, and then describe in detail the expectant and other methods of treatment. Prophylaxis of Syphilis. We distinguish general prophylaxis, embracing whole coun- tries, and one that has reference to the individual. The for- mer belongs to the domain of sanitary police, and the student is referred to the literature on that subject. Since syphilis has been better known, remedies have been sought which would afford protection against the absorption of the syphilitic virus, and would make the absorbed virus in- nocuous. Quacks often pretend that they have many remedies capa- ble of accomplishing this purpose ; but none ever proved effect- ive. The best protection, comparatively speaking, is derived from the use of the condom. If a person apprehends that the syphilitic contagium has gained an entrance into his system through any point on the skin or mucous membrane, the physician can only suggest to him to take such measures of protection against the further effects of the virus as are employed against the absorption of 22 338 PATHOLOGY AND TREATMENT OF SYPHILIS. other pernicious matter (glanders, rabies, and soft-chancre vi- rus). Strong caustics, such as penetrate deeply into the tis- sues, may be used for the purpose of destroying the poison at the place of entrance. We know, from countless experiments with the virus of the soft chancre, that it can be made harmless to the system, if the place where it was deposited is thoroughly destroyed with caustics within three days. But the time in which the syphilitic virus can be rendered innocuous by destroying it with caustics has not yet been definitely ascertained by similar experiments. It was supposed that, since certain excoriations, that originate during intercourse, through which the syphi- litic virus may take effect, were effectively cauterized within three days, the virus could certainly be destroyed by caustics within a few hours after it was absorbed, and thus rendered harmless. Unfortunately, most of the patients fail to notice the place of entrance of the poison into the system, and do not become aware of the fact till the specific primary lesion is fully developed, and is undergoing molecular degeneration — a process which, as a rule, takes place three weeks after infection has occurred, at a period, therefore, when the blood is already contaminated. The best agents with which to cauterize the place where the virus penetrated is caustic potash and Vienna paste. Mercurial treatment will not protect one against the origin of syphilis, for even persons who are engaged in pursuits where a great deal of the mineral is used — for instance, mirror-platers, gilders, and others — are not proof against the disease, as has been found by experience. An English physician (Wilks) propounded the question whether syphilis could be aborted. The deliberations of a commission resulted in the conclusion that it was totally use- less to remove a Hunterian primary indurated lesion, since sec- ondary symptoms would nevertheless appear. Sigmund and Ricord came to the same conclusions ; the latter says the indu- ration is not to be regarded as the cause (origin) of syphilis, but as the effect of the constitutional affection. Quite re- cently, many physicians have again taken up the subject, and stated that they have obtained good results by excising thejpri- SYPHILIS. 339 mary lesion / that is to say, no secondary syphilitic phenom- ena ensued. Of the authors referred to, Auspitz and Unna, Kolliker, Hueter, Chadzynski, and Ferari are the most promi- nent. Auspitz and Unna deserve credit for having lately given new impetus to this question. But we have convinced ourselves, by a great many experi- ments, that extirpation of the indurated primary lesion, how- ever early performed after infection, does not prevent the out- break of secondary phenomena. Quite recently, H. Zeissl had an opportunity of observing a striking instance, in which the initial indurated lesion was excised with apparent success, so that, according to the statement of the patient, some of the most prominent of the French syphilographers, Bassereau, Fournier, and Ricord, considered the infecting focus as having been completely destroyed, and yet, three months after the operation, secondary phenomena appeared in the form of ery- thema papulosum on the general skin, although there was no possibility that the patient had been reinfected. At the time the patient presented himself to H. Zeissl, the erythema was in full bloom. The striking case reported by Mauriac is espe- cially convincing : A patient contracted a primary lesion which was excised fifty hours after it appeared, and, although no in- guinal glandular enlargement was present at the time of ex- cision, yet general secondary syphilis ensued. This and other facts have led us to doubt the effectiveness of the abortive treatment of syphilis, and to assert that if there is such a con- dition as an incubation period of syphilis, it is of very short duration. The excision of the specific primary lesion will not prevent the development of constitutional manifestations, whether the adjacent lymphatic glands be swollen at the time of the operation or not. "We will also remark that it is doubtful whether even the earliest cauterizations of the infecting initial lesion (Hunte- rian induration) are of any use, as a preventive measure against constitutional syphilis, because, in the course of an extensive practice, we have seen repeated instances in which, according to the statements of reliable physicians and patients, the sores were cauterized within a few hours after coitus, and yet the initial indurated lesion with all its consequences followed. — 34:0 PATHOLOGY AND TREATMENT OF SYPHILIS. The imperative duty devolves upon the physician of exercising the utmost caution in procuring the purest vaccine lymph for the purpose of vaccinating infants and revaccinating adults, and the same precautions should be employed in selecting a wet-nurse. Those about to marry, too, might be none the worse if they submitted themselves to a careful examination by the physician. Treatment of the Initial Phenomena of Syphilis ; the Hunterian Indurated Chancre; and Indolent, Multiple, and Strumous Buboes. The treatment of the initial lesions of syphilis is similar to that of the other manifestations of the disease. Sometimes, however, they require special measures, because they frequently cause (local) disturbances and complications that can not be relieved speedily enough by the general treatment. The site of a syphilitic infecting chancre requires a differ- ent local treatment according as it is also the site of a soft chancre or not. In the former case, the chancre should be treated in the same manner and with the same remedies, re- gardless of the induration, as if it were situated upon a non- indurated base or non-syphilitic person. In the second case, the local treatment is only intended to aid the cicatrization of the sore, which is desirable, because the Hunterian chancre, so long as it is uncicatrized, causes more or less pain ; and, in case it is contaminated with impurities, it is apt to assume a condi- tion of phlegmonous inflammation that may spread to the adja- cent skin and lymphatic glands of the vicinity. Especially is it desirable to cause those Hunterian chancres to cicatrize that are situated upon the internal surface of the mucous mem- brane of the prepuce, in or near the fossa coronaria, and in females at the introitus vaginae, because they frequently give rise to protracted balano-blenorrhoea and vulvar blennorrhea ; further, those on the lips, at the anus, and meatus of the urethra, because they occasion pain in speaking, defecation, and urination. The cicatrization of the initial induration is expedited by keeping it clean, by the application of iodoform dressing, or emplastrum hydrargyri. If the Hunterian chancre on the mucous membrane of the prepuce has occasioned phi- SYPHILIS. 341 mosis, some tolerably strong astringent, or slightly caustic preparation, such as a solution of carbolic acid or chlorate of potash, should be injected between the foreskin and glans penis several times daily. After this, bits of muslin, dipped in the same preparation, should be inserted under the former for the purpose of keeping the inflamed parts asunder. If this does not answer, circumcision will be required. If the Hunterian chancre is situated at the lips of the urethral mea- tus, it should be touched daily with nitrate of silver, and a small wedge of emplastrum hydrargyri inserted between the lips. The same method should be pursued in chancres at the anus or vulva. Hunterian indurated lesions situated on the skin of the penis, labia majora, or fingers, cicatrize quickest when they are covered with adhesive or mercurial plaster. Indolent buboes of the size of a hazel-nut require no local treatment. The treatment directed against the general disease usually suffices to reduce them in size or to bring about reso- lution. If the indolent bubo accompanying the syphilitic initial lesion undergoes suppuration, it should be treated, cceteris pari- bus, like any other suppurating glandular abscess ; but if the syphilitic, indolent buboes, fostered by the scrofulous or tuber- culous tendency of the patient, or by ulcerating or moist pap- ules in the vicinity, gradually increase, notwithstanding the general treatment already instituted, an effort should be made by appropriate local treatment to prevent suppuration, because of the fistulous passages that usually result from inflammation of the hyperplastic enlarged glands (strumous buboes). The reader is referred to what has already been said upon this sub- ject on page 141. In some cases we succeeded in gradually diminishing these adenopathies by several subcutaneous injec- tions of a few drops of tincture of iodine. A concentrated solution of nitrate of silver, or compresses dipped in a concen- trated solution of basic acetate of lead, or iodide of lead-plaster, tincture of iodine, belladonna, or gallic acid, will be found useful. The following is one of the best preparations : ^ Aqua destil., 20*00 [ § ss., 3 iv] ; Nitr. arg. cryst., 5-00 [3 iv]. M. S. The glandular swelling to be penciled twice daily with a cam- el's-hair brush. 342 PATHOLOGY AND TREATMENT OF SYPHILIS. Emplastrum de Vigo curia hydrargyri will usually cause a diminution of strumous buboes. If the strumous bubo, per se, does not prevent the patient from walking, it is not absolutely necessary that he should re- main in bed ; indeed, a moderate amount of exercise out-of- doors seems to hasten resolution. If fluctuation has been detected at any place, the efforts to bring about absorption should not yet be abandoned, nor the abscess opened immediately, because experience has shown that even indolent buboes that fluctuated distinctly were neverthe- less made to undergo resolution by the continuous application of tincture of iodine, lead-plaster, etc. Not till a prolonged trial of the above-mentioned remedies causes no diminution of the swelling, on the contrary, seems to increase it, make it more tense, and give the patient severe pain, may the spontaneous bursting of the abscess be expedited by the application of cata- plasms, etc. ; or it may be incised with a sharp-pointed bis- toury. The part of the skin that has become thin, red, and undermined may be removed at once with the scissors. The opened indolent bubo should then be treated in accordance with the rules of antiseptic surgery. If fistulse form, the measures advocated on page 14:2 may be adopted. Treatment of Secondary Phenomena of Syphilis. (A.) Expectant Method. The expectant plan of treatment consists in regulating the diet of the patient, and in the local application of remedies to the primary lesion, none being administered against the general specific disease. If the primary lesion has begun to suppurate, the patient should be prohibited from taking active exercise, in order to avoid the risk of causing suppuration in the in- guinal glands ; if it has cicatrized, or did not suppurate at all, the patient should be in the open air as much as possible. He should avoid catching cold, abstain from the use of tobacco, and partake of nutritious food, especially meat. He may be allowed a moderate amount of wine and beer, but tobacco should be prohibited absolutely, because the irritation pro- duced by its use will occasion the formation of syphilitic SYPHILIS. 343 efflorescences on the mucous membrane of the mouth, tongue, and fauces. It is highly important for the patient to wash the anal region with water after each stool. In corpulent persons contiguous parts should be kept asunder by the interposition of bits of lint. The constant contact of two opposing sur- faces, as at the anus, groin, etc., always produces considerable moisture, and this results in the development of papules. If secondary phenomena, in the form of a macular or papu- lar syphilide, have finally appeared, the physician should still content himself with carrying out these hygienic measures. Syphilitic phenomena last a variable length of time in differ- ent persons. Roseola undergoes resolution without medication quite rapidly. In one case we saw it disappear within seven days. Papular syphilides often require a loug time to under- go involution. Psoriasis palmaris and plantaris frequently re- quire, if not treated, ten to twelve months before they dis- appear by resolution. An equal length of time often elapses before the syphilitic initial induration completely subsides. But it should not be forgotten that similar conditions are often seen in persons who undergo active mercurial treatment. We have observed that the individuality exercises considerable infiuence over the rapidity with which the syphilitic symptoms disappear. In general, it may be said that the cure of syphilis in anaemic and weak persons takes a longer time and is more difficult than in the robust and well - nourished. In regard to pustular syphilides, these, too, often require, under ex- pectant treatment, seven to eight months to disappear by resolution. The expectant treatment has taught us, on the one hand, that constitutional syphilis will follow even if not a particle of mercury is used, and, on the other hand, that the assertion of the anti-mercurialists, that the so-called secondary and tertiary syphilis are only the manifestations of the mercurializatidn, is not true. Relapses and the gravest forms of syphilis (symp- toms denoting lesions of the central nervous system, of the viscera, etc.) may supervene just as well after a strict and scru- pulously carried out expectant plan as after an anti-specific treatment. We only wish to say that these phenomena occur comparatively rarely after expectant treatment, and that re- 344 PATHOLOGY AND TREATMENT OF SYPHILIS. lapses are apt to occur less often than after an early mercurial treatment. If serious syphilitic symptoms have appeared, such as affections of the brain or eye, the anti-specific remedies should be employed at once, and the life of the patient or the integrity of an important organ should not be endangered by delay. All recent cases of acquired secondary syphilis are well adapted for treatment by the expectant method. If a febrile disease — pneumonia, dysentery, typhoid fever, etc. — super- venes upon the specific phenomena, mercury, iodine, and all depressing remedies must be discontinued, and the syphilitic disease treated with expectants for the time. In very severe forms of pustular syphilide similar indications prevail. Little can be hoped for from the expectant method in cases in which, after a long or short use of specific remedies, especially mer- cury, a relapse ensues. Cases of congenital syphilis which ap- pear in youth, and are likely to cause destruction of some of the soft or bony parts (lupus syphilitica), are not adapted for the expectant method of treatment. If the phenomena of the second period have resisted this method for eight or ten weeks, the treatment with iodine may be commenced. The treatment with preparations of iodine is adapted to all phases of syphilis, and, according to H. Zeissl's experience, the results derived from it are second to those of the expectant procedure, since relapses occur less often after an early treatment with iodine than with mercury. Iodine in proper quantities, in conjunction with a carefully regulated regimen, are sufficient to cause the symptoms of syphilis to disappear, or at least to oe weakened so that only a few mercurial inunctions will he necessary to complete the cure, without fear of a relapse occurring in years to come. In pregnant women the symptoms of syphilis resist treat- ment much more than in non-pregnant women, especially if pregnancy is as old as the infection ; they do not disappear en- tirely till the contents of the uterus have been expelled. "We were, therefore, always obliged to continue the treatment with the preparations of iodine after the confinement, and, where this remedy proved insufficient, a few inunctions of mercury completed it. SYPHILIS. 345 Therapeutical Application of Iodine and Iodine-Salts against Syphilis. (B.) Medicinal Treatment. Since 1822 iodine has been used with good results in syphi- lis by Formey, Brera, Lugol, Cullerier, and Eicord; but it became famous as an antisyphilitic remedy mainly through the writings of Professor Wallace, of Dublin, who, in the year 1836, published a report of one hundred and forty-two cases treated with iodide of potassium, in which he obtained most fa- vorable results. We employ mainly iodide of potassium, iodide of sodium, iodide of iron, iodoform, and iodide of lithium. Pure iodine, which, owing to its corrosive action, is not adapted for internal use, may be given in the form of tincture. Of the latter we prescribe 1-00 [grs. xvj] to 100*00 [ § iij, 3 iij] water, and allow the patient to take two teaspoonfuls a day. Of iodide of potas- sium or sodium we order 1*00 [grs. xvj] either in solution or pill. The latter is preferable, because the bad taste of the medicine is thus avoided. En passant, we will state that iodide of sodium is less disagreeable than iodide of potassium. We use iodide of iron, either in the form of pills or sirup, as follows : 5 Ferri ioclat., 10*00 [3 viij] ; Extract, et pulvis trifolii fibrini aa q. s. ut ft. pilulae No. 100. Consperge pulvere eodem. S. Ten pills, to be taken daily. ¥? Syr. ferri iodat., 2*00 [grs. xxxij] ; Syr. mororum, 20*00 [ § ss., 3 iv], M. S. To be taken in one day. Iodide of iron is especially adapted for the treatment of syphilitic patients who are markedly angemic. A gramme [grs. xvj] of iodide of iron daily, in pills, is very well tolerated ; we have often given as much as 2*50 [grs. xl] without causing any digestive disturbances. In very weak patients, whose di- gestive organs are not strong, the sirup of the iodide of iron may be prescribed, but only in quantities necessary for each day, as it easily decomposes, and the free iodine then produces 346 PATHOLOGY AND TREATMENT OF SYPHILIS. pain in the stomach and vomiting. The decomposition of the iodide of iron is prevented in Blancard's pills, which are wrapped up in balsam of Torn. Each pill contains 0*07 [1-J- gr.], of which the patient takes four or fi.ye each day. Much benefit is derived from the internal use of iodoform, according to H. Zeissl's method. It is prescribed in pill-form : 3 Iodoform., 1'50 [grs. xxiij] ; Ext. et pulv. trifolii fibrini aa ut ft. pil. No. 20. Consperge pulvere eodem. S. Five pills to be taken daily. Good results are obtained from iodoform, especially in cases of neuralgia caused by syphilis. In addition, we only wish to mention here that patients, after the internal use of iodoform, sometimes suffer for a long time from unpleasant eructations. It should not be prescribed in large doses ; some physicians have seen intense excitement and mental disturb- ances arise in patients to whom large quantities of the drug were administered. . Iodide of lithium, which till now has not been much noticed, may be given in doses similar to those of iodoform. We have used it for several months, injecting it subcutaneously. It forms a perfectly clear solution when dissolved in water ; 1*50 [grs. xxiij] may be injected hypodermically. The patients complain of pain at the site of injection, but it soon subsides. In this manner the preparation is very well tolerated, pro- ducing no other unpleasant effects except a moderate iodine acne in some cases. The involution of the syphilitic phe- nomena proceeded as rapidly as after the use of any other preparation of iodine. Iodide of lithium may also be adminis- tered internally in pills from 0*50 [grs. viij] to l'OO [grs. xvj] per day. This preparation accomplishes as few miraculous cures as any other. Recently Thomann, of Gratz, and J. Neumann, injected iodoform in solution or emulsion hypodermically with good effect. As already said, all phases of syphilis are adapted for treatment with the preparations of iodine. We have seen numerous cases of iritis cured by the administration of iodine and application of atropine to the eye, not the least impairment of vision remaining in a single patient. SYPHILIS. 347 The rule that mercury causes the symptoms of syphilis in all cases to disappear more rapidly than any other anti-specific remedy, has but a limited application ; in some cases both mer- cury and iodine act quickly, in others their effects upon the patient are very slow. Too much stress can not be laid upon the fact that even in the gravest forms of syphilis the prepa- rations of iodine alone will often be found sufiicient. In regard to the subcutaneous employment of the prepa- rations of iodine, it may be used with advantage in persons troubled with weak digestive organs ; but this method will no more take the place of the internal use of the drug than the hypodermic injection of mercury has till now succeeded in re- placing mercurial inunction. However slight the pains may be, the patients seek to avoid them if not absolutely necessary. Besides, it has the additional diad vantage that in private prac- tice a syphilitic patient can not be seen every day. Patients, whose health and other circumstances permit, should go at the proper season of the year to iodine min- eral springs. There are several places in the Austro-Hunga- rian Empire where valuable iodine springs are found, such as Hall in Upper Austria, Ivonicz in Galicia, Lippik in Slavonia, Luhatschowitz in Mahren, and Darkau in Silesia. In these places the patients not only drink iodine- water, but also bathe in it. Professor Rosenthal, of Vienna, under the direction of Professor Schneider, has shown, in a paper presented to the Imperial Academy of Sciences in the year 1862, that iodine is absorbed into the blood by the skin. It is a mistaken idea to prohibit the patient from partaking of articles of food containing starch during the treatment with iodine. Starch alone, without the simultaneous intervention of an acid, is not capable of separating the iodine from its compounds and forming a combination with it. The acids of the stomach are much too feeble for that purpose ; and admit- ting that a partial decomposition of the iodides takes place from an excess of starch in the stomach, then only an iodide of starch would form, which is the very substance recom- mended by Buchanan against syphilis on account of its non- irritating action on the gastric mucous membrane. Equally little injury results to the patient, according to our experience, 34:8 PATHOLOGY AND TREATMENT OF SYPHILIS. from the decomposition of the preparations of iodine, owing to the nse of acids during the treatment with iodides. Be- cently, English physicians have actually sought to increase the action of this remedy, aud obtained favorable results from the combined use of tolerably strong acids (ozonized water, nitric acid) with preparations of iodine. The powerful action of the salts of iodine, in bringing about a metamorphosis of the tis- sues, is reason enough for allowing the patient, during the iodine-cure, to partake of as much nourishing diet, especially animal food, as possible, still the cure should not be made un- necessarily irksome by prohibiting the ingestion of bread. The preparations of iodine, as already stated above, are adapted to all forms of syphilitic disease. The iodides have proved especially efficacious against gum- mous periostitis and ostitis, gummata of the skin, tongue, respiratory organs, etc. ; in muscular contractions, sarcocele syphilitica, specific eye, brain, and nervous affections, inherited syphilis, appearing in the shape of scrofulous manifestations, and in cases in which scrofula and syphilis are combined. Still, there are cases in which all the morbid forms men- tioned obstinately resist the action of the iodine remedies ; in such, if the condition of the patient permits, we resort to the mildest of all mercurial preparations, Zittmann's decoction. The mercurials generally achieve more if they have been pre- ceded by a course of treatment with iodine. It follows, from what has been said, that the salts of iodine are the chief remedies for so-called tertiary syphilis. Still, it can not be denied that all the other specific phenomena may be made to undergo involution by the use of iodine ; but it is equally true that there are exceptional cases, which can not be foretold, in which mercury may be advantageously substituted for the iodide. When iodine preparations are used in appropriate cases and in proper doses, the appetite of the patient increases, and nutri- tion improves proportionally. Sometimes, however, the appe- tite increases to a ravenous hunger. Occasionally the internal use of the iodides causes ringing in the ears and intestinal catarrh, which sometimes is attended by loose stools, then again by constipation. The pathogenic action of iodine manifests SYPHILIS. 349 itself most strikingly upon the nasal mucous membrane, a violent nasal catarrh originating in most patients after this rem- edy has been used .for two or three days. This phenomenon is generally accompanied by an irritated condition of the mu- cous membrane of the fauces and pain over the frontal sinus. The catarrhal affection of the mucous membranes mentioned extends to the lachrymal apparatus and Eustachian tube. More or less severe febrile movement, according to the sensi- tiveness of the patient, ensues. In most cases we noticed, in consequence of the continuous use of the iodides, marked red- ness and looseness of the gums of the upper incisor teeth (gingivitis), which persisted for many weeks, along with ob- stinate salivation. The pathogenic action of iodine salts mani- fests itself just as frequently upon the general skin as upon the naso-faucial mucous membrane. An acne-like eruption occurs in some persons, especially those having a tender skin, on the face, nape, shoulders, and upper arms. The iodine catarrh and acne may indeed occur simultaneously, but, as a rule, these two affections exclude each other. In some patients the use of the salts of iodine produces sleeplessness. In rare cases we have observed, in consequence of the internal use of the prepa- rations under consideration, episcleral ecchymoses and ncevus- UJce teleangiectases, as big as a pin's head, on the general integu- ment. In some cases the action of the heart is accelerated to such a degree, by a prolonged use of this remedy, that the rapidity of the pulse is increased to one hundred and forty per minute, the patient being at the same time exceedingly irri- table and exhausted. We also saw pleurodynia occasionally in consequence of the use of iodine — a phenomenon first point- ed out by Wallace. The pain, which is usually limited to the left side of the thorax, is so violent at times as to hinder the patients from breathing, resembling very much in severity that occurring in true pleurisy. Iodine catarrh and iodine acne disappear when the iodides are discontinued. For the relief of the gingivitis, the astrin- gent mouth-washes recommended against mercurial stomatitis may be used. The ravenous hunger and sleeplessness, the pleurodynia, and increased action of the heart are markedly diminished by an active purgative (Saidschiitzer or Pullnaer 350 PATHOLOGY AND TREATMENT OF SYPHILIS. bitter-water), and disappear entirely after the use of a few doses of quinine, 0*3 to 0*4 [grs. v to vij] daily. The Treatment of Syphilis by Vegetable Remedies. Of the vegetable remedies, we will only mention tayuya, pi- locarpine, and Zittmann's decoction. Tayuya-tincture has been recommended by the Ubicini brothers. It is prepared from the root or bulb of one of the cucurbitacea plants. This remedy was used in the form of subcutaneous injection, and also inter- nally in H. Zeissl's hospital division. The results were such that it may be said that time and not the remedy accomplished the cure. However, it exercises no injurious effect upon the system. Lewin made numerous experiments with jpiloca/rpin, the alkaloid of jaborandi. He used the muriate, and treated thirty-two women with it by hypodermic injections ; twenty- five of the patients were cured. In three of the seven that were not cured, such violent symptoms of collapse appeared that the treatment had to be discontinued. One patient was attacked by haemoptysis — in another endocarditis supervened. In two others the syphilitic manifestations did not disappear, notwithstanding the large doses of pilocarpine employed. The longest time required for a cure was forty-three days, the shortest fourteen. Lewin thinks that a cure could be achieved in a still shorter time, if it were not necessary to sus- pend the treatment, even when no accidents occurred, on ac- count of the patients' being frequently very much affected by it. The average quantity of pilocarpine required for a cure is 0-372 [grs,vss.]. The relation of pilocarpine to the different forms of syphi- lis is pretty much the same as that of mercury. The relapses in these twenty-seven patients amounted to only six per cent, against eighty per cent after a vegetable cure or previous treat- ment with mercury. Nevertheless, Lewin gives the preference to hypodermic injections of corrosive sublimate over the treat- ment with pilocarpine, for, although the percentage of cures with the latter is decidedly greater, yet the use of the remedy is attended by such unpleasant symptoms. In some cases in which we employed hypodermic injections of pilocarpine the unpleasant effects were so violent that we had to abandon all SYPHILIS. 351 further treatment with it, especially since the curative effects were by no means satisfactory. But from Zittmann's decoction we have seen very brilliant results. It is difficult to say whether this remedy should be classed among the vegetable or the mercurial preparations. In preparing this decoction, as is well known, 1*00 [grs. xvj] of white sugar, a like quantity of powdered alum, 0*8 [grs. xij] powdered calomel, and 0*2 [grs. iij] powdered cinnabar, are boiled in a little bag with sarsaparilla. Mitscherlich was unable to detect any mercury in the decoction, while Zanten, Wiggers, and Winkler found traces of it in large quantities of the preparation. Skoda found Zittmann's decoction less effica- cious when calomel and cinnabar were omitted. For these reasons, we have to assign to Zittmann's decoction a hybrid position between the vegetable and purely mercurial remedies. We order the patient to take 30O00 [ § ixss., 3iv] of decoct. Zittmanni fortius every morning, and the same quantity of the weaker decoction in the evening. At the same time the diet must be strictly regulated. He should drink no liquor, beer, or milk. Fruits, salads, all kinds of vegetables and fruits — in a word, everything that is likely to cause diarrhoea and flatus — must be strictly prohibited. At 7.30 a. m., the patient takes his breakfast, consisting of a cup of black tea and toast. Half an hour after, he begins to drink the decoction, which he finishes in the course of half an hour to two hours. Generally, from one to three evacuations from the bowels then occur in the course of the forenoon. At one o'clock he takes his din- ner, consisting of soup, roast beef, and rice, with a glass of wine, and, if the weather is pleasant, he may take some exer- cise out-of-doors, and, at 4 p. m., drinks a second bottle of the (weaker) decoction, likewise consuming it in the course of half an hour to two hours. If the patient has five or six evacuations daily, he may con- tinue to take the decoction ; but if they become too frequent, and perceptibly reduce him, or vomiting ensues, the remedy must be immediately discontinued. In the majority of cases, not more than three or four evacuations take place daily, the decoction agreeing very well with most patients. The effects of the remedy usually become manifest after using it ten or 352 PATHOLOGY AND TREATMENT OF SYPHILIS. twelve clays ; it has an exceedingly favorable effect upon all forms of syphilis, but is especially applicable in patients who are somewhat exhausted by a severe course of mercury, and in whom the syphilitic disease obstinately resists the preparations of iodine. It is an indisputable fact that, in patients who had been treated early and for a long time with mercury, obstinate relapses of the syphilitic disease, in the form of psoriasis pal- maris or plantaris, will not disappear at all, or but very slowly, under the use of the iodides, the malady improving only when mercury is again administered. But, if it be not deemed proper to give such patients more mercury, because they are already reduced by the preceding active treatment with it, Zittmann's decoction may be prescribed. Truly wonderful effects may be expected from it, though such an expression ought not to be used in the practice of medicine at the present day. It ren- ders excellent service in diffused pustular syphilides, and in suppurating gumma-nodes, whether situated upon the common integument cr the mucous membrane. If the decoction occa- sions violent colic-pains or profuse diarrhoea, and its further employment is indicated notwithstanding, it will be well to omit the senna-leaves from the preparation. [The formula given above for the preparation of Zittmann's decoction being incomplete, that described in the United States Dispensatory is here appended : Take of sarsaparilla twelve ounces, spring-water ninety pounds ; digest for twenty-four hours, then introduce, inclosed in a small bag, an ounce and a half of sugar of alum (consisting of equal parts of white sugar and powdered alum), half an ounce of calomel, and a drachm of cinnabar. Boil to thirty pounds, and, near the end of the boil- ing, add of anise-seed, fennel-seed, each half an ounce, senna three ounces, liquorice-root an ounce and a half. Put aside the liquor under the name of the strong decoction. To the residue add six ounces of sarsaparilla and ninety pounds of water. Boil to thirty pounds, and, near the end, add lemon-peel, cinnamon, cardamom, liquorice, of each three drachms. Strain, and set aside the liquor, under the name of the weak decoction.'] Therapeutic Use of Mercury. Mercury may be introduced into the system in two ways — through the mucous membrane of the digestive and respiratory SYPHILIS. 353 organs, and through the general skin. Now, if in the patient who is about to be treated, one of these ways become unavail- able, in consequence of syphilis itself, or because of some morbid alterations or complications, it will be necessary to find some other course whereby the mercury may be introduced into the system. Further, if it is the intention of the physi- cian to produce a mild and gradual therapeutic effect, and if the digestive organs of the patient are in a good condition, the latter may be employed. But if he desires to introduce a large quantity of mercury into the system in a short time, the external skin is certainly best adapted for that purpose. If it is desired to produce a direct specific effect upon the respira- tory organs, mercury may be inhaled in the form of vapor. Mercurial Preparations which are best adapted for Introduction into the Blood through the Digestive Organs. Although we entirely agree with Mialhe in his theory that all preparations of mercury introduced into the system must, before developing their therapeutic effects, become converted into corrosive sublimate, and hence that it would seem to be more advantageous to use the bichloride at once, nevertheless, we must say that the other preparations of mercury, are by no means to be discarded. Experience has shown that some per- sons are apt to suffer from gastric pain after taking corrosive sublimate, while the protoiodide of mercury or calomel agrees with them very well indeed. It therefore seems as if some persons tolerate better the sublimate that forms within their systems from the protoiodide or calomel than when it is ad- ministered to them directly. Most German physicians at present prefer corrosive subli- mate to any other preparation of mercury, because it so seldom produces ptyalism, while this unpleasant by-effect almost always attends the use of the protoiodide, calomel, and mercurius solu- bilis Hahnemanni. The salivation which sometimes supervenes very rapidly upon the use of mercurial preparations seems to us to be due more to individual idiosyncrasy than to the chemical properties of the drug ; hence the reason why some of the most accomplished physicians differ so much upon this point. 354 PATHOLOGY AND TREATMENT OF SYPHILIS. Hydrargyri protoioduretum, iodide of mercury, a greenish insoluble combination of iodine with mercury, is especially recommended by Kicord, and adapted in cases in which the pri- mary induration still exists, in recent erythematous and papu- lar syphilides, and in psoriasis palmaris and plantaris dissemi- nata. As a rule, the involution of the specific efflorescences on the skin and mucous membrane begins after using the protoiodide for two or three weeks. The papules on the palms of the hands and soles of the feet offer the most obsti- nate resistance to the action of the remedy, and local applica- tions will almost always be required to assist the protoiodide in discussing them. The dose of the protoiodide is 0*02 to 0*04 [gr. i to §]. Generally, patients who take 0*10 [gr. If] of this remedy in twenty-four hours have two or three liquid evacuations, at- tended by colic-pains. To prevent the latter, the mercurial should be combined with extract of lactucaria or opium in the following manner : B Protoiod. hydrargyri: Extr. lactucarii, aa 1*00 [grs. xvj] ; Opii puri, O50 [grs. viij] ; Extr. et pulv. rad. liquiritia, aa q. s. ut ft. pil. No. 50. S. One pill to be taken in the morning and two in the evening. ' So long as the protoiodide exercises a perceptibly favorable effect over the induration or the other syphilitic manifestations present, and the mucous membrane of the mouth remains un- affected, the dose recommended above may be continued. But, if the improvement of the syphilitic lesion is arrested, two pills should be given in the morning and two in the evening. Should the patient's gums become red and swollen, and his breath acquire a repulsive odor, the remedy will have to be discontinued till the mucous membrane regains its normal condition. If the protoiodide, despite the addition of the nar- cotic, causes intense colic-pains; if profuse, liquid, or, still worse, bloody stools take place, the internal use of all kinds of mercury should be suspended, and the patient subjected to an inunction-cure, or the iodides may be prescribed. Chloride of mercury, being soluble, is a more useful rem- edy than the protoiodide ; still, it can only be used internally in SYPHILIS. 355 persons who have perfectly healthy digestive organs and sound respiratory apparatus. There are patients in whom the use of corrosive sublimate occasions gastralgia, and for that reason the remedy must be replaced by one that is less useful. In persons who have already suffered from attacks of hemopty- sis, mercury in general, but especially corrosive sublimate, should be used cautiously. If albuminuria is present, large doses of the bichloride act equally unfavorably. No corrosive sublimate, and, still less, other drastic mercurial preparations, should be prescribed for syphilitic pregnant women. The treatment of syphilis with corrosive sublimate was introduced into Western Europe by Yan Swieten, from Russia. The Rus- sians take this medicine in corn-whisky (liquor Yan Swietenii). Adult patients readily tolerate a dose of the sublimate of 0-005 to 0*02 [gr. ^ to -§-] per day. As a rule, it is best to continue to the end of the sublimate cure with a dose of say 0*010 [gr. £] per day. But if the syphilitic phenomena re- main at a standstill for several days, and there are no contra- indications in the constitution of the patient against larger doses of mercury, it may be increased gradually at the end of three or four weeks to 0*012 or 0*015 [gr. \ to £]. It is better to administer it in the form of pills than dissolved in water or alcohol. The following is the most convenient method : 5 Mur. hydrarg. cor., 0*10 [gr. 1£] ; Solve in pauxillo aether snlph., et adde Pulv. aniyli q. s. ut ft. pil. No. 20. D. S. One pill to be taken morning and evening. IJ Mur. hydrarg. cor., 0*10 [gr. H] ; Aqua destil., 300-00 [ § ixss., 3 iv]. M. S. One tablespoonful to be taken morning and evening. For the purpose of preventing the gastralgia and the colic- pains, the patient should avoid taking the medicine, especially his morning dose, on an empty stomach ; a bowl of broth or milk should always precede it by about half an hour. If the patient is in the habit of drinking tea, morning and evening, then the following may be prescribed : B Rhum. optimi, 20*00 [ I ss., 3 iv] ; Sublimat. cor., 0-10 [gr. 1J], M. D. S. Twenty drops to be taken in the tea, morning and evening. 356 PATHOLOGY AND TREATMENT OF SYPHILIS. We seldom prescribe calomel or submuriate of mercury ; in fact, only in such cases in which we desire to administer large doses of mercury through the digestive system in a short time. In dangerous iritis especially, and in specific affections of the fauces, calomel has proved to be one of the quickest remedies to produce good effects. In adults it may be given in the follow- ing form : 3 Calomel laevigati, 0*50 [grs. viij] ; Opii puri, 0*10 [gr. lfj. Sacchar. alba, 5-00 [3 iv]. M. Div. in dosis No. 12. D. S. One powder to be taken morning, noon, and night. On the whole, we have used very little sublimate or sub- muriate of mercury for many years past, because we have con- vinced ourselves that no other preparations will produce such peculiar and obstinate alterations of the epithelial cells of the mucous membrane of the mouth and tongue as these, especially if the patient is addicted to the use of tobacco. In these pa- tients there are found most frequently on the mucous mem- brane of the tongue, lips, and cheeks, especially on the places that come in contact with the angles of the teeth, pearly- white, opalescent opacities of the epithelial cells, varying in size from that of a pin's head to that of a bean, which may be either scattered or aggregated. These places look as if they had been touched with nitrate of silver. They are distinguished from mucous-membrane papules by the absence of diphtheritic slough upon them ; they do not ulcerate, display no local pro- liferation of the papilla, often terminate in retractions of the affected places of the mucous membrane, because, in conse- quence of the pressure of the epithelial thickening upon the affected papillae, the latter retract, while the epithelial opacity is so persistent that it remains unaltered for many years. In accordance with an article published by Wiensky, a Eussian physician, who on injecting cinnabar into the blood of animals found it again encysted in the epithelial cells, H. Zeissl feels justified in asserting that the opacities spoken of are nothing more than epithelial cells containing mercury. In proof of this view, we can say that we never saw these persistent opaci- ties in persons who were not treated with corrosive sublimate. SYPHILIS. 357 As an additional proof, we may point to an analogous alteration of the epithelial cells seen in the blue color on the gums ot persons who handle lead, and in the bronzing of the skin and buccal mucous membrane produced by the internal administra- tion of nitrate of silver. As the internal employment of mer- cury is generally adopted in the treatment of recent manifesta- tions of syphilis, that is to say, at a time when the indurated infecting places are still suppurating and the indolent buboes are still progressing, it will be well for the patient to avoid all active exercise, though it is not necessary that he should stay in bed. Furthermore, as the patient frequently suffers from rheumatoid pains at the beginning of syphilis, he should not expose himself unnecessarily to sudden changes of temperature, and especially should he protect himself against cold and damp night-air. It is even beneficial for him to sweat some at night. Under moderate diaphoresis, the disease not only runs a fa- vorable course, but the internal use of mercury is better tol- erated. For this reason, most physicians order the patient to take a larger dose of mercury on going to bed than at other times. In regard to the diet, the patient may be allowed to take a moderate amount of nourishment ; it is only necessary for him to avoid all kinds of vegetables and fruit that cause flatus, and all articles that contain vegetable acids, lemonades, etc., which are incompatible with the remedies, and readily give rise to nausea, colic-pains, and diarrhoea. If calomel is used internally, the patient should not be allowed to partake of very salty food, such as salt herring, or drinks containing soda ; nor of am- monia, because the composition of the calomel is thereby liable to be changed, and, it is claimed by some physicians, that sudden deaths have resulted from it. He should i enounce the use of tobacco in every shape absolutely during the treat- ment with mercury, especially when the sublimate is used. How long a time is required to accomplish a cure with mer- cury, and how much of the different preparations is necessary to completely annihilate syphilis, depends upon the individual case. As a rule, the mercurials should be administered to the patient, if he tolerates them, till all the symptoms have disap- peared, which will seldom occur in less than two or three 358 PATHOLOGY AND TREATMENT OF SYPHILIS, months. Accordingly, a patient will consume about 4*00 [grs. lxij] of the protoiodide, or 0*5 to 1*00 [grs. viij to xvj] of corrosive sublimate. The treatment must be suspended, at least for a time, as soon as the mucous membrane of the mouth is affected, and the patient should rinse his mouth with some astringent preparation every half -hour. External Application of Mercury and its Preparations. The absorption of mercury into the blood through the skin can be accomplished in the following manner : (a) By repeated inunctions of salve, containing mercury, over a large portion of the skin (epidermatic mercurial treat- ment). (b) By injections into the subcutaneous tissue (hypodermic mercurial treatment). (c) By the action of vapor of mercury through the skin. (d) By the use of mercurial baths. And, lastly — (e) By the local use of mercury in the form of suppositories upon the mucous membrane of the rectum. (a) Mercurial Inunction Treatment. The method of treating syphilis by means of mercurial ointment came into vogue at the very beginning of the epidemic of syphilis in Europe ; but even the systematic directions laid down for its application by Louvrier and Rust at the begin- ning of this century led to so much misuse, that all sensible physicians denounced it. Our method of employing the inunction-cure is the follow- ing : "We begin the inunctions without any special preparations, simply allowing the patient to take a lukewarm bath. We order from two to five grammes [ 3 ss. to 3 jss.] of blue-oint- ment for each inunction. The inunctions may be performed by the patient himself, or by an attendant with leather gloves upon his hands. They may be resorted to daily, or every second or third day, according to the intensity of the syphilitic lesion and the constitution of the patient, and are carried out in the following order upon the various parts of the body : On the first day of the treatment the ointment is rubbed in on the anterior surfaces of both arms ; on the second day, SYPHILIS. 359 on the anterior surfaces of both thighs ; on the third day, on the anterior surfaces of both forearms ; on the fourth day, on the anterior surfaces of both legs ; on the fifth day, on both loins ; on the sixth day, on the back ; on the seventh day, the order of arrangement is begun anew. The patient should thoroughly rub in the whole dose of the salve, taking care that none of it remains in lumps upon his hand or upon the body. The hairy parts of the body should be avoided as much as pos- sible, because the inunctions are there apt to produce an erup- tion of small pustules, an inflammation of the apertures of the hair-follicles. If the patient's hands are tough and callous, he should put on a pair of tight-fitting leather gloves wherewith to perform the inunction. In unpleasant weather the patient should remain in his room ; but when the weather is favorable, especially during the warm season of the year, he should spend the greater part of the day out-of-doors. During the cold season, the tem- perature of the room should be 15° or 16° Reaumur [6Q° or 68° Fahr.], and, if possible, the apartment should be thoroughly ventilated twice a day. The physician should pay special attention to the condi- tion of the mouth of the patient. From the very beginning of the treatment, the latter should be instructed to rinse his mouth repeatedly during the day with pure water, or water containing some astringent remedy, such as chlorate of potash, alum, borax, tannic acid, laudanum, etc., I'M [grs. xvj] to lOO'OO [^iij, 3viij] of water. In addition, he should prevent the formation of tartar on Ins teeth by brushing them several times daily with a soft tooth-brush and water. In accordance with the views already enunciated, we only resort to the inunction-treatment in the advanced stages of the disease, and especially in those cases which resist the action of less powerful remedies — the iodides. All relapses of the first phase of syphilis, such as relapsing papular syphilides, pso- riasis palmaris diffusa, impetigo, and ecthyma syphilitica, and partly, also, nodular syphilides, are particularly well adapted for treatment by inunction. In some cases certain special physiological and pathological conditions that may obtain will serve to determine the physician in preferring the inunction 360 PATHOLOGY AND TREATMENT OF SYPHILIS. method over any other form of mercurial treatment. Thus, it is vastly preferable to subject syphilitic pregnant, and puerperal women to an inunction-cure, than to administer mercury to them internally. Persons having feeble digestive organs, those suffering from suspicious laryngeal and bronchial catarrhs, from frequent gastro-intestinal catarrh, or those who only recently re- covered from typhoid fever or dysentery, are more advan- tageously treated by inunctions than by the internal admin- istration of mercury. Further, the morbid syphilitic condi- tions best adapted for the inunction-treatment are those which are complicated with constitutional or other affections that also require internal treatment — for instance, scrofula, tuber- culosis, chlorosis, intermittent fever, etc. In these cases, cod- liver oil, iron, and quinine, may be employed in addition to the inunctions of mercury ; but the inunctions are principally applicable in those cases in which dangerous symptoms su- pervene, because they afford such rapid relief : thus, in sup- puration of the nasal passages, in iritis syphilitica, specific affections of the head, brain, and nerves, especially those that depend upon extra-cerebral morbid changes. The number of inunctions that may be necessary varies, of course, according to the form and intensity of the disease ; the individual condition of the patient ; and, lastly, whether the pa- tient had taken mercury shortly before beginning the inunction- treatment or not. The treatment of syphilitic ulcers, nodular syphilides, and large tophi, will require more inunctions than that of a papular syphilide. In regard to the individuality, experience has shown that there are persons in whom the employment of this method, and the mercurial treatment generally, exercise a favorable in- fluence upon the involution of the morbid phenomena in a very few days, while in others the lesions obstinately resist all kinds of mercurial medication. Fewer inunctions will be re- quired if employed in conjunction with Zittmann's decoction than without the aid of the latter. We have seldom found less than twelve to sixteen inunctions sufficient, nor more than thirty required in the patients that came under our observa- tion. If this number is not capable of subjugating the most essential features of the disease ; still more, if an aggravation SYPHILIS. 361 of the syphilitic symptoms, or of the general condition super- venes, the treatment should be suspended for the time being, and an effort made by a proper diet and mode of living (some- times by the intercalation of a moderate grade of cold-water cure) to invigorate the system. When this has been achieved, the inunctions of mercury may be resumed. Sometimes it becomes necessary to suspend the inunction- cure for a time, owing to the supervention of certain physio- logical or pathological conditions. The physiological condi- tions referred to here are menstruation and confinement. The acute, febrile, contagious exanthemata, measles, scarlet fever^ variola, acute inflammations of some of the organs, intense catarrhal or inflammatory affections of the intestinal canal, ac- companied by exhaustive diarrhoeas, may be classed among the pathological conditions. Above all, however, an intercurrent haemoptysis in tuberculous syphilitic patients will require the immediate suspension of the inunction-treatment. But the application of the mercurial ointment per se not infrequently gives rise to morbid phenomena, which necessitate a suspen- sion of the procedure. Stomatitis mercurialis is one of the most frequent pathogenetic effects of mercury ; next in fre- quency are eczematous affections of the skin, occurring in hairy individuals on the places where the ointment is rubbed in, and in blondes with a tender skin over a larger part of the integu- ment. During the inunction-treatment the patient should be nour- ished with easily digestible food in quantities proportionate to his age, habits, and bodily conformation. We allow the pa- tient in the morning either a cup of tea, coffee, or a bowl of broth or milk, with one or two slices of wheaten bread ; for dinner, nutritious beef-soup, from fifty to seventy grammes [ 5 jss., 3 iv to § ij, 3 viij] ; veal, or chicken, twenty grammes [ 1 ss., 3 iv] ; rice boiled in milk or water, or some other di- gestible farinaceous food, or spinach in the same quantity ; even- ings, the patient gets another bowl of concentrated broth, with wheaten bread and coffee, chocolate, or milk. Special condi- tions, such as pregnancy, confinement, scorbutus, convalescence from typhoid fever, and intermittent fever, require special dietary regulations. Pure cold spring-water is the best drink 362 PATHOLOGY AND TREATMENT OF SYPHILIS. that can be recommended. In the hot season of the year the patients, especially scorbutic convalescents, may be permitted to drink lemonade or water flavored with some fruit-sirup. Those who have been greatly reduced in strength by a pre- ceding typhoid or intermittent fever, loss of blood, or vicious mode of life, may be allowed to drink a proper quantity of good wine. During the inunction-treatment the patient's bow- els should move at least once a day, because experience has shown that those suffering from constipation are more liable to be affected with salivation than those who are not constipated. If the bowels are sluggish, cathartics or some mineral water that contains sulphate of magnesia or Glauber's salts, such as Saidschiitz, Piillna, Ofner, Elizabeth Spring, or the like, should be ordered. During treatment we often give a small quantity of Zittmann's decoction. If no contraindication against the continuation of the in- unction-treatment supervene, it should be prolonged till the physician has good reason to believe that the disease is entirely cured. The good effects of an inunction-cure, and of the internal use of mercury, soon manifest themselves by the fact that the patient loses his former cachectic appearance, gains perceptibly in weight, acquires a healthy color, and the evi- dences of the syphilitic diathesis capable of undergoing resolu- tion disappear. So long as the circumscribed discolored spots have not totally disappeared, so long as the syphilitic scars have not become perfectly pale, so long as there is falling out of the hair and fragility of the nails, the patients can not be deemed entirely cured. When the inunction-cure is completed, the patient should take one or more warm baths, protect himself against catch- ing cold by remaining a few days more in a warm room, and then may gradually resume his usual mode of living. To avoid all possible risks of the effects of a lowering temperature upon the system that may have become sensitive during the treatment, several hot vapor- baths, with subsequent cold douch- ing, or a moderate grade of cold-water treatment, may be rec- ommended to the patient. [The problem at the outset in the treatment of syphilis is to free the system of a poison that possesses the property of SYPHILIS. 363 tenaciously clinging to it and of undermining it for years, per- meating all the tissues and fluids of the body. "We must bear in mind that so long as the poison is active the natural recu- perative powers of the body are insufficient to overcome the disease which has a tendency in many cases to be aggressive, progressing in its morbid changes, and, when left to itself, causing serious damage to many important organs. If the sys- tem is to be saved from permanent injury, if it is to be freed from the syphilitic poison and cured perfectly, the physician and patient must unite and continue their work together per- sistently until it is brought to a happy termination. The antidotes to the syphilitic poison are mercury and iodide of potassium ; upon that point there is no longer any question. The best authorities are now agreed that the disease can not be cured effectually without them. But they are only antidotes when properly handled. If given in insufficient doses, the disease soon obtains the mastery; if used in ex- cess, they become poisons themselves. To hit the exact and happy medium, to avoid both dangerous extremes, we must not confine ourselves to strictly arbitrary doses, but admin- ister them in quantities not only sufficient to control, but to eradicate the disease, in accordance with the requirements of each individual case, being ever ready to reduce the quan- tity or discontinue it entirely as soon as any untoward symp- toms manifest themselves. At the same time we must avail ourselves of such other agents as will aid in bringing about the transformation of diseased into healthy tissues, by increas- ing their nutrition with healthy blood, and removing effete matter — i. e., by a generous diet, diaphoretics, tonics, etc. To Yon Sigmund belongs the credit of having pointed out the fact that in the treatment of syphilis with mercury we must not only not produce any signs of mercurial poisoning, but the more perfectly we guard the system against the toxic effects of this drug the surer shall we be to cure our patient of his syphilitic disease. In the vast majority of cases the inunc- tion method is the best form of employing mercury, and, hav- ing obtained the most satisfactory results from it, I seldom use any other. In regard to the fear of patients taking cold during its employment, all I can say is that I have repeatedly 364 PATHOLOGY AND TREATMENT OF SYPHILIS. seen patients come to my clinic in inclement weather with a considerable amonnt of mercurial ointment still fresh upon their persons, having neglected to wash it off for days to- gether (though they were cautioned against such a course) — many of them being insufficiently clad at that, without suffer- ing any ill effects from it. In the inunction-treatment, the following additional prac- tical suggestions may be of value to the practitioner : 1. The body should be prepared to absorb the mercury, and a quantity of blue-mass used sufficient to produce an effect upon the syphilitic lesion. The preparation of the body simply consists in the patient taking a warm-water bath before rubbing in the salve ; he should remain in the bath from a quarter to half an hour. Poor patients who can not procure these baths should wash the part of the body upon which the salve is to be rubbed with diluted alcohol or vinegar and water, and afterward rub the part dry with a coarse towel ; in fact, simply rubbing the skin with a coarse dry towel accomplishes the same object — of stim- ulating the absorbent powers of the skin — as the use of hot baths. Sometimes, however, various obstacles may inter- vene, such as mercurialization and febrile phenomena, caused perhaps by a local affection, which have to be removed before the patient can be subjected to the inunction method. Para- doxical as it may seem, yet it is nevertheless true that a pa- tient may be brought to a state of mercurialization and sto- matitis without being benefited in the least, and it will be necessary to cure him of these complications before it is pos- sible to administer any more mercury to him. If the febrile phenomena are due to an intercurrent acute disease, or the patient has been intemperate, and indulged in excesses, it will be necessary to defer the inunction-treatment till his system has had an opportunity of recuperating somewhat, and been improved by proper restrictions, baths, tonics, etc. I deem the manner of rubbing in the ointment of the ut- most importance. Usually the patient takes a lump of salve and rubs it in upon his person without care or attention, leav- ing perhaps half of it in lumps on the skin or on his fingers. Naturally, little or no good is derived from such inunctions. SYPHILIS. 365 the disease remaining unaffected — nay, more, often progresses unchecked. I therefore give him explicit instructions to rub the salve into his groins, thighs, or axillae, in such a man- ner that the whole mass of ointment is thoroughly rubbed away — consumed, as it were — and none remains on his lingers or in lumps on his body. If possible to employ a trained nurse to do the inunction, better results will, of course, be at- tained than when the patients do it themselves. If time per- mits, I order the patient to rub in the salve leisurely on one side first, and then on the other ; in this manner he is sure to rub it in more thoroughly than when he rubs it on both sides simultaneously. In order to avoid irritating the skin, I cause the salve to be rubbed in each day on a different part of the body, as recommended above. The amount of unguentum hydrargyri necessary for each inunction varies with the size of the body and susceptibility of the individuality — from 2*00 to 5'00 (grs. xxx to lxxv) for an adult, and from 1*00 to 2*00 (grs. xvj to xxx) for a child. A very good method I have found is to order the patient to rub in the required amount of the ointment just before go- ing to bed, drink a pint of hot milk, get into bed, wrap him- self up in blankets, and sweat. In the morning he should take a bath, or at least wash the part where the salve was rubbed in with warm water and soap. The hot milk is both nutritious and sudorific, and is an invaluable adjuvant in helping the system to get rid of the syphilitic virus. One great advantage of this method is that no patient is so poor that he can not provide himself with the agents necessary to carry it out. The rubbing in of the salve before going to bed does not interfere with his vocation, and his remaining in bed the whole night obviates the danger of his taking cold. For the sake of greater cleanliness, I sometimes use the oleate of mercury, but the objection to unguentum hydrargyri on the score of uncleanli- ness is obviated if the patient uses the same night-shirt while undergoing the course of inunction. 2. The body must be maintained in a good state of health during the treatment. Above all things, it is necessary that the patient should breathe plenty of good air. The lungs must work in a good 366 PATHOLOGY AND TREATMENT OF SYPHILIS. atmosphere, while the skin is impressed into service and com- pelled to absorb the antidote against the syphilitic poison. The patients should be out in the open air as much as possible, and sleep in as large a room as they can obtain. In small rooms more or less of the vapor of mercury accumulates in the air, and a tainted atmosphere is thus inhaled. For this reason, also, no one should share the room with the patient. The physician should insist upon the patients' taking sufficient out-of-door exercise, and properly ventilating the room they sleep in ; the fear of taking cold is so great that they often go to the opposite extreme, shutting themselves up in small, poorly ventilated rooms, and thus do themselves great in- jury- In regard to nutrition, it is only necessary to say that syphi- lis ushers in an acute anaemia, which saps and vitiates the sys- tem of the patient in proportion to the severity of the disease ; the debility is proportional to the loss of bodily weight. Hence the necessity of placing the patient upon the best possible diet. The brilliant results which the inunction-cure and low diet achieved in former years can not be set up against this prop- osition A sufficient amount of good and nutritious food should be allowed ; I am even in favor of according the privilege of partaking of a moderate amount of good wine or malt liquor daily, for the purpose of stimulating digestion and assimilation, and thus expediting the metamorphosis of the tissues by a better and richer blood-supply. However, owing to the gluttonous habits of some individuals, it will be well for the physician to prescribe for the patient the amount of food and drink necessary for him. It is of the utmost im- portance that he should not overtask his digestive organs, for upon the ability of the latter to prepare a proper pabulum will depend the recuperation of the entire system. It is highly essential that the mucous membrane of the mouth be maintained in a good, healthy state, and the tendency to mercurial stomatitis be obviated by appropriate local treat- ment. There is great diversity among patients in this re- spect. Some are very prone to suffer from mercurial stoma- titis, and others remain exempt from it throughout the whole course of the disease. But whenever the tendency manifests SYPHILIS. 367 itself it should be counteracted by the use of some of the remedies mentioned above. If ulcers form in the mouth, they should be cauterized with nitrate of silver or chromic acid — the latter solution being employed one hundred grains to a drachm. In addition to this treatment, the patient must be enjoined to keep his mouth perfectly clean, and renounce the use of tobacco absolutely. I wish to say here that it is possible to habituate patients to the use of mercury, however sensitive they may be to it, and, if such a person comes under treatment, it is best to be- gin with a small quantity of mercurial salve and gradually increase it. If perchance salivation has been produced, the inunction should be suspended altogether till all the symptoms of mercurialization have disappeared. Sometimes it is difficult to distinguish mercurial from syphilitic ulcerations. Both occur on various parts of the mu- cous membrane of the mouth and resemble each other very closely. This is especially true of mercurial ulcers that oc- cur on the tonsils and palate. Here the matter can only be decided by time, watching the case carefully, and, if necessary, suspending the inunctions for a while. If the ulcers are mer- curial in origin, they will get well by the use of the above- described lotions for the mouth, but if syphilitic they will constantly become aggravated. They also act quite differently in reference to cauterizations. A syphilitic ulcer will get well — a mercurial ulcer becomes aggravated by cauterization. An increased flow of saliva may also cause uncertainty in regard to its origin, for sometimes cases are met with in which this con- dition is simply due to irritation of the nerves of the mucous membrane of the mouth and of the sab vary glands by the syphilitic virus. This point, however, can be decided by the history of the case and whether the patient has been subjected to a treatment with mercury or not. Another objection has been urged against the inunction method, namely, the production of sleeplessness. But, on in- vestigation, I have found that it is not of sufficient conse- quence to cause a suspension of the treatment. It occurs very seldom, and its effects are transient. I am, moreover, of the opinion that it is due to the general nervous irritation 368 PATHOLOGY AND TREATMENT OF SYPHILIS. of the system caused by the syphilitic virus, as is manifest by the loss of sensibility of the cutis, and by the dilated pupils, and is therefore a still greater indication for persevering with the treatment. A word or two in reference to the local treatment of syphi- litic lesions during the inunction-cnre. Although the latter will almost always prove sufficient to cause ulcerations of the skin and other parts to heal, still a proper local treatment will be found of the utmost advantage. Above all, the sores are to be kept scrupulously clean, in whatever stage of the disease and upon whatever part of the body they may be. Solutions of bichloride of mercury, of carbolic acid, nitrate of silver, iodoform, boracic-acid ointment, etc. — any one of these will render efficient service. For the nose, vagina, or rectum, Esmarch's irrigator will be found indispensable. 3. The inunctions must be continued long enough. To cause the morbid lesions to heal, and prevent relapses — that is our task. The earlier the syphilitic patient is taken in hand, and subjected to a thorough anti-specific treatment, the milder the disease will run its course, and the more rapidly will the symptoms disappear. I have seen so many hard, initial sclerotic nodes, or hard chancres, attended by indurated plaques of inguinal glands, disappear, melt away as if by magic under the inunction-treatment, the patients remaining subsequently free from relapses, that I no longer hesitate to put a patient under the specific inunction-treatment as soon as I have satisfied myself of the true nature of the lesion. It is con- ceded by some of the best authorities that it is easier to cure a patient radically of his syphilis while the infecting virus is still localized in the initial sclerosis, or even if it has affected the inguinal lymphatic glands, than when it has permeated his entire system, less medicine and a shorter time being neces- sary to counteract a poison confined to a limited space than when diffused throughout the tissues and fluids of the body. I prefer the inunction method for this purpose, because I can accomplish more with it in a given time than by the internal administration of mercury. Besides, it possesses the additional advantage over the latter of not interfering with the patient's digestion. The complications of the inunction-cure spoken of SYPHILIS. 369 above are only seen in exceptional cases, and have been referred to at length because of the greater value it possesses over other methods of treatment. I quite agree with Yon Sigmund in his statement that there will scarcely ever be seen a case of syphi- lis which the inunction method, if continued long enough, will not cure eifectually. It is well to state here that, to cure a patient radically, and render him proof against relapses, it is necessary to prolong the inunctions of mercury for from eight to ten days after the symptoms of syphilis have entirely dis- appeared. One of the most useful adjuvants in the treatment of syphi- lis is the hot-air bath, Russian or Turkish. The use of topical bathing before and after the rubbing in of the mercury has al- ready been alluded to. The hot-vapor bath for the purpose of causing profuse diaphoresis is an invaluable remedy. I cause my patients to take one and often two a week. It is well to caution them against remaining too long a time in the hot-air chambers, fifteen or twenty minutes being sufficient to cause active turgescence of the skin, attended by a profuse flow of perspiration. A longer stay will relax the system too much and prove debilitating. The physiological action of these baths is that of a derivative of the greatest power, and their good effects are soon manifest. A word or two more in reference to the use of the iodides. Everything that has been said concerning the susceptibility of certain individuals to the use of mercury is applicable with still greater force to the preparations of iodine. Often they are tolerated badly, or not at all, even when taken after meals and largely diluted. Thus, in one patient, it was impossible to administer the remedy unless it was preceded by a teaspoon- ful of brandy largely diluted with water. The individual was not of intemperate habits. In other patients, again, the dose required to produce a physiological impression upon the sys- tem, to bring about a state of iodism, may vary in amount from 0*60 to 4*00 (grs. x to 3 j) every three or four hours. Many physicians prescribe small doses of the iodide in com- bination with mercury, even for the early manifestations of the disease, in what is denominated the " mixed treatment," each dose containing about 0*01 (gr. -fa) of corrosive sublimate, 24 370 PATHOLOGY AND TREATMENT OF SYPHILIS. and 0*30 (grs. v) of iodide of potassium, properly diluted. When an important organ is involved and is in danger of -be- ing irreparably damaged, full doses of the drug — from 1-00 to 4*00 (grs. xv to 3 j) three or four times a day — will render efficient service ; likewise, when the use of the mercury has to be suspended and it is necessary to prolong its specific effect. On account of its rapid action, it is especially useful in those terrible night-pains that sometimes threaten to drive a patient to distraction. Finally, the remedy is often serviceable in de- tecting the true nature of an obscure syphilitic lesion. The many cases of nervous affection whose etiology is so difficult to elucidate, and in which cures are reported to have been achieved, are doubtless of syphilitic origin. Patients are often met with who form their own diagnosis by the statement that iodide of potassium has repeatedly relieved them of their dis- tressing ailment, thus affording the physician an indication of the true nature of their disease. Thus, one patient informed me that he had been suffering for five years from the most violent pains in his stomach and frequent emesis, which was always controlled by iodide of potassium ; and, on inquiry, I found that he had had a chancre some eight years before, fol- lowed by a slight syphilitic eruption, but supposed himself to be entirely cured of his disease. It may be remarked en passant that the remedy is often abused. Many of the morbid lesions of this disease get well under its use, and thus the patient becomes accustomed to resort to it whenever anything happens to him. In the course of time he finds, greatly to his surprise, that the remedy makes no impression upon the disease, the symptoms remaining stationary, or even becoming aggravated, a condi- tion of tolerance having taken place ; not only has the iodide lost its power over the disease, but it may happen that, when the patient submits himself to radical treatment, such as may become necessary upon the supervention of some acute specific lesion, he is extremely unimpressionable to the action of the remedies. A longer or shorter interval of abstinence from all medication will then be necessary before the remedies can ex- ert their power over the disease.] SYPHILIS. 371 (b) Hypodermic Mercurial Treatment of Syphilis. Lewin was the first physician who systematically practiced hypodermic injections of corrosive sublimate in the treatment of syphilis, though many had employed various preparations of mercury subcutaneously before him. Before we relate the results of our experience with hypo- dermic injections, we desire to say a word concerning the technique and the precautions that are necessary. A broad fold of skin should be pinched up and made as tense as pos- sible, because the point of the hypodermic needle will then penetrate the skin much more easily, the pain will also be lessened, and a vacuum is thereby created over a com- paratively large surface for the absorption of the injected fluid. These factors obviate, to a great extent, the danger of the formation of an abscess. The oiling of the needle be- fore injecting the medicine is superfluous, but the entire in- strument should be cleansed in water and dried before each operation, so that the canula does not become rough and clogged up, and particles of corrosive sublimate forced into the skin. The piston should work smoothly, failing in which, and if much force has to be used, there is danger that the op- posite fold of skin will be punctured, and the injected fluid penetrate into, instead of under, the skin. In injections with corrosive sublimate, such an accident is liable to be attended by unpleasant results ; the puncture becomes inflamed, suppu- rates, and causes severe pain. The skin should be punctured and the entire injection performed as quickly as possible. In corpulent persons the injections, it is true, are made with more difficulty ; still, they can be performed if a fold of skin suf- ficiently broad is pinched up. We have never seen any bleed- ing from puncture of a blood-vessel. In regard to the frequency of salivation, we must say that gingivitis and stomatitis did not occur oftener in the patients we treated by hypodermic injections than in those treated by inunctions with mercury. Relapses and successive outbreaks of syphilitic phenomena occur just as often in the injection- treatment as in that by inunctions. It is a curious fact that if gingivitis develop during the mercurial inunction method, the 372 PATHOLOGY AND TREATMENT OF SYPHILIS. pyramids of the incisor teeth of the lower jaw, as a rule, are the first to swell up, while in the treatment by hypodermic subli- mate injections gingivitis of the upper incisors usually develops first. If the injections are made in the vicinity of the pri- mary induration and indolent absorption buboes in the groin, the latter will be the first to disappear ; ulcerating papules offer the greatest degree of resistance to the hypodermic injections. The maximum of a total dose of 0*2 [grs. iij], either of calo- mel or of bichloride, was needed only in the most obstinate cases. In regard to the choice of the mercurial to be used, we prefer corrosive sublimate to calomel, although, as a rule, we have seen the syphilitic phenomena disappear sooner from the use of calomel injections. But this advantage which calo- mel possesses is greatly offset by the fact that the injections are almost always followed by boils, despite the utmost care adopted. Although they did not always suppurate, still they were very painful for a long time. According to the statement of the patients, the pains last longer after injections with a purely watery solution of sublimate than when the watery so- lution is mixed with glycerine. Gingivitis, as a rule, comes on later in injections with corrosive sublimate than with calomel. "We use the following formula : IJ Sublimat. corrosivi, 1*00 [grs. xvj]; Glycerini puri, 70*00 [ § ij, 3 viij] ; Aqua destil., 30-00 [ § j]. M. S. For injections. A syringeful of this solution contains 0*01 [gr. £]. The injections should be made into the back and sides of the thorax. Some physicians — Legeois, for instance — fearing the corro- sive effects of the sublimate, have injected a minimum dose, 0*005 [gr. -j^], combined with muriate of morphia. Dr. Staub, of Strasburg, employed for that purpose, a preparation of corrosive sublimate free from acid. He dissolved the sub- limate and chlorate of ammonium in distilled water, and fil- tered the solution ; next he dissolved the white of an egg in SYPHILIS. 373 distilled water and filtered it ; lastly, lie mixed both solutions, and filtered for the third time. Cullingworth found Staub's solution, aside from the trouble of preparing it, exceedingly liable to become decomposed, and injections made with it were followed by indurations that disappeared very slowly. No indurations, however, followed the use of solutions obtained by the method described by Yon Bamberger, in 1876, and many patients treated alternately with Staub's and Bamberger's solu- tions maintained that the latter preparation is much less pain- ful. In Bamberger's solution pepton is used in place of albumen, which simplifies its preparation, and renders it more permanent. He dissolved 1*00 [grs. xvj] of meat- pepton in 50 ccm. [ § j, 3 v] distilled water, and filtered the solution. To this he added 20 ccm. [ 3 v] of a five-per-cent sublimate solution, and dissolved the resulting precipitate with the requisite quantity (15 to 16 ccm. [ 3 iv]) of a solution of table- salt, poured the liquid into a graduated glass, and added dis- tilled water till the whole amounted to 100 ccm. [ 5 iij, 3 ij]- Every cubic centimetre then contains exactly 0*01 [gr. -J-] mer- cury combined with pepton. The liquid should be covered and allowed to stand quietly for several days. A slight amount of white flaky precipitate settles, from which it is finally sepa- rated by filtering. This preparation keeps better than the al- buminate, and injections made with it only cause so much pain as is experienced from the sudden tension of the subcutaneous connective tissue. Other physicians (Boulton, for instance) inject iodide of mercury in a solution of iodide of potassium. Still others have tried various other preparations of quick- silver for injections, especially hydrarg. acet., hydrarg. ioda- tum, and hydrarg. biniodatum rubrum, and, lastly, a watery solution of iodide of potassium containing the protoiodide. But the last-mentioned injecting fluid is now almost en- tirely abandoned, as it is liable to be precipitated and act as an irritant. Lately, the chromate of the oxydul of mercury and the methyloxydhydrat have been tried ; we have had no ex- perience with these preparations. Cullingworth, Yon Sig- mund, and Gurtz recommend hydrarg. bicyanetum. Quite recently a one-per-cent solution of mercury formcu- mid was recommended for subcutaneous injection by Lieb- 37± PATHOLOGY AND TREATMENT OF SYPHILIS. reich. We have tried this preparation quite extensively. In its action it differs in no respect from other mercurial compounds ; it causes the symptoms of syphilis to disappear just as quickly, and also produces salivation as readily as other preparations of mercury, and the relapses, too, occur just as often after its use as after any other. The main advantage of the hypodermic mercurial treat- ment is that the dose of the medicine introduced into the sys- tem is not only very much smaller than that which is admin- istered by the mouth or in the inunction method, but it can also be measured accurately. Furthermore, it is also a much cleaner and less expensive method than the inunction or in- ternal treatment, circumstances which, in private or even hos- pital practice, can not be over-estimated. Nevertheless, we seldom resort to this method now, because it is by no means painless, is as little capable of preventing relapses, and just as often occasions mercurial stomatitis, as any of the other methods of administration. (c) Treatment of Syjphilis hy Mercurial Fumigations. For many years H. Zeissl and others treated their syphilitic patients in the Vienna General Hospital by mercurial fumiga- tions, according to the method described by Dr. Henry Lee, of London. The patient, entirely nude, is placed upon a cane- bottom chair and wrapped in a cotton gown provided with a hood, the face only being exposed. A funnel-like vessel, open below and perforated with holes all around, is placed under the seat. At one place it is cut out for the admission of a spirit-lamp. Above, the vessel is shut off by a plate which is depressed in the middle, where a small saucer is placed. The depression in the plate is filled with water for the purpose of generating steam-vapor, and in the saucer 1*50 [grs. xxij] of calomel is placed. On lighting the lamp, vapor, impreg- nated with the fumes of calomel, is generated and deposited upon the skin of the patient. Most patients feel very com- fortable during and after the fumigation, the respiration being in no way interfered with by the process. Directly after the fumigation they must go to bed, to avoid taking cold. The fumigations may be made every day, or every other SYPHILIS. 375 day, or even at still greater intervals. The greatest number of fumigations necessary to perform a cure was fifty-five. Salivation occurred in ten cases. Relapses sometimes ensued after numerous fumigations. No syphilitic patients, who are liable to attacks of haemoptysis, should be subjected to the fumigation-treatment with mercury. AVe never employ this method now. (d) Treatment of Syphilis with Baths containing Mercury. Corrosive sublimate is the only preparation used in treating syphilitic patients with baths containing mercury in solution, and by the addition of muriate of ammonia it is rendered more soluble. The following is the formula we use : 5 Sublimat. corros., 15*00 [ § ss.] ; Mur. ammonia, 5 -00 [3 iv] ; Aqua destil., 100-00 [ | iij, 3 viij]. M. In vitro bene obturato. This solution is poured into a bath at a temperature of 27° to 28° Reaumur [92° to 95° Fahr.]. The patient remains in it for about an hour and a half, during which time it is cov- ered so that only his head is exposed. Corrosive-sublimate baths are adapted for individuals whose skin will not bear in- unctions, whose respiratory organs do not tolerate inhalations, and whose digestive organs rebel against the internal admin- istration of mercury. They are especially useful in patients suffering from pustular and ulcerating syphilis, and those in whom mercury when internally administered produces un- pleasant digestive disturbances. But they should not be em- ployed if the pustules are dry and exfoliate, and leave behind perceptibly hard perifollicular infiltrations — a phenomenon which we often had an opportunity of observing in variola syphilitica. While the sublimate baths are being used the same die- tary measures should be enforced as in any other method of mercurial treatment. These baths likewise are apt to occasion salivation. It is not possible to presage the exact number of baths that will be necessary in any given case. As the absorbing power of the skin is undoubtedly differ- 376 PATHOLOGY AND TREATMENT OF SYPHILIS. ent in different persons, it is not possible to say how much sub- limate of mercury — which, as is well known, is a very active remedy — is absorbed, and hence this method is not likely to be extensively used. (e) Treatment of Syphilis by the Application of Mercurial Suppositories to the Mucous Membrane of the Bectum. In many cases H. Zeissl has used suppositories of unguen- tum hydrargyri by way of experiment, in the following form : B Ung. hydrarg., 1*50 to 3*00 [grs. xxirj to xlvij]; Ung. ceti., 5-00 [3 iv]. M. Ft. sup. No. IV. The patient inserts one of the stronger suppositories in the evening into the rectum, and of the weaker suppositories one in the morning and one in the evening. By this method of applying the mercury we have often caused recent relapses of papular eruptions to disappear. In some cases evidences of beginning disease of the mucous membrane of the mouth — sto- matitis were produced. The mucous membrane of the rectum was not directly affected by the suppositories. Pathogenetic Effects which Mercury and its Preparations may produce during Treatment. In some persons, the preparations of mercury, like the pure mineral, when introduced into the system, produce in a re- markably short time, in others after a longer period, certain morbid effects. Collectively, the phenomena produced by the toxic effect of quicksilver have been described by the name of mercurialism, hydrargyrosis, or quicksilver-disease. An acute and chronic hydrargyrosis is distinguished, and according as it is produced by the industrial use of mercury or by medicinal application it is known as industrial or medicinal hydrargy- rosis. The latter manifests itself by a peculiar affection of the mucous membrane of the mouth, namely, stomatitis mercu- rialis. We have never seen any ulceration of the skin or dis- ease of the bones, or paralysis, in consequence of the thera- peutic use of mercury, even in cases in which its misuse was carried to the extreme. SYPHILIS. 377 Mercurial affection of the oral mucous membrane mani- fests itself usually by an unpleasant metallic taste in the mouth. The patient has the sensation as if the teeth are blunted and elongated, and of dryness in the mouth. An effort to chew solid food causes pain and slight bleeding of the gums. Gradually the patient finds that he wants to spit often. If at this time pressure is made upon the submaxillary gland, pain will be experienced, because the gland is somewhat enlarged. The gums, especially of the lower incisors (less of the upper), the lips, the mucous membrane of the cheeks, especially around the mouths of the mucous follicles, are of a bright-red color, swollen, and in places ecchymotic. The edges of the gums are livid, tumefied, surround the individual teeth like a wall, and separated from them ; and for that reason they seem to the patient to be elongated and loose. In the spaces between the teeth the secretion of the glandulse tartricas accumulates, in the form of a sticky, yellowish-green, offensive substance. The secretion of saliva increases more and more, and becomes an actual salivation. Lastly, the tongue swells, and becomes cov- ered with a dirty, slimy coating. The patient experiences dif- ficulty in moving the organ, and it sometimes attains to such a size that the mouth is not large enough to contain it, so that the apex protrudes between the incisor teeth, and the lateral sur- faces bear the indentation of the rest of the teeth (lingua cre- nata). The patient suffers from thirst, and the large quantity of saliva which he swallows sometimes causes nausea and vom- iting. If the action of the mercury is not arrested, and if the patient in addition is subjected to such influences as will nat- urally occasion stomatitis and scorbutus, the entire mucous membrane of the mouth will become coated with a grayish, diphtheritic layer, which can not be brushed off without caus- ing loss of substance. The mucous membrane finally also be- comes infiltrated and sloughs form, particularly on those places that are pressed upon by the teeth. When the sloughs are cast off considerable bleeding takes place, and then irregular, excavated, painful ulcers covered with a grayish coating origi- nate. The quantity of saliva secreted sometimes amounts to several kilogrammes [many pounds]. It is a remarkable fact that the saliva, according to some of the most eminent chemists 378 PATHOLOGY AND TREATMENT OF SYPHILIS. (Schneider), contains very little or no mercury ; on the other hand, according to Kletzinsky, sulpho-hydrate of ammonia and traces of urea are found in it — the former apparently being the cause of the offensive odor. The teeth may ultimately become so loose that they fall out. In consequence of the mercuri- alization the soft parts of the lower jaw are sometimes de- stroyed by sloughing, periostitis ensues, followed by deposits of porous, pumice-stone-like substance, which are known by the name of osteophytes. Carious teeth, or other morbid conditions of the mouth, neglect and uncleanliness of the teeth and gums, cold and wet, and foul air, promote the development of stomatitis. In some persons salivation ensues after they have undergone a mild course, in others after a severe course, of mercury. It hardly ever occurs in infants and old, toothless persons. A slight mercurial affection of the mouth, and tenderness of the gums, is of no consequence. On the contrary, even the opponents of the salivation-cure do not object to it, because they deem it a favorable prognostic sign in regard to the cure of syphilis. But severe stomatitis, produced by prolonged and excessive use of mercury, may be followed by very sad results. By the sloughing of the lips, mucous membrane of the cheeks or tongue, irremediable loss of substance may ensue ; the mu- cous membrane of the lips may become united to the jaws, the tongue, or floor of the mouth, so that, on the one hand, the opening of the mouth, on the other, the movements of the tongue, may be prevented (Bamberger). In order to prevent the occurrence of mercurial stomatitis the patient should be informed at the commencement of the treatment of the prodromata of the disease, so that he may sus- pend its use as soon as they appear. Furthermore, the patients should be instructed to rinse their mouths several times every day during the time they are undergoing the mercurial treat- ment ; they should be cautioned against exposing themselves to a too high or too low temperature, and the room they oc- cupy should be carefully ventilated at least once a day. If the stomatitis is already fully developed, the patient should be removed, if possible, from the atmosphere that is impreg- nated with particles of quicksilver into a purer one. His SYPHILIS. 379 clothes, utensils, etc., to which mercurial ointment may ad- here, should be removed, and he should be immersed in a warm bath. The local treatment depends upon the intensity of the affection. If the mucous membrane of the mouth is only catarrhally red or loose, the patient should be instructed to rinse his mouth every half-hour with one of the follow- ing lotions : 5 Tr. opii, 5-00 [3 iv]; Aqua fontan., 500-00 [ § xv]. M. S. For gargle. 5 Glycerini puri, 20-00 [ § jss., 3iv] ; Tannini puri, 5*00 [3iv] ; Aqua font., 500*00 [ § xv]. M. S. For gargle. Lotions for the mouth, consisting of solution of alum, bo- rax, tincture of rhatany, salvia, tormentilla, etc., are equally efficacious. When the salivation is severe, use — 5 Tr. iodines, 5-00 [3iv]; Aq. fontan., 500-00 [ § xv] ; Aq. cinnamom., Syr. cinnamom., aa, 50*00 [ § jss., Biv]. M. S. Mouth-wash. Lotions composed of chlorine abolish the offensive odor of the mouth very rapidly. The following may be ordered for this purpose : B Chlorin. liquid., 10*00 [Bviij]; Decoct, althse, 500-00 [ f xv] ; Mel. rosarum, 50-00 [ § jss., 3iv]. M. S. Lotion. 5 Kalichlor., 5-00 [2)ivj; Aq. font., 500-00 [ § xv] ; Syr. moror., 20-00 [§ss., Biv]. M. S. Gargle. If diphtheritic or gangrenous sloughing of the mucous membrane of the mouth has already taken place, either of the following may be ordered : 380 PATHOLOGY AND TREATMENT OF SYPHILIS. 5 Ext. ligni. campechiani., 20-00 [ § jss., 3iv]; Aq. fontis., Aq. salvias, aa, 200*00 [ § vj, 3 vss.]. M. S. A lotion for the mouth. 3 Emuls. commun., 300'00 [ § ixss., 3 iv] ; Camphora., 3*00 [grs. xlvij]. M. S. A lotion for mouth, and for painting the gangrenous sores. If these remedies prove ineffectual, pyroligneous acid or chloride of calcium should be tried ; mixed with an appropri- ate amount of water, they may be used as a wash for the mouth and application to the ulcers. The diphtheritic patches may also be touched with nitrate of silver, or painted with tincture of iodine. Narcotics, especially opium, may be used locally and internally for the relief of the pain. If the bowels are confined, some laxative should be administered, and water, acidulated with some vegetable acid, may be given as a drink. In cachectic persons who are greatly debilitated, care should be taken to invigorate them as much as possible. Effects of Cold-Water Treatment, Sea-Baths, and Sulphur Ther- mal Baths on Syphilis and Hydrargyrosis. In regard to hydropathic treatment as a curative remedy of syphilis, most authors are now agreed that it is an excellent adjuvant to other therapeutic measures. But the hydropathic treatment accomplishes no quicker results in syphilis than the expectant method. Cold-water treatment and sea-baths are especially useful in those patients who become greatly enfeebled by syphilis, or who suffer in consequence of the injudicious administration of mercury. Sulphur -baths gen- erally have an excellent effect upon syphilitic patients. Under the use of sulphur thermal baths, the intense pains in the bones, especially, are greatly relieved. If the patients are suf- ficiently careful, some of the most obstinate syphilides, such as psoriasis palmaris, etc., will disappear more quickly with the use of the sulphur thermal, if appropriate anti-specific treat- ment is simultaneously carried out, than without the latter. Martineau recently asserted that sulphur-baths were a test of the persistence of latent syphilis. Still, should a relapse ensue SYPHILIS. 381 in a syphilitic patient who was under treatment with sulphur- baths, it is no proof that the baths occasioned it. For a long time the use of sulphur internally and sulphur- baths were highly praised as remedies against hydrargyrosis, especially mercurial tremor. All we can say is, that we have obtained good results from sulphur-baths in persons who have not suffered long nor very severely from the tremor, and who, during the use of the baths, abstained from handling all kinds of mercurial preparations. It is possible that we would have obtained the same results from ordinary baths, but it is also probable that, by the use of the sulphur thermal, the tis- sues are stimulated to greater metamorphosis, and thus the quicksilver is more rapidly eliminated from the system. Syphilophobia and Mercuriophobia or Hypochondria Mercu- rialis. There are persons who, having suffered from syphilis or some other venereal disease, become a prey to feelings of de- spondency, which is best described by the term syphilophobia. They fear that they are still afflicted with syphilis, though not one symptom of it or any morbid alteration can be detected on their person. All rational attempts to convince them that they are free from the disease are useless. Day and night they busy themselves with their imaginary disease, and actually hunt for symptoms upon their persons, or conjure up some in support of their statement. " Thus they go about," says Eicord, correctly, " a burden to themselves and the whole world, ruin themselves by all sorts of cures which they practice upon themselves, or are induced so to do by ignorant or dishonest physicians." On the other hand, there are also hypochondriac persons who, having heard of the injurious effects that may be pro- duced by the improper use of mercury, imagine, when they ascertain that they took some of it, even the minutest quan- tity, that they will forever suffer the most dire effects. These persons think of nothing but their imaginary disease, neglect their affairs, and lose all interest in life. Any sensation they experience, any redness or swelling noticed by them ; some- times, indeed, perfectly normal elevations on the joints, bones, 382 PATHOLOGY AND TREATMENT OF SYPHILIS. etc., such as the cristge tibiae, which they accidentally discover, are attributed to the mercury, taken perhaps many years be- fore. All the arguments that may be used to such psychical patients are in vain. The delusion that they are suffering from mercurial poisoning, and the hatred they entertain for the physician who gave them mercury, cling to them all the more if they have read mercurio-phobic writings, or are con- firmed in their views by mercurio-phobic physicians. "We have never yet found this psychopathy in persons belonging to the lower order of people, but only in those of the more affluent class. Syphilization. The treatment of syphilis by the method erroneously styled syphilization, has, since the death of Boeck, been entirely abandoned. Auzias Turenne first suggested it in 1844. He observed that, if a person is inoculated with the virus of a soft chancre for a long time, he will finally acquire an im- munity against the poison, and the subsequent inoculations fail to take. Such persons are said to be syphilized. But, as we know that the soft chancre and the syphilitic primary le- sion, or, as the French physicians call it, the infecting chancre, are two different morbid processes, like pneumonia and pleu- risy, we must, like Haye, call this method simply " curative chancroid inoculation." But a healthy person who has been inoculated with the matter taken from a syphilitic primary lesion and has had syphilis, may be said to be proof against syphilitic infection a second time, because we know that rein- fection with syphilitic virus is one of the rarest occurrences. A prophylactic and a therapeutic syphilization is distinguished. The former, it is claimed, acts in the same manner as vaccina- tion. In regard to the effect of the soft chancre upon a person already affected with syphilis, Haye says that the in- oculated chancroids are derivative foci, " exutoria," similar to those that may be produced by inoculations with croton-oil, tartar emetic, etc. These methods of treatment have been tried by Langenbeck, Hjort, and others. As we have al- ready said, this kind of prophylaxis and treatment of syphi- lis is not employed any more, and is only historically inter- esting. SYPHILIS. 383 Treatment of some of the Local Syphilitic Affections. Among the morbid alterations that may be occasioned by syphilis there are some which, partly owing to the disturbances of sensation, partly owing to the mutilation and disfigurement they produce, require local treatment in addition to the treat- ment of the general constitutional disease. These are affec- tions of the organs of sight and hearing, the moist papules, mucous-membrane papules around the anus, on the genital or- gans, on the mucous lining of the mouth and fauces, syphilitic affections of the larynx and trachea, psoriasis paimaris and plantaris, deep ulcers of the skin and of the mucous mem- brane, solid and suppurating periosteal and osseous nodes, ab- scesses of the soft parts, caries and necrosis of a part of a bone, especially ozsena, perionychia, sarcocele syphilitica, strictures of the rectum, etc. In regard to affections of the organ of sight, we refer the reader to the section on syphilitic affections of the eye, by Professor Mauthner. Syphilitic affections of the ear require local treatment in accordance with the principles of otology. According to the statements of the most experienced otologists, the local treat- ment requires a long time before a cure can be accomplished, the general treatment being unable to achieve a satisfactory result. In regard to the local treatment of syphilitic affections of the larynx and trachea, we refer the reader to the therapeutic recommendations of Professor von Schrotter, in the section on those diseases. Mucous - membrane papules require different local treat- ment according to their site and metamorphosis. If they are situated in the mouth, and if, when they undergo degeneration, they assume only the form of erosions, simply washing them . with a mild, astringent lotion, will often suffice to bring about cicatrization. But if they have become transformed into deep ulcers, it will be necessary to touch them once or twice daily with lunar caustic, or they should be penciled with a solution of iodo-glycerine like the following : 1$ Glycerine, 10-00 [3 yiij]; Kali hydroiod., 0'50 [grs. viij]; Iodine puri, 0*05 [grs. £]. M. 384 PATHOLOGY AND TREATMENT OF SYPHILIS. Vegetations growing upon proliferating papules of the mu- cous membrane of the mouth, if they do not shrink after the application of astringent or caustic remedies, must be removed with the scissors and the wounds cauterized. Papules on the mucous membrane of the genital organs and rectum should be treated in the same manner, except that the j may be cauterized much more vigorously. Moist papules around the anus and genital organs require, above all, the utmost cleanliness, which can only be secured by frequently bathing or washing the parts. By inserting pledg- ets of lint between an affected and a sound part, the opposing surfaces are kept asunder, and the disease is prevented from spreading or infecting a normal part. Proliferating growths that frequently develop, and the fetid odor of the moist pap- ules, should be destroyed as speedily as possible. For this pur- pose a modified Plenk's paste is used now, which is composed according to the following formula: 3 Sublimat. corros. ; Camphorse ; Aluminis ; Cerusse alb. ; Spirit, vim ; Aceti vini, aa 5'00 [3iv]. M. These ingredients, being partly or entirely insoluble in spirit of wine and acetic acid, are precipitated and form a soft paste ; the supernatant fluid is poured off, and the paste is applied with a small brush to the part which is to be cauterized. It causes little pain when first applied, but it soon becomes very severe ; and for the purpose of relieving it, and of preventing the swelling of the parts, cold-water compresses should be applied. Care should be taken not to allow the paste to get upon any part of the skin covering loose cellular tissue, such as the labia majora and minora, the glans penis, cervix uteri, etc., as it is apt to occasion intense inflammation of the parts, which swell up excessively and may become gangrenous. Labaraque's paste, modified by H. Zeissl, is very well adapted for cauterizing moist papules. Labaraque causes the papules to be moistened with a solution of table-salt, and after- ward he strews calomel over them. H. Zeissl uses diluted SYPHILIS. 385 liquid chlorine instead of salt. The calomel, when it comes in contact with the chlorine, is probably converted into corrosive sublimate, and this sublimate in statu nascenti causes the warty growths to shrink almost painlessly, while a concentrated solu- tion of corrosive sublimate that will serve the purpose of de- stroying the adventitious growths occasions the most violent pains. Sublimate collodion is another caustic used for the pur- pose of removing papillary infiltration and proliferations, and is prepared in the following manner : 5 Sublimat. corro?., 1*50 [grs. xxij] ; Collodii, 20 00 [ § as., 3 iv]. M. S. For external use. This preparation is carefully applied to the parts with a camel's-hair brush daily, or every other day, and afterward they are covered with wadding or charpie. If severe inflam- mation ensues, cold-water compresses should be applied. Ow- ing to the intense pains which this caustic preparation occa- sions, we only use it in places where the epidermis is very thick. We use local applications in addition to general remedies only in those forms of psoriasis palmaris et plantaris in which numerous deep fissures and epidermal welts develop in the palms of the hands and soles of the feet, accompanied by intense onychia. In mild cases we simply prescribe an ointment of fat and spermaceti, or unguentum diachylon in oleo-coctum, or paint the palms and soles with a lotion containing tar, and then dust the parts with powder, or apply emplastrum hy- drargyri to the diseased places ; or, lastly, we use white pre- cipitate ointment, 4-00 [3j] to 35*00 [5j, 3 iv] of cerate, of which the patient may rub a piece as big as a hazel-nut upon the palm of the hand and sole of the foot. Painting the affected parts with sublimate collodion or tincture of iodine also promotes desquamation and absorption. Ulcers originating as a result of paronychia should be cov- ered with adhesive plaster, mercurial plaster, or traumaticin. Deep ulcers of the skin should be cleansed as often as pos- sible, and then covered with emplastrum de Yigo or sapona- 25 386 PATHOLOGY AND TREATMENT OF SYPHILIS. turn. If cicatrization does not ensue, the ulcers should be covered with pledgets of lint smeared with the following ointment : 5 Argent, nitratis cryst., 0*10 [gr. 1-J] ; Ung. simpl., 10-00 [ 3 lj, ^ ij] ; Bals. Peruv., 1*00 [grs. xvj]. M. Ft. ung. Iodoform, too, has rendered excellent service in torpid and proliferating ulcers. If suppurating gummata are situated upon the soft palate, and if the latter is in danger of perforation, the margins of the ulcer should be touched with lunar caustic every day. If general treatment is simultaneously instituted, small per- forations of the palate will often become smaller, so that it is barely possible to put a fine probe through them — a matter that is of great importance in phonation. The perforations of the mucous membrane on the hard palate may likewise be re- duced in size by the use of nitrate of silver. The local treatment of ozsena syphilitica has for its object the speedy exfoliation of the necrotic piece of nasal bone. This is best promoted by injecting dilute solutions of muriatic acid or chloride of calcium into the nasal cavities. In these cases we prescribe : ^ Acidi mur. dil., 5-00 [3 iv] ; Aqua destil., 300*00 [ § ixss., 3 iv] ; Aqua salvise, 100*00 [§iij, Bviij], M. S. For external use. 3 Ohlor. calcis, 5*00 [3 iv] ; Aqua destil., 300-00 [3 ixss., 3 iv] ; Aqua rosarura, 15-00 [ ^ ss.]. M. To be put in a black bottle for external use. The nasal cavities should be injected with either of these solutions four or five times every day by means of a syringe provided with a long nozzle ; or, if a fountain-syringe is used, the tube is inserted into the nose, the patient being directed to hold his head backward for a few moments, when some of the fluid will flow into the nasal passages. OzcBna syphilitica frequently is the residuum of syphilis SYPHILIS. 387 that has already reached its end, the prolonged ulceration of the nasal bones and nasal mncoiis membrane, and the ichor- ous discharge, being kept up by the irritation which the ne- crosis of the bone exercises upon the surrounding structures. General treatment is only indicated in ozsena when new syphi- litic outbreaks occur on different parts of the body, or if those that already exist do not disappear. In these cases reliable proof of the specific character of the lesion will be necessary before treatment with mercury or iodine is resorted to. In most ozsena patients scrofula will be found to play a great part, and they will require cod-liver oil and tonics more than anti- specific remedies. In syphilitic sarcocele Fricke's compression-bandage may be employed in addition to internal general treatment, or the af- fected half of the scrotum may be covered with mercurial plaster. The coexisting hydrocele disappears spontaneously when the swelling of the testis has subsided ; if not, the drop- sical tumor may be tapped, and a dilute solution of iodine in- jected, or the operation for the radical cure may be performed. In pains of the bones and joints, which sometimes do not yield to either mercurial or iodine treatment, nor are assuaged by narcotics, we found in many cases the local treatment rec- ommended by Ricord to be of great benefit. He recom- mends a blister to be applied upon the painful part, and after the skin has been removed the place is either covered with cerate-plaster, or morphine is strewed upon the raw sur- face. Li periosteal thickenings an attempt should be made to bring about resolution by painting the part with tincture of iodine or moderately concentrated iodo-glycerine. Even if fluctuation is detected, the swelling should not be hastily opened, for absorption may sometimes take place. Should the pain, however, become aggravated, and the tumor larger, it should be opened by a valvular incision, in order to prevent the entrance of air into the cavity of the abscess. In very intense, painful periosteal swellings, Ricord and other physi- cians recommend deep crucial incisions and scarifications of the bone. Ulcers of the rectum should be washed several times a day, 388 PATHOLOGY AND TREATMENT OF SYPHILIS. especially after each stool, and a tolerably strong solution of iodo-glycerine applied four or five times a day, or they may be cauterized with nitrate of silver. Id case stricture of the rec- tum is apprehended, in consequence of contracting cicatrices, compressed sponge-tents or cones of laminaria digitata should be inserted early into the gut. If stricture has already formed, an attempt should be made to dilate the rectum by the aid of bougies ; unfortunately, the results of this treatment usually are only temporary. There is no other therapeutic resource in such cases than to promote evacuations from the bowels by the administration of oleaginous clysters and purgative reme- dies. The Nursing of the Syphilitic Child and the Treatment of Con- genital Syphilis. So long as no evidences of syphilis are observed on a child begotten by syphilitic parents, it should not be subjected to antisyphilitic treatment, though it requires careful attention. The question arises, How should a child be nursed that is born with manifest evidences of syphilis, or that is suspected of being afflicted with hereditary syphilis? Should it be suckled by its mother, or by a wet-nurse ? That the milk of a healthy wet-nurse is the best nutriment for such an unfortunate creat- ure admits of no question. If the mother was affected with constitutional syphilis during pregnancy, and yet gave birth to a child free from all evidences of general syphilis, as is often the case, such a child, if possible, should be suckled by a healthy wet-nurse. Even admitting that the mother's milk does not serve as a vehicle for conveying the syphilitic virus, and although no morbid alteration can be discovered in it chemically or microscopically, still it can not be deemed healthy nutriment, coming as it does from a diseased, feeble constitution. But, if the mother and child are manifestly affected with syphilis, it will be absolutely necessary to procure a healthy wet-nurse for the child, because the debilitated mother will be- come still more enfeebled by nursing, and the infant will not thrive upon the unhealthy milk. But such a child should only be given to another woman after she has been fully in- SYPHILIS. 389 formed of the risk she runs of being infected. To hide the true nature of the child's illness, to persuade a healthy woman to undertake the nursing of a syphilitic child, would be an unpardonable act, because the health of the woman is thereby endangered, while the saving of the child is doubtful; in- deed, in our opinion, highly improbable. However, if after the woman was fully informed she is disposed to undertake the duties of a wet-nurse, she should be instructed to keep herself and child scrupulously clean. On discovering any fissure on a nipple, she should not put the child to the affected breast, but nurse it on the sound breast only. She should not allow the child, as is customary with wet-nurses, to he at her breast by the hour, for then the nipples, being in contact with the lips of the diseased child, are sure to become injured. Both the nipple and breast should be washed clean every time the baby has been suckled. A sure protection for the wet- nurse is the use of a nipple-shield during the suckling of the infant. If the mother displays no evidences of constitutional syphi- lis, it will be far more judicious for her to wet-nurse her own child. So far, only three instances are known in which syphi- litic children infected their own mothers. The circumstance that mothers are never, or hardly ever, infected during wet- nursing by their hereditary syphilitic offspring, is now known by the name of Colles's law. Still, since it may happen that a perfectly healthy mother may become infected by her own syphilitic infant, it will be well, as Behrend suggests, to allow her to wet-nurse her child only so long as no evidences of syphilitic manifestations are observed on the mouth and fauces of the nursling. As soon as any specific symptoms appear on the infant, and the mother remains apparently well, she should be advised to discontinue w r et-nursing it, and bring it up on artificial food. If no wet-nurse can be procured to suckle such a child, and if the mother is not very much reduced by the syphilitic diathe- sis, she, being put simultaneously with the infant upon an antisyphilitic treatment, may be allowed to put it to her breast. But if the mother already shows evidences of the syphilitic dyscrasia, it will be preferable to bring up the child artificially 390 PATHOLOGY AND TREATMENT OF SYPHILIS. upon good, fresh cow's milk, or the milk of a wet-nurse, ob- tained by a nursing-tube. In the treatment of syphilitic infants and nurslings, the care, cleanliness, and attention they will require deserve special consideration. The mouth of the nursling, especially, should be cleansed every time it is nursed, and, after each stool, the ex- coriated places at and around the anus should be washed clean and wiped dry. The medical treatment is both local and general. The local treatment consists in the application of slightly caustic remedies, such as the nitrate- of -silver stick to the ulcer- ating places on the lips and anus, for the purpose of hastening their cicatrization, of assuaging the pain during suckling and during evacuations from the bowels, and, above all, by the production of an escharotic slough to protect the ulcers on the mucous membrane against irritation and uncleanliness. For the purpose of promoting absorption of the mucous- membrane papules situated on the lips, angles of the mouth, on the anus and genital organs, and the moist papules on con- tiguous parts, Labaraque's paste, or a weak solution of iodo- glycerine, may be used. In regard to the general treatment, it has been suggested that, in view of the tender constitution of the nursling, to ad- minister mercurial remedies indirectly, namely, through the milk of the wet-nurse, who is treated with antisyphilitic medi- cine, or mercury is administered to goats or asses, and the syphilitic child is then fed with the milk from these animals. But numerous examinations of the milk of wet-nurses treated with mercury, and that of animals in whose fodder mercury w T as put, have shown that but very small quantities of the drug are found in it, and only after it had been administered to them for many days. In view of the fact that the dose of the medicine given to a child in this manner can not be properly controlled, as also the fact, often observed, that nurslings in many respects toler- ate mercury better than adults, we prefer the direct to the indirect methods. If no diarrhoea or other complications contraindicate it, calomel should be used, this preparation being best tolerated SYPHILIS. 391 by infants, or the protoiodide of mercury may be prescribed , according to the following formula : 3 Calomel, laevigata., or protoiod. hydrarg., 0*15 [grs. ijss.J ; Sacch. alba., 5-00 [3iv]. M. Div. in dos. aequales Xo. xij. M. S. One powder to be given morning and evening. If profuse evacuations of the bowels, with or without colic- pains, ensue, one drop of the tincture of opium should be given during the intervals. If the diarrhoea does not diminish from the use of this remedy, the above-named preparations should be discontinued, and, after the diarrhoea has been checked, corrosive sublimate should be resorted to, as follows : 5 Sublim. corros., 0*005 [gr. T y] ; Aq. font,, 50-00 [ § jss., 9ivj. M. S. To be taken in one day. As is well known, adults not infrequently complain of gas- tralgia from the use of corrosive sublimate, but infants are troubled with vomiting. If that be the case, small inunctions should be ordered on some parts of the body, provided the skin is not profusely covered with pustules, or the body is not ex- tensively denuded of epidermis, or the infant is not too feeble. From 0*3 to 0*5 [grs. v to viij] of blue-mass may be used daily. The inunctions should be omitted every third day, and the infant placed in a tepid or warm bath. If, on account of numerous pustules (pemphigus syphiliticus) and excoriated places on the body, it is not possible to use the inunctions of mercury, the child should be put once or twice daily into a bath, containing corrosive sublimate, and prepared as follows : 5 Sublim. corros., 2-00 to 5-00 [grs. xxxij to Ixxx] ; Mur. ammon., 2*00 [grs. xxxij] ; Aq. font., 100-00 [§iij, 3 viij]. M. To be added to the bath. The child should be kept about half an hour in this bath, and afterward carefully dried with warm towels. The in- ternal use of mercury and inunctions act much more rapidly than corrosive-sublimate baths. The preparations of iodine do not seem to agree well with infants ; they appear to promote marasmus in sickly children. 392 PATHOLOGY AND TREATMENT OF SYPHILIS, The disappearance of the external manifestations of syphi- lis, however, does not by any means prove that the child has been cnred of the disease. But the administration of mercury may be suspended for a time, the child meanwhile taking the lactate of iron, 0-15 [grs. ijss.] twice a day. Several days aft- erward, the mercury may again be administered in smaller doses than before. Unfortunately, however, our skillfully de- vised cures and plans frequently miscarry, for, contrary to all our wishes and efforts, the little patients often succumb to the disease. INDEX. Abscess of lymphatic vessels and glands of labia majora and minora, 85. Acne-like syphilide, 202; differential diagnosis from acne vulgaris, 203. Acne-pustular, syphilide, 180. Action of chancrous virus, 109. Acute catarrh of the bladder, TO. of the larynx, syphilitic, 252. of the trachea, syphilitic, 252. Acute gonorrhoea, 13, 19. hydrocele, 54. Adenitis, multiple, 128, 131, 174. Affections of the bladder, 265. of the bones, differential diagnosis of, 304. of the eye in infants in congenital syphilis, 328. of the joints, syphilitic, 305. of the kidney, 265. of the lymphatic glands in gonorrhoea, 51. of the lymphatic vessels in gonor- rhoea, 51. of the lymphatic glands in the begin- ning of syphilis, 159. of the supra-renal capsule, 265. Age, influence of, in syphilitic disease of the larynx, 251. Air-passages, cicatrices of the, 261. new growths of, 263. Albuginitis, 265. Alopecia areata, 223 ; senilis, 223 ; vul- garis prematura, 223. Alteration of the blood, pathological, 167. pathological, of male urethra, 25. Amyloid degeneration of the kidneys, 250. Anatomy of the syphilitic initial sclero- sis, 151. Angina syphilitica erythematosa, 233. gummosa, 235. papulosa, 234. Aphthae, syphilitic, 228. Aura gonorrhoea, 14. Bacilli, syphilitic, of Lustgarten, 168. of Doutrelepont, 168. Balanitis, 46. Balano-blenorrhcea, 46. -postheitis, 46. -pyorrhoea, 46. Bartolini glands, disease of, 83 ; of the ducts, 83. Baths, mercurial, 375 ; sulphur, 380 ; thermal, 380. Black gonorrhoea, 1 3, 23. Bladder, diseases of the, gonorrhoeal, 69. acute catarrh of, 70 ; chronic catarrh, 71; treatment of, 72, 73. syphilitic affections of, 265. Blenorrhcea, chronic, 92. Blood, pathological alterations of, in syphilis, 167. Bloody seminal emissions, 66. Bones of infants, syphilitic affections of, 326. syphilitic affections of, differential di- agnosis of, 304. syphilitic ulcers of, 302. Bright's disease in syphilis, 173. Bronchi, syphilitic affections of, 263. ulcers of the, 257. Bubo, constitutional, 131 ; idiopathic, 131 ; deuteropathic, 131 ; proto- pathic, 131; resolution, 131; stru- mous, 137; virulent, 132. differential diagnosis of, 137 ; prog- nosis of, 137. site of, 135 ; shape of, 135 ; size of, 135. 394 INDEX. Bubo, treatment of the opened, 141 ; of the unopened, 139. chancroid, 132; size of, 135; shape of, 135. Bubonuli, 131. Bursa, syphilitic affections of, 310. Cachexia, the syphilitic, 170. Cartilages, syphilitic affections of, 30V. Catarrh, acute, of the bladder, 71. of the larynx, syphilitic, 252. chronic, of the bladder, VI. of the glans penis and prepuce, 48 ; differential diagnosis of, 48 ; treat- ment of, 48. irritative, 16. renal, course of, VV ; treatment of, VV. venereal, 12. vesical, chronic, VI. of vagina, epithelial, 80 ; mucous, 80 ; purulent, 80; serous, 80; treat- ment of, 82. vulvar, 78 ; treatment of, V9. chronic gonorrhoeal, 14. chronic, of the trachea, syphilitic, 252. chronic vaginal gonorrhoea, 81. Catarrhal nephritis, V6. Cauterisatio provocatoria of Tarnowski, 171. Cerebral disease, syphilitic, 1V3. Chancre, hard, 156; duration of, 15V; size of, 15V ; differential diagnosis of, 158. parcheminee, Ricord, 154. Chancroid, 108. atonic, 114. diphtheritic, 111. erethetistic, 114. flat, 112. gangrenous, 114. phagedenic, 114. serpiginous, 114. serpigino-phagedenic, 114. course of, 112; differential diagnosis of, 118; duration of, 112. bubo, 132 ; shape of, 135 ; size of, 135. Chancrous and syphilitic virus, com- bined effects of, 155. virous action of, 109. Chorda venerea, 23. Chordee, 23. Chronic catarrh of the bladder, VI. hydrocele, 58. Chronic syphilitic catarrh of the larynx, 252. Cirrhosis of the liver, syphilitic, 248. Cicatrices of the air-passages, 261. of the epiglottis, 262. of the larynx, 261. of the trachea, 262. Cold water in the treatment of syphilis, 380. Co-effects of gonorrhoea in men, 29. Color, peculiar, of syphilitic eruptions, 1V6. Combination of phases of syphilis, 1V1. Condyloma latum, 198. Condylomata, 196 ; moist, 9V ; treat- ment of, 100. Congenital syphilis, manifestations of, 319. diagnosis and prognosis of, 333. treatment of, 388. Conjunctivitis granulosa, 92. Contagions, the venereal, 3. Constitutional buboes, 131. syphilis, 1V2; course of, 1V2. development of, 1V3 ; duration of, 1V3. mortality in, 173. Construction of the scales and crusts in syphilis, 178. Corona venerea, 188. Corpora cavernosa penis, syphilitic af- fections of, 272. Coryza syphilitica neonatorum, 326. Course of constitutional syphilis, 172. Cowper's glands, inflammation of, 60. Craneotabes, 328. Deep syphilitic cutaneous nodes, 180. Definition and classification of syphilitic skin-diseases, 180. Defcedatio or scabrities unguium, 226. Deutropathic buboes, 131. Development of lymphatic glandular dis- ease in soft chancre, 128. in syphilis, 74. INDEX. 395 Diathesis, syphilitic, 166. Differential diagnosis of syphilis from erythema mercuriale, 185; from morbili, 1S4; pityriasis versicolor, 185; roseola balsamica, 184; rose- ola typhosa, 184; rubeola, 184; urticaria, 184; scarlatina, 184. in paraphimosis and phimosis, 48. Disease, lcproid or syphiloid, 311. of the kidney caused by gonorrhoea, 74. Diseases of the skin in syphilis, 175. syphilitic, of the fauces, 22%. syphilitic, of the mouth, 238. Duration of syphilis, 173. Ecthyma pustular syphilide, 180. Ecthyma syphiliticum, 201, 209 ; differ- ential diagnosis from folliculitis barbae, 208; from eczema rubrum, 209 ; from ecthyma vulgar cachec- ticorum, 211 ; from impetiginosum, 209 ; from sycosis, 209. Eczema rubrum, differential diagnosis from syphilitic ecthyma, 209 ; from confluent moist papules, 200. Effects of syphilitic aud chancroid virus combined, 155. Elephantiasis arabrum fuscum, 85. arabrum pudendum, 84. Elytritis papulosa, 81. Ephelides syphilitica, 182. Emissions, seminal bloody, 66. Endemic syphilis, 311. Endometritis placentaris gummosa, 317. Epididymis, inflammation of, 52 ; neu- ralgia of, 55 ; treatment of, 56. Epididymitis, symptoms of, 53. Epithelial cancer, differential diagnosis from chancroid, 121. Epithelial gonorrhoea, 13. Erosions of os uteri, 85. Erythema elevatum or papulatum, 180. glabrum, 54. maculosum, 180. maculo-papulatum syphiliticum neo- natorum, 320. syphiliticum membranae mucosas, 226. Erythematous angina, syphilitic, 233. Eruption, time of appearance in general syphilis, 169. Eruption, circumscribed form of, 176. Eruptive fever of syphilis, 168. Excoriations, differential diagnosis from chancroid, 119. Exhalations and transudations peculiar to syphilis, 179. Expectant method of treatment of syph- ilis, 342. External application of mercury in syph- ilis, 358. Eye, affections of, in hereditary syphilis, 32S. gonorrhoea of the, 90 ; treatment of, 92. Factors favoring gonorrhceal infection, 18. False vocal cords, ulcers of, 257. Fallopian tubes, syphilitic affections of, 270. Fauces, syphilitic disease of, 237, 238. Female, urethral gonorrhoea in, 8S. Fever, eruptive, of syphilis, 168. First period of incubation of syphilis, 150. Fistula following suppurating bubo, 142 ; treatment of, 143. Flat condylomata, 196. papules, 196. Flores, or mendacea unguium, 225. Folliculitis barbae, differential diagnosis from syphilitic ecthyma, 209. Foci, localization of syphilitic, 169. French's observations on syphilitic dis- ease of the liver, 248. Functional disease of the seminal vesi- cle, 67. Functional disease of the testicle, 67. Galloping or malignant syphilis, 172, 312. General syphilis, time of eruption of, 169. Glands of Bartolini, disease of, 83 ; of the ducts, 83. Glans penis, catarrh of, 46 ; differential diagnosis of, 48 ; treatment of, 46. 396 INDEX. Glossitis syphilitica circumscripta super- ficialis, 242. Glossitis syphilitica diffusa, 242. gummatous, 238, 241, 242. indurativa, 238, 241, 242. macular, 242. papular, 242. . profunda, 242. Gonoccocus, Xeisser's, 15. Gonorrhoea, acute, 12, 13. black, 13, 23. chronic, 14. epithelial, 13. hemorrhagic, 23. mucous, 13. purulent, 13. Russian, 13, 23. serous, 13, site of, 17. uterine, 85 ; complications of, 85. virulent, 16. of female urethra, 78, 88. of male urethra, 19. co-effects of, 29. complications of, 83. pathological alterations caused by, 25. prognosis of, 30. prophylaxis against, 31. of mouth and nasal cavities, 90 ; of rectum, 89 ; treatment of, 90. of vulva, idiopathic, 78. of vulva, propagated, 78. of vulva, indirect, 42. of vulva, internal, 42. treatment of, 31. of the eye, 90 ; treatment of, 92. of vagina, 80 ; epithelial, 80 ; mucous, 80; purulent, 80; serous, 80. Gonorrheal rheumatism, 94; treatment of, 96. Granulations of os uteri, 85. Gummata, 213 ; of the trachea, 254. Gumma of the mucous membrane, 23 1 ; of the larynx, 254. Gummatous phase of constitutional syph- ilis, 172. Gummous syphilide in the infant, 322. Hematocele, 59. Hemorrhagic syphilide in the infant, 322. gonorrhoea, 23. Hair, syphilitic affections of, 222; dif- ferential diagnosis from alopecia senilis vulgaris prematura, 223 ; from herpes tondens, 223 ; from phyto-alopecia, 223. Hard chancre, treatment of, 340. Hereditary syphilis, 315. Hereditary syphilitic disease of the breasts, 332 ; testes, 332 ; thymus gland, 332. Hernia aquosa, 58. labialis, 84. Herpes, differential diagnosis from chan- croid, 118. Herpes tondens, 223. Humid or moist papules, ISO, 196. Hunterian induration, site of, 153 ; form of, 153. Hutchinson's syphilitic affection of the tongue, 244. Hydrocele, acute, 54 ; treatment of, 57. chronic, 58 ; treatment of, 59. Hydrops sanguinolentus, 317. Hypochondria mercurialis, 381. Hypodermic injections of mercury, 371. Hydrargyrosis, use of cold water and sulphur thermal baths in, 380. Idiopathic buboes, 131. Impetigo-pustular syphilide, 180. syphilitica, 206 ; differential diagnosis from impetigo vulgaris, 208. Impetiginous syphilide, 201. Incubation, first period of, in syphilis, 150. Indirect treatment of gonorrhoea, 42. Induration and hypertrophy of lymphatic vessels and glands in syphilis, 165. Induration, Hunterian, 153 ; site of, 153 ; form of, 154. Infants, gummous syphilide of, 322. hemorrhagic syphilide in, 322. macular syphilides in, 320. syphilitic affection of the mucous mem- branes of, 325. Infantes semicocti, 317. INDEX. 397 Infants, syphilitic nursing of, 388. Infection, factors favoring gonorrhoea!, 18. Infection, syphilitic, method of trans- mitting, 146. Infection, syphilitic, unicity of, 158. Infiltration of the larynx, syphilitic, 254. of the trachea, 254. Initial syphilitic lesion, differential diag- nosis from chancroid, 119. Initial multiple and strumous buboes, treatment of, 340. Influence syphilis exercises on pregnan- cy, 317. Influence syphilis exercises on mothers, 318. Inflammation of the epididymis, 52. of Cowper's glands, 60. of pelvis of the kidney, 76. of seminal vesicles, 66. of vas deferens, 52. of glands of Bartolini, 83 ; of the ducts, 83 ; treatment of, 85. Inflammatory catarrh, purulent, 13. gonorrhoea, acute, 19. Inoculability of the sclerotic ulcer, 156. Internal organs, morbid alterations of, in hereditary syphilis, 328. Intestines, syphilitic diseases of, 245. Intestinal glands, syphilitic disease of, in the foetus, 331. Intra-uterine renal syphilis, 330. Introduction, 1. Iodine and iodine-salts, therapeutic use of, in syphilis, 345. Irritative catarrhs, 16. Itching of the skin in syphilis, 179. Joints, syphilitic affections of, 305. Kidneys, affections of, 265. amyloid degeneration in syphilis, 250. disease of, caused by gonorrhoea, 74. Klebs's observations on syphilitic disease of the liver, 248. Kolpitis, 80. Lacerations, differential diagnosis from chancroid, 119. La luette, vesicle of Amusset, 70. Larynx, syphilitic affections of, 251. cicatrices of, 261. syphilitic infiltrations of, 254. gumma of, 254. new growth in, 263. stenosis of, syphilitic, 173. ulcers in, 256. j La vessie a Colonne, 71. Lesions, morbid, of the skin in syphilis, 175. Leproid or syphiloid disease, 311. Lenticular papule, 186, 188 ; differential diagnosis from lupus, 219. Lentigenes syphilitica, 182. Leucorrhoea, 81. Lichen scrophulosorum, resemblance of, to papular syphilide, 192. Lies, 225. Liver, syphilitic disease of, 247. Local syphilitic affections, treatment of, 383. Localization of syphilitic foci, 169. of syphilitic eruptions, 177. Lungs, syphilitic affections of, 263. Lupus syphiliticus, exulcerativus, 218. hypertrophicus, 218. serpiginosus, 218. syphiliticus, differential diagnosis from lenticular papules, 219; from mol- luscum, 220; from acne rosacea tuberosae, 220; from rhino-sclero- ma, 220; from lupus vulgaris, 221 ; from multiple carcinoma of the skin, 221 ; from sarcoma and me- lanosis, 221. syphilitica hereditaria, 318. Lymphatic glands, affections of, in gon- orrhoea, 51; in syphilis, 174; in soft chancre, 128. . and vessels in gonorrhoea, 51, 128. of labia majora and minora, inflam- mation of, 85. Lymphatic glands, diseased, treatment of, 139. Lymphatic system of vessels, affec- tion of, in beginning syphilis, 159. Lymphatic system, induration of , 165. Lymphangioitis, 128. 398 INDEX. Microglossia syphilitica, 242. Macular glossitis, 242. syphilide in infants, 320. Markedly circumscribed form of syphi- litic eruptions, 175. Male urethra, gonorrhoea of, 19. Malignant syphilis, 172, 312. Manifestations of congenital syphilis, 319. Manustupration, 14. Mechanism of gonorrheal infection, 1 7. Melanosis, differential diagnosis from lupus syphiliticus, 221. Mendacea unguium, 225. Mercury, external use of, in syphilis, 358 ; inunctions of, 358 ; hypoder- mic injections of, 371 ; fumigations of, 374 ; baths of, 375 ; supposito- ries of, 376. Mercury, pathogenic effects of, 376. therapeutic uses of, 352. Mercuriophobia, 381. Mercurial preparations best adapted for introduction into the blood, 353. Miliary papules, 186. Miliary syphilides, 180, 189 ; differential diagnosis from scabies, 192. Moist or humid papules, 180, 196. warts, 97 ; treatment of, 100. Morbid lesions of the skin, 175. Mortality in syphilis, 172. Mouth and nasal cavities, gonorrhoea of, 90. Mouth and nasal cavities, papular an- gina of, 234. Mouth and nasal cavities, syphilitic dis- ease of, 233. Mucous membranes of infants, syphilitic affections of, 325. Mucous membranes, syphilitic erythema of, 226. Mucous membranes of genital organs, syphilitic affections of, 271. Mucous membranes, nodes of, 231. Mucous gonorrhoea, 13. Mucous plaques, 170, 183, 203. Multiple adenitis, 174. Myer's observations on syphilitic dis- ease of the liver, 248. Nails, non-syphilitic disease of, 225. syphilitic disease of, 223. Nature of the syphilitic virus, 145. Neisser's gonococcus, 15. Nephritis, catarrhal, 76. New growths in larynx, 263, in trachea, 263. on vocal cords, 263. Nez de mouton, 230. Nodes of the cutis, syphilitic, 213. of the mucous membrane, 231. of the subcutaneous tissue, 213. of the soft palate, 235. Nodular syphilide of the skin, 213. Nursing of syphilitic children, 388. Occupation, influence of, in syphilitic disease of the larynx, 251. (Esophagus, syphilitic disease of, 244. Onychia sicca, 225. syphilitica, 224. Opened bubo, treatment of, 141. Ophthalmia gonorrhoica blennorrhoica, 90. Orchitis syphilitica, 265. Ostitis syphilitica, 300. Os uteri, erosions of, 85. granulations of, 85. Ovaries, syphilitic disease of, 270. Ovula Nabothi, 86. Ozsena syphilitica, 318. Palate, node of soft, 235. Pancreas, syphilitic affections of, 250; evidences of syphilitic disease, 330. Papular angina of the mouth, 234. glossitis, 238. syphilide, 186, 188, 192. syphilide, lenticular, 188. syphilide in the infant, 321. Papules in syphilitic laryngitis, 253; moist, 196. Papules, syphilitic, of the mucous mem- brane, 227. Paraphimosis, 47 ; differential diagnosis of, 48 ; treatment of, 48. Paronychia syphilitica, 224. lateralis, 224. lunularis, 224. INDEX. Parrot's natiform skull, 328. Pathogenic effects of mercury, 376. Pathological alterations of the blood in syphilis, 168. Pathological alterations of the male urethra from gonorrhoea, 25. Pathology of the soft chancre, 110. Peculiar form of the syphilitic ulcer, 178. color of the eruptions, 176. Pederasty, 89. Pelvis of kidney, inflammation of, 76. Pemphigus cachecticorum, differential diagnosis from pustular syphilide of infants, 323. Perichondritis syphilitica, 261. Period of incubation, first, in syphilis, 150. Periostitis and ostitis, site and effects of, 303. Pharynx, ulcers of, 238; cicatrices of, 262 ; new growths in, 263. Pharyngitis syphilitica, 238. Phimosis, 47 ; differential diagnosis of, 48 ; treatment of, 48. Phyto-alopecia, 223. Pigment syphilis, 222. Plaques muqueuses, 170, 183, 203. opalines, 228. Pollutions, red (bloody), 66. Pollutio diurna, 67. Polymorphous form of syphilitic erup- tions, 178. Prepuce, catarrh of, 46. Prognosis of gonorrhoea in men, 3~>. Prophylaxis against gonorrhoea, 31. of syphilis, 337. Prostate, morbid alterations of, in gon- orrhoea, 61. Prostatic catarrh, glandular, 62. mucous, 61. purulent, 61, 62. serous, 62. symptoms of, 62. treatment of, 65. Prostatorrhoea, differential diagnosis from prostatic catarrh, 63, 67. Prostatorrhoea, differential diagnosis from spermatorrhoea, 64. Protopathic buboes, 131. Psoriasis syphilitica, 178. palmaris et plantaris, 180, 186, 192. linguae, 239. nigricans of Cazenave, 178. of the tongue, 239. differential diagnosis from aphthae, 240. Psoriasis syphilitica of washer-women, 196. Pulmonary syphilis, 264. Punaise, 326. Purulent gonorrhoea, 13. Pustula foetida ani, 196. Pustule plates, 196. Pustular syphilide, 201. in infants, 322; differential diagnosis from pemphigus cachecticorum, 323. Quantity and successive form of syphi- litic eruptions, 177. Racedo syphilitica, 233. Rectum, gonorrhoea of, 89 ; treatment of, 90. Relation of vaccine lymph to syphilitic virus, 147. Renal catarrh, course of, 77 ; treatment of, 77. syphilis, intra-uterine, 330. Rhagades, 229. Rheumatism, gonorrhoeal, 94 ; treatment of, 96. Ricord's division of syphilis, 171. Roseola syphilitica, 180. evanida, 182. Rupia syphilitica, 180, 201, 211. differential diagnosis from rupia vul- garis, 212. Russian gonorrhoea, 13, 23. Salivary glands, syphilitic affections of, 250. Sarcocele syphilitica, 265. Sarcoma, differential diagnosis from lu- pus syphilitica, 221. Scabies pistorum, 196. Scabrities unguium, 226. Sclerotic ulcer, inoculability of, 156. 400 INDEX. Sclerosis, initial pathology of, 151. Sea-baths in the treatment of syphilis, 380. Seborrhoea sicca congestiva, 183. Secondary phenomena, treatment of, 342. Seminal vesicles, inflammation of, 65. functional disease of, 67. Seminal emissions, bloody, 66. Sequelae of gonorrhoea in men, 29. general, 93. Sequelae of urethral gonorrhoea, 93. Serous gonorrhoea, 13. Sheaths of tendons, syphilitic affections of, 308. Sheep-nose, 230. Site and effects of periostitis and ostitis syphilitica, 303. Skin, nodular syphilide of, 213. Small papular syphilide, 189. Soft chancre, 108; atonic, 113; erethis- tic, 113; gangrenous, 114; phage- denic, 114; serpiginous, 114; ser- pigino-phagedenic, 114 ; develop- ment of, 109 ; differential diagnosis of, 118; pathology of, 110; site of , 115; prognosis of, 121; treatment of, 121. Spermatic cord, inflammation of, 52 ; treatment of, 56. syphilitic affection of, 265. Spermatorrhoea, 67; differential diagnosis from prostatorrhoea, 64, 67 ; treat- ment of, 68. Spermatorrhoea cruenta, 54. Spitze or moist warts, 97 ; treatment of, 100. Spleen, syphilitic affections of, 250. intra-uterine affections of, 329. Squamous syphilide of the hands and feet, 192. Stricture of the urethra, 101 ; inflam- matory, 102 ; organic, 102 ; spastic, 102 ; treatment of, 104. Stomach, syphilitic disease of, 245. Succession and phases of syphilitic af- fections, 171. Sulphur-thermal baths in treatment of syphilis, 380. Superficial cutaneous nodes, 180. Suppositories, mercurial, in syphilis, 376. Supra-renal capsule, affections of, 265. Suppurating bubo, fistula of, 142 ; treat- ment of, 143. Sycosis, differential diagnosis from syphi- litic ecthyma, 209. Syphiloma, 213; Wagner's, 214; Yir- chow's, 214. Syphiliphobia, 381. Syphilis, 145. aquisita, 146. congenital, 319 ; manifestations of, 319; diagnosis and prognosis of, 333. endemic, 311. hereditary, morbid alterations of in- ternal organs, 328 ; hereditaria, 146. hereditaria tarda, 334. malignant or galloping, 172, 312. haemorrhagica, 324. of the cornea, 192. of the fauces, 233. constitutional, 172; course of, 173; development of, 172 ; duration of, 173 ; mortality in, 173. combinations of, 170. eruptive fever of, 168. first period of incubation of, 150. influence on pregnancy, 317. influence on the mother, 318. of the mouth, 233. papulosa lenticularis, 180. papulosa miliaris, 180, 189 ; differen- tial diagnosis from scabies, 192; from psoriasis vulgaris, 191 ; from lichen scrophulosorum, 192; from herpes circinatus, 192. pigmentosa, 222. prophylaxis of, 337. pulmonary, 264. raceformis, 218. treatment of, 334 ; of the initial phe- nomena, 340 ; of the secondary phenomena, 342. treatment of local affections, 383 ; of congenital, 388 ; expectant meth- od, 342 ; medical, 345 ; by vegeta- ble remedies, 350 ; by inunctions of mercury, 358 ; by hypodermic in- INDEX. 401 jections, 371 ; by fumigations, 374 ; by baths, 375 ; by suppositories, 376. transmission of, by vaccination, 147. transmissibility of, 146 ; in warm- blooded animals, 149. Syphilides, 175; acne-like, 202; gum- mous, 322 ; hemorrhagic, 322 ; im- petiginous, 201 ; lenticular, 188 ; macular, 320 ; nodular, 213 ; papu- lar, 188, 189, 321 ; pustular, 201, 322 ; squamous, 192 ; varicella- like, 204 ; vesicular, 201. Syphilitic affections, Ricord's classifica- tion of, 171. Zeissl's classification of, 171. of the bones in infants, 326 ; in adults, 304 ; of the bronchi, 263 ; of the bursae, 310 ; of the cartilages, 307 ; corpora cavernosa penis, 272 ; hair, 222 ; Fallopian tubes, 270 ; intes- tinal glands, 331 ; joints, 305 ; larynx, 251 ; lungs, 263 ; mucous membranes, 226 ; fauces, 237 ; of infants, 325; genital organs of both sexes, 271 ; nails, 223 ; larynx, 251, 254; muscles, 308; pancreas, 250; ostitis, 300; ovaries, 270; salivary glands, 250 ; spermatic cord, 265 ; spleen, 250 ; trachea, 251 ; tongue, 244; ulcers of bones, 302; cicatrices, 308; testicle, 332, 265 ; uterus, 270. aphthae, 228. combinations and phases of, 171. erythema, 226 ; of the mouth, 238 ; catarrhal inflammation of, 226. infants, nursing of, 388. cirrhosis, 248. foci, location of, 169. gumma, 231. nodes of the cutis, 213 ; of the sub- cutaneous tissue, 213. papules of the mucous membrane, 227. diathesis, 165. disease, definitions and classification of, 180 ; of the fauces, 237, 238 ; in- testines, 245; liver, 247; mouth, 238; nails, 223 ; oesophagus, 244 ; skin, 175; stomach, 245 ; tongue, 238. 26 glossitis, gummatous, 238, 241, 242 ; indurated, 238 ; macular, 242 ; pap- ular, 242. Syphilitic infection, method of trans- mitting it, 146. unicity of, 158. Syphilitic initial sclerosis, anatomy of, 151. Syphilitic virus, nature of, 145. relation of, to vaccine lymph, 147. and chancroid virus, combined effects of, 155. Syphiliphobia, 381. Syphilization, 382. Tendons, syphilitic affections of, 308. Testicles, functional disease of, 67 ; treat- ment of, 68. syphilitic affections of, 265 ; heredi- tary, 332. Therapeutic use of iodides in syphilis, 345. Therapeutical use of mercury, 352. Thymus glands, hereditary syphilis of, 332. Time of general eruption of syphilis, 169. Tongue, syphilitic disease of, 238 ; gum- mata of, 242, 244 ; epithelial catarrh of, 241 ; Hutchinson's observations of, 244 ; macular, 238 ; papular, 238. Trachea, cicatrices in, 262 ; gummata in, 254 ; infiltrations in, 254 ; new growths in, 263 ; papules in, 254. syphilitic affections of, 251. catarrh of, 252. chronic catarrh of, 252. ulcers of, 256. Trachoma, 92. Transmission of syphilis by vaccination, 147. Treatment of catarrh of glans penis, 48. of gonorrhoea in men, 31 ; indirect, 42 ; internal, 42. of paraphimosis, 48. of phimosis, 48. of syphilis, 334, 358 ; by mercurial baths, 375 ; by inunctions, 358 ; by fumigations, 374 ; by hypodermic 402 INDEX. injections, 371 ; with suppositories, 376 ; of initial phenomena, 340 ; of Hunterian induration, 340 ; ex- pectant method, 342 ; medicinal, 345 ; by vegetable remedies, 350. of congenital syphilis, 388. Tripper, 12. True vocal cords, ulcers of, 257. Tubera syphilitica, 213. Tubercula syphilitica, 213. Tarnowsky, cauterisatio provocatorio of, 171. Ulcers of bones, syphilitic cicatrization of, 302. of bronchi, 257 ; of pharynx, 238 ; on false vocal cords, 257 ; on true vocal cords, 257 ; in trachea, 256 ; symptoms of, 260. Ulcer, sclerotic, inoculability of, 156. Ulcus elevatum, 111. framboesoides, 111. fungosum, 111. Unicity of syphilitic infection, 158. Unopened bubo, treatment of, 139. Urethral gonorrhoea of male, 19. in female, 88. sequelae of, 93. Urethritis blennorrhoica, 28. granulosa, 29. membranacea, 29. purulenta, 19. Urethra, stricture of, 102 ; inflamma- tory, 102 ; organic, 102 ; spastic, 102 ; treatment of, 104. Uterine gonorrhoea, complications of, 85. Uterus, syphilitic affections of, 270. Vaccination, transmission of syphilis by, 147. Vaccine lymph to syphilitic virus, rela- tion of, 147. Vagina, gonorrhoea of, 80 ; chronic, 81 ; treatment of, 82. Vaginitis papulosa, 81; Varicella syphilitica confluens neona- torum, 322. like syphilide, 204 ; differential diag- nosis from varicella vulgaris, 205. pustular syphilide, 180. Vas deferens, inflammation of, 52. Vegetations, 97. Venereal catarrh, 12; epithelial or mu- cous, 12; purulent, 12; serous, 12. contagions of, 3. Vesical catarrh, chronic, 71. Vesicular syphilide, 201. Virulent buboes, 132. Virus, syphilitic nature of, 145. Visceral syphilis, 173. Virchow's observation on syphilitic dis- ease of the liver, 247. on nodes, 214. Vocal cords, new growth of, 263. Vulvar catarrh, epithelial, 79 ; mucous, 79 ; serous, 79 ; treatment of, 79. Vulva, gonorrhoea of, idiopathic, 78 ; propagated, 78 ; treatment of, 79. Vulvitis purulenta, 79. Vulgar lupus, differential diagnosis from lupus syphilitica, 221. Vulvo-vaginal gonorrhoea, complications of, 83. Wagner's syphiloma, 214. observation on syphilitic disease of the liver, 247. Warm-blooded animals, transmission of syphilis in, 149. Warts, moist, 97 ; treatment of, 100. Wetzler's observation on syphilis of the liver, 248. Xerosis vaginae, 81. Zeissl's classification of syphilitic affec- tion, 171. THE END, REASONS WHY PHYSICIANS SHOULD SUBSCRIBE FOR THE I]ew York EQedical Jourijal, Edited by FRANK P. FOSTER, M. D., Published by D. APPLETON & CO., New York. "DECAUSE : It is the LEADING JOURNAL of America and contains more reading- -^ matter than any other journal of its class. "DECAUSE : It is the exponent of the most advanced scientific medical thought. "DECAUSE : Its contributors are among the most learned medical men of this country. "DECAUSE : Its " Original Articles " are the results of scientific observation and re- search, and are of infinite practical value to the general practitioner. "DECAUSE : The " Reports on the Progress of Medicine," which are published from time to time, contain the most recent discoveries in the various departments of medicine, and are written by practitioners especially qualified for the purpose. "DECAUSE : The column devoted in each number to " Therapeutical Notes " contains a resume of the practical application of the most recent therapeutic novelties. "DECAUSE : The Society Proceedings, of which each number contains one or more, ■^ are reports of the practical experience of prominent physicians who thus give to the profession the, results of certain modes of treatment in given cases. "DECAUSE : The Editorial Columns are controlled only by the desire to promote the welfare, honor, and advancement of the science of medicine, as viewed from a standpoint looking to the best interests of the profession. "DECAUSE : Nothing is admitted to its columns that has not some bearing on medicine, -^ or is not possessed of some practical value. "DECAUSE : It is published solely in the interests of medicine, and for the upholding ■^ of the elevated position occupied by the profession of America. The volumes begin with January and July of each year. Subscriptions can be arranged to begin with the volume. Subscription Price, $5.00 per Annum. The Popular Science Monthly and the New York Medical Journal to the same address, $9.00 per Annum (full price, $10.00). New York : D. APPLETON & CO., 1, 3, & 5 Bond Street. THE POPULAR SCIENCE MONTHLY. CONDUCTED BY E. L. AND W. J. YOUMANS. The Popular Science Monthly will continue, as heretofore, to supply its readers with the results of the latest investigation and the most valuable thought in the various departments of scientific inquiry. Leaving the dry and technical details of science, which are of chief concern to specialists, to the journals devoted to them, the Monthly deals with those more general and practical subjects which are of the greatest interest and importance to the public at large. In this work it has achieved a foremost position, and is now the acknowl- edged organ of progressive scientific ideas in this country. The wide range of its discussions includes, among other topics : The bearing of science upon education ; Questions relating to the prevention of disease and the improve- ment of sanitary conditions ; Subjects of domestic and social economy, including the introduc- tion of better ways of living, and improved applications in the arts of every kind ; The phenomena and laws of the larger social organizations, with the new standard of ethics, based on scientific principles ; The subjects of personal and household hygiene, medicine, and architecture, as exemplified in the adaptation of public buildings and private houses to the wants of those who use them ; Agriculture and the improvement of food-products ; The study of man, with what appears from time to time in the departments of anthropology and archaeology that may throw light upon the development of the race from its primitive conditions. Whatever of real advance is made in chemistry, geography, astron- omy, physiology, psychology, botany, zoology, paleontology, geol- ogy, or such other department as may have been the field of research, is recorded monthly. Special attention is also called to the biographies, with portraits, of representative scientific men, in which are recorded their most marked achievements in science, and the general bearing of their work in- dicated and its value estimated. Terms : $5.00 per annum, in advance. The New York Medical Journal and The Popular Science Monthly to the same address, $9.00 per annum (full price, $10.00). D. APPLETON & CO., 1, 3, & 5 Bond Street, New York. %* The Books advertised in this List are commonly for sale by booksellers in all parts of the coimtry j but any work will be sent by D. Appleton & Co. to any address in the United States, postage prepaid, on receipt of the advertised price. CATALOGUE OF MEDICAL WORKS. THE PUERPERAL DISEASES. Clinical Lectures deliv- ered at Bellevue Hospital. By Fordyce Barker, M. D., Clinical Professor of Midwifery and the Diseases of Women in the Bellevue Hospital Medical College ; late Obstetric Physician to Bellevue Hospital ; Surgeon to the New York State Woman's Hospital, etc. Fourth edition. I vol., 8vo, 526 pp. Cloth, $5.00; sheep, $6.00. " For nearly twenty years it has been my duty, as well as my privilege, to give clinical lectures at Bellevue Hospital, on midwifery, the puerperal, and the other diseases of women. This volume. is made up substantially from phonographic reports of the lectures which I have given on the puerperal diseases. Having had rather exceptional opportunities for the study of these diseases, I have felt it to be an imperative duty to utilize, so far as lay in my power, the advantages which I have enjoyed for the promotion of science, and, I hope, for the interests ot humanity." — From Author's Preface. ON SEA-SICKNESS. By Fordyce Barker, M. D. 1 vol., i6mo, 36 pp. Flexible cloth, 75 cents. Reprinted from the "New York Medical Journal." By reason of the great demand for the number of that Journal containing the paper, it is now presented in book form, with such prescrip- tions added as the author has found useful in relieving the suffering from sea-sickness. PARALYSIS FROM BRAIN DISEASE IN ITS COM- MON FORMS. By H. Charlton Bastian, M. A., M. D., Fellow of the Royal College of Physicians ; Professor of Pathological Anatomy in Uni- versity College, London. With Illustrations. I vol., i2mo, 340 pp. Cloth, $1.75. " These lectures were delivered in University College Hospital last year, at a time when I was doing duty for one of the senior physicians, and during the same year — after they had been repro- duced from very full notes taken by my friend Mr. John Tweedy — they appeared in the pages of ' The Lancet.' They are now republished at the request of many friends, though only after having undergone a very careful revision, during which a considerable quantity of new matter has been added. It would have been easy to have very much increased the size of the book by the intro- duction of a larger number of illustrative cases, and by treatment of many of the subjects at greater length, but this the author has purposely abstained from doing under the belief that in its present form it is likely to prove more acceptable to students, and also perhaps more useful to busy prac- titioners." — Extract from Preface. THE MANAGEMENT OF INFANCY, Physiological and Moral. Intended chiefly for the Use of Parents. By Andrew Combe, M. D. Revised and edited by Sir James Clark, K. C. B., M. D., F. R. S., Physician- in-ordinary to the Queen. First American from the tenth London edition. I vol., i2mo, 302 pp. Cloth, $1.50. " This excellent little book should be in the hand of every mother of a family."— The Lancet. D. APPLETON &* CO.'S MEDICAL WORKS. ADOLPH STRECKER'S SHORT TEXT-BOOK OF OR- GANIC CHEMISTRY. By Dr. Johannes Wislicenus. Translated and edited, with Extensive Additions, by W. H. Hodgkinson, Ph. D., and A. J. Greenaway, F. I. C. 8vo, 789 pp. Cloth, $5.00. The great popularity which Professor Wislicenus's edition of " Strecker's Text-Book of Or- ganic Chemistry " has enjoyed in Germany has led to the belief that an English translation will be acceptable. Since the publication of the book in Germany, the knowledge of organic chem- istry has increased, and this has necessitated many additions and alterations on the part of the translators. Specimen of Illustration. n "Let no one suppose that in this ' short text- book ' we have to deal with a primer. Everything is comparative, and the term 1 short ' here has relation to the enormous develop- ment and extent of recent organic chemistry. This solid and comprehensive volume is intended to rep- resent the present condi- tion of the science in its main facts and leading principles, as demanded by the systematic chemical student. We have here, probably, the best extant text-book of organic chem- istry. Not only is it full and comprehensive and remarkably clear and me- thodical, but it is up to the very latest moment, and it has been, moreover, pre- pared in a way to secure the greatest excellences in such a treatise." — The Popular Science Monthly. PRINCIPLES OF MENTAL PHYSIOLOGY, with their Applications to the Training and Discipline of the Mind and the Study of its Morbid Conditions. By William B. Carpenter, M. D., LL. D., Reg- istrar of the University of London, etc. 1 vol., 8vo, 737 pp. Cloth, $3.00. "Among the numerous eminent writers this country has produced, none are more deserving of praise for having attempted to apply the results of physiological research to the explanation of the mu- tual relations of the mind and body than Dr. Car- penter." — The Lancet. HEALTH. By W. H. Corfield, Professor of Hygiene and Public Health at University College, London. 1 vol., i2mo. Cloth, $1.25. " Few persons are better qualified than Dr. Cor- field to write intelligently upon the subject of health, and it is not a matter for surprise, therefore, that he has given us a volume remarkable for accuracy and interest Commencing with general anatomy, the bones and muscles are given attention ; next, the circulation of the blood, then respiration, nutrition, the liver, and the execretory organs, the nervous system, organ's of the senses, the health of the indi- vidual, air, foods and drinks, drinking-water, cli- mate, houses and towns, small-pox, and communi- cable diseases." — Philadelphia Item. D. APPLE TON 6- CO.'S MEDICAL WORKS. 5 THE BRAIN AS AN ORGAN OF MIND. By H. Charlton Bastian, M. A., M. D., Fellow of the Royal College of Phy- sicians ; Professor of Pathological Anatomy in University College, London. With 184 Illustrations and an Index. I vol., i2mo, 708 pp. Cloth, $2.50. " This work is the best book of its kind. It is full, and at the same time concise ; comprehensive, but confined to a readable limit ; and, though it deals with many subtile subjects, it expounds them in a style which is admirable for its clearness and simplicity." — Nature. " The fullest scientific exposition yet published of the views held on the subject of psychology by the advanced physiological school. It teems with new and suggestive ideas." — London Athenceum. " Dr. Bastian's new book is one of great value and importance. The knowledge it gives is univer- sal in its claims, and of moment to everybody. It should be forthwith introduced as a manual into all colleges, high schools, and normal schools in the country ; not to be made a matter of ordinary me- chanical recitations, but that its subject may arrest attention and rouse interest, and be lodged in the minds of students in connection with observations and experiments that will give reality to the knowl- edge required." — Popular Science Monthly. TREATISE ON MATERIA MEDICA AND THERA- PEUTICS. Revised and enlarged. Edition of 1883, with Complete Index and Table of Contents. By Roberts Bartholow, M. A., M. D., LL.D., Professor of Materia Medica and Therapeutics in the Jefferson Medical Col- lege ; formerly Professor of the Theory and Practice of Medicine, and of Clinical Medicine, and Professor of Materia Medica and Therapeutics in the Medical College of Ohio, etc. Fifth edition, revised and enlarged. I vol., 8vo. Cloth, $5.00; sheep, $6.00. " The appearance of the sixth decennial revision of the ' United States Pharmacopoeia ' has imposed on me the necessity of preparing a new edition of this treatise. I have accordingly adapted the work to the official standard, and have also given to the whole of it a careful revision, incorpo- rating the more recent improvements in the science and art of therapeutics. Many additions have been made, and parts have been rewritten. These additions and changes have added about one hundred pages to the body of the work, and increased space has been secured in some places by the omission of the references. In the new material, as in the old, practical utility has been the ruling principle, but the scientific aspects of therapeutics have not been subordinated to a utilita- rian empiricism. In the new matter, as in the old, careful consideration has been given to the physiological action of remedies, which is regarded as the true basis of all real progress in thera- peutical science ; but, at the same time, I have not been unmindful of the contributions made by properly conducted clinical observations." — From Preface to Fifth Edition. " The author has adapted the present edition to the changes made in the sixth edition of the ' Unit- ed States Pharmacopoeia.' He has also given the whole work a careful revision, incorporating the more recent improvements and additions to thera- peutics. About one hundred pages are thus added to the volume. The valuable practical character of Dr. Bartholow's treatise has been recognized by the profession, and probably no one has succeeded bet- ter in popularizing the physiological in distinction from the empirical mode of studying therapeutics. The book is so excellent a one that we can hardly pick out any faults without venturing dangerously near hypercriticism." — Medical Record. " Professor Bartholow has special talent for con- densation, combined with a comprehensive knowl- edge of his subject, and a power of direct expres- sion. That this combination is gratefully appre- ciated by the overworked American student, and the no less overworked physician, has been fully demon- strated by the remarkable demand for this work on Therapeutics, which has now attained its fifth edi- tion in less than seven years. On account of its convenience for reference and completeness, it has been adopted as a text-book in many of our medi- cal colleges." — Philadelphia Medical Times. " A book which has reached its fifth edition so rapidly as this has done, and upon which the pro- fession has passed so favorable a judgment, hardly stands in need of a review, or of having its merits pointed out. It is not out of place, however, to note that it has been kept fully abreast of the many and important changes constantly making in the knowledge of drugs, and their application to dis- ease, to say nothing of hydro-, electro-, and metallo- therapeutics, all of which are thoroughly treated in this edition. . . ." — American Journal of the Med- ical Sciences. " We have lately had occasion to notice a num- ber of new works, and new editions of well-known text-books, on materia medica and therapeutics, and on a great proportion of them we have bestowed high commendation. To none, however, is greater praise to be awarded than to this fifth edition of Professor Bartholow's. The appearance of the new Pharmacopoeia has rendered a number of changes in phraseology necessary, but, in addition to those, the volume bears evidence throughout of having been brought well up to the present state of our knowledge. In consonance with the general voice of the profession, we must say that practitioners of medicine can scarcely afford to forego the advan- tages to be derived from the possession of this book." — New York Medical Journal. D. APPLETON &* CO.'S MEDICAL WORKS. A TREATISE ON THE PRACTICE OF MEDICINE, for the Use of Students and Practitioners. By Roberts Bartholow, M. A., M. D., LL. D., Professor of Materia Medica and General Therapeu- tics in the Jefferson Medical College of Philadelphia; recently Professor of the Practice of Medicine and of Clinical Medicine in the Medical College of Ohio, in Cincinnati, etc., etc. Fifth edition, revised and enlarged. I vol., 8vo. Cloth, $5.00; sheep or half russia, $6.00. The same qualities and characteristics which have rendered the author's "Treatise on Materia Medica and Therapeutics » so acceptable are equally manifest in this. It is clear, condensed and accu ate The whole work is brought up on a level with, and incorporates, the latest acquisitions of medical science, and may be depended on to contain the most recent information up to the date of publication. Specimen of Illustration. ;ttr- :: " Probably the crowning feature of the work be- fore us and that which will make it a favorite with practitioners of medicine, is its admirable teaching on the treatment of disease. Dr. Bartholow has no sympathy with the modern school of therapeutical nihilists, but possesses a wholesome belief in the value and efficacy of remedies. He does not fail to indicate, however, that the power of remedies is limited, that specifics are few indeed, and that rou- tine and reckless medication are dangerous. But throughout the entire treatise in connection with each malady are laid down well-defined methods and true principles of treatment. It may be said with justice that this part of the work rests upon thoroughly scientific and practical principles of ther- apeutics, and is executed in a masterly manner. No work on the practice of medicine with which we are acquainted will guide the practitioner in all the de- tails of treatment so well as the one of which we are writing. "—American Practitioner. "The work is concise and definite in its state- ments, and eminently practical in its teachings. It is written with special reference to the needs of the student, and will at once take its place as a text- book in many medical schools. It will be found of equal value to the practicing physician."— Maryland Medical Journal. " The volume before us gives not only full and correct descriptions of diseases, but the treatment is enlivened under the instruction of a new therapy, v/hich must commend itself to every student. It is an honor alike to authors and the profession of the country."— Sout/iem Medical Record. "The work as a whole is peculiar, in that it is stamped with the individuality of its author. The reader is made to feel that the experience upon which this work is based is real, that the statements of the writer are founded on firm convictions, and that throughout the conclusions are emi- nently sound. It is not an elaborate trea- tise, neither is it a manual, but half-way between ; it may be considered a thorough- ly useful, trustworthy, and practical guide for the general practitioner." — Medical Rec- ord. ' ' It may be said of so small a book on so large a subject, that it can be only a sort of compendium or vade mecum. But this criticism will not be just. For, while the author is master in the art of condensation, it will be found that no essential points have been omitted. Mention is made at least of every unequivocal symptom in the narra- tion of the signs of disease, and character- istic symptoms are held well up in the fore- ground in every case."— Cincin?iati Lancet and Clinic. " Dr. Bartholow is known to be a very clear and explicit writer, and in this work, which we take to be his special life-work, we are very sure his many friends and admirers will not be disappointed. We can not say more than this without attempting to follow up the details of the plan, which, of course, would be useless in a brief book-notice. We can only add that we feel confident the verdict of the profession wiU place Dr. Bartholow's ' Practice among the standard text-books of the day. — Cin- cinnati Obstetric Gazette. "It is refreshing to turn from a work so crude and incomplete, so full of the exploded theories of by-eone days, as that of Professor Palmer, to the clear lucid pages of Professor Bartholow. Pro- fessor Bartholow has won for himself so high a posi- tion as an original thinker and clear and forcible writer that any work from his pen would command attention and respect. One great charm of the writer is the intelligence and original thought which he brings to the discussion of every subject, and the directness, clearness, and vigor of his style. In his treatment he is much in advance of the leading writers of his school, and gives marked indications ot having studied appreciatively some of the best writers of the new school."— New York Medical Times. ^ " The book is marked by an absence of all dis- cussion of the latest, fine-spun theories of points in pathology : by the clearness with which points m diagnosis are stated ; by the conciseness and per- spicuity of its sentences ; by the abundance of the author's therapeutic resources ; and by the copious- ness of its illustrations. "-CW* Medical Recorder. D. APPLETON &* CO.'S. MEDICAL WORKS. » ON THE ANTAGONISM BETWEEN MEDICINES AND BETWEEN REMEDIES AND DISEASES. Being the Cart- wright Lectures for the Year 1880. By Roberts Bartholow, M. A., M. D., LL. D., Professor of Materia Medica and General Therapeutics in the Jefferson Medical College of Philadelphia, etc., etc. 1 vol., 8vo. Cloth, $1.25. "We are glad to possess, in a form convenient no doubt that this, his latest contribution to medi- for reference, this most recent summary of the physi- cal science, will add materially to his previously high ological action of important remedies, with the de- reputation. Much profit, no little pleasure, and ductions of a careful and accomplished observer, re- material assistance in the solution of many thera- garding the applications of this knowledge to dis- peutical problems are to be obtained from a perusal eased states." — College and Clinical Record. of these lectures. The author has done wisely and "There are few writers who have taken the conferred a boon by permitting their publication in trouble to compile the lucubrations of the multitude * he present book-form, and we are satisfied it will of scribblers who find a specific in every drug they be extensively asked for, and just as extensively read happen to prescribe for a self-limited, non-malig- ^nd appreciated. —Canada Medical and Surgical nant disease , and fewer who can detect the trashy Journal. chaff and garner only the ripe, plump grains. This " It will be observed that the scope of the work Bartholow has done, and no one is more ripe, nor is extensive, and, in justice to the author, not only better qualified for this herculean task ; and, the is the extent of this indicated, but the character of best of all is, condense it all in his antagonisms. it is also furnished. No one can read the synopsis No one can peruse its pregnant pages without no- given without being impressed with the importance ticing the painstaking research and large collection and diversity of the subjects considered. Indeed, of authorities from which he has drawn his conclu- most of the important forces in therapeutics and sions. The practitioner who purchases these antag- materia medica are herein stated and analyzed " — onisms will find himself better qualified to cope with American Medical Bi- 11 'eekly. the multifarious maladies after its careful perusal." «. Probably most of our readers will consider —Indiana Medical Reporter. that we have awarded this treatise high praise when "The criticisms made upon these lectures have we say that it seems to us the most carefully writ- invariably been most favorable, the topic itself is ten, best thought-out, and least dogmatic work one of the most interesting in the entire range of which we have yet read from the pen of its author, medicine, and it is treated of by the accomplished It is indeed a very praiseworthy book ; not an origi- author in a most scholarly manner. Dr. Bartholow nal research, indeed, but, as a resume of the world's worthily ranks as one of the best writers, while at work upon the subject, the best that has hitherto the same time one of the most diligent workers, in been published in any language." — Philadelphia the medical field in all America, and there can be Medical Times. WINTER AND SPRING ON THE SHORES OF THE MEDITERRANEAN; or, the Genoese Rivieras, Italy, Spain, Corfu, Greece, the Archipelago, Constantinople, Corsica, Sicily, Sardinia, Malta, Algeria, Tunis, Smyrna, Asia Minor, with Biarritz and Arcachon, as Winter Climates. By James Henry Bennet, M. D., Member of the Royal College of Physicians, London, etc., etc. Fifth edition. With numerous Illustrations and Maps. I vol., i2mo, 655 pp. Cloth, $3.50. This work embodies the experience of fifteen winters and springs passed by Dr. Bennet on the shores of the Mediterranean, and contains much valuable information for physicians in relation to the health-restoring climate of the regions described. " We commend this book to our readers as a vol- once entertaining and instructive." — New York ume presenting two capital qualifications — it is at Medical Journal. ON THE TREATMENT OF PULMONARY CON- SUMPTION, by Hygiene, Climate, and Medicine, in its Connection with Modern Doctrines. By James Henry Bennet, M. D., Member of the Royal College of Physicians, London; Doctor of Medicine of the Uni- versity of Paris, etc., etc. 1 vol., thin 8vo, 190 pp. Cloth, $1.50. An interesting and instructive work, written in the strong, clear, and lucid manner which ap- pears in all the contributions of Dr. Bennet to medical or general literature. "We cordially commend this book to the at- temperate climates, pulmonary consumption." — De* tention of all, for its practical, common-sense news troit Review of Medicine. of the nature and treatment of the scourge of all 8 D. APPLETON &* CO.'S MEDICAL WORKS. GENERAL SURGICAL PATHOLOGY AND THERA- PEUTICS, in Fifty-one Lectures. A Text-Book for Students and Phy- sicians. By Dr. Theodor Billroth, Professor of Surgery in Vienna. With Additions by Dr. Alexander von Winiwarter, Professor of Surgery in Ltittich. Translated from the fourth German edition with the special per- mission of the author, and revised from the tenth edition, by Charles E. Hackley, A. M., M. D., Physician to the New York and Trinity Hospitals; Member of the New York County Medical Society, etc. I vol., 8vo, 835 pp. Cloth, $5.00; sheep, $6.00. Giant-celled Sarcoma with Cysts and Ossifying Foci from the Lower Jaw. — Magnified 350 diameters. " Since this translation was revised from the sixth German edition in 1874, two other editions have been published. The present revision is made to correspond to the eighth German edition. " Lister's method of antiseptic treatment is referred to in various places, and other new points that have come up within a few years are discussed. "A chapter has been written on amputation and resection. In all, there are seventy -four additional pages, with a number of woodcuts." — Extract from Translator 's Preface to the Revised Edition. " The want of a book in the English language, ture to say no book could more perfectly supply presenting in a concise form the views of the Ger- that want than the present volume." — The Lan- man pathologists, has long been felt, and we ven- cet. THE PHYSIOLOGICAL AND THERAPEUTICAL ACTION OF ERGOT. Being the Joseph Mather Smith Prize Essay for 1881. By Etienne Evetzky, M. D. I vol., 8vo. Limp cloth, $1.00. "In undertaking the present work my object was to present in a condensed manner all the therapeutic possibilities of ergot. In a task of this nature, original research is out of the ques- tion. No man's evidence is sufficient to establish the merits of a drug considered in the manner indicated, and no one man's opportunities are sufficient to grasp the entire subject. Consequently it remained to gather from the volumes of past and current periodical literature the testimony of the multitude of physicians that had been led to use ergot in different morbid conditions. I have recorded everything that has come to my notice, I have grouped and classified the immense mate- rial in our possession. In all cases in which the action of ergot could be explained, I have at- tempted to do so, although this task is frequently difficult, if not impossible. . . . The reader will see that ergot has been used in a large number of diseases ; some of these uses have little or no practical value, yet it is very important to know them, as they serve to illustrate the therapeutic properties of the drug. They have been brought to the notice of the reader without any com- ments, but those that are essential and of the greatest practical importance have been dealt with more fully. Among the latter may be mentioned the use of ergot in inflammation, aneurism, car- diac diseases, the post-parturient state, uterine fibroid tumors, rheumatism, etc." — From Preface. D. APPLETON &> CO.'S MEDICAL WORKS. g OBSTETRIC CLINIC. A Practical Contribution to the Study of Obstetrics, and the Diseases of Women and Children. By George T. Elliot, M. D., late Professor of Obstetrics and Diseases of Women and Children in the Bellevue Hospital Medical College ; Physician to Bellevue Hospital and to the New York 'Lying-in Asylum, etc. i vol., 8vo, 458 pp. Cloth, $4.50. This work is, in a measure, a resume 'of separate papers previously prepared by the late Dr. Elliot; and contains, besides, a record of nearly two hundred important and difficult cases in mid- wifery, selected from his own practice. The cases thus collected represent faithfully the diffi- culties, anxieties, and disappointments inseparable from the practice of obstetrics, as well as some of the successes for which the profession are entitled to hope in these arduous and responsible tasks. It has met with a hearty reception, and has received the highest encomiums both in this country and in Europe. THE SOURCE OF MUSCULAR POWER. Arguments and Conclusions drawn from Observations upon the Human Subject under conditions of Rest and of Muscular Exercise. By Austin Flint, Jr., M. D., Professor of Physiology in the Bellevue Hospital Medical College, New- York, etc., etc. 1 vol., 8vo, 103 pp. Cloth, $1.00. "There are few questions relating to Philosophy of greater interest and importance than the one which is the subject of this essay. I have attempted to present an accurate statement of my own observations and what seem to me to be the logical conclusions to be drawn from them, as well as from experiments made by others upon the human subject under conditions of rest and of muscular exercise." — From the Preface. ON THE PHYSIOLOGICAL EFFECTS OF SEVERE AND PROTRACTED MUSCULAR EXERCISE. With special ref- erence to its Influence upon the Excretion of Nitrogen. By Austin Flint, Jr., M. D., Professor of Physiology in the Bellevue Hospital Medical Col- lege, New York, etc., etc. 1 vol., 8vo, 91 pp. Cloth, $1.00. This monograph on the relations of Urea to Exercise is the result of a thorough and careful investigation made in the case of Mr. Edward Payson Weston, the celebrated pedestrian. The chemical analyses were made under the direction of R. O. Doremus, M. D., Professor of Chem- istry and Toxicology in the Bellevue Hospital Medical College, by Mr. Oscar Loew, his assistant. The observations were made with the co-operation of J. C. Dalton, M. D., Professor of Physiol- ogy in the College of Physicians and Surgeons; Alexander B. Mott, M. D., Professor of Surgical Anatomy; W. H. Van Buren, M. D., Professor of Principles of Surgery; Austin Flint, M. D., Professor of the Principles and Practice of Medicine; W. A. Hammond, M. D., Professor of the Diseases of the Mind and Nervous System — all of the Bellevue Hospital Medical College. MANUAL OF CHEMICAL EXAMINATION OF THE URINE IN DISEASE. With Brief Directions for the Examination of the most Common Varieties of Urinary Calculi. By Austin Flint, Jr., M. D., Professor of Physiology and Microscopy in the Bellevue Hospital Medical College ; Fellow of the New York Academy of Medicine, etc. Fifth edition, revised and corrected. I vol., i2mo, 77 pp. Cloth, $1.00. The chief aim of this little work is to enable the busy practitioner to make for himself, rapidly and easily, all ordinary examinations of Urine; to give him the benefit of the author's experience in eliminating little difficulties in the manipulations, and in reducing processes of analysis to the utmost simplicity that is consistent with accuracy. " We do not know of any work in English so reputation of the author is a sufficient guarantee of complete and handy as the Manual now offered to the accuracy of all the directions given."— Journal the Profession by Dr. Flint, and the high scientific of Applied Chemistry. IO D. APPLETON &* CO.'S MEDICAL WORKS. TEXT-BOOK OF HUMAN PHYSIOLOGY, for the Use of Students and Practitioners of Medicine. By Austin Flint, Jr., M. D., Professor of Physiology and Physiological Anatomy in the Bellevue Hospital Medical College, New York ; Fellow of the New York Academy of Medi- cine, etc. Third edition. Revised and corrected. In one large 8vo volume of 978 pp., elegantly printed on fine paper, and profusely illustrated with three Lithographic Plates and 315 Engravings on Wood* Cloth, $6.00; sheep, $7.00. Stomach, Pancreas, Large Intestine, etc. " The author of this work takes rank among the very foremost physiologists of the day, and the care which he has bestowed in bringing this third edition of his text -book up to the present position of his science is exhibited in every chapter. " — Medical and Surgical Reporter {Philadelphia). "In the amount, of matter that it contains, in the aptness and beauty of its illustrations, in the variety of experiments described, in the complete- ness with which it discusses the whole field of human physiology, this work surpasses any text-book in the English language." — Detroit Lancet. " The student and the practitioner, whose sound practice must be based on an intelligent appreciation of the principles of physiology, will herein find all sub- jects in which they are interested fully discussed and thoroughly elaborated." — College and Clin. Record. "We have not the slightest intention of criticis- ing the work before us. The medical profession and colleges have taken that prerogative out of the Longitudinal Section of the Human Larynx, ^showing the Vocal Cords. hands of the journalists by adopting it as one of their standard text-books. The work has very few equals and no superior in our language, and every- body knows it." — Hahnemannian Monthly. " We need only say that in this third edition the work has been carefully and thoroughly revised. It is one of our standard text -books, and no physician's library should be without it. We treasure it highly, shall give it a choice, snug, and prominent position on our shelf, and deem ourselves fortunate to pos- sess this elegant, comprehensive, and authoritative work." — American Specialist. " Professor Flint is one of the most practical teachers of physiology in this country, and his book is eminently like the man. It is very full and com- plete, containing practically all the established facts relating to the different subjects. This edition con- tains a iiumber of important additions and changes, besides numerous corrections of slight typographical and other errors." — Ohio Medical Recorder. D. APPLETON &» CO.'S MEDICAL WORKS. II THE PHYSIOLOGY OF MAN. Designed to represent the Existing State of Physiological Science as applied to the Functions of the Human Body. By Austin Flint, Jr., M. D., Professor of Physiology and Physiological Anatomy in the Bellevue Hospital Medical College, New York; Fellow of the New York Academy of Medicine, etc., etc. New and thoroughly revised edition. In 5 vols., 8vo. Per volume, cloth, $4.50; sheep, $5.50. Volume I. The Blood ; Circulation ; Respiration. Volume II. Alimentation ; Digestion ; Absorption ; Lymph and Chyle. Volume III. Secretion; Excretion; Ductless Glands; Nutrition; /.nimal Heat ; Movements ; Voice and Speech. Volume IV. The Nervous System. Volume V. Special Senses ; Generation. "As a book of general information it will be found useful to the practitioner, and, as a book of reference, invaluable in the hands of the anatomist and physiologist." — Dublin Quarterly Journal of Medical Science. " Dr. Flint's reputation is sufficient to give a character to the book among the profession, where it will chiefly circulate, and many of the facts given have been verified by the author in his laboratory and in public demonstration." — Chicago Courier. " The author bestows judicious care and labor. Facts are selected with discrimination, theories crit- ically examined, and conclusions enunciated with commendable clearness and precision." — A?nerican Journal 0/ the Medical Sciences. SYPHILIS AND MARRIAGE. Lectures delivered at the St. Louis Hospital, Paris. By Alfred Fournier, Professeur a la Faculte de Medecine de Paris; Medecin de l'Hopital Saint-Louis. Translated by P. Albert Morrow, M. D., Physician to the Skin and Venereal Department, New York Dispensary, etc., etc. 1 vol., 8vo. Cloth, $2.00; sheep, $3.00. " The book supplies a want long recognized in medical literature, and is based upon a very ex- tended experience in the special hospitals for syphilis of Paris, which have furnished the author with a rich and rare store of clinical cases, utilized by him with great discrimination, originality, and clinical judg- ment. It exhibits a profound knowledge of its sub- ject under all relations, united with marked skill and tact in treating the delicate social questions neces- sarily involved in such a line of investigation. The entire volume is full of information, mnemonically condensed into axiomatic 'points.' It is a book to buy, to keep, to read, to profit by, and to lend to others." — Boston Medical and Surgical Journal. " This work of the able and distinguished French syphilographer, Professor Fournier, is without doubt one of the most remarkable and important produc- tions of the day. Possessing profound knowledge of syphilis in all its protean forms, an unexcelled experience, a dramatic force of expression, untinged, however, by even a suspicion of exaggeration, and a rare tact in dealing with the most delicate prob- lems, he has given to the world a series of lectures which, by their fascination of style, compels atten- tion, and by their profundity of wisdom carries con- viction." — St. Louis Courier of Medicine and Col- lateral Sciences. "Written with a perfect fairness, with a supe- rior ability, and in a style which, without aiming at effect, engages, interests, persuades, this work is one of those which ought to be immediately placed in the hands of every physician who desires not only to cure his patients, but to understand and fulfill his duty as an honest man." — Lyon Medicate. " No physician, who pretends to keep himself informed upon the grave social questions to which this disease imparts an absorbing interest, can afford to leave this valuable work unread." — St. Louis Clinical Record. " The author handles this grave social problem without stint. A general perusal of this work would be of untold benefit to society." — Louisville Medical News. " The subject is treated by Professor Fournier in a manner that is above criticism. Exhaustive clini- cal knowledge, discriminating judgment, and thor- ough honesty of opinion are united in the author, and he presents his subject in a crisp and almost dramatic style, so that it is a positive pleasure to read the book, apart from the absolute importance of the question of which it treats." — New York Medical Record. " Every page is full of the most practical and plain advice, couched in vigorous, emphatic lan- guage." — Detroit Lancet. " The subject here presented is one of the most important that can engage the attention of the pro- fession. The volume should be generally read, as the subject-matter is of great importance to society." — Maryland Medical Journal. "We can give only a very incomplete idea of this work of M. Fournier, which, by its precision, its clearness, by the forcible manner in which the facts are grouped and presented, defies all analysis. ' Syphilis and Marriage ' ought to be read by all physicians, who will find in it, first of all, science, but who will also find in it, during the hours they devote to its perusal, a charming literary pleasure." — Annates de Dermatologie et de Syphiligraphie. 12 D. APPLETON 6- CO.'S MEDICAL WORKS. CYCLOPEDIA OF PRACTICAL RECEIPTS, and XDol- lateral Information in the Arts, Manufactures, Professions, and Trades, including Medicine, Pharmacy, and Domestic Economy. Designed as a Comprehensive Supplement to the Pharmacopoeia, and General Book of Reference for the Manufacturer, Tradesman, Amateur, and Heads of Fam- ilies. Sixth edition, revised and partly rewritten by Richard V. Tuson, Professor of Chemistry and Toxicology in the Royal Veterinary College. Complete in 2 vols., 1,796 pp. With Illustrations. Cloth, $9.00. Cooley's "Cyclopaedia of Practical Receipts " has for many years enjoyed an extended reputa- tion for its accuracy and comprehensiveness. The sixth edition, now just completed, is larger than the last by some six hundred pages. Much greater space than hitherto is devoted to Hygiene (including sanitation, the composition and adulteration of foods), as well as to the Arts, Phar- macy, Manufacturing Chemistry, and other subjects of importance to those for whom the work is intended. The articles on what is commonly termed "Household Medicine" have been ampli- fied and numerically increased. The design of this work is briefly but not completely expressed in its title-page. Independ- ently of a reliable and comprehensive collection of formulae and processes in neaidy all the indus- trial and useful arts, it contains a description of the leading properties and applications of the substances referred to, together with ample directions, hints, data, and allied information, cal- culated to facilitate the development of the practical value of the book in the shop, the laboratory, the factory, and the household. Notices of the substances embraced in the Materia Medica, in addition to the whole of their preparations, and numerous other animal and vegetable substances employed in medicine, as well as most of those used for food, clothing, and fuel, with their eco- nomic applications, have been included in the work. The synonyms and references are other addi- tions which will prove invaluable to the reader. Lastly, there have been appended to all the principal articles referred to brief but clear directions for determining their purity and commercial value, and for detecting their presence and proportions in compounds. The indiscriminate adop- tion of matter, without examination, has been uniformly avoided, and in no instance has any form- ula or process been admitted into this work, unless it rested on some well-known fact of science, had been sanctioned by usage, or come recommended by some respectable authority. THE COMPARATIVE ANATOMY OF THE DOMES- TICATED ANIMALS. By A. Chauveau, Professor at the Lyons Vet- erinary School. Second edition, revised and enlarged, with the co-operation of S. Arloing, late Principal of Anatomy at the Lyons Veterinary School ; Professor at the Toulouse Veterinary School. Translated and edited by George Fleming, F. R. G. S., M. A. L, Veterinary Surgeon, Royal Engineers, vol., 8vo, 957 pp. With 450 Illustrations. Cloth, $6.00. Specimen of Illustration. "Taking it altogether, the book is a very wel- come addition to English literature, and great credit is due to Mr. Fleming for the excellence of the trans- lation, and the many additional notes he has ap- pended to Chauveau's treatise." — Lancet {London). " The descriptions of the text are illustrated and assisted by no less than 450 excellent woodcuts. In a work which ranges over so vast a field of anatomi- cal detail and description, it is difficult to select any one portion for review, but our examination of it enables us to speak in high terms of its general ex- cellence. . . ." — Medical Times and Gazette {Lon- don). D. APPLETON 6- CO.'S MEDICAL WORKS. 13 THE HISTOLOGY AND HISTO-CHEMISTRY OF MAN. A Practical Treatise on the Elements of Composition and Struc- ture of the Human Body. By Heinrich Frey, Professor of Medicine in Zurich. Translated from the fourth German edition, by Arthur E. J. Bar- ker, Surgeon to the City of Dublin Hospital ; Demonstrator of Anatomy, Royal College of Surgeons, Ireland ; and revised by the Author. With 680 Engravings. 683 pp. Cloth, $5 ; sheep, $6. vol. >vo. CONTEXTS.— The Elements of Composition and of Structure of the Body : Elements of Com- position — Albuminous or Protein Compounds, Haemoglobulin, His- togenic Derivatives of the Albu- minous Substances or Albumi- noids, the Eatty Acids and Fats, the Carbo-hydrates, Non-Nitro- genous Acids, Nitrogenous Acids, Amides, Amido-Acids, and Or- ganic Bases, Animal Coloring Matters, Cyanogen Compounds, Mineral Constituents ; Elements of Structure — the Cell, the Origin C| of the Remaining Elements of 1& Tissue ; the Tissues of the Body — Tissues composed of Simple Cells, with Fluid Intermediate Substance, Tissues composed of Simple Cells, with a small amount of Solid Intermediate Substance, Tissues belonging to the Con- nective Substance Group, Tissues composed of Transformed and, as a rule, Cohering Cells, with Homogeneous, Scanty, and more or less Solid Intermediate Substance ; Composite Tissues : The Organs of the Body — Organs of the Vegetative Type, Organs of the Animal Group. Transverse Section 01 a Human Bone. CONSERVATIVE SURGERY, as exhibited in remedying some of the Mechanical Causes that operate injuriously both in Health and Disease. With Illustrations. By Hexry G. Davis, M. D., Member of the American Medical Association, etc., etc. 1 vol., 8vo, 315 pp. Cloth, $3. The author has enjoyed rare facilities for the study and treatment of certain classes of disease, and the records here presented to the profession are the gradual accumulation of over thirty years' investigation. " Dr. Davis, bringing as he does to his specialty deem it worthy of a place in every physician's li- a great aptitude for the solution of mechanical prob- brary. The style is unpretending, but trenchant, lems, takes a high rank as an orthopedic surgeon, graphic, and, best of all, quite intelligible." — Medi- and his very practical contribution to the literature cal Record. of the subject is both valuable and opportune. We YELLOW FEVER A NAUTICAL DISEASE. Its Origin and Prevention. By John Gamgee. 1 vol., 8vo, 207 pp. Cloth, $1.50. The theory is certainly shown to be a plausible " The author discusses, with a vast array of clear and well-digested facts, the nature and prevention of yellow fever. The work is admirably written, and the author's theories plausible and well sus- tained by logical deductions from established facts." — Homoeopathic Times. one ; and every reader, whether he be convinced or not, can not but be interested, instructed, and set to thinking." — Lancet and Clinic. H D. APPLETON &* CO.'S MEDICAL WORKS. Specimen of Illustration. CONTRIBUTIONS TO REPARATIVE SURGERY, show- ing its Application to the Treatment of Deformities, produced by Destruc- tive Disease or Injury; Congenital Defects from Arrest or Excess of Devel- opment ; and Cicatricial Contractions following Burns. Illustrated by Thirty Cases and fine Engravings. By Gurdon Buck, M. D. i vol., 8vo, 237 pp. Cloth, $3. " There is no department of surgery where the ingenuity and skill of the surgeon are more severely taxed than when required to repair the damage sustained by the loss of parts, or to remove the disfigurement produced by destructive dis- ease or violence, or to remedy the deformities of congenital malformation. The results obtained in such cases within the last half-century are among the most satisfactory achieve- ments of modern surgery. The term * Reparative Surgery ' chosen as the title of this volume, though it may, in a com- prehensive sense, be applied to the treatment of a great variety of lesions to which the body is liable, is, however, restricted in this work exclusively to what has fallen under the author's own observation, and has been subjected to the test of experience in his own practice. It largely embraces the treatment of lesions of the face, a region in which plastic surgery finds its most frequent and important applications. Another and no less important class of lesions will also be found to have occupied a large share of the author's atten- tion, viz., cicatricial contractions following burns. While these cases have a very strong claim upon our commisera- tion, and should stimulate us, as surgeons, to the greatest efforts for their relief, they have too often in the past been dismissed as hopelessly incurable. The satisfactory results obtained in the cases reported in this volume will encour- age other surgeons, we trust, to resort with greater hope- fulness in the future to operative interference. Accuracy of description and clearness of statement have been aimed at in the following pages; and if, in his endeavor to attain this important end, the author has incurred the reproach of tediousness, the difficulty of the task must be his apology." — Extract from Preface. THE CHEMISTRY OF COMMON LIFE. Illustrated with numerous Wood Engravings. By the late James F. W. Johnson, F. R. S., Professor of Chemistry in the University of Durham. A new edition, revised and brought down to the Present Time. By Arthur Her- bert Church, M. A., Oxon. Illustrated with Maps and numerous Engravings on Wood. In one vol., i2mo, 592 pp. $2. SUMMARY OF CONTENTS.— The Air we Breathe; the Water we Drink; the Soil we Cultivate ; the Plant we Rear ; the Bread we Eat ; the Beef we Cook ; the Beverages we Infuse ; the Sweets we Extract ; the Liquors we Ferment ; the Narcotics we Indulge jn ; the Poisons we Select; the Odors we Enjoy; the Smells we Dislike; the Colors we Admire ; What we Breathe and Breathe for ; What, How, and Why we Digest ; the Body we Cherish ; the Circulation of Matter. THE TONIC TREATMENT OF SYPHILIS. By E. L. Keyes, A. M., M. D., Adjunct Professor of Surgery and Professor of Der- matology in the Bellevue Hospital Medical College, etc. 1 vol., 8vo, 83 pp. Cloth, $1. " My studies in syphilitic blood have yielded results at once so gratifying to me, and so con- vincing as to the tonic influence of minute doses of mercury, that I feel impelled to lay this brief treatise before the medical public in support of a continuous treatment of syphilis by small (tonic) doses of mercury. I believe that a general trial of the method will, in the long run, vindicate its excellence." — Extract from Preface. D. APPLETON &* CO.'S MEDICAL WORKS. 15 A PRACTICAL TREATISE ON TUMORS OF THE MAMMARY GLAND : embracing their Histology, Pathology, Diagnosis, and Treatment. By Samuel W. Gross, A. M., M. D., Surgeon to, and Lecturer on Clinical Surgery in, the Jefferson Medical College Hospits-1 and the Philadelphia Hospital, etc. In one handsome 8vo vol. of 246 pp., with 29 Illustrations. Cloth, $2.50. "The work opportunely supplies a real want, and is the result of accurate work, and we heartily recommend it to our readers as well worthy of care- ful study." — Lotidon Lancet. " We know of no book in the English language which attempts to cover the ground covered by this one — indeed, the author seems to be the first who has sought to handle the whole subject of mammary tumors in one systematic treatise. How he has suc- ceeded will best be seen by a study of the book itself. In the early chapters the classification and relative frequency of the various tumors, their evolution and transformations, and their etiology, are dealt with ; then each class is studied in a separate chapter, in which the result of the author's work is compared with that of others, and the general conclusions are drawn which give to the book its great practical value ; finally, a chapter is devoted to diagnosis, one to treatment, and one to the tumors in the mam- mary gland of the male." — New York Medical Journal. "We heartily commend this work to the profes- sion, knowing that those who study its pages will be well repaid and have a better understanding of what to the average practitioner is obscure and un- satisfactory." — l^oledo Medical and Surgical Jour- nal. " Dr. Gross has produced a work of real and permanent value ; it is not overstating the truth to say that this little volume is probably the best con- tribution to medical science which the present year has brought forth. We believe that the author has Development ot Carcinoma. Cystic Encephaloid Carcinoma. - done what he has set out to do, viz., constructed a systematic and strictly accurate treatise on mammary tumors, and brought to his task all the light afforded by the most recent investigations into their pathol- ogy." — St. Louis Clinical Record. " This book is a real contribution to our profes* sional literature ; and it comes from a source which commands our respect. The plan is very systematic and complete, and the student or practitioner alike will find exactly the information he seeks upon any of the diseases which are incident to the mammary gland." — Obstetrical Gazette. " Altogether, the work is one of more than ordi nary interest to the surgeon, gynaecologist, and phy- sician." — Detroit Lancet. "The work is at once original, scientific, and practical. Its histology will receive the careful at- tention of the specialist ; the surgeon will find it a guide and help ; while the general practitioner, who would be informed, and desires to know what will be taught in our text-books and in our colleges, must study it. It is an effort' that will add new honor to an honorable name, and of which we, as / mericans, may all be proud as an example of origi- nal work and investigation." — Buffalo Medical and Surgical Journal. " Dr. Gross has given to the profession, in his 1 Treatise on Tumors of the Mammary Gland,' one of the most useful and original surgical works of the nineteenth century. It is but honest and just praise to say that in this treatise the author shows himself the intellectual peer of his great father, America's great surgeon." — Louisville Medical News. "A treatise based upon the systematic analysis of so large an amount of material can not fail to recommend itself to the intelligent surgeon, espe- cially as it, so far as we know, is the only recent work published which affords any trustworthy in- formation on this important subject. The author shows an intimate knowledge of the investigations of others, and refers to them frequently throughout the work, a fact which materially adds to its value." — Philadelphia Medical and Surgical Reporter. "He deserves the thanks of the profession for his bold and direct opinions, and doubtless in the future the general surgical practitioner will attack these tumors with more painstaking, and with more confidence in the results." — North Carolina Medi- cal Journal. i6 D. APPLETON &* CO.'S MEDICAL WORKS. EMERGENCIES, AND HOW TO TREAT THEM. The Etiology, Pathology, and Treatment of Accidents, Diseases, and Cases of Poisoning, which demand Prompt Action. Designed for Students and Practitioners of Medicine. By Joseph W. Howe, M. D., Clinical Profess- or of Surgery in the Medical Department of the University of New York, etc., etc. Fourth edition, revised. I vol., 8vo, 265 pp. Cloth, $2.50. 1 ' To the general practitioner in towns, villages, and in the country, where the aid and moral sup- port of a consultation can not be availed of, this volume will be recognized as a valuable help. We commend it to the profession." — Cincinnati Lancet a7id Observer. ' ' The author wastes no words, but devotes him- self to the description of each disease as if the pa- tient were under his hands. Because it is a good book we recommend it most heartily to the profes- sion." — Boston Medical and Surgical Journal. " This work bears evidence of a thorough prac- tical acquaintance with the different branches of the profession. The author seems to possess a peculiar aptitude for imparting instruction as well as for simplifying tedious details. A careful perusal will amply repay the student and practitioner." — New York Medical Jour?ial. A TREATISE ON THE DISEASES OF THE NERV- OUS SYSTEM. By William A. Hammond, M. D., Surgeon-General U. S. Army (retired list) ; Professor of Diseases of the Mind and Nervous System, in the New York Post-Graduate Medical School; President of the American Neurological Association, etc. Seventh edition, rewritten, enlarged and improved. In one large 8vo vol. of 929 pp., with Com- plete Index and 150 Illustrations. Cloth, $5 ; sheep or half russia, $6. Specimen of Illustration. This, the seventh edition of Dr. Hammond's well-known work, has been thoroughly re- vised, and enlarged by the ad- dition of new chapters, and of a section on Diseases of the Sympathetic System. The work has received the honor of a French translation by Dr. Labadie-Lagrave, of Paris, and an Italian transla- tion by Professor Diodato Bor- relli, of the Royal University, is now going through the press at Naples. "Dr. Hammond's work has now been before the profession for many years, and its charac- teristics are very generally known. The present edition has a good many valuable additions, but has lost nothing of its previous indi- viduality as a medical work. Dr. Hammond has the qualities of a successful author. His practical ex- perience is large, his convictions are positive, and he can set them forth clearly and attractively. It is not surprising that his book has been a very popular one. And the present edition is, as modestly stated on the title-page, ' improved.' " — Medical Record. " This is unquestionably the most complete trea- tise on the diseases to which it is devoted that has yet appeared in the English language ; and its value is much increased by the fact that Dr. Hammond has mainly based it on his own experience and prac- . tice, which, we need hardly remind our readers, have been very extensive." — Medical Times and Gazette. "The author is a concise writer, who never wastes any paper, and he has, as he says himself in his preface, views of his own on every disease con- sidered, and he is not afraid to express them ; in short, the work is largely the result of his own ob- servation and experience, though the labors of others are by no means ignored." — Medical and Surgical Reporter ; Philadelphia. " It everywhere evinces comprehensive apprecia- tion of the scope of the subjects considered, offering what is known and at the same time indicating the paths by which further observation will lead to more perfect knowledge. It is a reliable guide to the study and treatment of a most highly interesting class of diseases, and will unquestionably maintain if not extend in its present form the approbation and appreciation its merits have hitherto com- manded." — New York Medical Gazette. " The merits of this book, like those of its au- thor, have not been hid under a bushel. It shows great facility of expression, much thought, and wide reading, with an uncommon faith in the power of remedies over diseases commonly found intract- able." — Louisville Medical News. D. APPLETON S* CO.'S MEDICAL WORKS. 17 "... We have only to wish this book a con- tinuance of its well-deserved popularity, and to recommend it to our readers as a work which any one who has to do with nervous diseases can not well afford to be without." — Dublin Medical Jour- nal. " Our space, and indeed the very nature of the work, forbids a detailed notice of the book. Suffice it to say that we are convinced, from a by no means superficial examination of it, that there is no work on the subject better adapted to the wants of the general practitioner at least." — Michigan Medical News. "We regard Dr. Hammond's work as excellent authority on the subject of nervous diseases, and frequently refer to it in our study of these affec- tions." — Canada Lancet. " Dr. Hammond's book is the only complete one on nervous diseases accessible to the English-read- ing student, which is the work of a competent writ- er, one who has observed, studied, and treated these affections himself." — St. Louis Clinical Rec- ord. "A careful examination shows this to be essen- tially a new volume, and the rewriting and remod- eling having wrought such changes, that it will be consulted with an increased degree of confidence by general practitioners." — North Carolina Medical Journal. Specimen of Illustration ;;' '} : 'i^/^fO tdi^ [ w v ° CLINICAL LECTURES ON DISEASES OF THE NERVOUS SYSTEM. Delivered at the Bellevue Hospital Medical Col- lege. By William A. Hammond, M. D., Professor of Diseases of the Mind and Nervous System, etc. Edited, with Notes, by T. M. B. Cross, M. D., Assistant to the Chairs of Diseases of the Mind and Nervous System, etc. In one handsome volume of 300 pages. $3.50. These lectures have been reported in full, and, together with the histories of the cases, which were prepared by the editor after careful study and prolonged observation, constitute a clinical volume which, while it does not claim to be exhaustive, will nevertheless be found to contain many of the more important affections of the kind that are commonly met with in practice. As these lectures were intended especially for the benefit of students, the author has confined himself to a full consideration of the symptoms, causes, and treatment of each affection, without attempting to enter into the pathology or morbid anatomy. THE ANATOMY OF VERTEBRATED ANIMALS. By Thomas Henry Huxley, LL. D., F. R. S. I vol., i2mo. Illustrated. 431 pp. Cloth, $2.50. " The present work is intended to provide students of comparative anatomy with a condensed statement of the most important facts relating to the structure of vertebrated animals which have hitherto been ascertained. The Vertebrata are distinguished from all other animals by the circum- stance that a transverse and vertical section of the body exhibits two cavities completely separated from one another by a partition. The dorsal cavity contains the cerebro-spinal nervous system ; the ventral, the alimentary canal, the heart, and usually a double chain of ganglia, which passes under the name of the ' sympathetic. ' It is probable that this sympathetic nervous system repre- sents, wholly or partially, the principal nervous system of the Annulosa and Mollusca. And, in any case, the central parts of the cerebro-spinal nervous system, viz., the brain and the spinal cord, would appear to be unrepresented among invertebrated animals." — The Author. ' ' This long-expected work will be cordially wel- comed by all students and teachers of Comparative Anatomy as a compendious, reliable, and, notwith- standing' its small dimensions, most comprehensive guide on the subject of which it treats. To praise or to criticise the work of so accomplished a master of his favorite science would be equally out of place. It is enough to say that it realizes, in a remarkable degree, the anticipations which have been formed of it ; and that it presents an extraordinary combi- nation of wide, general views, with the clear, accu- rate, and succinct statement of a prodigious number of individual facts." — Nature. i8 D. APPLETON &* CO.'S MEDICAL WORKS. A TREATISE ON ORAL DEFORMITIES, as a Branch c£ Mechanical Surgery. By Norman W. Kingsley, M. D. S., D. D. S., President of the Board of Censors of the State of New York, late Dean of the New York College of Dentistry and Professor of Dental Art and Mech- anism, etc., etc. With over 350 Illustrations. Specimen of Illustration. One vol., 8vo. Cloth, $5 ; sheep, $6. " I have read with great pleasure and much profit your valuable ' Treatise on Oral Deformi- ties.' The work contains much original matter of great practical value, and is full of useful in- formation, which will be of great benefit to the profession."— Lewis A. Sayre, M. D., LL. D., Professor of Orthopedic Surgery and Clinical Surgery, Bellevue Hospital Medical College. ' ' A casual glance at this work might impress the reader with the idea that its contents were of more practical value to the dentist than to the general practitioner or surgeon. But it is by no means a mere work on dentistry, although a prac- tical knowledge of the latter art seems to be es- sential to the carrying out of the author's views regarding the correction of the different varieties of oral deformities of which he treats. We would be doing injustice to the work did not we make particular reference to the masterly chapter on the treatment of fractures of the lower jaw. The whole subject is so thoroughly studied that noth- ing is left to be desired by any surgeon who wish- es to treat these fractures intelligently and success- fully. The work, as a whole, bears marks of originality in every section, and impresses the reader with the painstaking efforts of the author to get at the truth, and apply it in an ingenious and practical way to the wants of the general practitioner, the surgeon, and the dentist."— Medical Record. " The profession is to be congratulated on possessing so valuable an addition to its litera- ture, and the author to be unstintedly praised for his successful issue to an arduous undertaking. The work bears, in a word, every evidence of having been written leisurely and with care. . . ."—Dental Cosmos. " To the surgeon and general practitioner of medicine, as well as the dentist, its instruction will be found invaluable. It is clear in style, practical in its application, comprehensive in its illustrations, and so exhaustive that it is not likely to meet in these respects a rival."— William H. Dwinelle, A. M., M. D. " I consider it to be the most valuable work that has ever appeared in this country in any department of the science of dental surgery. t "There is no doubt of its great value to every man who wishes to study and practice this branch of surgery, and I hope it may be adopted as a text-book in every dental college, that the students may have the benefit of the great experience of the author. " It places many things between the covers of one book which heretofore I have been obliged to look for in many directions, and often without success."— Frank Abbot, M. D., Dean of the New York College of Dentistry. " The writer does not hesitate to express his belief that the chapters on the ' aesthetics of den- tistry ' will be found of more practical value to the prosthetic dentist than all the other essays on this subject existent in the English language. ... A perusal of its pages seems to compel the mind to advance in directions variously indi- cated ; so variously, indeed, that there is hardly a page of the book which does not contain some important truth, some pregnant hint, or some valuable conclusion." — Dental Miscellany. "I congratulate you on having written a book containing so much valuable and original matter. It will prove of value not only to den- tists, but also to surgeons and physicians." — Frank Hastings Hamilton, M. D., LL. D., Professor of the Practice of Surgery with Opera- tions, and of Clinical Surgery in Bellevue Hos- pital Medical College. Specimen of Illustration. Illlillllll D. APPLETON &* CO.'S MEDICAL WORKS, 19 THE BREATH, AND THE DISEASES WHICH GIVE IT A FETID ODOR. With Directions for Treatment. By Joseph W. Howe, M. D., Clinical Professor of Surgery in the Medical Department of the University of New York, etc. Second edition, revised and corrected. 1 vol., i2mo, 108 pp. Cloth, $1. " This little volume well deserves the attention of physicians, to whom we commend it most high- ly." — Chicago Medical Journal. " To any one suffering from the affection, either in his own person or in that of his intimate ac- quaintances, we can commend this volume as con- taining all that is known concerning the subject, set forth in a pleasant style." — Philadelphia Medical Times. ' ' The author gives a succinct account of the dis- eased conditions in which a fetid breath is an im- portant symptom, with his method of treatment. We consider the work a real addition to medical lit- erature." — Cincinnati Medical Journal. ON THE BILE, JAUNDICE, AND BILIOUS DIS- EASES. By J. Wickham Lego, M. D., F. R. C. S., Assistant Physician to St. Bartholomew's Hospital, and Lecturer on Pathological Anatomy in the Medical School. In one volume, 8vo, 719 pp. With Illustrations in Chromo-lithography. Cloth, $6; sheep, $7. "... And let us turn — which we gladly do — to the mine of wealth which the volume itself contains, for it is the outcome of a vast deal of labor ; so great indeed, that one unfamiliar with it would be surprised at the number of facts and references which the book contains." — Medical Times and Ga- zette, London. " The book is an exceedingly good one, and, in some points, we doubt if it could be made better. . . . And we venture to say, after an attentive perusal of the whole, that any one who takes it in hand will derive from it both information and pleasure ; it gives such ample evidence of honest hard work, of wide reading, and an impartial at- tempt to state the case of jaundice, as it is known by observation up to the present date. The book will not only live, but be in the enjoyment of a vig- orous existence long after some of the more popular productions of the present age are buried, past all hope of resurrection." — London Medical Record. "This portly tome contains the fullest account of the subjects of which it treats in the English lan- guage. The historical, scientific, and practical de- tails are all equally well worked out, and together constitute a repertorium of knowledge which no practitioner can well do without. The illustrative chromo-lithographs are beyond all praise." — Edin- burgh Medical Journal. " Dr. Legg's treatise is a really great book, ex- hibiting immense industry and research, and full of valuable information." — American Journal 0/ Med- ical Science. "It seems to us an exhaustive epitome of all that is known on the subject." — Philadelphia Medi- cal Times. "This volume is one which will command pro- fessional respect and attention. It is, perhaps, the most comprehensive and exhaustive treatise upon the subject treated ever published in the English language." — Maryland Medical Journal. " It is the work of one who has thoroughly stud- ied the subject, and who, when he finds the evi- dence conflicting on disputed points, has attempted to solve the problem by experiments and observa- tions of his own." — Practitioner, Lo?idon. "It is a valuable work of reference and a wel- come addition to medical literature. — Dublin Jour- nal of Medical Science. "... The reader is at once struck with the im- mense amount of research exhibited, the author having left unimproved no accessible source of in- formation connected with his subject. It is, indeed, a valuable book, and the best storehouse of knowl- edge in its department that we know of." — Pacific Medical and Surgical Journal. FIRST LINES OF THERAPEUTICS as Based on the Modes and the Processes of Healing, as occurring spontaneously in Dis- eases ; and on the Modes and the Processes of Dying as resulting naturally from Disease. In a Series of Lectures. By Alexander Harvey, M. A., M. D., Emeritus Professor of Materia Medica in the University of Aber- deen, etc., etc. 1 vol., i2mo, 278 pp. Cloth, $1.50. " If only it can get a fair hearing before the pro- fession it will be the means of aiding in the devel- opment of a therapeutics more rational than we now dream of. To medical students and practi- tioners of all sorts it will open up lines of thought and investigation of the utmost moment." — Detroit \Lancet. "We may say that, as a contribution to the philosophy of medicine, this treatise, which may be profitably read during odd moments of leisure, has a happy method of statement and a refreshing free- dom from dogmatism."— New York Medical Rec- ord. 20 D. APPLETON &* CO.'S MEDICAL WORKS. THE SCIENCE AND ART OF MIDWIFERY. By William Thompson Lusk, M. A., M. D., Professor of Obstetrics and Dis- eases of Women and Children in the Bellevue Hospital Medical College ; Obstetric Surgeon to the Maternity and Emergency Hospitals ; and Gynae- cologist to the Bellevue Hospital. New edition. Revised and enlarged. Complete in one volume, Svo, with 246 Illustrations. Cloth, $5.00; sheep, $6.00. „ It contains one of th£ best ^ positions of the obstetric science and' practice of the day with which we are acquainted. Throughout the work the author shows an intimate acquaintance with the literature of obstetrics, and gives evidence of large practical experience, great discrimi- nation, and sound judgment. We heartily recommend the book as a full and clear exposition of obstetric science and safe guide to student and practitioner." — London Lancet. " Professor Lusk's book presents the art of midwifery with all that modern science or earlier learning it. -Medical has contributed to Record, JSiew York. "This book bears evidence on every page of being the result of patient and laborious research and great personal experience, united and harmonized by the true critical or scientific spirit, and we are con- vinced that the book will raise the general standard of obstetric knowl- edge both in his own country and in this. Whether for the student obliged to learn the theoretical part of midwifery, or for the busy prac- titioner seeking aid in face of practical difficulties, it is, in our opinion, the best modern work on mid- wifery in the English language." — Dublin Journal of Medical Science. D'Outrepont's Method, modified by Scan: Author's Modification of Tarnier's Forceps. " Dr. Lusk's style is clear, generally concise, and he has succeeded in putting in less than seven hun- dred pages the best exposition in the English lan- guage of obstetric science and art. The book will prove invaluable alike to the student and the prac- titioner." — American Practitioner. " Dr. Lusk's work is so comprehensive in design and so elaborate in execution that it must be recog- nized as having a status peculiarly its own among the text-books of midwifery in the English lan- guage." — New York Medical Journal. "The work is, perhaps, better adapted to the wants of the student as a text-book, and to the practitioner as a work of reference, than any other •one publication on the subject. It contains about all that is known of the ars obstetrica, and must add greatly to both the fame and fortune of the distinguished author." — Medical Herald, Louis- ville. "Dr. Lusk's book is eminently viable. It can not fail to live and obtain the honor of a second, a third, and nobody can foretell how many editions. It is the mature product of great industry and acute observation. It is by far the most learned and most complete exposition of the science and art of obstet- rics written in the English language. It is a book so rich in scientific and practical information, that nobody practicing obstetrics ought to depiive him- self of the advantage he is sure to gain from a fre- quent recourse to its pages." — American Journal of Obstetrics. "It is a pleasure to read such a book as that which Dr. Lusk has prepared ; everything pertain- ing to the important subject of obstetrics is dis- cussed in a masterly and captivating manner. We recommend the book as an excellent one, and feel confident that those who read it will be amply re- paid."— Obstetric Gazette, Cincinnati. D. APPLETON &* CO.'S MEDICAL WORKS. 21 "To consider the work in detail would merely involve us in a reitera- tion of the high opinion we have al- ready expressed of it. What Spiegel- berg has done for Germany, Lusk, imitating him but not copying him, has done for English readers, and we feel sure that in this country, as in America, the work will meet with a very extensive approval." — Edinburgh Medical Journal. " The whole range of modern ob- stetrics is gone over in a most system- atic manner, without indulging in the discussion of useless theories or con- troversies. The style is clear, concise, compact, and pleasing. The illustra- tions are abundant, excellently exe- cuted, remarkably accurate in outline and detail, and, to most of our Ameri- can readers, entirely fresh." — Cincin- nati Lancet a?td Clinic. "We thank Dr. Lusk for his most valuable work, which is, in our opin- ion, as we have said before, the best representative of the state of obstetric science and art at the present day that exists in the English language. Stu- dent and practitioner will alike find it suitable to their needs, and there are few specialists who will not gain instruction from it." — Medical Times and Gazette, London. " This is undoubtedly the best book on the sub- "A work which, like the one before us, com- ject in the language. It is written from a physio- bines the qualities of being a safe and reliable guide Appearance of Cervix in Multipara; Ninth Month. logical stand-point, combined with an extended clinical knowledge. It is evident that teachers of obstetrics will not only be glad to commend such a work to their pupils, but will find it a most valuable guide for themselves." — Chicago Medical Review. to the practitioner, at the same time that it presents to the reader a fair statement of the labors of recent investigators, can not but prove useful." — Medical and Surgical Reporter, Philadelphia. HEALTH PRIMERS. Edited by J. Langdon Down, M. D., F. R. C. P. ; Henry Power, M. B., F. R. C. S. ; J. Mortimer-Granville, M. D. ; John Tweedy, F. R. C. S. In square i6mo volumes. Cloth, 40 cents each. Though it is of the greatest importance that books upon health should be in the highest degree trustworthy, it is notorious that most of the cheap and popular kind are mere crude compilations of incompetent persons, and are often misleading and injurious. Impressed by these considera- tions, several eminent medical and scientific men of London have combined to prepare a series of Health Primers of a character that shall be entitled to the fullest confidence. They are to be brief, simple, and elementary in statement, filled with substantial and useful information suitable for the guidance of grown-up people. Each primer will be written by a gentleman specially com- petent to treat his subject, while the critical supervision of the books is in the hands of a commit- tee who will act as editors. As these little books are produced by English authors, they are naturally based very much upon English experience, but it matters little whence illustrations upon such subjects are drawn, because the essential conditions of avoiding disease and preserving health are to a great degree everywhere the same. Volumes now ready. I. Exercise and Training. II. Alcohol : its Use and Abuse. III. Premature Death : its Promotion and Prevention. IV. The House and its Surroundings. V. Personal Appearance in Health and Disease. VI. Baths and Bathing. VII. The Skin and its Troubles. VIII. The Heart and its Functions. IX. The Nervous System. 22 D. APPLETON &° CO.'S MEDICAL WORKS. ANALYSIS OF THE URINE. With Special Reference to the Diseases of the Genito-Urinary Organs. By M. B. Hoffman, Professor in the University of Gratz, and R. Ultzmann, Docent in the University of Vienna. Translated from the German edition under the special super- vision of Dr. Ultzmann. By T. Barton Brune, A. M., M. D., Resident Physician Maryland University Hospital, and H. Holbrook Curtis, Ph. B. With Eight Lithographic Colored Plates from Ultzmann and Hoffman's Atlas, and from Photographs furnished by Dr. Ultzmann, which do not appear in the German edition or any other translation. I vol., 8vo, 200 pages. $2. "We have not space for further analysis of the sis of the urine and diseases of the kidney, it ad- work, but would simply state that it well deserves mirably well fulfills the purpose of its being, viz., the reputation it has already obtained abroad. It is to concisely yet clearly present to the student an ac- eminently practical, and adapted, as the authors count of the normal and abnormal constituents of claim, to the wants of the physician and student the urine, the methods of their detection, and of rather than of the medical chemist, although the their diagnostic significance in general and local latter can ill afford to dispense with it." — Philadel- disease." — Southern Practitioner, phia Medical Times. < < We indorse the statement that the book is fully "At the present time we are unacquainted with up to the times, and heartily recommend it to stu- any work at all equal to this in meeting the needs dents and practitioners of medicine as the most use- of the medical student. The elegant form in which f ul and concise book on the subject. The practi- the publishers have issued it adds still further to its tioner, when he reads this little book, will be as- desirable qualities." — Detroit Lancet. tonished at the simplicity of ordinary urinalyses, "Throughout, the book is characterized by sound and » instead of sending to experts, will save time doctrine, scientific accuracy, and careful compila- and tr ° ub ! e b ? ma kmg them for himself."— Louis tion ; while, as a translation from a foreign tongue, ville Medical News. its lucidity of style, terseness, and perspicuity are " An examination of the book satisfies us that it veritably surprising. It can not fail, in our opin- has been carefully prepared, and can be relied on ion, to attain the end set before its authors in its for correctness. The new chemical notation is used, preparation, and prove a most valuable aid alike to and also the metrical system of weights and meas- student and practitioner in the urological diagnosis ures. As an appendix to the text, eight colored and study of disease. Eight very good double plates illustrate the solid constituents of the urine, plates, portraying the microscopic deposits of the « n the whole, we regard the book as well urine, complete the book."— Canada Journal of adapted to its purpose, and a decided convenience Medical Science. t t he practitioner who aims at something beyond " We advise our readers to procure the Apple- guess-work in diagnosis and prognosis of urinary tons' edition by all means ; making no pretensions disorders." — New York Medical and Surgical to be an exhaustive treatise on the subject of analy- Journal. CLINICAL ELECTRO-THERAPEUTICS. (Medical and Surgical.) A Manual for Physicians for the Treatment more especially of Nervous Diseases. By Allan McLane Hamilton, M. D., Physician in charge of the New York State Hospital for Diseases of the Nervous System, etc., etc. With numerous Illustrations. I vol., 8vo. Cloth, $2. This work is the compilation of well-tried measures and reported cases, and is intended as a simple guide for the general practitioner. It is as free from confusing theories, technical terms, and unproved statements as possible. Electricity is indorsed as a very valuable remedy in certain diseases, and as an invaluable therapeutical means in nearly all forms of Nervous Disease j but not as a specific for every human ill, mental and physical. THE ANATOMY OF INVERTEBRATED ANIMALS. By Thomas Henry Huxley, LL. D., F. R. S. I vol., i2mo. Illustrated. 596 pp. Cloth, $2.50. " My object in writing the book has been to make it useful to those who wish to become ac- quainted with the broad outlines of what is at present known of the morphology of the Inverte- brata ; though I have not avoided the incidental mention of facts connected with their physiology and their distribution. On the other hand, I have abstained from discussing questions of etiol- ogy, not because I underestimate their importance, or am insensible to the interest of the great problem of evolution, but because, to my mind, the growing tendency to mix up etiological^ specu- lations with morphological generalizations will, if unchecked, throw biology into confusion." — From Preface. D. APPLETON &* CO.'S MEDICAL WORKS. 23 HAND-BOOK OF SKIN DISEASES. By Dr. Isidor Neumann, Lecturer on Skin Diseases in the Royal University of Vienna. Translated from the German, second edition, with Notes, by Lucius D. Bulkley, A. M., M. D., Surgeon to the New York Dispensary, Department of Venereal and Skin Diseases ; Assistant to the Skin Clinic of the College of Physicians and Surgeons, New York, etc., etc. I vol., 8vo, 467 pp., and 66 Woodcuts. Cloth, $4; sheep, $5. Professor Neumann ranks sec- ond only to Hebra, whose assist- ant he was for many years, and his work may be considered as a fair exponent of the German practice i\ ■ ,. , v *iV of Dermatology. The book is abundantly illustrated with plates of the histology and pathology of the skin. The translator has en- deavored, by means of notes from French, English, and American sources, to make the work valua- ble to the student as well as to the practitioner. h " It is a work which I shall hearti- ly recommend to my class of students at the University of Pennsylvania, 7l- and one which I feel sure will do much toward enlightening the pro- fession on this subject." — Louis A. Duhring. ff ' 41 There certainly is no work ex- tant which deals so thoroughly with the Pathological Anatomy of the Skin as does this hand-book." — New York Medical Record. " I have already twice expressed my favorable opinion of the book in f, print, and am glad that it is given to the public at last." — James C. White, Boston. " More than two years ago we noticed Dr. Neumann's admirable work in its original shape, and we are therefore absolved from the necessity of saying more than to repeat our strong recommendation of it to Eng- lish readers." — Practitioner. |P'\p V/rHWifth ^^^ Lichen scrofulosorum. THE PATHOLOGY OF MIND. Being the third edition of the Second Part of the " Physiology and Pathology of Mind," recast, enlarged, and rewritten. By Henry Maudsley, M. D., London. I vol., l2mo, 580 pp. $2. CONTENTS.— Chapter I. Sleeping and Dreaming; II. Hypnotism, Somnambulism, and Allied States ; III. The Causation and Prevention of Insanity : ( A) Etiological ; IV. The same continued; V. The Causation and Prevention of Insanity : (B; Pathological; VI. The Insanity of Early Life; VII. The Symptomatology of Insanity; VIII. The same continued; IX. Clinical Groups of Mental Disease; X. The Morbid Anatomy of Mental Derangement; XI. The Treat- ment of Mental Disorders. The new material includes chapters on "Dreaming," " Somnambulism and its Allied States," and large additions in the chapters on the " Causation and Prevention of Insanity." "Unquestionably one of the ablest and most "Dr. Maudsley has had the courage to under- important works on the subject of which it treats take, and the skill to execute, what is, at least in that has ever appeared, and does credit to his philo- English, an original enterprise." — London Satur- sophical acumen and accurate observation." — Medi- day Review. cal Record. 24 D. APPLETON &» CO.'S MEDICAL WORKS. MEDICAL RECOLLECTIONS OF THE ARMY OF THE POTOMAC. By Jonathan Letterman, M. D., late Surgeon U. S. A., and Medical Director of the Army of the Potomac. I vol., 8vo, 194 pp. Cloth, $1. " We venture to assert that but few who open this volume of medical annals, pregnant as they are with instruction, will care to do otherwise than finish them at a sitting." — Medical Record. RESPONSIBILITY IN MENTAL Henry Maudsley, M. D., London. I vol., i2mo, 313 pp 1 ' This book is a compact presentation of those facts and principles which require to be taken into account in estimating human responsibility — not le- gal responsibility merely, but responsibility for con- duct in the family, the school, and all phases of Cloth, $1.50. DISEASES. By social relation, in which obligation enters as an element. The work is new in plan, and was writ- ten to supply a wide-felt want which has not hither- to been met." — The Popular Science Monthly. BODY AND MIND: An Inquiry into their Connection and Mutual Influence, especially in reference to Mental Disorders ; an enlarged and revised edition, to which are added Psychological Essays. By Henry Maudsley, M. D., London. I vol., i2mo, 275 pp. Cloth, $1.50. The general plan of this work may be described as being to bring man, both in his physical and mental relations, as much as possible within the scope of scientific inquiry. " Dr. Maudsley has had the courage to under- take, and the skill to execute, what is, at least in English, an original enterprise. This book is a manual of mental science in all its parts, embracing all that is known in the existing state of physiology. . . . Many and valuable books have been written by English physicians on insanity, idiocy, and all the forms of mental aberration. But derangement had always been treated as a distinct subject, and therefore empirically. That the phenomena of sound and unsound minds are not matters of dis- tinct investigation, but inseparable parts of one and the same inquiry, seems a truism as soon as stated. But, strange to say, they had always been pursued separately, and been in the hands of two distinct classes of investigators. The logicians and meta- physicians occasionally borrowed a stray fact from the abundant cases compiled by the medical author- ities ; but the physician, on the other hand, had no theoretical clew to his observations beyond a smat tering of dogmatic psychology learned at college, To effect a reconciliation between the Psychology and the Pathology of the mind, or rather to con- struct a basis for both in a common science, is the aim of Dr. Maudsley 's book." — London Saturday Review. "A representative work, which everyone must study who desires to know what is doing in the way of real progress, and not mere chatter, about men- tal physiology and pathology." — Lancet. "It distinctly marks a step in the progress of scientific psychology." — The Practitioner. HEALTH, AND HOW TO PROMOTE IT. By Richard McSherry, M. D., Professor of Practice of Medicine, University of Mary- land ; President of Baltimore Academy of Medicine, etc. 1 vol., l2mo, 185 "An admirable production which should find its way into every family in the country. It comprises a vast amount of the most valuable matter expressed in clear and terse language, and the subjects of which it treats are of the deepest interest to every human being."— Prof. S. D. Gross, of Jefferson Medical College, Philadelphia. " On the whole, this little book seems to us very well adapted to its purpose, and will, we hope, have a wide circulation, when it can not fail to do much good." — American Journal of Medical Sciences. "It is the work of an able physician, and is written in a style which all people can understand. It deals with practical topics, and its ideas are set forth so pointedly as to make an impression." — The Tndependent. pp. Cloth, $1.25. " This is a racy little book of 185 pages, full of good advice and important suggestions, and written in a free and easy style, which crops out in con- tinued humor and crispness by which the advice is seasoned, and which render the reading of the book a pleasant pastime to all, whether professionals or non-professionals." — Canadian Journal of Medical Sciejice. " It contains a great deal of useful information, stated in a very simple and attractive way." — Balti- more Gazette. 1 ' This is one of the best popular essays on the subject we have ever seen. It is short, clear, posi- tive, sensible, bright and entertaining in its style, and is as full of practical suggestions as a nut is full of meat." — Literary World. D. APPLETON &* CO.'S MEDICAL WORKS. 25 THE PHYSIOLOGY OF THE MIND. Being the First Part of a third edition, revised, enlarged, and in a great part rewritten, of " The Physiology and Pathology of the Mind." / By Henry Maudsley, M. D., London. 1 vol., i2mo, 547 pp. Cloth, $2. CONTENTS.— Chapter I. On the Method of the Study of the Mind; II. The Mind and the Nervous System; III. The Spinal Cord, or Tertiary Nervous Centers; or, Nervous Centers of Reflex Action; IV. Secondary Nervous Centers, or Sensory Ganglia; Sensorium Commune; V. Hemispherical Ganglia; Cortical Cells of the Cerebral Hemispheres; Ideational Nervous Cen- ters ; Primary Nervous Centers; Intellectorium Commune; VI. The Emotions ; VII. Volition; VIII. Motor Nervous Centers, or Motorium Commune and Actuation or Effection ; IX. Memory and Imagination. "The ' Physiology of the Mind,' by Dr. Mauds- ley, is a very engaging; volume to read, as it is afresh and vigorous statement of the doctrines of a grow- ing scientific school on a subject of transcendent moment, and, besides many new facts and impor- tant views brought out in the text, is enriched by an instructive display of notes and quotations from authoritative writers upon physiology and psychol- ogy ; and by illustrative cases, which add materi- ally to the interest of the book." — Popular Science Monthly. PHYSICAL EDUCATION ; or, THE HEALTH LAWS OF NATURE. By Felix L. Oswald, M. D. l2mo, cloth. $1. "Dr. Oswald is a medical man of thorough preparation and large professional experience, and an extensively traveled student of nature and of men. While in charge of a military hospital at Vera Cruz, his own health broke down from long exposure in a malarial region, and he then struck for the Mexican mountains, where he became direct- or of another medical establishment. He has also journeyed extensively in Europe, South America, and the United States, and always as an open-eyed, absorbed observer of nature and of men. The 4 Physical Education ' is one of the most whole- some and valuable books that have emanated from the American press in many a day. Not only can everybody understand it, and, what is more, feel it, but everybody that gets it will be certain to read and re-read it. We have known of the positive and most salutary influence of the papers as they ap- peared in the ' Monthly,' and the extensive demand for their publication in a separate form shows how they have been appreciated. Let those who are able and wish to do good buy it wholesale and give it to those less able to obtain it." — The Popular Science Monthly. " Here we have an intelligent and sensible treat- ment of a subject of great importance, viz. , physi- cal education. We give the headings of some of the chapters, viz. : Diet ; In-door Life ; Out-door Life ; Gymnastics ; Clothing ; Sleep ; Recreation ; Remedial Education ; Hygienic Precautions ; Pop- ular Fallacies. These topics are discussed in a plain, common-sense style suited to the popular mind. Books of this character can not be too widely read." — Albany (N. Y.) Argus. "Dr. Oswald is as epigrammatic as Emerson, as spicy as Montaigne, and as caustic as Heine. And yet he is a pronounced vegetarian. His first chapter is devoted to a consideration of the diet suitable for human beings and infants. In the next two he contrasts life in and out of doors. He then gives his ideas on the subjects of gymnastics, cloth- ing, sleep, and recreation. He suggests a system of remedial education and hygienic precautions, and he closes with a diatribe against popular fallacies." — Philadelphia Press. " It is a good sign that books on physical train- ing multiply in this age of mental straining. Dr. Felix L. Oswald, author of the above book, may be somewhat sweeping in his statements and beliefs, but every writer who, like him, clamors for sim- plicity, naturalness, and frugality in diet, for fresh air and copious exercise, is a benefactor. Let the dyspeptic and those who are always troubling them- selves and their friends about their manifold ail- ments take Dr. Oswald's advice and look more to their aliments and their exercise." — New York Herald. " One of the best books that can be put in the hands of young men and women. It is very inter- esting, full of facts and wise suggestions. It points out needed reforms, and the way we can become a strong and healthy people. It deserves a wide cir- culation." — Boston Commonwealth. GALVANO -THERAPEUTICS. The Physiological and Therapeutical Action of the Galvanic Current upon the Acoustic, Optic, Sympathetic, and Pneumogastric Nerves. By William B. Neftel. Fourth edition. I vol., i2mo, 161 pp. Cloth, $1.50. This book has been republished at the request of several aural surgeons and other professional gentlemen, and is a valuable treatise on the subjects of which it treats. Its author, formerly visit- ing physician to the largest hospital of St. Petersburg, has had the very best facilities for investi- gation. "This little work shows, as far as it goes, full " Those who use electricity should get this work, knowledge of what has been done on the subjects and those who do not should peruse it to learn that treated of, and the author's practical acquaintance there is one more therapeutical agent that they could with them." — New York Medical Journal. and should possess." — The Medical Investigator. 26 D. APPLETON &* CO.'S MEDICAL WORKS. OVARIAN TUMORS ; their Pathology, Diagnosis, and Treat- ment, with Reference especially to Ovariotomy. By E. R. Peaslee, M. D., Professor of Diseases of Women in Dartmouth College ; formerly Professor of Obstetrics and Diseases of Women in the New York Medical College, etc. I vol., 8vo, 551 pp. Illustrated with many Woodcuts, and a Steel Engraving of Dr. E. McDow- ell, the "Father of Ovariotomy." Cloth, $5; sheep, $6. This valuable work, embracing the results of many years of successful experience in the de- partment of which it treats, will prove most acceptable to the entire profession ; while the high standing of the author and his knowledge of the subject combine to make the book the best in the language. Fully illustrated, and abounding with information, the result of a prolonged study of the subject, the work should be in the hands of every physician in the country. " In closing our review of this work, we can not avoid again expressing our appreciation of the thor- ough study, the careful and honest statements, and candid spirit, which characterize it. For the use of the student we should give the preference to Dr. Peaslee 's work, not only from its completeness, but from its more methodical arrangement ." — Ameri- can Journal of Medical Sciences. "We deem its careful perusal indispensable to all who would treat ovarian tumors with a good con- science." — American Journal of Obstetrics. " It shows prodigal industry, and embodies with- in its five hundred and odd pages pretty much all that seems worth knowing on the subject of ovarian diseases." — Philadelphia Medical Times. A TREATISE ON DISEASES OF THE BONES. By Thomas M. Markoe, M. D., Professor of Surgery in the College of Physi- cians and Surgeons, New York, etc. With numerous Illustrations. 1 vol., 8vo, 416 pp. Cloth, $4.50. Specimen of Illustration. This valuable work is a trea- tise on Diseases of the Bones, embracing their structural changes as affected by disease, their clinical history and treat- ment, including also an account of the various tumors which grow in or upon them. None of the injuries of bone are in- cluded in its scope, and no joint diseases, excepting where the condition of the bone is a prime factor in the problem of disease. As the work of an eminent sur- geon of large and varied experi- ence, it may be regarded as the best on the subject, and a valuable contribution to medical literature. DR. PEREIRA'S ELEMENTS OF MATERIA MEDICA AND THERAPEUTICS. Abridged and adapted for the Use of Medical and Pharmaceutical Practitioners and Students, and comprising all the Medicines of the British Pharmacopoeia, with such others as are frequently ordered in Prescriptions, or required by the Physician. Edited by Robert Bentley and Theophilus Redwood. New edition. Brought down to 1872. 1 vol., royal 8vo, 1,093 pp. Cloth, $7; sheep, $8. NOTES ON NURSING: What it is, and what it is not. By Florence Nightingale. 1 vol., i2mo, 140 pp. Cloth, 75 cents. These notes are meant to give hints for thought to those who have personal charge of the health of others. E very-day sanitary knowledge, or the knowledge of nursing, or, in other words, of how to put the constitution in such a state as that it will have no disease or that it can recover from disease, is recognized as the knowledge which every one ought to have— distinct from medical knowledge, which only a profession can have. D. APPLETON &* CO.'S MEDICAL WORKS. 27 A TEXT-BOOK OF PRACTICAL MEDICINE. With Particular Reference to Physiology and Pathological Anatomy. By the late Dr. Felix von Niemeyer, Professor of Pathology and Therapeutics ; Director of the Medical Clinic of the University of Tubingen. Translated from the eighth German edition, by special permission of the author, by George H. Humphreys, M. D., one of the Physicians to Trinity Infirmary, Fellow of the New York Academy of Medicine, etc., and Charles E. Hackley, M. D., one of the Physicians to the New York Hospital and Trinity Infirmary, etc. Revised edition of 1880. 2 vols., 8vo, 1,628 pages. Cloth, $9; sheep, $11. The author undertakes, first, to give a picture of disease which shall be as life-like and faithful to nature as possible, instead of being a mere theoretical scheme ; secondly, so to utilize the more recent advances of pathological anatomy, physiology, and physiological chemistry, as to furnish a clearer insight into the various processes of disease. The work has met with the most flattering reception and deserved success ; has been adopted as a text-book in many of the medical colleges both in this country and in Europe ; and has re- ceived the very highest encomiums from the medical and secular press. " This new American edition of Niemeyer fully sustains the reputation of previous ones, and may be considered, as to style and matter, superior to any translation that could have been made from the latest German edition. It will be recollected that since the death of Professor Niemeyer, in 1871, his work has been edited by Dr. Eugene Seitz. Although the latter gentleman has made many additions and changes, he has destroyed somewhat the individual- ity of the original. The American editors have wisely resolved to preserve the style of the author, and adhere, as closely as possible, to his individual views and his particular style. Extra articles have been inserted on chronic alcoholism, morphia-poi- soning, paralysis agitans, scleroderma, elephantiasis, progressive pernicious anaemia, and a chapter on yellow fever. The work is well printed as usual." — Medical Record. "The first inquiry in this country regarding a German book generally is, ' Is it a work of practi- cal value ? ' Without stopping to consider the just- ness of the American idea of the ' practical,' we can unhesitatingly answer, ' It is ! ' " — New York Medi- cal Journal. " It is comprehensive and concise, and is char* actenzed by clearness and originality." — Dublin Quarterly Journal of Medicine. 44 Its author is learned in medical literature ; he has arranged his materials with care and judgment, and has thought over them." — The Lancet. 44 While, of course, we can not undertake a re- view of this immense work of about 1,600 pages in a journal of the size of ours, we may say that we have examined the volumes very carefully, as to whether to recommend them to practitioners or not ; and we are glad to say, after a careful review, ' Buy the book.' The chapters are succinctly written. Terse terms and, in the main, brief sentences are used. Personal experience is recorded, with a' : prop- er statement of facts and observations by other au- thors who are to be trusted. A very excellent index is added to the second volume, which helps very much for ready reference." — Virginia Medical Monthly. ESSAYS ON THE FLOATING MATTER OF THE AIR, in Relation to Putrefaction and Infection. By Professor John Tyn- dall, F. R. S. l2mo. Cloth, $1.50. CONTENTS.— I. On Dust and Disease; II. Optical Deportment of the Atmosphere in Re- lation to Putrefaction and Infection; III. Further Researches on the Deportment and Vitality of Putrefactive Organisms; IV. Fermentation, and its Bearings on Surgery and Medicine; V. Spon- taneous Generation ; Appendix. 44 In the book before us we have the minute de- tails of hundreds of observations on infusions ex- posed to optically pure air ; infusions of mutton, beef, haddock, hay, turnip, liver, hare, rabbit, grouse, pheasant, salmon, cod, etc. ; infusions heated by boiling water and by boiling oil, some- times for a few moments and sometimes for several hours, and, however varied the mode of procedure, the result was invariably the same, with not even a shade of uncertainty. The fallacy of spontaneous generation and the probability of the germ theory of disease seem to us the inference, and the only inference, that can be drawn from the results of nearly ten thousand experiments performed by Pro- fessor Tyndall within the last two years." — Pitts- burg Telegraph. 44 Professor Tyndall's book is a calm, patient, clear, and thorough treatment of all the questions and conditions of nature and society involved in this theme. The work is lucid and convincing, yet not prolix or pedantic, but popular and really en- joyable. It is worthy of patient and renewed study. " — Philadelphia Times. 44 The matter contained in this work is not only presented in a very interesting way, but is of great value." — Boston Journal of Commerce. 44 The germ theory of disease is most intelli- gently presented, and indeed the whole work is instinct with a high intellect." — Boston Common- wealth. * 2% D. APPLETON 6- CO:S MEDICAL WORKS. THE APPLIED ANATOMY OF THE NERVOUS SYSTEM, being a Study of this Portion of the Human Body from a Stand- point of its General Interest and Practical Utility, designed for Use as a Text-book and as a Work of Reference. By Ambrose L. Ranney, A. M., M. D., Adjunct Professor of Anatomy and late Lecturer on the Diseases of the Genito-Urinary Organs and on Minor Surgery in the Medical Depart- ment of the University of the City of New York, etc., etc. I vol., 8vo. Profusely illustrated. Cloth, $4; sheep, $5. Distribution of the Hypo-glossal Nerve. "This is a useful book, and one of novel de- sign. It is especially valuable as bringing together facts and inferences which aid greatly in forming correct diagnoses in nervous diseases." — Boston Medical and Surgical Journal. " This is an excellent work, timely, practical, and well executed. It is safe to say that, besides Hammond's work, no book relating to the nervous system has hitherto been published in this country equal to the present volume, and nothing superior to it is accessible to the American practitioner." — Medical Herald. " There are many books, to be sure, which con- tain here and there hints in this field of great value to the physician, but it is Dr. Ranney's merit to have collected these scattered items of interest, and to have woven them into an harmonious whole, thereby producing a work of wide scope and of cor- respondingly wide usefulness to the practicing physi- cian. " The book, it will be perceived, is of an emi- nently practical character, and, as such, is addressed to those who can not afford the time for the perusal of the larger text-books, and who must read as they run."— New York Medical Journal. " Professors of anatomy in schools and colleges can not afford to be without it. We recommend the book to practitioners and students as well." — Virginia Medical Monthly. " It is an admitted fact that the subject treated of in this work is one sufficiently obscure to the pro- fession generally to make any work tending to elu- cidation most welcome. " We earnestly recommend this work as one un- usually worthy of study." — Buffalo Medical and Surgical Journal. " Dr. Ranney has firmly grasped the essential features of the results of the latest study of the nervous system. His work will do much toward popularizing this study in the profession. '' We are sure that all our readers will be quite as much pleased as ourselves by its careful study." — Detroit Lancet. "A useful and attractive book, suited to the time." — Louisville Medical News. ' ' Our impressions of this work are highly fa- vorable as regards its practical value to students, as well as to educated medical men." — Pacific Medical and Surgical Journal. D. APPLETON &° CO.'S MEDICAL WORKS. 2 9 "The work shows great care in its preparation. We predict for it a large sale among the more progres- sive practitioners." — Michigan Medi- cal News. " We are acquainted with no re- cent work which deals with the sub- ject so thoroughly as this ; hence, it should commend itself to a large class of persons, not merely specialists, but those who aspire to keep posted in all important advances in the science and art of medicine." — Maryland Medical Journal. "This work was originally ad- dressed to medical under-graduates, but it will be equally interesting and valuable to medical practitioners who still acknowledge themselves to be students. It is to be hoped that their number is not small." — New Orleans Medical and Surgical Journal. "We think the author has cor- rectly estimated the necessity for such a volume, and we congratulate him upon the manner in which he has executed his task. "Asa companion volume to the recent works on the diseases of the nervous system, it is issued in good time." — North Carolina Medical Journal. " A close and careful study of this work, we feel convinced, will impart to the student a large amount of practical knowledge which could not be gained elsewhere, except by wading through the enormous quan- tity of neurological literature which has appeared during past years, a task which few would have either time or inclination to accomplish. Here it will all be found condensed, simplified, and systematically arranged. The nature of the work is so fully explained in its title that little or nothing on that point need be said here. We will, how- ever, say that the whole subject is treated in a lucid manner, and that, so far as we are able to judge, nothing seems left out which could in any way improve or add to the value of the book." — Medical and Surgical Reporter {Philadelphia). "Dr. Ranney has done a most useful and praiseworthy task in that he will have saved many of the profession from the choice of going through the research we have indicated, or remaining in igno- rance of many things most essential to a sound medical knowledge." — Medical Record. "We are sure that this book will be well received, and will prove itself a very useful companion both for regular students of anatomy and physiology, and also for practitioners who wish to work up the diag- nosis of cases of disorder of the nervous system." — Canada Medical and Surgical Journal. " Dr. Ranney has done his work well, and given accurate information in a simple, readable style." — Philadelphia Medical Times. Th= Deep Hranch of the External Plantar Nerve. The Small Sciatic Nerve, with its Branches of Distribution and Termination. A MINISTRY OF HEALTH AND OTHER AD- DRESSES. By Dr. B. W. Richardson, M. D., M. A., F. R. S., etc., etc. I vol., i2mo, 354 pp. Cloth, $1.50. " The author is so widely and favorably known that any book which bears his name will receive re- spectful attention. He is one of those highly edu- cated yet practical, public-spirited gentlemen who adorn the profession of medicine and do far more than their share toward elevating its position before the public. This book, owing to the character of the matter considered and the author's attractive style, affords means for relaxation and instruction to every thoughtful person." — Medical Gazette. " This book is made up of a number of addresses on sanitary subjects, which Dr. Richardson deliv- ered at various times in Great Britain, and which are intended to invite attention to the pressing re- forms that are making progress in medical science. The work, which has the great merit of being writ- ten in the simplest and clearest language, gives special attention to the origin and causes of diseases, and a demonstration of the physical laws by which they may be prevented. . . . " The author does not, like some members of his profession, enter into a learned description of cures, but traces the causes of diseases with philosophical precision. The book contains what every one should know, and members of the medical profession will not find a study of it in vain." — Philadelphia En- quirer. " The wide study of these lectures by both the profession and the laity would greatly advance the interests of both by stimulating thought and action respecting the most vital subjects that can engage the human mind." — Detroit Lancet. 3Q D. APPLETON &* COJS MEDICAL WORKS. DISEASES OF MODERN LIFE. By Dr. B. W. Richard- son, M. D., M. A., F. R. S., etc., etc. I vol., I2ijio, 520 pp. Cloth, $2. " In this valuable and deeply interesting- work of atmospheric temperature, of atmospheric press- Dr. Richardson treats the nervous system as the ure, of moisture, winds, and atmospheric chemical very principle of life, and he shows how men do it changes, which are of great general interest." — Na- violence, yet expect immunity where the natural sen- ture. tence is death."— Charleston Courier. « Particular attention is given to diseases from " The work is of great value as a practical guide worry and mental strain, from the passions, from to enable the reader to detect and avoid various alcohol, tobacco, narcotics, food, impure air, late sources of disease, and it contains, in addition, sev- hours, and broken sleep, idleness, intermarriage, eral introductory chapters on natural life and natu- etc., thus touching upon causes which do not enter ral death, the phenomena of disease, disease ante- into the consideration of sickness." — Boston Com- cedent to birth, and on the effects of the seasons, monwealth. THE WATERING-PLACES AND MINERAL SPRINGS OF GERMANY, AUSTRIA, AND SWITZERLAND. With Notes on Climatic Resorts and Consumption, Sanitariums, Peat, Mud, and Sand Baths, Whey and Grape Cures, etc. By Edward Gutmann, M. D With Illustrations, Comparative Tables, and a Colored Map, explaining the Situation and Chemi- cal Composition of the Spas. I vol., l2mo. Cloth, $2.50. " Dr. Gutmann has compiled an excellent medi- tions, with the therapeutical applications of the cal guide, which gives full information on the man- mineral waters, are very thoroughly presented in ners and customs of living at all the principal separate parts of the volume." — New York Times. watering-places in Europe. The chemical composi- A PRACTICAL MANUAL ON THE TREATMENT OF CLUB-FOOT. By Lewis A. Sayre, M. D., Professor of Orthopedic Surgery and Clinical Surgery in Bellevue Hospital Medical College ; Con- sulting Surgeon to Bellevue Hospital, Charity Hospital, etc., etc. Fourth edition, enlarged and corrected. I vol., i2mo. Illustrated. Cloth, $1.25. "Amore extensive experience in the treatment of club-foot has proved that the doctrines taught in my first edition were correct, viz., that in all cases of congenital club-foot the treatment should commence at birth, as at that time there is generally no difficulty that can not be overcome by the ordinary family physician ; and that, by following the simple rules laid down in this volume, the great majority of cases can be relieved, and many cured, without any operation or surgical inter- ference. If this early treatment has been neglected, and the deformity has been permitted to in- crease by use of the foot in its abnormal position, surgical aid may be requisite to overcome the difficulty ; and I have here endeavored to clearly lay down the rules that should govern the treat- ment of this class of cases." — Preface. "The book will very well satisfy the wants of use, as stated, it is intended.'' — New York Medical the majority of general practitioners, for whose Journal. COMPENDIUM OF CHILDREN'S DISEASES. A Hand-Book for Practitioners and Students. By Dr. Johann Steiner, Professor of the Diseases of Children in the University of Prague. Trans- lated from the second German edition by Lawson Tait, F. R. C. S., Sur- geon to the Birmingham Hospital for Women. 1 vol., 8vo. Cloth, $3.50; sheep, $4.50. "Dr. Steiner's book has met with such marked success in Germany that a second edition has already appeared, a circumstance which has delayed the appearance of its English form, in order that I might be able to give his additions and corrections. " I have added as an Appendix the ' Rules for Management of Infants,' which have been issued by the staff of the Birmingham Sick Children's Hospital, because I think that they have set an ex- ample, by freely distributing these rules among the poor, for which they can not be sufficiently commended, and which it would be wise for other sick children's hospitals to follow. " I have also added a few notes, chiefly, of course, relating to the surgical ailments of chil- dren." — Extract from Translator 's Preface. D. APPLETON &* CO.'S MEDICAL WORKS. 31 HEALTH : A Hand-Book for Households and Schools. By Edward Smith, M. D., F. R. S., Fellow of the Royal College of Physicians and Surgeons of England, etc. 1 vol., i2mo. Illustrated. 198 pp. Cloth, $1. It is intended to inform the mind on the subjects involved in the word Health, to show how health may be retained and ill-health avoided, and to add to the pleasure and usefulness of life. " The author of this manual has rendered a real service to families and teachers. It is not a mere treatise on health, such as would be written by a medical professor for medical students. Nor is it a treatise on the treatment of disease, but a plain, common-sense essay on the prevention of most of the ills that flesh is heir to. There is no doubt that much of the sickness with which humanity is af- flicted is the result of ignorance, and proceeds from the use of improper food, from defective drainage, overcrowded rooms, ill-ventilated workshops, im- pure water, and other like preventable causes. Legislation and municipal regulations may do something in the line of prevention, but the people themselves can do a great deal more — particularly if properly enlightened ; and this is the purpose of the book." — Albany Journal. LECTURES ON ORTHOPEDIC SURGERY AND DIS- EASES OF THE JOINTS. By Lewis A. Sayre, M. D., Professor of Orthopedic Surgery and Clinical Surgery in Bellevue Hospital Medical Col- lege ; Consulting Surgeon to Bellevue Hospital, Charity Hospital, etc., etc. Second edition, revised and greatly enlarged, with 324 Illustrations. I vol., 8vo, 569 pp. Cloth, $5; sheep, $6. This edition has been thoroughly revised and rearranged, and the subjects classified in the ana- tomical and pathological order of their development. Many of the chapters have been entirely rewritten, and several new ones added, and the whole work brought up to the present time, with all the new improvements that have been developed in this department of surgery. Many new engravings have been added, each illustrating some special point in practice. Specimen of Illustration. "The name of the author is a sufficient guar- antee of its excellence, as no man in America or elsewhere has devoted such unremitting attention for the past thirty years to this department of Sur- gery, or given to the profession so many new truths and laws as applying to the pathology and treat- ment of deformities." — Western Lajtcet. " The name of Lewis A. Sayre is so intimately connected and identified with orthopaedics in all its branches, that a book relating his experience can not but form an epoch in medical science, and prove a blessing to the profession and humanity. Dr. Sayre' s views on many points differ from those entertained by other surgeons, but the great suc- cesses he has obtained fully warrant him in main- taining the ' courage of his opinions.' " — American Journal of Obstetrics. "Dr. Sayre has stamped his individuality on every part of his book. Possessed of a taste for mechanics, he has admirably utilized it in so modi- fying the inventions of others as to make them of far greater practical value. The care, patience, and perseverance which he exhibits in fulfilling all the conditions necessary for success in the treatment of this troublesome class of cases are worthy of all praise and imitation." — Detroit Review of Medi- cine. "Its teaching is sound, and the originality throughout very pleasing ; in a word, no man should attempt the treatment of deformities of joint affections without being familiar with the views contained in these lectures." — Canada Medical and Surgical Journal. 32 D. APPLETON &• CO.'S MEDICAL WORKS. Index. Specimen of Illustration. LECTURES UPON DISEASES OF THE RECTUM AND THE SURGERY OF THE LOWER BOWEL. Delivered at the Bellevue Hospital Medical College by W. H. Van Buren, M. D., late Professor of the Principles and Practice of Surgery in the Bellevue Hospi- tal Medical College, etc., etc. Second edition, revised and enlarged, i volume, 8vo, 412 pp., with 27 Illustrations and complete Cloth, $3; sheep, $4. " The reviewer too often finds it a difficult task to discover points to praise, in order that his criticisms may not seem one-sided and un- just. These lectures, however, place him upon the other horn of the dilemma, viz., to find somewhat to criticise severely enough to clear himself of the charge of indiscriminating lau- dation. Of course, the author upholds some views which conflict with other authorities, but he substantiates them by the most powerful of arguments, viz., a large experience, the results of which are enunciated by one who elsewhere shows that he can appreciate, and accord the due value to, the work and experience of others." — Archives of Medicine. " The present is a new volume rather than a new edition. Both its size and material are vastly beyond its predecessor. The same scholarly method, the same calm, convincing statement, the same wise, carefully matured counsel, pervade every paragraph. The dis- comfort and dangers of the diseases of the rectum call for greater consideration than they usually receive at the hands of the pro- fession." — Detroit Lancet. ' ' These lectures are twelve in number, and may be taken as an excellent epitome of our present knowledge of the diseases of the parts in question. The work is full of practical matter, but it owes not a little of its value to the original thought, labor, and suggestions as to the treatment of disease, which always characterize the productions of the pen of Dr. Van Buren." — Philadelphia Medical Times. ' ' The most attractive feature of the work is the plain, common-sense manner in which each subject is treated. The author has laid down instructions for the treatment, medicinal and opera- tive, of rectal diseases in so clear and lucid style as that any practitioner is enabled to follow it. The large and successful experience of the distinguished author in this class of diseases is sufficient of itself to warrant the high character of the book." — Nashville Journal 0/ Medicine and Surgery. We have thus briefly tried to give the known to the profession as one of our most accom- :^f : y ' f reader an idea of the scope of this work : and the work is a good one— as good as either Allingham's or Curling's, with which it will inevitably be com- pared. Indeed, we should have been greatly sur- prised if any work from the pen of Dr. Van Buren had not been a good one ; and we have to thank him that for the first time we have an American text-book on this subject which equals those that have so long been the standards." — New York Med- ical Journal. ' ' Mere praise of a book like this would be super- fluous—almost impertinent. The author is well plished surgeons and ablest scientific men. Much is expected of him in a book like the one before us, and those who read it will not be disappointed. It will, indeed, be widely read, and, in a short time, take its place as the standard American authority." — St. Louis Courier of Medicine. " Taken as a whole, the book is one of the most complete and reliable ones extant. It is certainly the best of any similar work from an American au- thor. It is handsomely bound and illustrated, and should be in the hands of every practitioner and student of medicine." — Louisville Medical Herald. REPORTS. Bellevue and Charity Hospital Reports for 1870, containing valuable contributions from Isaac E. Taylor, M. D., Austin Flint, M. D., Lewis A. Sayre, M. D., William A. Hammond, M. D., T. Gaillard Thomas, M. D., Frank H. Hamilton, M. D., and others. 1 vol., 8vo, 415 pp. Cloth, $4. "These institutions are the most important, as connected with them are acknowledged to be among regards accommodations for patients and variety of the first in their profession, and the volume is an •ases treated, of any on this continent, and are sur- important addition to the professional literature of passed by but few in the -world. The gentlemen this country." — Psychological Journal. • D. APPLE TON &> CO.'S MEDICAL WORKS. 33 THE POSTHUMOUS WORKS OF SIR JAMES YOUNG SIMPSON, Bart., M. D. In Three Volumes. Volume I. — Selected Obstetrical and Gynaecological Works of Sir James Y. Simpson. Edited by J. Watt Black, M. D. 1 vol., 8vo, 852 pp. Cloth, $3; sheep, $4. This first volume contains many of the papers reprinted from his Obstetric Memoirs and Con- tributions, and also his Lecture Notes, now published for the first time, containing the substance of the practical part of his course of midwifery. It is a volume of great interest to the profession, and a fitting memorial of its renowned and talented author. Volume II. — Anesthesia, Hospitalism, etc. Edited by Sir Walter Simp- son, Bart. "We say of this, as of the first volume, that it maybe picked out and studied with pleasure and should find a place on the table of every practi- profit."— The Lancet {Loudon). tioner ; for, although it is patchwork, each piece I vol., 8vo, 560 pp. Cloth, $3 ; sheep, $4. Volume III. — Diseases of Women. Edited by Alexander Simpson, M. D. 1 vol., 8vo, 789 pp. Cloth, $3; sheep, $4. One of the best works on the subject extant. Of inestimable value to every physician. ON FOODS. By Edward Smith, M. D., LL. B., F. R. S.> Fellow of the Royal College of Physicians of London, etc., etc. 1 vol., i2mo, 485 pp. Cloth, $1.75. " Since the issue of the author's work on ' Prac- "The book contains a series of diagrams, dis- tical Dietary,' he has felt the want of another, which playing the effects of sleep and meals on pulsation would embrace all the generally known and some and respiration, and of various kinds of food on less known foods, and contain the latest scientific respiration, which, as the results of Dr. Smith's own knowledge respecting them. The present volume is experiments, possess a very high value. We have intended to meet this want, and will be found use- not far to go in this work for occasions of favorable ful for reference, to both scientific and general criticism ; they occur throughout, but are perhaps readers. The author extends the ordinary view of most apparent in those parts of the subject with foods, and includes water and air, since they are which Dr. Smith's name is especially linked." — important both in their food and sanitary aspects. London Examiner. A HAND-BOOK OF CHEMICAL TECHNOLOGY. By Rudolph Wagner, Ph. D., Professor of Chemical Technology at the University of Wurtzburg. Translated and edited, from the eighth German edition, with Extensive Additions, by William Crooks, F. R. S. With 336 Illustrations. I vol., 8vo, 761 pp. Cloth, $5. Under the head of Metallurgic Chemistry, the latest methods of preparing iron, cobalt, nickel, copper, copper-salts, lead and tin and their salts, bismuth, zinc, zinc-salts, cadmium, antimony, arsenic, mercury, platinum, silver, gold, manganates, aluminum, and magnesium, are described. The various applications of the voltaic current to electro-metallurgy follow under this division. The preparation of potash and soda-salts, the manufacture of sulphuric acid, and the recovery of sulphur from soda waste, of course occupy prominent places in the consideration of chemical manu- factures. It is difficult to overestimate the mercantile value of Mond's process, as well as the many new and important applications of bisulphide of carbon. The manufacture of soap will be found to include much detail. The technology of glass, stone-ware, limes, and mortars will pre- sent much of interest to the builder and engineer. The technology of vegetable fibers has been considered to include the preparation of flax, hemp, cotton, as well as paper-making ; while the application of vegetable products will be found to include sugar-boiling, wine- and beer-brewing, the distillation of spirits, the baking of bread, the preparation of vinegar, the preservation of wood, etc. Dr. Wagner gives much information in reference to the production of potash from sugar-resi- dues. The use of baryta-salts is also fully described, as well as the preparation of sugar from beet-roots. Tanning, the preservation of meat, milk, etc., the preparation of phosphorus and ani- mal charcoal, are considered as belonging to the technology of animal products. The preparation of materials for dyeing has necessarily required much space ; while the final sections of the book have been devoted to the technology of heating and illumination. 34 D. APPLETON &* CO.'S MEDICAL WORKS. A PRACTICAL TREATISE ON THE SURGICAL DISEASES OF THE GENITOURINARY ORGANS, including Syphilis. Designed as a Manual for Students and Practitioners. With Engravings and Cases. By W. H. Van Buren, A. M., M. D., late Profess- or of Principles of Surgery, with Diseases of the Genito-Urinary System and Clinical Surgery, in Bellevue Hospital Medical College, etc., and E. L. Keyes, A. M., M. D., Professor of Dermatology in Bellevue Hospital Medi- cal College; Surgeon to the Charity Hospital, Venereal Diseases, etc. i vol., 8vo, 672 pp. Cloth, $5; sheep, $6. it deals. These facts are largely drawn from the extensive and varied experience of the au- thors. Many important branches of genito-urinary diseases, as the cutaneous maladies of the penis and scrotum, receive a thorough and exhaustive treatment that the professional reader will search for elsewhere in vain. The subject of syphilis is included, of neces- sity, in this treatise. Although properly be- longing to the department of Principles of Sur- gery, there is no disease falling within the limits of this work concerning which clear and correct ideas as to nature and treatment will, at the present time, so seriously influence success in practice. The work is elegantly and profusely illus- trated, and enriched by fifty-five original cases, setting forth obscure and difficult points in diag- nosis and treatment. ' ' The authors ' appear to have succeeded admi- rably in giving to the world an exhaustive and re- liable treatise on this important class of diseases.' " — Northwestern Medical and Surgical Journal. " It is a most complete digest of what has long been known, and of what has been more recently discovered, in the field of syphilitic and genito-urin- ary disorders. It is, perhaps, not all exaggeration to say that no single work upon the same subject has yet appeared, in this or any foreign language, which is superior to it." — Chicago Medical Exam- iner. " The commanding reputation of Dr. Van Buren in this specialty, and of the great school and hos- pital from which he has drawn his clinical materials, together with the general interest which attaches to the subject-matter itself, will, we trust, lead very many of those for whom it is our office to cater, to possess themselves at once of the volume and form their own opinions of its merit." — Atlanta Medical and Surgical Journal. Showing Enlarged Prostate with "Third Lobe," through the Base of which a False Passage has been made. This work is really a compendium of, and a book of reference to, all modern works treating in any way of the surgical diseases of the genito- urinary organs. At the same time, no other single book contains so large an array of original facts concerning the class of diseases with which A MANUAL OF MIDWIFERY. Including the Pathology of Pregnancy and the Puerperal State. By Dr. Carl Schroeder, Professor of Midwifery and Director of the Lying-in Institution in the University of Erlangen. Translated from the third German edition by Charles H. Carter, B. A., M. D., B. S., London, Member of the Royal College of Physicians, London. With Twenty-six Engravings on Wood. I vol., 8vo, 388 pp. Cloth, $3.50; sheep, $4-5°- " The translator feels that no apology is needed in offering to the profession a translation of Schroeder's < Manual of Midwifery.' The work is well known in Germany, and extensively used as a text-book; it has already reached a third edition within the short space of two years, and it is hoped that the present translation will meet the want, long felt in this country, of a manual of midwifery embracing the latest scientific researches on the subject." D. APPLETON 6- CO.'S MEDICAL WORKS. 35 HOSPITALS : Their History, Organization, and Construction. Boylston Prize-Essay of Harvard University for 1876. By W. Gill Wylie, M. D. 1 vol., 8vo, 240 pp. Cloth, $2.50. A TREATISE ON CHEMISTRY. By H. R. Roscoe, F. R. S., and C. Schorlemmer, F. R. S., Professors of Chemistry in the Victoria University, Owens College, Manchester. Illustrated. INORGANIC CHEMISTRY. 8vo. Vol. I : Non-Metallic Elements. $5. Vol. II, Part I : Metals. $3. Vol. II, Part II : Metals. $3. ORGANIC CHEMISTRY. 8vo. Vol. Ill, Part I : The Chemistry of the Hydrocarbons and their Derivatives. $5. Vol. Ill, Part II, com- pleting the work : The Chemistry of the Hydrocarbons and their Derivatives. $5. " It has been the aim of the authors, in writing their present treatise, to place before the read- er a fairly complete and yet a clear and succinct statement of the facts of Modern Chemistry, while at the same time entering so far into a discussion of chemical theory as the size of the work and the present transition state of the science will permit. " Special attention has been paid to the accurate description of the more important processes in technical chemistry, and to the careful representation of the most approved forms of apparatus employed. " Much attention has likewise been given to the representation of apparatus adopted for lec- ture-room experiment, and the numerous new illustrations required for this purpose have all been taken from photographs of apparatus actually in use." — Extract from Preface. Specimen of Illustration. "The authors are evidently bent on making their book the finest systematic treatise on modern chemistry in the English language, an aim in which they are well seconded by their publishers, who spare neither pains nor cost in illustrating and otherwise setting forth the work of these distin- guished chemists." — London Athenceum. " It is difficult to praise too highly the selection of materials and their arrangement, or the wealth of illustrations which explain and adorn the text. In its woodcuts, in its technological details, in its historical notices, in its references to original memoirs, and, it may be added, in its clear type, smooth paper, and ample margins, the volume un- der review presents most commendable features. Whatever tests of accuracy as to figures and facts we have been able to apply have been satisfactorily 3 met, while in clearness of statement this volume leaves nothing to be desired. Moreover, it is most satisfactory to find that the progress of this valuable work toward completion is so rapid that its begin- ning will not have become antiquated before its end has been reached — no uncommon occurrence with elaborate treatises on natural science subjects." — London Academy. " We have no hesitation in saying that this vol- ume fully keeps up the reputation gained by those that preceded it. There is the same masterly hand- ling of the subject-matter ; the same diligent care has been bestowed on hunting up all the old history connected with each product. It is this that lends so great a charm to the whole work, and makes it very much more than a mere text-book." — Satur- day Review. 36 D. APPLETON &* CO.'S MEDICAL WORKS. THE BRAIN AND ITS FUNCTIONS. Physician to the Hospice de la Salpetriere. With Illustrations. i2mo. Cloth, $1.50. By J. Luys, 4 ' No living physiologist is better entitled to speak with authority upon the structure and func- tions of the brain than Dr. Luys. His studies on the anatomy of the nervous system are acknowl- edged to be the fullest and most systematic ever un- dertaken." — St. 'James's Gazette. " It is not too much to say that M. Luys has gone further than any other investigator into this great field of study, and only those who are at least dimly aware of the vast changes going on in the realm of psychology can appreciate the importance of his revelations. Particularly interesting and valuable are the chapters dealing with the genesis and evolu- tion of memory, the development of automatic ac- tivity, and the development of the notion of person- ality." — Boston Evening Traveller. " Dr. Luys, at the head of the great French In- sane Asylum, is one of the most eminent and suc- cessful investigators of cerebral science now living ; and he has given unquestionably the clearest and most interesting brief account yet made of the structure and operations of the brain." — Popular Science Monthly. GENERAL PHYSIOLOGY OF MUSCLES AND NERVES. By Dr. I. Rosenthal, Professor of Physiology at the Univer- sity of Erlangen. With 75 Woodcuts. i2mo. Cloth, $1.50. " Dr. Rosenthal claims that the present work is recondite as to be unprofitable or uninteresting to the ' first attempt at a connected account of general the inquiring general reader." — New York Ob- physiology of muscles and nerves.' This being the server. case, Dr. Rosenthal is entitled to the greatest credit for his clear and accurate presentation of the ex- perimental data upon which must rest all future knowledge of a very important branch of medical and electrical science. The book consists of 317 pages, with seventy-five woodcuts, many of which represent physiological apparatus devised by the author or by his friends, Professor Du Bois-Rey- mond and Helmholtz. It must be regarded as in- dispensable to all future courses of medical study." — New York Herald. "Although this work is written for the instruc- tion of students, it is by no means so technical and In this volume an attempt is made to give a connected account of the general physiology of muscles and nerves, a subject which has never be- fore had so thorough an exposition in any text- book, although it is one which has many points of interest for every cultivated man who seeks to be well informed on all branches of the science of life. This work sets before its readers all, even the most intricate, phases of its subject with such clearness of expression that any educated person though not a specialist can comprehend it." — New Haven Palla- dium. MEDICAL AND SURGICAL ASPECTS OF IN-KNEE (Genu-Valgum) : Its Relation to Rickets ; its Prevention ; and its Treat- ment, with or without Surgical Operation. By W. J. Little, M. D., F. R. C. P., late Senior Physician to and Lecturer on Medicine at the London Hospital; Visiting Physician to the Infant Orphan Asylum at Wanstead; the Earlswood Asylum for Idiots ; Founder of the Royal Orthopaedic Hos- pital, etc. Assisted by E. Muirhead Little, M. R. C. S. One 8vo vol., containing 161 pages, with complete Index, and illustrated by upward of 50 Figures and Diagrams. Cloth, $2. A DICTIONARY OF MEDICINE, including General Pathology, General Therapeutics, Hygiene, and the Diseases peculiar to Women and Children. By Various Writers. Edited by Richard Quain, M. D., F. R. S., Fellow of the Royal College of Physicians ; Member of the Senate of the University of London ; Member of the General Council of Medical Education and Registration ; Consulting Physician to the Hospital for Consumption and Diseases of the Chest at Brompton, etc. In one large 8vo volume of 1,834 pages, and 138 Illustrations. Half morocco, $8. Sold only by subscription. This work is primarily a Dictionary of Medicine, in which the several diseases are fully dis- cussed in alphabetical order. The description of each includes an account of its etiology and ana- tomical characters; its symptoms,* course, duration, and termination; its diagnosis, prognosis, D. APPLETON &° CO.'S MEDICAL WORKS. 37 and, lastly, its treatment. General Pathology comprehends articles on the origin, characters, and nature of disease. General Therapeutics includes articles on the several classes of remedies, their modes of ac- tion, and on the methods of their use. The articles devoted to the subject of Hygiene treat of the causes and prevention of disease, of the agencies and laws affecting public health, of the means of preserving the health of the individual, of the construction and management of hospitals, and of the nursing of the sick. Lastly, the diseases peculiar to women and children are discussed under their respective head- ings, both in aggregate and in detail. Among the leading contributors, whose names at once strike the reader as affording a guaran- tee of the value of their contributions, are the following : Allbutt, T. Clifford, M. A., M. D. Barnes, Robert, M. D. Bastian, H. Charlton, M. A., M. D. Binz, Carl, M. D. Bristowe, J. Syer, M. D. Brown-Sequard, C. E., M. D., LL. D. Brunton, T. Lauder, M. D., D. Sc. Fayrer, Sir Joseph, K. C. S. I., M. D., LL. D. Fox, Tilbury, M. D. Galton, Captain Douglas, R. E. (retired). Gowers, W. R., M. D. Wells, T " Not only is the work a Dictionary of Medicine in its fullest sense ; but it is so encyclopedic in its scope that it may be considered a condensed review of the entire field of practical medicine. Each sub- ject is marked up to date and contains in a nutshell the accumulated experience of the leading medical men of the day. As a volume for ready reference and careful study, it will be found of immense value to the general practitioner and student." — Medical Record. "The 'Medical Dictionary' of Dr. Quain is something more than its title would at first indicate. It might with equal propriety be called an encyclo- paedia. The different diseases are fully discussed in alphabetical order. The description of each in- cludes an account of its various attributes, often covering several pages. Although we have pos- sessed the book only the short time since its publica- tion, its loss would leave a void we would not know how to fill." — Boston Medical and Surg, journal. " Although a volume of over 1,800 pages, it is truly a mult um in parvo, and will be found of much more practical utility than other works which might be named extending over many volumes. The profession of this country are under obligations to you for the republication of the work, and I de- sire to congratulate you on the excellence of the illustrations, together with the excellent typograph- ical execution in all respects." — Austin Flint, M. D. "It is with great pleasure, indeed, that we an- nounce the publication in this country, by the Ap- pletons, of this most superb work. Of all the medical works which have been, and which will be, published this year, the most conspicuous one as embodying learning and research — the compilation into one great volume, as it were, of the whole sci- ence and art of medicine — is the ' Dictionary of Medicine ' of Dr. Quain. Ziemen's ' Practice of Medicine ' and Reynolds's ' System of Medicine ' are distinguished works, forming compilations, in the single department of practice, of the labors of many very eminent physicians, each one in his con- tributions presenting the results of his own observa- tions and experiences, as well as those of the inves- tigations of others. But in the dictionary of Dr. Quain there are embraced not merely the principles and practice of medicine in the contributions by the various writers of eminence, but general pathology, general therapeutics, hygiene, diseases of women and children, etc." — Cincinnati Medical News. " Criticism in detail we have not attempted, and this is in the main because there is not much room Greenfield, W. S., M. D. Jenner, Sir William, Bart., K. C. B., M. D. Legg, J. WlCKHAM, M. D. Nightingale, Florence. Paget, Sir James, Bart. Parkes, Edmund A., M. D. Pavy, F. W., M.D. Playfair, W. S., M.D. Simon, John, C. B., D. C. L. Thompson, Sir Henry. Waters, A. T. H., M. D. Spencer. for it. Those who are most competent to pass an opinion will, we believe, admit that Dr. Quain has carried out a most arduous enterprise with great success. His ' Dictionary of Medicine ' embodies an enormous amount of information in a most ac- cessible form, and it deserves to take its place in the library of every medical man as a ready guide and safe counselor. Others, too, will find within its pages so much information of various kinds that it can not fail to establish itself as a standard work of reference." — St. James's Budget. " Therefore we believe that as a whole the work will admirably fulfill its purpose of being a standard book of reference until, like other dictionaries of progressive science, it will require to be remodeled or supplemented to keep pace with advancing knowledge." — The Lancet {London). "I think 'Quain's Dictionary of Medicine ' an excellent work, and of great practical use for every- day reference by the physician." — Alexander J. C. Skene, M. D., Professor of the Medical and Surgi- cal Diseases of Women, Lo?ig Lsland College Hos- pital, Brooklyn, N. Y. " I regard ' Quain's Dictionary of Medicine' the most important, because most useful, publication of its kind issued from the medical press for many a year. In fact, I know of no similar work that can fitly be compared with it. The extraordinary facili- ties Dr. Quain possesses, in the choice of distin- guished collaborators, have been applied to the con- struction of a volume whose contents are so clear and compact, yet so full, that the hungriest seeker after the latest results of strictly medical research can be satisfied at one sitting." — Alexander Hutchins, M. D. " In this important work the editor has endeav- ored to combine two features or purposes : in the first place, to offer a dictionary of the technical words used in medicine and the collateral sciences, and also to present a treatise on systematic medi- cine, in which the separate articles on diseases should be short monographs by eminent specialists in the several branches of medical and surgical sci- ence. Especially for the latter purpose, he secured the aid of such well-known gentlemen as Charles Murchison, John Rose Cormack, Tilbury Fox, Thomas Hayden, William Aitken, Charlton Bas- tian, Brown-Sequard, Sir William Jenner, Eras- mus Wilson, and a host of others. By their aid he may fairly be said to have attained his object of 1 bringing together the latest and most complete in- formation, in a form which would allow of ready and easy reference."' — Med. and Surg. Reporter. 38 D. APPLETON &* CO.'S MEDICAL WORKS. A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Third American from the eighth German edition. Revised and enlarged. Illustrated by Six Lithographic Plates. By Alfred Vogel, M. D., Professor of Clinical Medicine in the University of Dorpat, Russia. Translated and edited by H. Raphael, M. D., late House Sur- geon to Bellevue Hospital ; Physician to the Eastern Dispensary for the Diseases of Children, etc., etc. I vol., 8vo, 640 pp. Cloth, $4.50 ; sheep, $5.50. The work is well up to the present state of pathological knowledge ; complete without un- necessary prolixity ; its symptomatology accurate, evidently the result of careful observation of a competent and experienced clinical practitioner. The diagnosis and differential relations of dis- eases to each other are accurately described, and the therapeutics judicious and discriminating. All polypharmacy is discarded, and only the remedies which appeared useful to the author commended. It contains much that must gain for it the merited praise of all impartial judges, and prove it to be an invaluable text-book for the student and practitioner, and a safe and useful guide in the difficult but all-important department of Paediatrica. THE NEW YORK MEDICAL JOURNAL: A Weekly Review of Medicine. Edited by Frank P. Foster, M. D. The New York Medical Journal, now in the twenty-second year of its publication, is pub- lished every Saturday, each number containing twenty-eight large, double-columned pages of reading matter. By reason of the condensed form in which the matter is arranged, it contains more reading matter than any other journal of its class in the United States. It is also more freely illustrated, and its illustrations are generally better executed, than is the case with other weekly journals. The special departments of the Journal are as follows : LECTURES AND ADDRESSES.— The effort is made to present didactic and clinical lectures, each in due proportion, and to give under this head only such lectures as are of interest to the great body of the profession. ORIGINAL COMMUNICATIONS.— These articles cover the whole range of the medical sciences, and include only those that are actually contributed by authors, and those that have been read before societies with which the Journal has a special arrangement (including the New York Surgical Society, the New York Obstetrical Society, the New York Clinical Society, and the Medical Society of the County of Kings). CLINICAL REPORTS. — These include reports of interesting cases in hospital practice. BOOK NOTICES. — In this department books are noticed strictly in accordance with their merits. CORRESPONDENCE.— Under this head we include only letters from the regular corre- spondents of the Journal, chance communications being given under a separate heading. LEADING ARTICLES. — Under this head we class the longer and more formal editorial articles. They consist either of resume's of scientific contributions, or of comments on matters of interest to the profession as a class, its welfare and its dignity. MINOR PARAGRAPHS. NEWS ITEMS. OBITUARY NOTES refer for the most part to well-known members of the profession, both in this country and abroad. LETTERS TO THE EDITOR embrace short communications from others than our regu- lar correspondents. PROCEEDINGS OF SOCIETIES.— The Journal gives the proceedings of all the lead- ing societies, national, State, and local, in a condensed form, but with a degree of fullness com- mensurate with their interest to the profession. REPORTS ON THE PROGRESS OF MEDICINE include abstracts of the better part of current literature, prepared by a staff of gentlemen specially employed for the purpose. These reports cover the whole range of medicine. MISCELLANY. — Under this head will be found abstracts which it is thought desirable to give in advance of the regular time for their appearance in the formal reports, especially Thera- peutical Notes, which, published in nearly every number, furnish the reader with the therapeuti- cal novelties of the day. The volumes begin with January and July of each year. Subscriptions can be arranged to begin with the volume. Terms, Payable in Advance : One Year, $5.00 ; Six Months, $2.50 ; Single Copy, 12 cents. (No subscriptions received for less than six months.) Binding Cases, Cloth, 50 cents. THE POPULAR SCIENCE MONTHLY and THE NEW YORK MEDICAL JOUR- NAL to the same address, $9.00 per annum (full price, $10.00). D. APPLETON &» CO:S MEDICAL WORKS. 39 ATLAS OF FEMALE PELVIC ANATOMY. By D. Berry Hart, M. D., F. R. C. P. E., Lecturer on Midwifery and Diseases of Women, School of Medicine, Edinburgh, etc. With Preface by Alex- ander J. C. Skene, M. D., Professor of the Medical and Surgical Diseases of Women, Long Island College Hospital, Brooklyn, etc. Large 4to, 37 Plates with 150 Figures, and 89 pages Descriptive Text. Cloth, $15.00. Sold only by subscription. "Within recent years much has been done to "As a new work by a well-known author, there weed the topographical anatomy of the pelvis of is a natural prejudice in its favor, but this becomes numerous errors which have encumbered it. Prom- the more deeply rooted as we constantly get new inent among those who have furthered this work is views of old fields, new landmarks for better out- the author of the 'Atlas ' now before us, and into looks, new light upon heretofore obscure points, this, his latest labor, he has entered with all his ac- In a word, we can, after the most critical study of customed vigor. . . . The ' Atlas deserves, and its contents, say with the distinguished editor, Pro- will surely have, a wide circulation ; and we are fessor Skene, that ' it is far in advance of any work confident that no one will rise from its careful pe- of its kind yet produced.' As such it becomes a rusal without having obtained clearer, more accu- necessity for the progressive gynaecologist, for the rate, and more intelligent views in regard to the operating surgeon, and for the leading general much-vexed questions of female anatomy, or with- practitioner. We congratulate the publishers on out having formed a very high opinion of the au- the reproduction of this grand work, and bespeak thor's industry, earnestness, and ability." — Edin- for it -a becoming appreciation by the profession of burgh Medical Journal. this country." — Medical Record. ELEMENTS OF PRACTICAL MEDICINE. By Alfred H. Carter, M. D., Member of the Royal College of Physicians, London ; Physician to the Queen's Hospital, Birmingham, etc. Third edition, revised and enlarged. I vol., i2mo, 427 pages. Cloth, $3.00. "Although this work does not profess to be a wisely, perhaps, since we know so little about it ; complete treatise on the practice of medicine, it is and of that other almost unknown quantity in too full to be called a compend ; it is rather an in- medicine, scrofula, the author has with equal pru- troduction to the more exhaustive study embodied dence abstained from saying much. He admits in the larger text-books. An idea of the degree to such a condition as scrofulosis, but thinks it has no which condensation has been carried in it can be necessary connection with tuberculosis. He is a gathered from the statement that but twenty-one believer in the germ-theory of disease, and speaks pages are occupied with the diseases of the circula- of Koch's investigations and discoveries as very im- tory system. If the reader gets the impression that portant, to him almost conclusive, the physical signs are given somewhat too meager- " Notwithstanding the condensed make-up of ly, it is to be said that, by way of compensation, the book, it is quite comprehensive, including even the symptomatolbgy in general is considered with cutaneous and venereal diseases. It contains much admirable perspicuity and good judgment. valuable information, and we may add that it is " Leucocythajmia is dismissed with one page — very readable." — New York Medical Journal. THE MINERAL SPRINGS OF THE UNITED STATES AND CANADA, with Analysis and Notes on the Prominent Spas of Europe and a List of Sea-side Resorts. An enlarged and revised edition. By George E. Walton, M. D., Lecturer on Materia Medica in the Miami Medical College, Cincinnati. Second edition, revised and enlarged. I vol., i2mo, 414 pp. With Maps. $2. The author has given the analysis of all the springs in this country and those of the principal European spas, reduced to a uniform standard of one wine-pint, so that they may readily be com- pared. He has arranged the springs of America and Europe in seven distinct classes, and de- scribed the diseases to which mineral waters are adapted, with references to the class of waters applicable to the treatment ; and the peculiar characteristics of each spring as near as known are given — also the location, mode of access, and post-office address of every spring are mentioned. In addition, he has described the various kinds of baths and the appropriate use of them in the treatment of disease. ' ' Precise and comprehensive, presenting not only use as intelligently and beneficially as they can other reliable analysis of the waters, but their therapeutic valuable alterative agents." — Sanitarian. value, so that physicians can hereafter advise their 4Q D. APPLETON &* CO.S MEDICAL WORKS. DISEASES OF MEMORY : An Essay in the Positive Psy- chology. By Th. Ribot, Author of " Heredity," etc. Translated from the French by William Huntington Smith. i2mo. Cloth, $1.50. ' ' Not merely to scientific, but to all thinking men, this volume will prove intensely interesting." — New York Observer. "M. Ribot has bestowed the most painstaking attention upon his theme, and numerous examples of the conditions considered greatly increase the value and interest of the volume." — Philadelphia North America7i. " 'Memory,' says M. Ribot, 'is a general func- tion of the nervous system. It is based upon the faculty possessed by the nervous elements of con- serving a received modification, and of forming as- sociations.' And again : ' Memory is a biological fact. A rich and extensive memory is not a collec- tion of impressions, but an accumulation of dynam- ical associations, very stable and very responsive to proper stimuli. . . . The brain is like a laboratory full of movement where thousands of operations are going on all at once. Unconscious cerebration, not being subject to restrictions of time, operating, so to speak, only in space, may act in several directions at the same moment. Consciousness is the narrow gate through which a very small part of all this work is able to reach us.' M. Ribot thus reduces diseases of memory to law, and his treatise is of ex- traordinary interest." — Philadelphia Press. " It is not too much to say that in no single work have so many curious cases been brought together and interpreted in a scientific manner." — Boston Evening Traveller. A TREATISE ON INSANITY, in its Medical Relations. By William A. Hammond, M. D., Surgeon-General U. S. Army (retired list) ; Professor of Diseases of the Mind and Nervous System, in the New- York Post-Graduate Medical School ; President of the American Neuro- logical Association, etc. 1 vol., 8vo, 767 pp. Cloth, $5; sheep, $6. In this work the author has not only considered the subject of Insanity, but has prefixed that division of his work with a general view of the mind and the several categories of mental faculties, and a full account of the various causes that exercise an influence over mental derangement, such as habit, age, sex, hereditary tendency, constitution, temperament, instinct, sleep, dreams, and many other factors. Insanity, it is believed, is in this volume brought before the reader in an original manner, and with a degree of thoroughness which can not but lead to important results in the study of psycho- logical medicine. Those forms which have only been incidentally alluded to or entirely disregard- ed in the text-books hitherto published are here shown to be of the greatest interest to the general practitioner and student of mental science, both from a normal and abnormal stand-point. To a great extent the work relates to those species of mental derangement which are not seen within asylum walls, and which, therefore, are of special importance to the non-asylum physician. Moreover, it points out the symptoms of Insanity in its first stages, during which there is most hope of successful medical treatment, and before the idea of an asylum has occurred to the patient's friends. commending the book to the medical profession, as it is to them it is specially addressed." — Therapeutic Gazette. " We believe we may fairly say that the volume is a sound and practical treatise on the subject with which it deals ; contains a great deal of information carefully selected and put together in a pleasant and readable form ; and, emanating, as it does, from an author whose previous works have met with a most favorable reception, will, we have little doubt, obtain a wide circulation." — The Dublin Journal of Medi- cal Science. "... The times are ripe for a new work on in- sanity, and Dr. Hammond's great work will serve hereafter to mark an era in the history of American psychiatry. It should be in the hands of every physician who wishes to have an understanding of the present status of this advancing science. Who begins to read it will need no urging to continue ; he will be carried along irresistibly. We unhesitat- ingly pronounce it one of the best works on insan- ity which has yet appeared in the English language." r— American Journal of the Medical Sciences. " Dr. Hammond is a bold and strong writer, has given much study to his subject, and expresses him- self so as to be understood by the reader, even if the latter does not coincide with him. We like the book very much, and consider it a valuable addition to the literature of insanity. We have no hesitancy in "Dr. Hammond has added another great work to the long list of valuable publications which have placed him among the foremost neurologists and alienists of America ; and we predict for this volume the happy fortune of its predecessors — a rapid jour- ney through paying editions. We are sorry that our limits will not permit of an analysis of this work, the best text-book on insanity that has yet appeared." — The Polyclinic. ' ' We are ready to welcome the present volume as the most lucid, comprehensive, and practical ex- position on insanity that has been issued in this country by an American alienist, and furthermore, it is the most instructive and assimilable that can be placed at present in the hands of the student unini- tiated in psychiatry. The instruction contained within its pages is a food thoroughly prepared for mental digestion : rich in the condiments that stimu- late the appetite for learning, and substantial in the more solid elements that enlarge and strengthen the intellect." — New Orleans Medical and Surgical Journal. D. APPLETON &> CO.'S MEDICAL WORKS, 4I THE POPULAR SCIENCE MONTHLY. Conducted by E. L. and W. J. Youmans. The volumes begin in May and November of each year. Subscriptions may begin at any time. Terms, $5 per annum ; single number, 50 cents. "The Popular Science Monthly" and "New York Medical Journal" to one address, $9 per annum (full price, $10). " The Popular Science Monthly " was established a dozen years ago to bring before the general public the results of scientific thought on many large and important questions which could find no expression in the current periodicals. Scientific inquiry was penetrating many new fields, extend- ing important knowledge, and profoundly affecting opinion upon numberless questions of specula- tive and practical interest. It was the policy of this magazine at the outset, and has been con- stantly adhered to since, to obtain the ablest statements from the most distinguished scientific men of all countries in their bearing upon the higher problems of investigation. Leaving the dry and technical details of science, which are of chief concern to specialists, to the journals devoted to them, " The Popular Science Monthly " has dealt with those more general and practical subjects which are of the greatest interest and importance to the people at large. That which was at first a dubious experiment has now become an assured and permanent suc- cess. Our " Monthly " is the acknowledged organ of progressive scientific ideas in this country. Received with favor at the outset, it has gone on increasing in circulation and in influence, until its power is felt and acknowledged in the highest departments of intellectual activity, and its leader- ship is recognized in the great work of liberalizing and educating the popular mind. Making neither sensational appeals nor flaring announcements, we may now refer to its course in the past as a sufficient guarantee that it will continue to discuss in the same earnest and fearless, but always respectful manner, the various important questions falling within its scope that are en- titled to the intelligent consideration of thinking people. The twenty-three volumes now published constitute the best library of advanced scientific knowledge to be found in any country, and each new volume is certain to prove of increasing interest and value. Science is the great agency of improvement in this age, private and public, individual, social, professional, and industrial. In its irresistible progress it touches everywhere, and affects every- body. It gives law to the material interests of the community, and modifies its ideas, opinions, and beliefs, so that all have an interest in being informed of its advancement. Those, therefore, who desire to know what is going on in the world of thought in these stirring times, when new knowledge is rapidly extending, and old errors are giving way, will find that they can keep informed only by subscribing for " The Popular Science Monthly." " This is one of the very best periodicals of its to persons of literary tastes who have neither time kind published in the world. Its corps of contribu- nor opportunity to prosecute special scientific re- tors comprise many of the ablest minds known to searches, but who, nevertheless, wish to have a cor- science and literature." — American Medical your- rect understanding of what is being done by others nal (St. Louis). in the various departments of science." — Louisia?ia " No scientific student can dispense with this *' monthly, and it is difficult to understand how any " A journal of eminent value to the cause of one making literary pretensions fails to become a popular education in this country." — New York regular reader of this journal. ' The Popular Sci- Tribune. ence Monthly ' meets a want of the medical profes- ,. „ , . . , . 1 . i , ,, . ... . sion not otherwise met. It keeps full pace with the . . Every physician s table should bear this valu- progress of the times in all the departments of sci- able monthly, which we believe to be one of the entitle pursuit. "- Virginia Medical Monthly. most m ^ r ! stmg a " d in structiye of the periodicals now published, and one which is destined to play a " Outside of medical journals, there is no peri- large part in the mental development of the laity of odical published in America as well worthy of being this country." — Canadian Journal of Medical Sci- placed upon the physician's library -table and regu- ence. larly read by him as " The Popular Science Month- ..r^,. . . ... . A . u . ,, . ly/»-St. Louis Clinical Record. . + This magazine is worth its weight m gold, for J its service m educating the people. — American " ' The Popular Science Monthly ' is invaluable Journal of Education (St. Louis). DISEASES OF THE OVARIES: Their Diagnosis and Treatment. By T. Spencer Wells, Fellow and Member of Council of the Royal College of Surgeons of England, etc., etc. 1 vol., 8vo, 478 pp. Illustrated. Cloth, $4.50. In 1865 the author issued a volume containing reports of one hundred and fourteen cases of Ovariotomy, which was little more than a simple record of facts. The book was soon out of print, and, though repeatedly asked for a new edition, the author was unable to do more than prepare papers for the Royal Medical and Chirurgical Society, as series after series of a hundred cases ac- cumulated. On the completion of five hundred cases, he embodied the results in the present vol- ume, an entirely new work, for the student and practitioner, and trusts it may prove acceptable to them and useful to suffering women. 42 D. APPLETON 6- CO.'S MEDICAL WORKS. LECTURES ON THE PRINCIPLES OF SURGERY. Delivered at the Bellevue Hospital Medical College. By the late W. H. Van Buren, M. D., LL. D. Edited by Dr. Lewis A. Stimson. i vol., 8vo, 588 pages. Cloth, $4.00 ; sheep, $5.00. "The name of the author is enough. The book will sell. The lectures are good." — Denver Medi- cal Times. " If we are to judge of the interesting style by the mere reading of these lectures, how greatly they must have been appreciated by those who heard them by the teacher ! There is nothing dry or prosy in them. The illustrations of principles are drawn from the clinical material of the teacher, and are always fresh and a, propos. Past and present theo- ries are compared in such a way as to give the stu- dent an interest in the work of older pathologists, and to point out progress made, without wearying him with a dry narration at a time when he is not able to comprehend the underlying philosophy. "Dr. Van Buren's popularity as a teacher can be easily understood from a study of this volume. His manner is vivacious, his matter select, and his fullness of knowledge easily discernible. He writes like one in authority, full of enthusiasm, and pos- sessed of the skill of imparting to students just that sort of knowledge best suited to their future intel- lectual growth. "The work is handsomely printed, with full- faced, clear type and leaded lines, and is in every way a credit to the publishers." — North Carolina Medical Journal. OSTEOTOMY AND OSTEOCLASIS, for the Correction of Deformities of the Lower Limbs. By Charles T. Poore, M. D., Surgeon to St. Mary's Free Hospital for Children, New York. 1 vol., 8vo, 202 pages, with 50 Illustrations. Cloth, $2.50. "This handsome and carefully-prepared mono- graph treats of osteotomy as applied to the repair of genu valgum, genu varum, anchylosis of the knee-joint, deformities of the hip-joint, and for curves of the tibia. The author has enjoyed large opportunities to study these special malformations in the hospitals to which he is attached, and de- scribes the operations from an ample observation. Quite a number of well-engraved illustrations add to the value of the volume, and an exhaustive bib- liography appended enables the reader to pursue any topic in which he may be interested into the productions of other writers." — Medical and Sur- gical Reporter. " Dr. Poore, who has already become so well known by journal articles on bone surgery, has con- densed his experience in the work before us. He has succeeded in doing this in a very satisfactory way. We can not too strongly commend the clear and succinct manner in which the author weighs the indications for treatment in particular cases. In so doing he shows a knowledge of his subject which is as extensive as it is profound, and no one at all interested in orthopedy can read his conclu- sions without profit. His own cases, which are carefully reported, are valuable additions to the lit- erature of the subject. These, together with oth- ers, which are only summarized, contain so much practical information and sound surgery that they give a special value to the work, altogether inde- pendent of its other excellences. It is a good book in every way, and we congratulate the author ac- cordingly." — Medical Record. D. APPLETON &> CO.'S MEDICAL WORKS. 43 A TREATISE ON BRAIN-EXHAUSTION, with some Preliminary Considerations on Cerebral Dynamics. By J. Leonard Corn- ing, M. D., formerly Resident Assistant Physician to the Hudson River State Hospital for the Insane ; Member of the Medical Society of the County of New York, of the Physicians' Mutual Aid Association, of the New York Neurological Society, of the New York Medico-Legal Society, of the Society of Medical Jurisprudence ; Physician to the New York Neu- rological Infirmary, etc. ; Member of the New York Academy of Medicine. Crown 8vo. Cloth, $2.00. " Dr. Coming's neat little volume has the merit of being highly suggestive, and, besides, is better adapted to popular reading than any other profes- sional work on the subject that we know of." — Pa- cific Medical and Surgical Journal. " This is a capital little work on the subject upon which it treats, and the author has presented, from as real a scientific stand-point as possible, a group of symptoms, the importance of which is sufficiently evident. To fully comprehend the ideas as presented by the author, the whole book should be read ; and, as it consists of only 234 pages, the task would not be a severe or tedious one, and the information or knowledge obtained would be much more than equivalent for the time spent and cost of book included. Literary men and women would do well to procure it." — Therapeutic Gazette. " This book belongs to a class that is more and more demanded by the cultured intelligence of the period in which we live. Dr. Corning may be ranked with Hammond, Beard, Mitchell, and Crothers, of this country, and with Winslow, An- stie, Thompson, and more recent authors of Great Britain, in discussing the problems of mental dis- turbance, in a style that makes it not only profit- able but attractive reading for the student of psy- chology. The author has divided the work into short chapters, under general headings, which are again subdivided into topics, that are paragraphed in a concise and definite form, which at once strikes the careful reader as characteristic of a method that is terse, concise, and readily apprehended. There are twenty-eight of these pithy chapters, which no student of mental diseases can fail to read without loss." — American Psychological Journal. PRACTICAL MANUAL OF DISEASES OF WOMEN AND UTERINE THERAPEUTICS. For Students and Practitioners. By H. Macnaughton Jones, M. D., F. R. C. S. I. and E., Examiner in Obstetrics, Royal University of Ireland ; Fellow of the Academy of Medi- cine in Ireland ; and of the Obstetrical Society of London, etc. 1 vol., i2mo. 410 pages. 188 Illustrations. Cloth, $3 co. "As a concise, well-written, useful manual, we consider this one of the best we have ever seen. The author, in the preface, tells us that ' this book is simply intended as a practitioner's and student's manual. I have endeavored to make it as practical in its teachings as possible. ' The style is pleasant to peruse. The author expresses his ideas in a clear manner, and it is well up with the approved meth- ods and treatment of the day. It is well illustrated, and due credit is given to American gynaecologists for work done. It is a good book, well printed in good, large type, and well bound." — New England Medical Monthly. " It is seldom that we see a book so completely fill its avowed mission as does the one before us. It is practical from beginning to end, and can not fail to be appreciated by the readers for whom it is intended. The author's style is terse and perspicu- ous, and he has the enviable faculty of giving the learner a clear insight of his methods and reasons for treatment. Prepared for the practitioner, this little work deals only with his every-day wants in ordinary family practice. Every one is compelled to treat uterine disease who does any general busi- ness whatever, and should become acquainted with the minor operations thereto pertaining. The book before us covers this ground completely, and we have nothing to offer in the way of criticism." — Medical Record. " The manual before us is not the work of a spe- cialist — using this term in a narrow sense — but of an author already favorably known to the students of current medical literature by various and com- prehensive works upon other branches of his profes- sion. Nor is it, on the other hand, the work of an amateur or merely ingenious collaborateur, for Dr. Macnaughton Jones's gynaecological experience in connection with the Cork Hospital for Women and the Cork Maternity was such as fairly entitles him to speak authoritatively upon the subjects with which it deals. But, after so many works by avowed specialists, we are glad to welcome one upon Gynae- cology by an author whose opportunities and energy- have enabled him to master the details of so many branches of medicine. We are glad also to be able to state that his work compares very favorably with others of the same kind, and that it does admirably fulfill the purposes with which it was written — ' as a safe guide in practice to the practitioner, and an assistance in the study of this branch of his profes- sion to the student.'" — Dublin Journal of Medical Science. 44 D. APPLETON 6- CO.'S MEDICAL WORKS. A HAND-BOOK OF THE DISEASES OF THE EYE, AND THEIR TREATMENT. By Henry R. Swanzy, A. M., M. B., F. R. C. S. L, Surgeon to the National Eye and Ear Infirmary ; Ophthalmic Surgeon to the Adelaide Hospital, Dublin. Crown 8vo, 437 pages. With 122 Illustrations, and Holmgren's Tests for Color-Blindness. Cloth, $3.00. " Though, amid the numerous recent text-books on eye-diseases, there would appear to be little room or necessity for another, we must admit that this one justifies its presence, by its admirable type, illustrations, and dress, by its clear wording, and, above all, by the vast amount of varied matter which it embraces within the relatively small com- pass of some four hundred pages. The author has omitted — and, in our opinion, with perfect wis- dom — the usual collection of indifferent, second- hand ophthalmoscopic plates. So, also, he has not included test-types, though he has appended, for explanatory purposes, the fan which is often used in astigmatism. Admirable samples of the colored wools, used in Holmgren's tests, are sewn into the cover, and, by aid of these, it will be perfectly within the power of any one, wherever residing, to make a proper collection of colored wools and tests for the qualitative estimation of congenital color-defects. We have criticised the book at length, and drawn at- tention freely to points on which the author's opin- ion is at variance with the commonly received teach- ing. This we have done because there is much individuality in the work, which bears every mark of having been well thought out and independently written. In these respects it presents a marked su- periority over the ordinary run of medical hand- books ; and we have no hesitation in recommending it to students and young practitioners as one of the very best, if not actually the best, work to procure on the subject of ophthalmology." — British Medi- cal Journal. DISEASES OF THE HEART AND THORACIC AOR- TA. By Byrom Bramwell, M. D., F. R. C. P. E., Lecturer on the Prin- ciples and Practice of Medicine and on Medical Diagnosis in the Extra- Academical School of Medicine, Edinburgh ; Pathologist to the Royal Infirmary, Edinburgh, etc. Illustrated with 226 Wood Engravings and 68 Lithograph Plates, showing 91 Figures — in all, 317 Illustrations. 1 vol., 8vo, 783 pages. Cloth, $8.00 ; sheep, $9.00. " A careful perusal of this work will well repay the student and refresh the memory of the busy practitioner. It is the outcome of sound knowledge and solid work, and thus devoid of all ' padding,' which forms the bulk of many monographs on this and other subjects. The material is treated with due regard to its proportionate importance, and the author has well and wisely carried out his apparent intention of rather furnishing a groundwork of knowledge on which the reader must build for him- self by personal observation, than of making excur- sions into the region of dogma and of fancy by which his book might have secured a perhaps more rapid but certainly a more evanescent success than that which it will now undoubtedly and deservedly attain." — Medical Times and Gazette. "In this elegant and profusely illustrated vol- ume Dr. Bramwell has entered a field which has hitherto been so worthily occupied by British au- thors — Hope, Hayden, Walshe, and others ; and we can not but admire the industry and care which he has bestowed upon the work. As it stands, it may fairly be taken as representing the stand-point at which we have arrived in cardiac physiology and pathology ; for the book opens with an extended account of physiological facts, and especially the advances made of late years in the neuro-muscular mechanism of the heart and blood-vessels. Al- though in this respect physiological research has outstripped clinical and pathological observation, Dr. Bramwell has, we think, done wisely in so in- troducing his treatise, and has thereby greatly add- ed to its value. A chapter upon thoracic aneurism terminates a work which, from the scientific man- ner in which the subject is treated, from the care and discrimination exhibited, and the copious elab- orate illustrations with which it is adorned, is one which will advance the author's reputation as a most industrious and painstaking clinical observer." — Lancet. THE ESSENTIALS OF ANATOMY, PHYSIOLOGY, AND HYGIENE. By Roger S. Tracy, M. D., Sanitary Inspector of the New York City Health Department. i2mo. Cloth, $1.25. This work has been prepared in response to the demand for a thoroughly scientific and yet practical text-book for schools and academies, which shall afford an accurate knowledge of the essential facts of Anatomy and Physiology, as furnishing a scientific basis for the study of Hygiene and the Laws of Health. It also treats, in a rational manner, of the physiological effects of alcohol and other narcotics, fulfilling all the requirements of recent legislative enactments upon this subject. D. APPLETON &* CCS MEDICAL WORKS. 45 THE RELATION OF ANIMAL DISEASES TO THE PUBLIC HEALTH, and their Prevention : With a Brief Historical Sketch of the Development of Veterinary Medicine, from the Earliest Ages to the Present Time ; and a Critical Historical Sketch of the Leading Schools of the World, showing the Reasons which led to their Foundation, and with the Endeavor to draw from their Experiences Teachings of Value toward the Establishment of a General Veterinary Police-hygienic System and Veterinary Schools in this Country. By Frank S. Billings, Veteri- nary Surgeon, Graduate of the Royal Veterinary Institute, Berlin ; Mem- ber of the Royal Veterinary Association of the Province of Brandenburg, Prussia ; Honorary Member of the Veterinary Society of Montreal, Can- ada, etc., etc. I vol., 8vo. Cloth, $4.00. " This is the great health-book of Dr. Frank S. least should be in the libraries of every national, Billing's, and it is not too much to promise that a State, city, town, and county Board of Health. It study and observance of its teachings, that are the certainly should be studied by every teacher and results of actual experiments, will work a revolution scientific practitioner of veterinary medicine, and in the sanitary condition of the United States. . . . will be of great service to every great stock and cat- It is a work for all stock-breeders and for all fami- tie holder and dealer. ... It is evidently written lies." — Louisville Courier-Journal. by a man of great ability and high culture, well ..„, . . ., ,.., r , . . . . .... versed both in the literature and science as well as 'This is the title of a work jus pven to the fa . ^ b ^ f ^ subject> Such maQ wor Id and in its pages subjects of vital interest are has £ at and ina f ienab i e right to have opinions treated of in a lucid and perspicuous manner. . . M * and he hag th & nd does not £ esitate These well-established statements should arouse the express them. ... We hope and believe that public feeling to provide that boards of health ^ ^ be receiyed ^ h should be careful and efficient m the exercise of by those especially attacked, with the great welcome their duties, as also that as individuals every one * . ^ &nd blishers must Expect for it. should labor to take good care of himself his f am- j ^ ^ . stand alongside of the popular trea- ily, and his domestic ammals."-^ York Times. ^ of Hmiard and Rob g ertsoI1) and ^/ all purely " This handsome volume does great credit to its scientific matters will lead them. Either of these author and publishers. It is an excellent book in works, together with Dr. Billings's, will make al- most respects, an extraordinary one in many, and most a complete library on veterinary medicine." — an objectionable one in very few. It at the very Journal 0/ Comparative Medicine and Surgery. PYURIA; or, PUS IN THE URINE, AND ITS TREAT- MENT : Comprising the Diagnosis and Treatment of Acute and Chronic Urethritis, Prostatitis, Cystitis, and Pyelitis, with especial reference to their Local Treatment. By Dr. Robert Ultzmann, Professor of Genito-Uri- nary Diseases in the Vienna Poliklinik. Translated, bv permission, by Dr. Walter B. Platt, F. R. C. S. (Eng.), Baltimore. i2mo. Cloth, $1.00. " Those of the profession who are familiar with but also for the many practical suggestions regard- the works of Professor Ultzmann will welcome this ing treatment to be found in the chapter on Thera- translation as constituting a real addition to our lit- peutics. The translator is to be congratulated upon erature on genito-urinary diseases. It can not be the excellent manner in which his work has been too highly recommended to the attention of the pro- accomplished. The book is neatly and tastefully got fession, not only on account of its scientific value, up by the publishers." — Maryland Med. Journal. HAND-BOOK OF SANITARY INFORMATION FOR HOUSEHOLDERS. Containing Facts and Suggestions about Ventila- tion, Drainage, Care of Contagious Diseases, Disinfection, Food, and Water. With Appendices on Disinfectants and Plumbers' Materials. By Roger S. Tracy, M. D., Sanitary Inspector of the New York City Health Department. i6mo. Cloth, 50 cents. 4 6 D. APPLETON &> CO.'S MEDICAL WORKS. A TREATISE ON NERVOUS DISEASES: Their Symp- toms and Treatment. A Text-book for Students and Practitioners. By S. G. Webber, M. D., Clinical Instructor in Nervous Diseases, Harvard Med- ical School ; Visiting Physician for Diseases of the Nervous System at the Boston City Hospital, etc. I vol., 8vo, 415 pp. 15 Illustrations. Cloth, $3.00. peculiar language of the more advanced neurologist. He covers very completely the field of nervous affec- tions, and his book will prove a very valuable acqui- sition to the library of the intelligent physician." — Medical Age. " The beauty and usefulness of the book are much enhanced by the fact that it is not loaded down with references to other authors, but proceeds in an orig- inal manner to sum up all that is known to the present day upon the subjects treated. Taking the book as a whole it is one of the best we have seen in many a day." — Texas Courier-Record. " The book before us is especially adapted to the needs of the general practitioner who, though con- scious of his inability to discern and trace the nerv- ous element in the cases under his care, realizes very fully that this inability is not consonant with the best interests of his patient. Dr. Webber has not written for the specialist, but for the student and general practitioner, who will find in his book what they most need for the diagnosis and treat- ment of the diseases as they present themselves in general practice. His style is very readable and lucid, and is well adapted to those who have not specially prepared themselves to understand the THE CURABILITY AND TREATMENT OF PUL- MONARY PHTHISIS. By S. Jaccoud, Professor of Medical Pathology to the Faculty of Paris ; Member of the Academy of Medicine ; Physician to the Lariboisiere Hospital, Paris, etc. Translated and edited by Montagu Lubbock, M. D. (London and Paris), M. R. C. P. (England), etc. 8vo, 407 pp. Cloth, $4.00. " This is the work of that most eminent French- man of the Ecole de Medecine of Paris, and the translation of Lubbock is strong and masterly inas- much as it evidences the possession of a large vocabulary knowledge of both the original and English. No man of the present day, with the single exception perhaps of Hughes Rennet, has devoted as much careful study to the climatic treat- ment of phthisis as Dr. Jaccoud, and his conclusions on this point so far as regards the Continent of Europe must be deemed final." — Cincinnati Lancet and Clinic. " M. Jaccoud, the author of the work, and the eminent professor of the Ecole de Medecine, Paris, is generally recognized on the Continent as one of the best authorities on pulmonary phthisis, so that an English edition of his work will certainly be very acceptable to those interested in the subject. . . . M. Jaccoud's reputation is justly so great that his opinions with respect to the treatment will be read with general interest." — Texas Courier- Record of Medicine. THE USE OF THE MICROSCOPE IN CLINICAL AND PATHOLOGICAL EXAMINATIONS. By Dr. Carl Friedlaen- der, Privat-Docent in Pathological Anatomy in Berlin. Translated from the enlarged and improved second edition, by Henry C. Coe, M. D., etc. With a Chromo-Lithograph. l2mo, 195 pp., with copious Index. Cloth, $1.00. " We are very much pleased to see Dr. Fried- laender's little book make its appearance in English dress. As we have a practical acquaintance of the German edition since its appearance, we can speak of it in terms of unqualified praise. . . . Every one doing pathological work should have this little book in his possession. . . . The translator has done his work well, and has certainly conferred a great favor on all microscopists by placing within the reach of every one the work of so accomplished a teacher as Dr. Carl Friedlaender." — Canada Medical and Sur- gical Journal. 1 ' Much good has been done in placing this little work in the hands of the profession. The technique of preparing, cutting, and staining specimens is given at some length ; also rules for the examination of the. various bodily fluids in both health and disease. The use of the microscope with high pow- ers, immersion lenses, and other accessories, is ex- plained very clearly. It is a very readable volume, even for those not engaged in actual laboratory work. A chromo-lithograph shows the various forms of disease-germs which have been definitely isolated." — Medical Record. MEDICAL ETHICS AND ETIQUETTE. Commentaries on the National Code of Ethics. By Austin Flint, M. D. i2mo, 101 pp. 60 cents. D. APPLE TON &* CO:S MEDICAL WORKS. 47 A MANUAL OF DERMATOLOGY. By A R. Robinson, M. B., L. R. C. P. and S. (Edinburgh), Professor of Dermatology at the New York Polyclinic ; Professor of Histology and Pathological Anatomy at the Woman's Medical College of the New York Infirmary. Revised and corrected. 8vo, 647 pp. Cloth, $5.00. "It includes so much good, original work, and so well illustrates the best practical teachings of the subject by our most advanced men, that I regard it as commanding at once a place in the very front rank of all authorities. . . . "—James Nevins Hyde, M. D. " Dr. Robinson's experience has amply qualified him for the task which he assumed, and he has given us a book which commends itself to the considera- tion of the general practitioner." — Medical Age. " In general appearance it is similar to Duhring's excellent book, more valuable, however, in that it contains much later views, and also on account of the excellence of the anatomical description accom- panying the microscopical appearances of the diseases spoken of." — St. Louts Med. and Surg. Journal. 1 ' Altogether it is an excellent work, helpful to every one who consults its pages for aid in the study of skin-diseases. No physican who studies it will regret the placing of it in his library." — Detroit Lancet. AN ATLAS OF CLINICAL MICROSCOPY. By Alex- ander Peyer, M. D. Translated and edited by Alfred C. Girard, M. D., Assistant Surgeon United States Army. First American, from the manu- script of the second German edition, with Additions. 90 Plates, with 105 Illustrations, Chromo-Lithographs. Square 8vo. Cloth, $6.00. "All who are interested in clinical microscopy will be pleased with the design and execution of this work, and will feel under obligation to the author, translator, and publishers for placing so valuable a work in their hands. The plates in which are figured the various urinary inorganic deposits are especially fine, and the various forms of tube-casts, hyaline, waxy, epithelial, and mucous, are depicted with great fidelity and accuracy." — Philadelphia Med. Times. " To those students and practitioners of medicine who are interested in microscopical work and who are familiar with the use of this valuable aid to hu- man vision in the study of nature, the present work will prove of incalculable value, since it represents the original work of an accomplished microscopist and artist. Accompanying the plates is a text of explanatory notes showing the various methods of working with the microscope and the significance of what is observed. The plates have been most handsomely printed. We have seen nothing in this special line of study that will compare in point of accuracy of detail and artistic effect with the work under consideration." — Maryland Med. Journal. ELEMENTS OF MODERN MEDICINE, including Princi- pies of Pathology and Therapeutics, with many Useful Memoranda and Valuable Tables of Reference. Accompanied by Pocket Fever Charts. Designed for the Use of Students and Practitioners of Medicine. By R. French Stone, M. D., Professor of Materia Medica and Therapeutics and Clinical Medicine in the Central College of Physicians and Surgeons, Indianapolis ; Physician to the Indiana Institute for the Blind ; Consulting Physician to the Indianapolis City Hospital, etc., etc. In wallet-book form, with pockets on each cover for Memoranda, Temperature Charts, etc., $2.50. "This is an abridged work in pocket-book form, presenting the more advanced views of leading authorities, with reference to general pathology and therapeutics. Under general pathology are included articles on the origin, nature, and duration of dis- ease, chief symptoms, diagnosis, prognosis, and treatment. In the second part will be found what is regarded by the author as an improved classification of drugs, followed by articles on their physiological action, indications, and methods of use. The work contains a fund of useful information culled from the best authorities in the Old and New World." — Canada Lancet. ' ' This is a neatly printed pocket manual of medi- cal practice. It is a well-condensed compilation of the kind, containing a short sketch of nearly every- thing that is met with in practice. The fever charts are well arranged, and there is a convenient thera- peutic table which will be found valuable. It will probably be more suitable for young practitioners, on account of its containing many practical points that are not to be found elsewhere in such a con- densed manner. It will be found a valuable aid to those just commencing practice." — Medical Herald. 4 8 D. APPLETON &» CO:S MEDICAL WORKS. A TEXT-BOOK OF OPHTHALMOSCOPY. By Edward G. Loring, M. D. Part I. — The Normal Eye, Determination of Refrac- tion, and Diseases of the Media. Specimen of Illustration. 8vo. 267 pp., with 131 Illustrations, and Four Chromo -Lithograph Plates, containing 14 Figures. Cloth, $5.00. 41 The ' Text-book of Oph- thalmoscopy,' by Edward G. Loring, M. D., is a splendid work. ... I am well pleased with it, and am satisfied that it will be of service both to the teacher and pupil. . . . In this book Dr. Loring has given us a substantial exposi- tion of Nature's deeds and misdeeds as they are found written in the eye, and the key by means of which they can be comprehended." — W. R. Amick, A. M., M. D., Pro- fessor of Ophthalmology and Otology, Cincinnati College of Medicine and Surgery. THE DISEASES OF SEDENTARY AND ADVANCED LIFE. A Work for Medical and Lay Readers. By J. Milner Foth- ergill, M. D., M. R. C. P., Physician to the City of London Hospital for Diseases of the Chest (Victoria Park) ; late Assistant Physician to the West London Hospital ; Hon. M. D., Rush Medical College, Chicago ; Foreign Associate Fellow of the Royal College of Physicians of Philadelphia. Small 8vo, 296 pp. Cloth, $2.00. "This work is written to fill a gap in medical literature. The diseases of sedentary and advanced life lie a little outside and beyond the ordinary text- books of practice of physic. As such a work is cer- tain to be read by lay-readers, the fact has not been forgotten. . . . The writer ventures to think that in this work an aspect of disease is presented which is not always kept sufficiently in view ; and which will make the work acceptable even to some well-read members of the profession. " — From the Preface. THE DIAGNOSIS AND TREATMENT OF DISEASES OF THE EAR. By Oren D. Pomeroy, M. D., Surgeon to the Manhat- tan Eye and Ear Hospital, etc. With One Hundred Illustrations. New- edition, revised and enlarged. 8vo. Cloth, $3.00. "The several forms of aural disease are dealt with in a manner exceedingly satisfactory. The work is quite exhaustive in its scope, and will repre- sent an authority on this subject which we believe will be duly appreciated by the profession." — Medi- cal Record. ''The author uses good language, telling in a clear and interesting manner what he has to say. The book is a valuable one for both students and practitioners." — Lancet and Clinic. "The author's opportunity to know of what he writes has been abundant, and the work itself shows that he has made good use of his information. We have not the slightest reason for not commending it not only to the otologist but also to the general student. " — Therapeutic Gazette. " Well arranged and well written, and not too scientific.'' — Boston Medical and Surgical Jour- nal. D. APPLETON &* CO.'S MEDICAL WORKS. ^g PRACTICAL SUGGESTIONS RESPECTING THE VARIETIES OF ELECTRIC CURRENTS AND THE USES OF ELECTRICITY IN MEDICINE, with Hints relating to the Selection and Care of Electrical Apparatus. By Ambrose L. Ranney, M. D., Pro- fessor of Nervous Diseases in the Medical Department of the University of Vermont ; Professor of the Anatomy and Physiology of the Nervous System in the New York Post-Graduate Medical School and Hospital, etc. l6mo, 147 pp., with 44 Illustrations and 14 plates, as an aid in treating morbid states of the motor or sensory apparatus. $1.00. A TEXT-BOOK OF NURSING. For the Use of Training- Schools, Families, and Private Students. Compiled by Clara S. Weeks, Graduate of the New York Hospital Training-School ; Superintendent of Training-School for Nurses, Paterson, New Jersey. l2mo, 396 pp., with 13 Illustrations, Questions for Review and Examination, and Vocabulary of Medical Terms. $1.75. " This book, in twenty-three chapters, communi- provingly of its design, scope, and execution." — cates a large quantity of useful information in a Philadelphia Medical Times. form intelligible to the public. It is well written, remarkably correct, sufficiently illustrated, and hand- " This is an admirably written book, and is full somely printed. The amount of technical skill and of those important practical details necessary for knowledge required of nurses at the present day the medical and surgical nurse. In fact, it could be makes the use of some text-book indispensable. read with profit by every medical student and young To those who need such a work we can speak ap- practitioner." — Medical Record. LOCAL ANESTHESIA IN GENERAL MEDICINE AND SURGERY. Being the Practical Application of the Author's Re- cent Discoveries in Local Anaethesia. By J. Leonard Corning, M. D., author of "Brain Exhaustion," "Carotid Compression," " Brain Rest," etc. ; Fellow of the New York Academy of Medicine, Member of the Medical Society of the County of New York, of the New York Neurological Society, etc. Small 8vo, 103 pp. With 14 Illustrations. Cloth, $1.25. THE METHODS OF BACTERIOLOGICAL INVESTI- GATION. By Ferdinand Hueppe, Docent in Hygiene and Bacteriology in the Chemical Laboratory of R. Fresenius, at Wiesbaden. Written at the request of Dr. Robert Koch. Translated by Hermann M. Biggs, M. D., Instructor in the Carnegie Laboratory, and Assistant to the Chair of Patho- logical Anatomy in Bellevue Hospital Medical College. 8vo, 218 pp. With 31 Illustrations. Cloth, $2.50. GYNECOLOGICAL TRANSACTIONS, VOL. VIII. Being the Proceedings of the Eighth Annual Meeting of the American Gynaecological Society, held in Philadelphia, September 18, 19, and 20, 1883. 8vo, 276 pp. Cloth, $5.00. GYNAECOLOGICAL TRANSACTIONS, VOL. IX. Be- ing the Proceedings of the Ninth Annual Meeting of the American Gynaeco- logical Society, held in Chicago, September 30, and October 1 and 2, 1884. 8vo, 000 pp. Cloth, $5.00. INDEX. PAGE Air, Essays on the Floating Matter of the 27 Anaesthesia, Local, in General Medicine and Surgery 49 Anatomy, Atlas of Female Pelvic 39 Of the Nervous System 28 Physiology and Hygiene, The Essentials of. 44 The Comparative, of the Domesticated Animals. 12 The, of Invertebrated Animals 22 The, of Vertebrated Animals 17 Animal Diseases, The Relation of, to the Public Health 45 Aorta, Diseases of the Heart and Thoracic 44 Bacteriological Investigation, The Methods of.. 49 Barker. On Sea-Sickness 3 The Puerperal Diseases 3 Bartholow. A Treatise on the Practice of Medi- cine 6 On the Antagonism between Medicines. ... 7 Treatise on Materia Medica and Therapeu- tics 5 Bastian. Paralysis from Brain Disease 3 The Brain as an Organ of Mind 5 Bennet. On the Treatment of Pulmonary Con- sumption 7 Winter and Spring on the Shores of the Mediterranean 7 Bile, Jaundice, and Bilious Diseases, On the... 19 Billings. The Relation of Animal Diseases to the Public Health 45 Billroth. General Surgical Pathology and Thera- peutics 8 Body and Mind 24 Bones, A Treatise on Diseases of the 26 Brain Disease, Paralysis from 3 Exhaustion, A Treatise on 43 The, and its Functions 36 The, as an Organ of Mind 5 Bramwell. Diseases of the Heart and Thoracic Aorta 44 Breath, The, and the Diseases which give it a Fetid Odor 19 Buck. Contributions to Reparative Surgery .... 14 Carpenter. Principles of Mental Physiology 4 Carter. Elements of Practical Medicine 39 Chauveau. The Comparative Anatomy of the Domesticated Animals 12 Chemical Technology, A Hand-book of 33 Chemistry, Inorganic 35 Organic 35 Short Text-book of Organic 4 The, of Common Life 14 Children, A Practical Treatise on Diseases of. . 38 Children's Diseases, Compendium of 30 Club-Foot, A Practical Manual on the Treat- ment of 30 Combe. The Management of Infancy 3 Consumption, on the Treatment of Pulmonary. . 7 Corfield. On Health 4 Corning. A Treatise on Brain-Exhaustion 43 Local Anaesthesia in General Medicine and Surgery 49 Cyclopaedia of Practical Receipts 12 Davis. Conservative Surgery 13 Deformities, A Treatise on Oral 18 Dermatology, A Manual of 47 Diseases, The, of Sedentary and Advanced Life. 48 Down. Health Primers 21 Ear, The Diagnosis and Treatment of Diseases of the 48 Education, Physical 25 Electricity in Medicine, The Uses of 49 Elliot. Obstetric Clinic 9 Emergencies, and How to Treat them 16 Evetzky. The Physiological and Therapeutical Action of Ergot 8 Eye, A Hand-book of the Diseases of the, and their Treatment 44 Flint. Manual of Chemical Examination of the Urine in Disease 9 Medical Ethics and Etiquette . 46 On the Physiological Effects of Severe and Protracted Muscular Exercise 9 Text-book of Human Physiology 10 The Physiology of Man n The Source of Muscular Power 9 Foods 33 Fothergill. The Diseases of Sedentary and Ad- vanced Life 48 Fournier. Syphilis and Marriage 11 Frey. The Histology and Histo-Chemistry of Man 13 Friedlaender. The Use of the Microscope in Clinical and Pathological Examinations ... 46 Gamgee. Yellow Fever a Nautical Disease 13 Genito-Urinary Organs, Surgical Diseases of the. 33 Gross. A Practical Treatise on Tumors of the Mammary Gland 15 Gutmann. The Watering- Places and Mineral Springs of Germany, Austria, and Switzer- land 30 Gynaecological Transactions. Vols. VIII and IX. 49 Hamilton. Clinical Electro-Therapeutics 22 Hammond. A Treatise on Insanity 40 A Treatise on the Diseases of the Nervous System 16 Clinical Lectures on Diseases of the Nerv- ous System 17 Hart. Atlas of Female Pelvic Anatomy 39 Harvey. First Lines of Therapeutics 19 Health 4, 31 A Ministry of, etc 29 And How to Promote it 24 Primers 21 Heart and Thoracic Aorta, Diseases of the 44 Histology and Histo-Chemistry, The, of Man.. 13 Hoffman and Ultzmann. Analysis of the Urine / 22 Hospital Reports. — Bellevue and Charity 32 Hospitals 35 Howe. Emergencies, and How to Treat them . 16 The Breath, and the Diseases which give it a Fetid Odor 19 Hueppe. The Methods of Bacteriological In- vestigation 49 Huxley. The Anatomy of Invertebrated Ani- mals 22 The Anatomy of Vertebrated Animals 17 Hygiene, Physiology, and Anatomy, The Essen- tials of , 44 Infancy, The Management of 3 In-Knee, Medical and Surgical Aspects of 36 Insanity, A Treatise on 40 Jaccoud. The Curability and Treatment of Pulmonary Phthisis 46 Johnson. The Chemistry of Common Life 14 Joints, Lectures on Orthopedic Surgery and Diseases of the 31 Jones. Practical Manual of Diseases of Women and Uterine Therapeutics 43 Journal, The New York Medical 38 Keyes. The Tonic Treatment of Syphilis 14 Kingsley. A Treatise on Oral Deformities .... 18 Legg. On the Bile, Jaundice, and Bilious Diseases 19 Letterman. Medical Recollections of the Army of the Potomac 24 Life, Diseases of Modern 30 The Diseases of Sedentary and Advanced . . 48 Little. Medical and Surgical Aspects of In-Knee. 36 Loring. A Text-book of Ophthalmoscopy 48 Lusk. The Science and Art of Midwifery 20